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HomeMy WebLinkAboutBuilding Permit # 12/11/2015 r - � & tkoRTH q BUILDINGPERMIT\MiT o A'L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: / Date Received �y ADgg7ED PPp icy SsacHus`` Date Issued: 411ORTANT:Applicant must complete all items on this page LOCATION -J " Print - PROPERTY OWNER % { - l L �- _ Print 100 Year Structure yes no MAP �l PARCELAO ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ane family ❑Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other P ❑ Se'`tic Well r .❑SFlood lain ❑Wetlands r3 ❑f 1/1/ate'rsFied D°;stnct� � f �/1��'..??; 17.F,. p s -rrf ✓""f -y,.n` - 4,s.. ,,.,.. r- `may - ` %"` . y:. �rr®�Water/5ewer�,�� , �,,�= .M DESCRIPTION OF WORK TO BE PERFORMED: dam:U'G �-C�s `•{ —41e fifie tion- Please Type or Print Clearly OWNER: Name: 4, - Phone: �'� 23 Address: ` E Contractor Name: yl��' ��a kj-,�Phone: Email: N Address _` � %'� , � Supervisor's Construction License: �' Exp. Date Home Improvement License: ._ ,; Exp. Date: zz ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PER [T.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: t Receipt No.: l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 4 44 re Siqhatb I 'Town oft%ORT EAndover ® �� .�•. + zh ver, Mass,, O "'"I COCKICK[WICK �� �RA7E0 PIVD S u BOARD OF HEALTH Food/Kitchen i7ERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .............. ....... ......... .. ...... . ............................................ has permission to erect buildings Foundation p .......................... .... ... ... .... .... .. . .. .......... AMk Rough tobe occupied as ....... ..... .. ...... .......................... ........ ... ..... .. ...®................. chimney provided that the person accepting this permit shall in eve spect 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 THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO Rough Service ................... .. !YN .... ................... Fina NG INSPECTOR 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA. 02114-2017 www mass.gov1dia ,,. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information l Please Print Lep-rib Name(Business/Organization/Individual): %� —, • ZZ6rv' /Y� "1 S Address: ��.a� , ,� d 6 City/State/Zip: /7` �l/l f ° one#: �` 137 A7eyomen employer?Checkflie appropriate box: Type of project(required): 1. m 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. Demolition 3.Q 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.FJ Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.PJI Oof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ Other oyees.[No workers'comp.insurance required.] 152,§1(4),and we have na empl *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi 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 employ ees,ley 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 1 'V, Insurance Company Name: / ` / G/��/4_/, J N-S `2 Policy#or Self-ins.Lie.#: -le 1414,W-d /rZ6)d Expiration Date: q7 ( �/j/ ,� City/State/Zip: � � Job Site Address: 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 cer tify�nder t�e pains andpenalties ofperjury that the information provided above is true and correct / ��-�fG"Z��. L'��" / Signature Date: /� / Phone#. 7k ­&'Z3 _7 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 Ifealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Page# of pages CS # 022680 IV V 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 159A Waverly Road 1-978-912-2853 North Andover, MA 01845 Proposal SubmittedTp: Job Nam Job# Address 4 i Job tion Date Date of Plans Phone# ax# Architect We hereby submit specifications and estimates for: c 61 We propose hereby to furnish material and labor—complete in accordance with the above specifications fort a sum of: Dollars with payments to bade as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only*upon written order, and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our cohtrol. Note—this proposal may be withdrawn by us if not accepted within days. acceptance at,propwaY The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. a Date of Acceptance Signature MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satisfies all basic requirements of the state's Home Improvement Contractor Law(N!PjL chapter 142A),but does not lnclude sfandaid language to protect homeowners. Seek legal advice if necessary, Any petsonplanning home"' e �tnprovemorrts should fiisE bbfain a Copy of a Massachusetts:consumer guide to home improvement'before agreeing to any work on yourresidenco:You may obtain a free copy by'calling the ' Office of Consumer Affairs and Business Regulation's Consumer Information Hotline att617-973'x8787 or 1:888.283-375.7: Homeowner Information Contractor Information am e _ Company eine.. Street Address(do not use aPost Office Bak address) ntrodor/S91esp7,o V Owner Nemo City/Town StatsCo/19 de usmess Address(must include a street address) . 1) _ Zip CbX194- /c)�Av1-am'/4 ,c. �d Daytime Phone EveningPhoue ity/Town State ZlpCodb r c� 6- - , ✓eJ iVQ L'' i =S S° �'. Mailing Address(It different from above) Business Phone ederal Employer ID or S.S.Number Lr e"*.Q.1 a toll Lome ie� RainebKpovanot Cmmetor Rea:Nmber I Err4soao4aw Pmvmm wetMas hew s The Contractor agreu to do the following work for•the Homeowner:- ' ���� l��'��'✓Cdr/�� � �/ Jf�'�� ;�/r'��L,Z,' C�.��ye C� �/L� Required Perurits-The following building permits aro required Proposed Start and Completlon Schedule-The filloviing scberlule will and will be secured by the contractor as the homeowner's agent; be adhered to'unles.circumstances beyond the contractor's control arise (Owners whti.secure their own permits will he excluded from the Guaranty Fti id:provisions of Date when contractorwill begin contracted work. MGL chapter 142A.) , to V O ` Date when contracted .work will be substantially completed. Total Contract Price sntl PaymentSchedule The Contractor.agrees to perform the'work,famish the material and labor specified above for the total sum of. 4-10 UU• (+) rayments will be made according to the folio ' schedule. ��/ $�� � U pop signing ontracC(notfo ekceed 1/3 o�fRhe total:6ontfacprice of the cost of special order items,whichever is greater) S by_�-f=t_ orupon completion of S_ by or upon completion of 't1 L d S600, 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 S to be paid for ordered before the'contracted'work begins in order S to be Paid for �.. . to meet the completion achedule.(a*) NOTES;(e)laclpding all finance charges(•-)Law requires that any deposit or down•Paymant required by the contractor before work begins may not exceed Ore gresterof(a)one-third of the tow contract price or(b)the ac wl con of any special.equlpment or costom made material which must be Special ordered in advance to meet the completion schedule. Express warranty-Is an axvress.warrsaty beine provided by the ron(�}edor! No Yet (at.r tet. ''- tp the contraell Subcontractors-The contractor agrees to be solely responsible for completion of the work deacnbed regerdlus of fire actions`ofany tfifrd party/subcontractor utilized by the contractor. The contractor fiuther agrees to be solely responsible for all payments to all subcontractors-foi materials and labor under this aereement Contract Acceptance-Upon signing,this document becomes a binding contract underiaw. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interesNas been placed on the residence. Review the following cautions and notices carefWly before signing this contract • Donn be pressured into sighing the contract.Take time to mad end fully understand it.-Ask'questioris ifsora'th�is Unclear. e Make sure the contractor has a valid Home Improvement Contractor R asstrm6gy The(sit;requires most home improvement contractors and. subcontractors to be registered with the Director ofHome Improvement Contract&Registration. You may inquire about.contmator registration by writing to the DirectoratOnc Ashburton Place,Room 1301;Boston,MA 02108 orby calling 617.727-3200 or . 1-800,223.0933. • Does the contractor have insurance? Check to sea that your contractor is properly insured e Know your rights and responsibilities. Read the important Information on the r'Veraeside of this foim'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 otherthan the contraetdr'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 then midnight ofthe. thiid business day following the signing of this agreement See theattached notice o£caneellation form fbr an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPA Sill " Two ideadrai copies oftheeopnactmwdbeeoeopretedand stood One copy aboWdaotothe bonvownee.The other mpysbmWbekept bythe oonumor. / DWROf'a.Signature Contractor's Signature -7/q hol.) Data Hata ' Ac ��® IFI LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/12/2015 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 00775-001 NRAJACT Durso&Jankowski Insurance Agency Inc PA/C.No.Ext: (978)682-5175 FA/C.No.: (978)794-0313 198 Mass Ave Suite 101 B Fb�S�Ess: North Andover,MA 01845 ER(S)AFFORDING COVERAGE i INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED -INSURERB Arthur Walsh A J Walsh & Sons INSURER 55 Pleasant Street North Andover, MA 01845 INSURER NSURER INSURER F COVERAGES CERTIFICATE NUMBER: 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, �gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED CCyyB��Y��pPAID ppCLAIMS. IN TYPE OF INSURANCE OO k SBS POLICY NUMBER MMI�D/YYYY MMI�D/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S E ISE aoccurrence) CLAIMS-MADE F—]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ ENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S OLICY r RCj OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ as i e ANY AUTO BODILY INJURY(Per person) S , ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( ) HIRED AUTOS NOWOWNED PROPERTY DAMAGE AUTOS Per accid nt S $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS MADE AGGREGATE $ y�oRKKOEDgg pp RETENTION $ yy g U 7H $ AND EMPLOCilEWtIAaILITY X TORY LIMITS OER A Y P AR E EXECUTIVE� E.L.EACH ACCIDENT $ 100,000,00 A o�Flc�tl r �a�� �xcl�DWD� I ' I N/A AWC-400-7014648-2014A 11/14/201f 11/14/201 (Mandatory in NH) E.L.DISEASE.EA EMPLOYEE S 100,000.00 6�9sCRIi VT A WF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000.00 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) '.. The workers compensation policy does not provide coverage for Arthur J Walsh CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i Massachusetts '7epartnient or Bo and of Building Hcgulatior,s U ;fl ' t.ds ColMruction Supers icor License: CS-022680 s ARTHUR J WALSA JR ;- 159A WAVERLY RD N ANDOVER MM 01845 oSi'21expiration Commissioner 06/09/2016 Oftce of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR eglstration: 103358 Type: expiration: 7/7/2016 Private Corporatio. A.J.WALSH&SONS,INC. Arthur Walsh 55 Pleasant St N Andover,MA 01845 Undersecretary