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HomeMy WebLinkAboutBuilding Permit # 10/7/2015 0.1..[OORTH BUILDING PERMIT 6 TOWN OF NORTH ANDOVER 10 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Receiveday AC S U Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION AY Print P PROPERTY OWNER INOD, Ces r Print� 100 Year Structure yes no MAP —PARCEL: ZONING DISTRICT:_HistoricDistrict yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building ne family El Industrial 0 Addition 0 Two or more family ri Commercial fAlteration No. of units: 0 Repair, replacement El Assessory Bldg [I Others: El Demolition El Other ❑FloodplainElv,�rbtl6Ms `❑ Watershed District I's ED: VerccS Identification-_rleqse Type or Print Clearly Phone: OWNER: Name: arkel-i-A-161 Address: Contractor Name: "rMCelljli Phone'. Contractor rac to, LLEmatil: Address: Akddress: A20 Supervisor's u p r,/iso Exp. Date: upervisor's Construction License: A Exp. Date:. HomeImprovement Home Improvement License: ARCHITECT/ENGINEER Phone: Reg.eg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$I000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 5—C FEE: Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund , 7-7- AM F t%ORTHAL uo",kwn .An.0 V V1 0 No. 17 C, LAKE h y ♦ er, ass, /� / coc KIc MEWIcK �,9 A°Rgreo PPa,��(5 S U BOARD OF HEALTH FERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .........�'•:�•�J.���r.�.���'�C�'!'-.::. .............................................................. BUILDING INSPECTOR has permission to erect buildings on l-%/. C.1�. i: Foundation .......................... .................. .... ..... ........................ Rough to be occupied as ........................ �r �/.°��:.. oc�J� /69 ............................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LES I ATS Rough Service .................... ..G.. ........................................ Final BUILDING INSPECTOR 7� y GAS INSPECTOR Occupancy 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts x F Department of IndlustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legib Name (Business/Organizationlludividual): ,:�,'_f44 P.:7 Address: . Q lfl� Cf!' City/State/Zip: Lai&idelyYJ //. Phone#: �, `�✓ � `�f Are you an employer?Cheek theappropriate box: Type of project(required): l.[ATam a employerwith 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. 0 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.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 F1 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractlid thtth ors listed on e attached sheet, ❑ 13.beollof 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 e. 14.F1 Other 152,§1(4),and we have na 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-coniracfors fiave employees,they must provide their workers'comp.policy number. -tam an employes'that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. �� Insurance Company Name: � y f� ,✓� Policy#or Self-ins,Lic.#: (.�� `t`®� t�ayexpiration Date: Job Site Address: /(® 11CQ.5J'� � 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 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. Ido Iaereby c y under kerains andpenalties ofpejjury that the information provided above is true and correct. Si nature: Date: Phone#: R � Official use only. Do not write in this area,to be completed by city or town official.. City or Town: PermitfLicense# 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#: 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. Seek 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 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 Name Compan ame .01 Street Address(d not use a Post Office,ox add r ) Contractor/Salesperserr NN e t CityiTovm State Zip Code Business AddN41 16-a ress( ust include a street address) tL -T1 D ytime Pho a Evening Phone City/f0State .Zip Code _ "° �C d - Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Homelmp,o mContuM1Reg.Number Epirationdote Lawreq=that mast home - * i.,—en cunitacton have ) ,�. •valid regbtntian 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.) f F 7 e(Froj &d— J)' ' A eweolo 14 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.) J-0"�(s' 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: 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) $ 0 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 $ 6 to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ 40 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. r-g� Express Warranty-Is an express warranty being provided by the contractor? El No Q 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 617-973-8787 or 888-283-3752 • 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 contractors 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. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the hon1wriiNn The other copy should be kept by the contractor. .j AAV JA Homeowner's Signa re CoOtIrr" nature e Date Date DATE(MMIDDfYYYY) ,g,�'a►�®tr CERTIFICATE OF LIABILITY INBIJR IAC= 05/21/2015 TH�RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERSALTER RIGHTS THE UPON GE AFFORDEYHE BY HE POLIO EATE HOLDER. IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THF 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 cel tificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT NAME: PRODUCER 02025 001 - - H N (978)688-4474 FAX (978)327-6558 .No.: Degnan Insurance Agency Inc AMA.No.Ext: - EMAIL 85 Salem Street ADDRESS: Lawrence,MA 01843 SU ERS AFFORDMIG COVERAGE INSURER • Q.I.M.Mutual Insurance Gompany INSURED INSURER B: -. ----- --- James Debrecini INSUEER C ----- - Family Roofing & Painting 2 Tanager Way i SU E D Londonderry, NH 03053 INSURER E: - - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED NAMED ABOVE IICY PERIOD NDCATED. NOTWITHSTANDINGr THE POLICIES OF ANY REQUIREMENT, TERMNCE ORCONDIBELOT ONAOF ANY CONE BEEN UTRAC R ED TO OTHER DOCUMENT WITH RESPECT THE LL LTHEWHIT 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, — LIMITS ADDL SUBR POLICY NUMBER POLICY Wp POLICY EXP - ILTR TYPE OF INSURANCE INSR OD MMIDDIYYYY MMI DDIYYYY EACH OCCURRENCE $ GENERAL LIABILITY DAMAGETO RENTED $ PREMISES Ea occurrence COMMERCIAL GENERAL LIABILITY HIED EXP(Any one person) $ CLAIMS-MADE F-]OCCUR PERSONAL E ADV INJURY $ GEIIIERAL AGGREGATE $ PRODUCTS-COMPIOPAGG $ EN'L AGGREGATE LIMIT APPLIES PER: -- OLICY RO OC — 50NIBINED—SINGLE LIMIT $ ECT Ea accident AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ '.. ANY AUTO BODILY INJURY(Per accident) $ '.. ALL OWNED SCHEDULED '.... AUTOS. AUTOS PROPERTY DAMAGE $ NON-OWNED Per acci ent HIRED AUTOS AUTOS $ EACH OCCURRENCE $ ',.. UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS MADE Tq TH $ yypRKDEERD pry RETENTION $ X TORY LIMITS OR- AtN�lyp ERRROO�Y�ErR�SR��L�I SIILNQETRY E.L.EACH ACCIDENT $ 100,000.00 A OFFICER/MEM BEREXCLU%MECUTIVE y] NIA AWC-400-7025900-2015A 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 Vyes describe under DESG`RIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) The workers compensation policy does not provide coverage for James Debrecini CANCELLATION CERTIFICATE HOLDER 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,MA 01810 ACCORDANCE WITH THE PdLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board o$¢uildirig Regulations and Standards Construction Supervisor Specialty License: CSSL-099685 JAMES J DEBREV- Z TANAGER WArY CONDONDERRI�NIEt 95/..1 Expiration Commissioner 12/06/2015 r - -. — -- — ---- _--. , cra on �cec�uael�7`. uzau,0)r[ueaz o� utati License or registration.valid for individul use only office of Co1's"Iller Affair CONTACTOR before the expiration date. If found return to: ME i,�ri2OVu:MEN' - Type: Office of Consumer Affairs and Business Regulation_ egistration, 122385 DBA 10 Park Plaza-Suite 5170 Xpirabon: (317_612016 Boston,MA 02116 i• J:&D WEATHERSEAL JAMES DEBRECENi 2 TANAGER WAY Undersecretary RRY,Nhi 03053 Not validwvithout signature LONDO NDE