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HomeMy WebLinkAboutBuilding Permit # 11/9/2015 BUILDING I DING P®R ® IT O.1 FORTH 9 - 1 TOWN OF NORTH ANDOVER ? ham,"`- "' a` APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received C"TEowPPR" y S Date Issued: MPORTANT: Applicant must complete all items on this page Prm A° 1��`RCEL Z��NING�DIS�TF�I��T`� Hi or c ®is r c no f< ... .:� I .. ��,�r. r's`��; �r>;, ri,�`,✓rrc,� "�. t���� '��'�� -� ":. ". es` � � ,uf{X ,H',r;,.�,� �f r�..;;�� �,/x. ✓��` .J: �r'r�''�sJr�.r r>rl .,,C'r. rr r �a r,'',/';3,�r�,��'�"'�£` ���,�„^`�Nlachi�e�Sho VI I.a.. e" �' +s-" � . ..,,..."'a_.n.,Xf..r die.,._�.rm° ,,..._c,� .,..�..,.. ,,.����l.�Y:�.��b", arF�.,u.��n'.r'�,=8,rf ,t,..0 rrr?^',f',`„u.p, t,;,r„r,:r.,.n...,. � ;,„�.aa.P_sr,��„�,::�mc.•sa°`. �P'�:v/ � n�; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other rz r.,r x:. t,;: z ;. ®Se tic ui�WeIG mr 17F ood Iain DfllUetlands r pk p r ❑.1Nate shed Distract t, r r r: /. ,r :fx ❑Water/Se�ve1� � �.�i�M DESCRIPTIO OFg RK TO BEP RF M jaim dentification--Please Type or Print Clearly �. OWNER: Name d3 s - Phone Address: ,✓r° rr r, r f -i'r✓' r.a a'. ...c” "_r” ..,iM' n ,,,✓ �"`'s7 �/�`�r'3 �Ys�'j i� r "<t �f orf �' 'r%7i r c� �.f' ^' 7Y � t..r :t ✓i r n e -I �,1�� � :� :.r r3 r"" � �`d7� Y rr a t r'a'f l � b.k.: ., ,',, ;'� � ,,�i ,�+lt' "x/ jr j",A'�°.:x ;ri yr r �" Pr rz. ,rat ;�r � ,✓� k'4<,-„�r �` .,� �• -ur„�". j-. r�"�rr r'✓:.,urlf e!r � ?rz�;,.t .r��'. t'lu." J �''L✓" M r:r r", r ;.,m°` �r ,.e"r f"�e"r""�,�aLh t 7, F�`r c t U i^.�. rrr "�?r' .. >t r'✓r r- .�,' .t%.v:'1 r t .,r`�`N ,.. ,�Em'a.il. za •� ,��:� l,�:r�..,�,,.�:�r � ��;r,^ .. arr,,. F ... r X/. i � .��,,fa",„:Il�^� t�`r., '�r'�.0 ,�' r,s 'r'u✓is� ✓rF I � �'�. ,� ¢rcx r-zrv.��x � r d a '' , fir r c ar- . � r i�� ey ,.tf r,r�.v�✓r�� ,,`,�£'r`'� f J/f r t ��""�"' ,r �Supe• iso' Const�uct'o�L ce se', , Exp ®a e r ���r� � �,�, blr ,?E 3`r• �` � "� rWn i r `fir � e mpoue enf�Lieense r � .wr fi � Exp r r� + .a..mrnF�+r a„; rru f .xdu r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ r FEE: $_ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t e guar ty fund �r � P Signature ofi Age_nt/Owner; Signafiure,of contractor NORTH Town of ndover - ot Co LAK@ ver 9 �iwfs y COCKIC A0R�4TED BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT . ,, BUILDING INSPECTOR ..... . . .. ...... ..... . . .............................................. . Foundation has permission to erect .......................... buildings on =4....... ....... Rough Ooft tobe occupied as ........ .. ................. ...... .............. ....... ........................................................ Chimney provided that the person accept this permit shall in every respect nform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Lavas 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 Irm IS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION Rough Service .. ................... . ...... B ILDING INSPECTOR. .. Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Nota Final No Lathing r 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. 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 NComp ny Name 004 ; AI(/t Street,Addres s(do not u a Post Office address) Con alespers er Name_ . City,f Statue Zip Code Bu ness Address(mustincludea street address) Daytime Phone Esv`e�ening Phoney City/Town State Zip Code Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Home improvement C-"u 1 rReg.Number Erpirotion date Imp requlro Ihol mors home j{ .va11J reghtnlfon number > 99/��"s" 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 unless circumstances beyond the contractor's control arise (Owners who secure their o n permits will be , :> excluded from the GuarantyFund provisions of when contractor will begin contracted work. MGL chapter 142A.) s r— �V.� cs 1r` ate 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 q.., _(*) Payments will be made according to the following schedule: $ 0 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 $ 0 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. El' Express Warranty-Is an express warranty beine provided by the contractor? 11L No "1 Yes fall 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 888-283-3757. • 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. 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 homeowner.The other copy shout be kept by the contractor. eowner's Signature ..' Conti or's Signature Date Date AC401? ® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE11/03/2015 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 SUBROGATIQN 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). CONTAPRODUCER NAME: Carla M Degnan DEGNAN INSURANCE AGENCY, INC. PHONE , (978)688-4474 FAX No: E-MAIL ADDRESS: cdegnan@degnaninsurance.com de naninsurance.com 85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC# LAWRENCE MA 01843 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: JAMES DEBRECINI INSURER C: FAMILY ROOFING & PAINTING INSURER D: 2 TANAGER WAY INSURER E: LONDONDERRY NH 03053 INSURER F, COVERAGES CERTIFICATE NUMBER: 9749 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 I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE 0 OCCUR PREMISES Ea occurrence $ '.. MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY❑PRO ❑LOC PRODUCTS-COMP/OPAGG $ $ OTHER: OAUTOMOBILE LIABILITY Ea aaddentSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ '.. AUTOS NONOOWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- /� STATUTE ER AND EMPLOYERS'LIABILITY YIN ''. ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 OO,000 A OFFICER/MEMBER EXCLUDED? N/A NIA NIA AWC40070259002015A 05/11/2015 05/11/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims 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.mass.gov/lwd/workers-compensation/investigations/. 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 City of Methuen ACCORDANCE WITH THE POLICY PROVISIONS, Searles Building 41 Pleasant Street AUTHORIZEDREPRESENTATIVE Methuen MA 01844 Daniel M.Cro v ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massa.chusetts Department of IndustrialAceidents I Congress Street,Suite 100 Boston,M4 02114-2017 .y; www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legib Name (Business/Organization/Individual): l., !` Address:, City/State/Zip: /Q A Phone#: f� Are you an employer?Check the appropriate box: Type of project(1•equired): I.U.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 10 ❑Building addition 4.❑I am a homeowner and will be hiring 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.[]Plumbing repairs or additions 5. I am a general contractor and I have rethe sub-contractors listedon e attachedsee. ❑ hired thht 13. oofrepairs 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 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 and then hire 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 providing workers'compensation insurancefor my employees.'Below is the policy and job site information. j Insurance Company Name: Policy#or Self-ins.Lic.#: 7(1C/ i - w/expiration Date: Job Site Address: 6'��� !�� Com-✓' 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. I do hereby certify under thep an enalties ofperjury that the information provided above is true and correct. Si nature: c `� Date: ✓ --> Phone#: 6 `' Official use only. Do not ivrite 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#: IJ eC'- ClJiL//LO/IIOC',Cllf�Q/C,iG�C(JJCYC�C(JG�I.; `:11_office of Consumer Affairs&Business Regulation SOME IIMP, OVEMENT CONTRACTOR u' 6 egistration: 122385 Type: l xpiration: 8/26/2016 DBA J&D WEATHERSEAL = JAMES DEBRECENI 2 TANAGER WAY LONDONDERRY, NH 03053 _ Undersecretary x a�sac us`tts -veoa�rr�ent of P.aelic Sa"er . -`� boa ci at•3uiltis ig Regq'.atiems and S arlciards onit:rUc?iOn SuPer"*isor S�ceial�_ 96 85 �r � SSL-09_ _3„e..�e. C ; ifF i3 JAMES J 3DEBREG-ENI 2'TANAGER W AY ` jL0ND0NDERRY-NH 0 053 ; 12/06!2015 ��mmsssione'