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HomeMy WebLinkAboutBuilding Permit # 8/6/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: , - Date Received Date Issued: IIMPORTANT:Applicant must complete all items on this page LOCATION t Z0 Print PROPERTY OWNER Print 100 Year Old structure yes no EMAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yesno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ^ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well 11 Floodplain- ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFWMED: Identification Please Type or Print Clearly) OWNER: Name: 4-JIU -+/ Phone: 9 Address: '7 C) �� -��� S /k/,,Y4 CONTRACTOR Name: AVJ �1/t) Phone: V�7 V Address: IeS Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ( % ARCHITECT/ENGINEER _ Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ x,53 , FEE: $ Check No.: Receipt No.: Mal . NOTE: Persons contracting with unregistered contractors do not have access Xtheuaranty fund Signature of Agent/Owner/ ! Q-E'� euk6!e, Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ t%OR y Town of '� t �. ...'., Over ® ,'1. � \•' ® h ver, Mass, o LAK* 1. COC NIC Off@ w1C X ®AERATE® u BOARD OF HEALTH E R Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT Y .... . . .... . . .... ` Foundation has permission to erect ...... ................... bulldin s on .. F-.. .......... ....1 l�........ ........ .. .�. .. ......... Rough � g uh �`oe to be occupied as .... ........ . ... . ... ...........�..... ......... ...�..�74rw1............... . . ..... chimney provided that the person acce tin this ermit shall in eve respect conform to the terms of the 1"' tion p p p g p every p pp 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STARTS Rough Service .................................. .... ............. .......................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancV Permit Required to OccupV Bulldlnt; Rough Islay 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. M YNIHAN-NORTH READING LUMBER, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 164 Chestnut Street FEIN:04-2261995 North Reading, MA 01861 A* Contractor Reg No.: 978-864-33101781-944-8500 Exp.Date:—/—I— L —//-- Salesperson(s): HOMEOWNER INFORMATION Name Daytime Phone Street Address(Not P.O.Box) Evening Phone City[Town State Zip Code Mailing Address(if different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan-North Reading Lumber, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall be adhered to unless circumstances arise beyond Moynihan-North Reading Lumber,Enc.'s coritrol:Work scheduled to begin: f Expected date of completion: —=�--4-- May be based upon arrival of special order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan- North Reading Lumber, Inc. agrees t form the work, and furnish the material and labor set forth in Exhibit A for the Total Contract Price of:$ (which amount includes all finance charges). Payments shall beJ7r ade by Homeowner according to the following payment schedule: $ / V742L D# Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third (1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $ cam, _ by_/ / or upon completion of delivery of materials $ �by_/ / or upon completion of install $ upon completion of the Contract In order to meet the completion schedule set forth above,the following materials/equipment must be special ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$ $ to be paid for b 'din I permit / $ Chi L-C to be paid for YL�ti'c2 $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES J &/L- ` Moynihan-North Reading Lumber Inc. Homeo' er's Signature Date Contractor Date By:Dale Fuller Homeowner's Name(Printed) Installed Sales Coordinator You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof, provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. See reverse side for additional Homeowner Terms and Conditions 1057-NR 1/11 White-Office Yellow-Sales/Service Pink-Customer Page 1 of 5 r,• _ r 1H N LUMBER NORTH READING PLAISTOW BEVERLY 12 Old Road 82 River Street 164 Chestnut street P.O-Box 1160 P.O.Box 126 Plaistow,NH 03865 P.O.Box 509 North Reading,MA 01864-0128 riy,MA 01915 (603)382-1535 8eve (978)6643310•(781)944-8500 FAX:(603)382-1935 (978)927-0032 FAX: (978)6640872 AX:(978)927-8201 Subcontractor Workers' Com ensation Waiver IShawn Arsenault ,. hereby acknowledge that I, as an independent contractor; have been asked by Moynihan Lumber on Company to provide it with a certificate of Worker` m ov dedl by Insurance coverage-for myself. Based on the exemptionp the Worker's Compensation Insurance coverage for mysoellf ld Moan se am a sole proprietor without employees . tTherefore, - han Lumber Company and Its related organizations and the Arcadia. Insurance and or Self Insured Lumber BusinessAssociacurredtion, ti myself totally harmless for any injuriest of (es myself from coverage because ! have voluntarily chosen to exclude by engaging the exemption provided under the Workers Compensation Laws. I have taken this option of my own freewill. Signa — Witness Date: Al.- Z Y /"QUALITY BACKED BY A DESIRE TO PLEASE" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name(Business/Organization/Individual): Shawn Aresnault & Eric Arsenault d/b../a. Arsenault Brothers Construction Address: 105 Hamilton Street, 1st Floor City/State/Zip: Leominster, MA 01453 Phone.#: 978-514-4848 Are you an employer? Check the appropriate bog: Type of project(required): 1.® I am a employer with 3 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. E] Remodeling 2.❑ I am a sole proprietor or partner- sub-contractors have ship and have no employees These8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition comp. insurance.$ [No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] ❑ officers have exercised their 11.❑Plumbing repairs or additions 3. I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers — Policy#or Self-ins. Lie.#: IHUB6B90875713 Expiration Date: 04/02/11 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine-Lip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signa "25z Phone# Official use only. Do not write in this area, to be completed by city or town 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 Phone#: Contact Person: ARSEN-2 OP ID:NB DATE(MM/DD/YYYY) CERTIFICATE LIABILITY INSURANCE 08/05/2015 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 Anderson Bagley&Mayo NAME: g y y PHONE FAX Insurance Agency,Inc. alC No Ext): A/C No)*. 44 Main Street,P.0.Box 360 E-MAIL Leominster,MA 01453 ADDRESS: Richard M.Bagley INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Charter Oak Fire Ins Company 25615 INSURED Shawn Arsenault& INSURER B:Travelers Indemnity of America 25666 Eric Arsenault Arsenault Brothers Constructio INSURER C:Travelers 105 Hamilton St 1st FL INSURER D: Leominster, MA 01453 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 DL BR POLICY NUMBER MM/DD Y EFF MMIDDI EXP LIMITS LTR10&WVD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY 16805583M546ACJ15 08/01/2015 08/01/2016 DAMAGE ( ED PREMISESSEa ED ) $ 300,000 CLAIMS-MADE I—XI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- Ll LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 500 000 Ea accident $ , A ANY AUTO BA-8672A678-i4-SEL 08/2612014 08/26/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS NON -0OWNED PER ACCIDENT) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU- H OT - AND EMPLOYERS'LIABILITY TORY OMITS ER C Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE IHUB6B90875715 04/02/2015 04102/2016 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? [—]IN/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Moynihan Lumber Co. ACCORDANCE WITH THE POLICY PROVISIONS. 164 Chestnut Street North Reading,MA 01864 AUTHORIZED REPRESENTATIVE Richard M.Bagley ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD E �s?- ��ie Cparrarrzarzcc�eccll�z a��UCcradcze�uoleGl3 Office of Consumer Affairs&Business Regulation W:pME IMPROVEMENT CONTRACTOR gistration: 171474 Type: iration: 3/21/20.6_;. Individual SHAWN y SHAWN ARSENAULT 24 GRAHAM ST LEOMINSTER, MA 01453, Undersecretary 1 �lassacnusetis -Gepar-man..�.�.'u-�iic 3a�?t'; ' Board of Building Regulations and Standards Construction Supp License CSFA-106031 `. SHAWN ARSENAHLT - 105 HAMILTON STREET _ ti Leominster MA 61 453 ✓mow Jy � "<piration Commissioner 08/24/2016 �-� e G-// Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Mas--sac ' segs Home Improvement Contractor Registration Registration: 136860 t Type: Private Corporation t i T C Expiration: 9/6/2016 Tr# 255814 MOYNIHAN NORTH READING LUIV48ER—, IN DALE FULLER PO BOX 128 N. READING, MA 01864 ` __ Update Address and return card.Mark reason for change. —L� D Address F-] Renewal F-] Employment ❑ Lost Card