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HomeMy WebLinkAboutBuilding Permit # 12/8/2015 OO R YH BUILDING PERMIT ��OyED. 6p6�O TOWN OF NORTH ANDOVER ® ; APPLICATION FOR PLAN EXAMINATION Date ReceivedCRATED Permit No#: �SS•�cwu5� i Date Issued: IMPORTANT:Applicant must complete all items on this page /r is LOCATION Print PROPERTY OWNER LAE11 100 Year Structure yes no Print PARCEL: ZONING DISTRICT: Historic District yes no MAP _ Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building e family ❑ Industrial ❑Addition ❑Two or more family ❑ Commercial ❑Alteration No. of units: epair, replacement ElAssessory Bldg ❑ Others. ElDemolition ❑ Other r r Well ❑Floodplain' Wetlands ❑ Wate�rshedDistnct ❑'Sept�G �f� % ar., ❑-Wafer/Sewer., DESCRIPTION OF WORK TO BE PERFORMED: r ----------- dentification- Please Type or Print Clearly a _ Phone: OWNER: Name: Address: one: Contractor Name: Email: Address: Supervisor's Construction License: _Exp. Date:Exp. Date:;YHome Improvement License: r w � s ARCHITECT/ENGINEER Phone: Reg. No. Address: FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON 25.00 PER S.F. Total Project Cost: $ �' � FEE: $ _Receipt No.: Check No.: NOTE: Persons contacting with unregisteredcontractors do not have access to the guaranty fun _ _ V40RTH A'. A Town of ndover 0 0 1, No ® 94- 261 � 4 ,r ver, Mass, • • COC HIC"a_CK AS4-13'E® mor— BOARD OF HEALTH RM 1, 1. T LD Food/Kitchen Septic System P FM THIS CERTIFIES THAT .... ..... BUILDING INSPECTOR jr has permission to erect .... buildings n Foundation .... ... ...... .... ...... . . ..... . ........... ............ Rough to be occupied as ....... .....� ...... ...... ............ ........... .. ...... � .. Chimney provided that the person accepting this permit shall i very respect conform to the terms o e 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 kS . Final PERMITEXPIRESTHS ELECTRICAL INSPECTOR ® UNLESS TRough Service 000 ........ ...... ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display i sConspicuous lace o t e remises — o of Remove Final .. No Lathing or all ToBe one 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 Name r CompanyName Z l i 6'7!3 Street Address Ldo �n+ot use a Post}Office Box ddress) Contr /Salesperso Owner Name � tI K, k9b re Cityown State Zip Code Business Address(must include a street address � . d 4I Daytim Phone Ev mg Phone City min State Zip Code 7 - - - `; Mailing Address(It different from above) Business Phone I Federal Employer ID or 5.S.Number Home Imprmement Conlmdor Reg.Numlxr Expiration date ImpI.. rthat most home n-vema.lenlmmncton have �o .rad rcghlnnon numher �;I SOP, 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 contractoes control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of o 5 Date when contractor will begin contracted work. MGL chapter 142A.) -� f 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:` Zo (*) 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 $ 1d3 to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ dp 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. Express warranty-Is an express warranty beine provided by the contractor? ❑No`�"'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 hour par.The other copy should be kept by the contractor. e I f Ho owner' afore ony. ox's igna r Date Date The Commonwealth ofMassa chusetts Department of IndustrialAccidents d 1 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 Legibly Name (Business/Organization/Iudividual): wC�C-Cf' Address: r Z ,�y City/State/Zip: �? ' Phone#: Are you an employer?Check thea appropriate box: Type of project(required): 1.HI am a employer with - employees(full and/or part-time). 7. F1 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. F1 Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 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-contractors listed on the attached sheet. ❑ • These sub-contractors have employees and have workers'comp,insurance.$ 13. oof repairs 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. 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,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. Insurance CompanyName: Policy#or Self ins. Lie.#: 116-11t .--701,6-9)642 /; Expiration Date: f fob Site Address: /° City/State/Zip:, o�1C E 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c tify under the pins andpenaltles ofperjury that the information provided above is true and correct. Si nature: x Date: Phone#• f `s P`v =-57_,,9 Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i T ® DATE(MMIDDNYYY) A`IO® CERTIFICATE OF LIABILITY INSURANCE 11/03/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANOE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED.. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSUREQ,the policy(les)must be endorsed, If SUBROGATION IS WAIVED,subject tp 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 CONT Carla M Degnan DEGNAN INSURANCE AGENCY, INC. PHONE 978)688-4474 FAX No: &MAL -ADDRESS: cdegnan@degnaninsurance.com 85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC# LAWRENCE MA 01843 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER 8: JAMES DEBRECINI INSURER C: FAMILY ROOFING & PAINTING INSURER D: 2 TANAGER WAY wsURERE: 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. ADDL SUBR POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE POLICY NUMBER MMIDDI YYY MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMA E TO RENTED CLAIMS-MADE FIOCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 1 PRO- F-1LOC PRODUCTS-COMPIOPAGG $ JECT OTHER: AUTOMOBILE LIABILITY Ea accoidentSINGLE LIMIT $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ _ $ WORKERS COMPENSATION X STATUTE 10 RH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 OO,000 A OFFICERIMEMBEREXCLUDED? NIA NIA NIA AWC40070259002015A 05/11/2015 05/11/2016 E.L,DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes,describe under E.L,DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 -XCCORDANCE WITH THE POLICY PROVISIONS, City of Methuen Searles Building 41 Pleasant Street AUTHORIZED,,REPRESENTATIVE Methuen MA 01844 DaniM.. oey,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 Massachusetts Department of Public Safety ; t Board of Building Regulations and Standards License: CSSL-099685 Construction Supervisor Specialty JAMES J DEBRECENI 2 TANAGER WAY LONDONDERRY NH --M Expiration: Commissioner 12/06/2017 CJ Ile rpa� nrancue�cl�a �%lLa9Jcic�ccJe t Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration 122385 Type xpiration: 8(26418:; DBA J4 D WEATHERSEX-111 l a= JAMES-DEBRECENI;`� is 2 TANAGER WAY g�ase LONDONDERRY,NH 030 & .f Undersecretary