HomeMy WebLinkAboutBuilding Permit # 11/9/2015 i
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BUILDING PERMIT
TOWN OF NORTH ANDOVER ;'
APPLICATION FOR PLAN EXAMINATION x. _
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Permit No#: - Date Received A�Rgreu `�
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Date Issued: 7 i IA
IMPORTANT: Applicant must complete all items on this page
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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
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DESC IPTION WORK TO BE PERFORMED:
Identification- lease Type or Print Clearly
OWNER: Name: °ln� Phone:W � 'v
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Address: gy
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
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Total Project Cost: $ C FEE: $
Check No.: Receipt No.:
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NOTE: Persons contracting with unregistered contractors Flo not have access to the guaranty fund
iSignatureof Agent/Owner ::� ',` : `Signature of_contractor,
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vtORT H
Town of
Andover
177"
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o"- , a ver, M SSy I �d (� 0113
COCMIC" WICK
RAO 11 bi\I-
�ArED r� 5
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BOARD OF HEALTH
Food/Kitchen
PERMI LD Septic System
THIS CERTIFIES THAT ...M BUILDING INSPECTOR
.... . ............ :�.. ........................................................................
has permission to erect .......................... buildings on ...����.......... t�®A ...�3. ............................. Foundation
Rough
to be occupied as ......... ����® ............................................................. 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
Rough
VIOLATION of the Zoning or Building Regulations voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI S TS Rough
Service
....................... ........................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
CCupancV Permit Required to Occupy Buildin Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathingor Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
M = X Congress Street, Suite 100
Boston,MA 02114-2017
:�;��` www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual): dht� I i�
Address:
City/State/Zip: to ..�mdekll , Phone#: 7 t 37-J l
Are you an employer?Check the appropriate box: Type of project(required):
1.®I am a employer with employees(full and/or part-time).* 7. Q New construction
2.rJ 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. ❑Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Building addition
4.F]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.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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.
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,ibey must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Beloty is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 7�� `� 1 � xpiration Date: J
Job Site Address: /, 7 - 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 Hereby cera gander the andpenalties ofpetjuty that the information provided above is true and correct.
3y d Date:
Signature:
Phone# `m-
Official use only. Do not u rite 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#:
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
St (do not use a Post® ice ddr-ms) Con Salespe on/Owner Na e - r
�`j p
CityiTown _ §State - Zip Code Business Address(must include astreet address)A
Vol
Daytin�Phone Evening Phone City/rown State Zip Code
7 9q _� 1 , J.
Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number
Home improvement Contractor Reg.Number Epimlion Into
Law racial-that mwt home
Improvement ao npjSY5 ,�1,/
.lid registration numberumher
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 own permits will be
excluded from the Guaranty Fund provisions of 004&when contractor will begin contracted work.
MGL chapter 142A.) �p p,
!Pw 1 when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perforin the work,furnish the material and labor specified above for the total sum of: ) (*)
Payments will be}made according to the following schedule:
$ (6pon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater)
6'
$ by _/ /_or upon completion of
$ 0 by / / or upon completion of
$ �L� 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 $ 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 meephe completion schedule.
Express Warranty-Is an express warranty being provided`1iv the contractor? ❑No Wyes(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,die
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 copLAWdbo,kept by the contractor.
t
bme 'er' ,ignature Cw
Vector's Signature
Date Date
DATE(MMIDD/YYYY)
ACC?RL? CERTIFICATE OF LIABILITY INSURANCE
11/03/2015
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 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 CONTANAME:CT Carla M Degnan
DEGNAN INSURANCE AGENCY, INC. PHONE (978)688-4474 NC No:
ADDRESS: cdegnan@degnaninsurance.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 ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DDIYYYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DA AGE 7NTED CLAIMS-MADE 1:1 OCCUR PREM M SES aE
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/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS
I L $
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $ '..
WORKERS COMPENSATION X STATUTE EORH
AND EMPLOYERS'LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000
A OFFICEWMEMBEREXCLUDED9 I N/A N/A NIA AWC40070259002015A 05/11/2015 05/11/2016
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500.000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/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 AUTHORIZED REPRESENTATIVE
Methuen MA 01844 Daniel M.C
y,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
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C��cor e-rirorr,crreccll�aC `�c ac�ccae//r`-
a`�°� Office of Consumer Affairs&Business Regulation
SOME iMr�20VEMENT CONTRACTOR
egistration: 122385 Type:
Xpiration: 8126/2016 DBA
J&D WEATHERSEAL. `
R- JAMES DEBRECEN[
2 TANAGER WAY
LONDONDERRY,NH 03053 - Undersecretary
:vIassac usetts
_ueoart ert or Public Sa;et;
3o rd't.5ulld ng Regulations and Standards
Constr,c Supervisor specialtti �
_;cense: CSSL-099685
�AIVIES J 1)EBREC—ENI
2 TANAGER W AY ,
cLONDONDERRY NH 0 053
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12/06/2015
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