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HomeMy WebLinkAboutBuilding Permit # 10/2/2015 OO R TH BUILDING PERMIT 0� �t4CD ,b�ti0 TOWN OF NORTH ANDOVER o ; Q APPLICATION FOR PLAN EXAMINATION 4t �" DRA cocw�newicx*V1' .m Date Received � reD PermitIV®#a �Ss•�c�eus`�R Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION i Print PROPERTY OWNER Print 1 oo Year Structure yes no MAP _PARCEL ZONING DISTRICT: Machine District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ne family ❑Two or more family ❑ Industrial ❑ Addition ❑ Commercial [XAlteration No. of units: ❑ Bldg Others: ❑Assessor ❑ Repair, replacement y g Demolition ❑ Other uiri,vy1/lei G!(ci iJ Uf (' ri/%/%//il%O / o7/rOr ❑ Dem011 I ,,�� ed�D _..r�� r i�wan ,�.�, ro./r /r// /,r/. �!/ /l%:(. ,,., ,rrv»7ir,xi lJ �i rl 1. 1.(,.,r4 /%,/ / , ,%/ J �r// 1.lrir i +g� �,�!/ „..fr (g+AJI!//...11��/ r� ,1 a / ,, 4.1 ��;, /, 1,❑iWe / ,/r, �, ' ",N l' nr V /,� /. f, off), , f/////�I, / / / ,J1 �f,Flood� I IdG tC, ,y®.`,�'e � ,/ � I/ �ir��'{�����f J ���w���Water��ewei>>��i.,,�e /��,��, DESCRIPTION OF WORK TO BE PERFORMED: dentification- Please Type or Print Clearly OWNER: Name: ,, teld Phone:� �' 54 Al, j 4n Address: 7 0 d MM&r Contractor Name: r( �Phone: Email: Address; Supervisor's Construction License: "" Exp. Date: �,_ Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$125.00 PER S.F. Total Project Cost: $ ' To � FEE: $ . Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guguarty fund Ic �;Idna `Jf 52�� wn ' SORT H Town of Andover ®4- 1 �► Ali- 2mp wa 6JOW01 C,0 LAK& h ver, ss' COC NIC"&WICK 41' S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ........ .. BUILDING INSPECTOR ...... ............................... ............... .................................................. mom .. .. Foundation has permission to erect .......................... buildings on .... ......... .................. ... ....................... Rough tobe occupied as ....... .... ......... .......... . ......V................................................. Chimney provided that the person acceptin 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 PERMITI IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO� STARTS Rough Service .......... .. . .............................................: BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. Massachusetts home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. SeeIr legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Constuner 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 Name Comp ame e� oC Street Address(do not use a Post Office Box address)— Contractor/SalesperswV 0erName A City/Town State Zip Code Business Address(must include a street address) At e,Vi Cric DaytimePhone Evening Phone City/1I StateZip Code y � Ca 169fa �j Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Numb er 191 Homelmprovement Contractor Reg.Number Eapiraton dale Iaiv requires ttotmastLome 3 impmvemenration number hove n valid registration number 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.) 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 miless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of A-° �A%ate when contractor will begs contracted work. MGL chapter 142A.) g .� ( s2 ` 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 o 0 (*) 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) $ by / / or upon completion of $ by / / or upon completion of 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 $ 1> to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) It to be paid for NOTES:(*)Including all finance charges(**)Lawrequires 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 15"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 fiudrer agrees to be solely responsible for all payments to all subcontractors for materials and labor tinder 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. Aslc questions if something is tmclear, • Make slue 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 617-973-8787 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 see a copy of a"proof of insurance"document. • Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. AO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identical copies of the contract mustbe completed and signed.Ona copy should ga to the homeowner.The other copy should be kept by die contractor. Homeowner's Signature Con or's Signature LL at ���_ Date Date The Commonwealth of Massachusetts Department of IndustrialAccidents ° X Congress Street,Suite 100 Boston,MA 02114-2017 sv;y�t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERA41TTING AUTHORITY. Applicant InformationPlease Print Le ibl Nam /In Name(Business/Organizationdividual): ~SVr epco Address: ' City/State/Zip: r3 . �6v� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[Kam.a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[❑Electrical repairs or additions proprietors with no employees. • 12.E]Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. 00f repairs • These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other oyees.[No workers'comp.insurance required.] 152,§1(4),and we have no.empl *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submif#his 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. Hthe sub-contractors have employees,'tliey 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: tt � Policy#or Self-ins.Lia#: d�� -qe6' 70-45-900h16-4— Expiration Date: fob Site Address: h"Mer City/State/Zip: l , ' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 STOP 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 verification. X do hereby ce i y under the pa' an penalties ofpeijuiy that the information provided above is true and correct. Si nature: o Date 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 Contact Person: Phone#: Oct/05/2015 11:47:10 AM Degnen Insurance 973-327-6553 1/1 ACZR a CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIVYYY) 16. 10105/2015 THIS CERTIFICATE 13 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 on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT Elizabeth Chavez NAME: DEGNAN INSURANCE AGENCY, INC. PHONE 978 688-4474 a No: MAIL ADDRESS: achavez@degnanlnsurar)co.com 85 SALEM ST. INSURERS AFFORDING COVERAGE NAICS LAWRENCE MA 01843 INOURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: JAMES DEBRECIN I INOURERC: FAMILY ROOFING & PAINTING INOURER0: 2 TANAGER WAY INSURER E.' LONDONDERRY NH 03053 INOURERF.- COVERAGES CERTIFICATE NUMBER: 3669 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. IITR Aoot. U6R POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICYNUMBER MMIDD MWDO COMMERCIAL GENERALLIAOIt" EACH OCCURRENCE $ DAMAGF_TO RTE CLAIMS-MADE FIOCCUR PREMISES Ea nccurrrnrr. $ MED EXP(A0y ane elson) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 71 PRO- JECT ❑ LOC PRODUCTS-COMPIOP AGG $ OTHER: S ACOMBINED SINGLE LIMIT $ Ea AUTOMOBILE LIABILITY arrident ANY AUTO BODILY INJURY(Pcr person) $ ALL OWNED SCHEDULED NIA BODILY INJURY(Par accident) $ AUTOS AUTOS NON-OWNED PcOPERe17YDAMAGE $ HIRED AUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE NIA AGGREGATE $ DED I RETENTIONS �/ $ WORKEROCOMPENOATION STRTUTE ETH AND EMPLOYERS'LIABILITY ANYPHOPRIE I ORIPAH I NEHIEXECU I IVE YIN E.L.EACH ACCIDENT $ 100,000 A OFHCERIMLMHLHbxCLUL NIA NIA NIA AWC40070259002015A 05/11(2015 05/1112016 '... (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 It Yee,C98CObe undef DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 NIA DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(ACORD 101,Addltlonal Remark:Schadula,may ba attached If mora spaaa Is raqulrod) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 OB B;no authorization is given to pay daima for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mase.govllwdlworkers-compensationfinveetigati one/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET BUILDING 20 SUITE 2035 AUTHORIZED REPRESENTATNE NORTH ANDOVER MA 01845 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA (�),1966.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD DATE(MMIDDIYYYY) CERTIFICATE F LIABILITY IN URANGE 05/21/2015 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(ies) 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). CONTACT PRODUCER 02025-00"1 NAMNNE: ---- �CNO..Ext: (978)688-4474 AIC.No: (978)327-6558 Degnan Insurance Agency Inc EMAIL 85 Salem Street ADDRESS: —_--- Lawrence,MA 01843N is SU ERS AFFORD NG COVERAGE INSURER , A.I.M.Mutual Insurance Company 33758 INSURED - INSURER B: ---- James Debrecini INSURER C, ------- Family Roofing & Painting 2 Tanager Way INSURER D: ---- Londonderry, NH 03053 INSURER E S COVERAGES CERTWICAT.E NUMBER: REVISION NUMBER: 3EEN ISSUED TO ED ABOVE POLICY FOR THE IOD NBELOW NTNHSW ITHIS IS'TO CERTIFY THAT THE POLICIES OF NDCATEDNOTWITHTANING ANY REQUIREMENT, TERM RCONDION OF ANY CONTRACT R OTHER DOCUMEIH 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 OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ADDI SUBR `POLICY EFF POLICY EXP LIMITS ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY EACH OCCURRENCE $ GENERAL UABILITY DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS-MADE ❑OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEI,IERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ EN'L AGGREGATE LIMIT APPLIES PER: ___]POLICY RO 71LOC COMBINED SINGLE LIMIT Ea accident $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO ALL:OWiJED SCHEDULED BODILY INJURY(Per.accident) $ AUTOS. AUTOS PROPERTY DAMAGE $ HIRED AUTOS NON-OWNED. Per accident AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB- CLAIMS MADE $ DED RETENTION $ WC S8TU- OTE- WpRKE M p pN X TORY LIMITS ER pNt]ERM�PpLRO�l�4ETR�SR�L�tgARB7I�NIETRY F� E.L.EACH ACCIDENT $ 100,000.00 A o� ICER/MEMBER/EXCLUDEID?ECUTIVEY� NIA AWC400-7025900-2015A 5/.11!2015 5/1112016 E.L.DISEASE-EA EMPLOYEE $ 100,000.00 (Mandatory In NH) E.L.DISEASE-POLICY LIMIT $ 500,000.00 If es desc ibe under DESCRIPTION AF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD io1,Addi4ionai Remarks Schedule,.if more spacers required) The workers compensation policy does not provide coverage for James Debrecini . CERTIFICATE HOLDER CANCELLATION Andover Town Offices SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 36 Bartlett.Street THE EXPIRATION DATE ,THEREOF,-:::NOTICE WILL BE DELIVERED IN Andover,MA0.1810 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE " ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD massac.husetts -Department of Public Safety Board of•5uildiri9 Regulations and Standards Construction Supervisor Specialty License: CSSL-099685 JAMES J DEBREV--�E z TANAGER WAY CONDONDERRY 'I 11A Expiration Commissioner 12/06/2015 _ �a��crc%«ealts' n ulation License or registration valid for individul use only Office of Louse n':r Affairs&BusinCTOR before the expiration date. If found return to: ME IMPROVEMENT CONTRA Type; Office of Consumer Affairs and Business Regulation egistration: 1223$5 DBA 10 Park Plaza-Suite 5170Xpiration 812612096. Boston,MA 02116 J&D WEATHERSEAL I= JAMES DEERECENT gQ 2 TANAGER WAY Undersecretary RY Not vali&w'ithout signature LONDONDERNH 1)3053