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HomeMy WebLinkAboutBuilding Permit # 6/12/2015 0� r10RTy BUILDING PERMIT3� ytt*�ao.,b!y�0� TOWN OF NORTHANDOVER ° A APPLICATION FOR PLAN EXAMINATION 4, n _ ®y Permit NO: Date Received - "I p W.11115 SR�DateIssued: S IMrrPORTAr NT: Applicant r, / mus/t complete le, tre ar ll item/ s on this page / r r .r rr/ r / /rr/ /✓ / / / I / / / ri rr / / i -/ ,.. ,,,1 r ,,..r ,, ,l 1, r,.L�//// , „.�'✓ /� ,. /ai, r / r� / r r a✓ �/ TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential Zw Building &,15ne family dition ❑ Two or more family ❑ Industrial [Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ D olition ❑ Other /i a p l ,LIIarIC{S a�n IaWe ,.,r a /, //. lve"ij �.. a A m -4 � . � � ' ° "r_ 1 Identification Please Type or Print Clearly) OWNER: Name: Pdt; Phone,2 lih 11 ..C :, � Address: _qD 00) fMLr IV r r/ rrrr /o / r r, r r / / / / r r r r / / / � »,f / f ! / r ARCHITECT/ENGINEER — Phone: /Po Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$128.00 PER S.F. �'y 'Total Project Cost: $ C , ° FEE: $ �, � / , C� Check No.: ! / Receipt No.: �'Z NOTE: Persons contra `cting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner ,. —`; '� ature of contractor �I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swimming Poll' 0 Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM \ PLANNING & DEVELOPMENT Reviewed On W57 Signature k ignatur6*k COMMENTS. VA CONSERVATION Reviewed`ons �natq�rel"- COMMENTS 0 HEALTH Reviewed oSi nature COMMENTS an. LL21v' � 73ae'a'L r V I L) Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/sr,gnature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE E R" n W 11;""�""'/""�"q Y"� f1g, .......... "M A55 tV E4TT','8/" t%ORTH own of . � E , Andover ® No. - C,0 LAKE h e`1 Mass, COCNICNEWICK y1' ?A-rEO S V BOARD OF HEALTH Food/Kitchen T 'T L rE �L- Septic System THIS CERTIFIES THAT ..... BUILDING INSPECTOR ��'.. ., �.r. �!..... ............................... . .. .................................... Foundation has permission to erect .......................... buildings on . .... ��..! �^: .45; ........... � Rough to be occupied as ...... . ��. ,1..... �/ .?� .r.......G.l��..r:. �l�� ....... .�1��. 1r.'.,lr? lt :. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMITIRE IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS C T TIO STARTS....... Rough ......... .. Service ............ ...... ...... .. . .. ....... Final BUILDING. . . .INSPECTOR GAS INSPECTOR Occupancy Permit Required t® OccupV Bulldln Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. owner D "L - KitcVtet�s$ptHS-RewwdeU wg-W'w�dows 781-858-5134 t Homeowner Information Contractor Information Name Company Name T Street Address(do not use a Post Offict Box address) Contractor/Salesperson/Owner Name q$, W 6 City/Town State Zip Code Business Address(must inclu e a street address) fA MA 0191r ' Daytime Phone Evening Phone City/Town State Zip Code Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number _ Home Improvement Contractor Reg.Number Expiration date Law requires that most home improvement contractors bare a valid registration numberIMS 3 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) 13 ul'id % . W p AeAto o . /K AaPi�kjd. Pit . a,4e Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of m (*) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ V by / / or upon completion of t1 $_ by / / or upon completion of 15 /( ?""S t, $ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following materiallequipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-473-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitr ' firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Re ation an the consun r shall be required t to such arbitration as provided In Massachusetts Getter ws, ap 42 oineowner's Signature Contractors tgnature NOTICE:The signatures of the parties a ove apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consurner/honteowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at bttn-//Rwiw.mas';,,-ov/ocabr! If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 021.16 617-973-8787,888-283-3757 or visit the HIC website at littp:H%vwiv.iiiass.gov/ocabr Qo online to view the status of a Homo Improvemont Contractor's Registration: litt1):Hdl)state ma us/hrniieimnrovement/iiceiisceIist.a.9 I For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: The Commonwealth of Massachusetts Department oflndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 •, ,gyp www.mass.gov/dia 4� Sy'v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A licant Information Name(Business/Organization/Individual): Address: :n w City/State/Zip: Phone#: Are you an I ployer?Cheek the appropriate box: �F` (required): i, am a employer with mployees(full and/or part-time).* 7. ❑New'construction 2.FJ I am a sole proprietor or partnership and have no employees Working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9, El Demolitioll 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be luring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 14.❑Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information- 'I Homeowners who submit this affidavit indicating they are doing all work andthenhire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is pr•ovidingwor^Icers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:_ /Ali/ Expiration Date: Policy#or Self-ins.Lie.#: 6t Job Site Address: City/State/Zip: 10 Attach a copy of the workers' compensation policy declaratio page(showing the policy number and expir tion date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verif . . I do hereh ertify un er t e pain and penalt' of r ry that tri Wit provided above is true and correct. Date: Si ature: Phone#: official use only. Do not write in this area,to he completed by city or tolvn official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: IUV IIIVVI IV.VUJJUl.I1V VU1VVIIV17 VVI IVI IVY411 VI 1\. IIIIUVVVI \IVIVVVVVV7L/ VU.'7'I VV/LV/IV VI11 VZ 1� V V Client#:256754 DUSSAULTC DATE(MM/DDIYYYY) AC®R ,ra CERTIFICATE OF LIABILITY INSURANCE 5/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: HUB International New England PHONE 978 657-5100 FAx 978-988-0038 AIC No Ext: AIC No: 4 West Mill Street E-MAIL ADDRESS: Medfield,MA 02052 INSURER(S)AFFORDING COVERAGE NAIC N 508 359-4151 INSURERA:Safety Safe insurance Co 39454 INSURED INSURER 8:Hartford Insurance CO Daniel Dussault dba Dussault Carpentry INSURER C 990 Johnson Street North Andover,MA 01845 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYY A GENERAL LIABILITY BMA0012372 9/15/2014 09115/2016 EACH OCCURRENCE $300000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea Deco enca) $100 000 CLAIMS-MADE ❑OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $300,000 GENERAL AGGREGATE $600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $600,000 POLICY JELOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTYacc DAMAGE $ AUTOS Per ident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 08WECEH1833 3126/2015 03/26/201 WC Y LIMIT ER AND EMPLOYERS'LIABILITY TORY LIMITS ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFiCER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Daniel Dussault CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1390230IM1367154 JC011 Massachusetts -Department of Public Safety Board of Building Regulations and Standards %-onstruction Supeh-isor '... License: CS-090846 DANIEL F DUSSAtI L 990 Johnson Street` North Andover MA 0 • Expiration Commissioner 12/26/2016 ��eao���to�zcaecclf� cadac%ae(Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 149853 xpiration: 2/14/201DBA Type, I A DUSSAULT CARPENTRY DANIEL DUSSAULT 990 JOHNSON STREET NORTH ANDOVER,MA 01845 g `— — Undersecretary ;j