HomeMy WebLinkAboutBuilding Permit # 9/3/2015 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIONIORTN
P
Permit Na Date Received
AT.D�T
CHUS
Date Issued:--
IMPORTANT:A2plicant m2sAcom Tete all items on this p!1ge
LOCATION I C1 .7� J�C
'Print
PROPERTY OWNER
Print
MAP NO.' PARCEL:/IV-- -111,409 ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0
TYPE OF IMPROVEMENT PROPOSED USE
I J wa( 0 ek Residential
V , — Non-Residential
0 New-guilding J k0ne family
E'Addition F-]Two or more family 0 Industrial
[J]Alteration No. of units:
0 Repair,replacement 0 Assessory Bldg 0 Commercial
L1 Demolition
r-!Moving(relocation)
El Foundationonly J Other 11 Others:
DESCRIRTION OF WO TO BE PRF , RMED
Identification Please Type or Print Clearly)
OWNER: Name:. L no I ---,)+A Phone:_u 11-7 CK-1
Address.
CONTRACTOR Name: IN Phone: &(v,
der f W, -C
Vla�L`1-16�111
Address:. . ix3 ,
Supervisor's Construction License: cj?-�
a3 >r�) Exp. Date:
Home Improvement License:,--.I 0Exp. Date:
ARCHITECUENGINEER I 1A Name: Phone:
Address: Reg. No.
FEESCHEDULE:BULDING PERMIT. $12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS 9D ON$125.00 PER S.F.
`Total Project Cost :$ CIO —x12.00=FEE:$-
Check No.: Receipt No.:.,)6
Page loft
FORTHm,% de%ver
Town of
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .............CA ................ MIJ O�.f. ...................................... BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings o ...(cis......:LA4.i�
.. . .....................
Rough
to be occupied as .. . L t� Chi y
.... .. .......... .. ..... ............................... Chimney
provided that the person accepting this permit shall in eve spect conform s of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning.or Building Regulations Voids this Permit. Rough
Final
PERMIT,EXPIRES e1NNTH ELECTRICAL INSPECTOR
UNLESS C® STRU T Rough
Service
........ ..... ............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
ccupancV Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises - Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Visit Our Showroom Ai: fwd � �� � � � � FaMOus Brand Names
354 N. Broadway Certainteed
Salem, NN 03079 �'� 1 1 IN Y ,. I � a Mastic
Mon, thru Fri. gam-5pm Alcoa
Most Saturdays 9am- 12prn �" �" � b � � e Andersen
or by Appointment �' j Inc. m Harvey
Tei. (603)1398-2259 ® Therma-Tru
- Agreement�
PROPOSAL SUBMITTEL} O PHONE DATE J
STREET JOB NAME
JC1 3
CITY,ST TE$ZIP COD JOB LOCAFION
`�d' _
We hereby propose to furnish all materials and labor necessary for the completion of the fallowing products in accordance with the
specifications and drawings
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Total contract price is: l�; •��, w I� ? i1 �` f G•. �-,I, dollars($ �� '
PAYMENTS TO BE MADE AS FOLLOWS:
' {`it vhf t '� sl r7 L GL4 t' dJ� (u . — a i t ✓' 1 �j, 4 and
ALL MAl'ERIAL IS GUARANTEED l'O BE AS SPECIFIED. ALL tNORK TO BE COMPLETED IN A AUTHORIZED<
VVORi«vANLIKa WANNER ACCORDING l'0 SPECIFICATIONS PER STANDARD PRACTICES. SIGNATURE '
ANl'ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS INVOLVING EXTRA
COST VUILL BE EXECUTED ONLY UPON WRITTEN ORDERS AND WILL BECOME AN EXTRA
CHARGE OVER AND ABOVE THE ESTIMATE.
ACCEPTANCE CBPPROPOSAL-THEABOVEPRICES,SPECIFICATIONSANO CONDITIONS � �• jp �
ARE S,%TISFACTORY AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE t /
WORKAS SPECIFIED. PAYMENTS WILL BE MADE AS OUTLINED ABOVE.
SIGNATURE
('USTONIER HAS THE RIGHT TO CANCEL THIS CONTRACT UP TO THREE(3)DAYS AFTER �
DATE OF ACCEPTANCE.
DATE OF ACCEPTANCE ���!�5� SIGNATURE
This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A), but does not include standar°d
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A
Massachusetts Consumer Guide to Rome Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information
Contractor Information
Namen Compa Name
V--f,
jtneet,Address(d notuse aPosoffice Box address)
Contractor/Salesperson/Owner Name
cityrfown S ate AKOA.
da S ate Zip Code Business Address(must include a street address)
Daytime Phone Evening Phone Cityflown state Zip Code
Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number
Law requires tbal most home Home invro%=temContractor Reg,slumber
Expiration date
impmementcontractors have
a viffld lVistntion n1imber
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed,specifying the type,brapd,and grade of materials to be used,use additional sheets ir
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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 -T�D Date When contractor will begin contracted work-
MGL chapter 142A.) AlaID Date when contracted work Nvill be substantially completed.
Total 0"Ira
I
Pri0 rindPayment
Schedule
, COa�ndotoragreestoperf0rmffiwork,
furnish
the
material dor�specified�above for the total sum
Payments'Will be made according to the f011oNving;schedule:
pon signing contract(not to exceed 113 of the total contract price or the cost of special order items,whichever is greater)
%, (
7qA33y 1 1 or upon completion of
) A
or upon completion of CA D
upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special S 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
"Vilich must be special ordered in-advance to meet the completion schedule.
�NoOl s all ter f the warran
Subcontractors L utract
_ of the must he �,o the,,
-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
patty/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for A payrflents to all subcontractors for
niatterials and labor under this amement
Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted Nvithin this document,the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the f0l]Oxving cautious 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 contractor,,;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,TVIA 02116 or by calling 617-973-8787 or 888-283-3757.
* Does the contractor have insurance? Ask the Contractor fbr his insurance anmnanv infn—ml�——fk—,—---
.. The Commonwealth efl ss r-husefis
e ail ent oj'Industrial Accidents
7 Office of Investigations
600 Washington treet
Boston,1 02,111
ww .muss.govIdia
Workers' Compeiisation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A lic ntInformatione� e int IJe � l
NaMe (Busitaess/Organization/Individual): i ( }
.Address: n
City/State/Zip: Sa I om WH 030 phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.I 1 ani a employer with 34. Q I am a general contractor and I 6. ❑New construction
employees(full and/or part-time),* have lured the sub-contractors
2.E1 I am a sole proprietor or partner- listed on the attached sheet.I 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for the in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers' comp,insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.[]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and vre have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13.�Qther ,t)t .Eot1
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 their workers'comp.policy information.
I am an emplar<yer Chart is providing workers'compensation insurancefor my employees. Below is the policy aand jrob site
hifirmaatiaom
Insurance Company Name: :
Policy 4 or Self-ins.Lic.#: S 1' (0 Expiration Date: j
Job Site Address: M,&City/State/Zip:_
Attach a copy of the workers'corp ensation 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 up 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 tip to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I(to hereby cert4y under the mors a nd en aldes ofperjury that the irajbrrraaation provided above is true and correct,
o r
Signature: ( Date:
009
Qjylciaal use only. Do not write in this area,to be completed by city or town aojjleiral,
City or Town: Permit/License##
Issuing Authority(circle cane):
i.Board of Health 2. building Department 3.City/Town Clerk 4.Electrical inspector S.Plt$anlriaag inspector,
b.Other
Contact Person: Phone t#•
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 arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to sr crit to such arbitration as provided In Massachusetts General Laws, chapter 142A.
Homeowner's gignature
Contractor's Signature
NOTICE:The signatures of the parties above 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.MOL 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 consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in icate 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 ajoint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Inforing-Ition
If you have general questions or need additional infori-nation 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
61'1-973-9787,898-9-93-3757 or Visit the()CAR.Rwobsito at
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,
A4*n----A --I!_
PELLE-3 OP IC: N
DATE(MMroDrvvYY)
CERTIFICATE OF LIABILITY INSURANCE 1tlt{26121J15
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 pollcy(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 an this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CO ACT
NAME: Jaynes A Santo
Planright Insurance-Salem PHONE 603-990439 FAX
224 Dain Street Suite 3G Arc No.E . Arc No):603-690-6521 —
Salem,NH 03079 E-MAIL
Jaynes A Santa ADDRESS:jam ie@santoinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC I
INSURER A:Acadia Insurance 31325
INSURED Pellerin Vinyl Siding--- INSURER B:
354 North Broadway
Salem,NH 03079 INSURERC: _T–
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.
I
TR SPE OF INSURANCE POLICY NUMBtp
ER _ M° POLICY
c MYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,O00,00
-DAMAGE TO—1TE CLAIMSMADE F]OCCUR SOA5122764.10 10/28/2014 10/28/2015 PREMISES Eaa occurrence) _ $ 500,000
MED EXP(Any one person) $ 5,000
_ _-- PERSONAL.&ADV INJURY $�! 1,000,00_0
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICYFIJCT PER
LOC PRODUCTS-COMPIOPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000000
Fa accidentr
A ANY AUTO BOA5122764 10/28/2014 10/2812015 BODILY INJURY(Perperson) $
ALL O'NNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $ u
X HIRED AUTOS K ON-OWNED PROPERTY DAMAGE $
AUTOS (Pere ccident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ ----+- — -$�--�
WORKERS COMPENSATION STATUTE cR
AND EMPLOYERS'LIABILITY
A ANY PROPRIETORIPARTNERIEXECUTIVE Y t N CA5122768-11 10128/2014 10/28/2015 E L.EACH ACCIDENT $ 500,00
OFFICERIMEMBER EXCLUDED? N t A 3A N
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Ken Perignyy .Paul Pellerin have elected to be excluded from Workers
Compensation coverage
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Carol Stannard ACCORDANCE WITH THE POLICY PROVISIONS,
193 Lacy St
AUTHORIZED REPRESENTATIVE
North Andover,MA 01645
-
(0198E-2014 ACORO CORPORATION. All rights reserved.
''. 71{idssfiChusett.? -Dep.al ment os ! i :.l1r Jcf f.
81,08,tci of Building ReguW4onr, and
ni�xrrractial� �ti>er�"isnr
se: CS-037603 ;
f t
Nt PE G y M
5 MCGRATH 5T
SALEM NH 03OT9
�y
C��rnissicarse: 04/17/2016
�e 1`"a'uw ww"verrlllr 1/0-1'��3 tac�rrseC!'
Office of Consumer Affairs&Business Regulation
" ME IMPROVEMENT CONTRACTOR
egistration 100286 Type:
xpirataon: 6!1512016 Private Corporation
PELLERIN VINYL SIOING
Kenneth Perigny
354 N.Broadway
Salem,NH 03079
Undersecretary
i