Loading...
HomeMy WebLinkAboutBuilding Permit # 12/21/2015 0.1 0ORT11 B6 UILDING PERMIT ,%.FD 16 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date ReceivedSS C S Date Issued: �4�PO�RTANT:Applicant must all items on this page LOCATION PROPERTY OWNER P T yes no Print 100 Year StructZure yes s 0 MAP PARCEL: ZONING DISTRICT: Historic District yes no P Village y s 0 Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building ef a�ryfi I y��� El Addition El Two or more family 0 Industrial 0 lteration No. of units: Ei Commercial El/Repair, replacement El Assessory Bldg 0 Others: El Demolition 11 Other a �fv Ile On LIP I G I "Ayffllygmelamom ,, Now"— DESCRIPTION OF WORK TO BE PERFORMED: Identifi ation Ple se Type or Print Clearly ' OWNER: Name: L-�4 t! 1 . Phone: Address:_ Contractor Name- Phone: 4V46 Contractor Address: Supervisor's Construction License: Exp, Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT:$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. =. Total Project Cost: $ 6-, j5KL_�FEE. $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu an fund OeL IAORTH Town of - ­: ® No. h ver, Mass, 2,- , O LAK! COC HIC HI WICM 1� oq Q \ S V BOARD OF HEALTH Food/Kitchen PERMIT TU LD Septic System THIS CERTIFIES THAT ......(....2.... .................. BUILDING INSPECTOR / ......................... Foundation has permission to erect .......................... buildings on .. 1..........fiv.......�.......... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final '6 _ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S-TOTS Rough V�D �j 14' -1 Service ................ .............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the 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 I-888-283-3757 or on our website. Homeowner Information Contractor Information Narrbe / Companame Street Address(do not use a Post Office Box address) CoMeW Salespe on/ a Name ) r City/Town State Zip Code Business Address(must melu e a street address) Daytime Phone Evening Phone Ci /Town tate Zip Code JV Mailing Address(It different from above) Business Phone I Federal Employer ID or S.S.Number - HomelmprocementContnctorReg.Numher Epintion date I.•w nqulm that mast home ,e E Im valid re hl contnc number have df'p�® i� .vclld btntlon numhcr e 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 r excluded from the Guaranty Fund provisions of / Date when contractor will begin contracted work. MGL chapter 142A.) B�J 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) $ by _/_/_ or upon completion of $ d 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 $ to be paid for ordered before the contracted work begins in order T 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. Express warranty-Is an express warranty beine Provided by the contractor? ❑No es fall terms of the warranty must be attached to the contractl 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!!! Ts ,do�ntwal cop s of the contract must be completed and signed.One copy should go to the homeotmer.The other copy t dd be kept by the contractor. owner's Signature Contr tor's Signatu e 4� 1�j Date Date The Commonwealth of Massachusetts Department of IndustrialAccidents - -d 1 Congress Street, Suite 100 Boston,M4.02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/OrganizationAndividual): t=• };� '� n Address: ® City/State/Zip: tod - Phone#: J Are you an employer?Check the appropriate box: Type of project(required): 1.Wam a employer with 3: employees(full and/or part-time).* 7. ❑New construction 2.F]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. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.F1 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 I L❑Electrical repairs Or additions proprietors with no employees. • 12.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.[�Jof 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.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submif 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. lam an employer that is pr oviding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: /7 Policy#or Self-ins,Lie. Expiration Date: Job Site Address: / /�+' �iCity/State/Zip: t 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 certify under thIlmVis andpenalties ofperjury that the information provided above is true andcorrect. •, j Si nature: l y Date: Phone Official use only. Do not write to 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#: ® ® Dec/23/2015 10:33:53 AM Degnan Insurance 973-327-6553 1/1 i® %E ® ® DATE(MMIDDIYYYY) %■A� CERTIFICATE OF LIABILITY INSURANCE 12/23/2015 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 thle certificate does not confer rights to the Certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Elizabeth Chavez NAME: DEGNAN INSURANCE AGENCY, INC. PHONNo E 978 688-4474 a Nn: MAIL echavez de nanlnsurance.com E ADDRSS: 85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC0 LAWRENCE MA 01843 INBURERA: AIM MUTUAL INS CO 33758 INSURED INSURER 13: JAMES DEBRECINI IN@URERC: FAMILY ROOFING I& PAINTING INBURER0: 2 TANAGER WAY INSURER E: LONDONDERRY NH 03053 INSURER F: COVERAGES CERTIFICATE NUMBER: 20172 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICYEXP LIMITS LTR POLICYNUMBER MMID❑ MWOD COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR PREMISES Ea occurrenre $ MED EXP(Aoy ane ersan) $ NIA PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 71 PROJECT- F-1LOC PRODUCTS-COMPIOPAGG $ OTHER: �' '... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS (Per arridrnl $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKEROCOMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPRONHIbl OHIPAHIN�H16x CL111V6 YIN E.L.EACH ACCIDENT $ 100,000 ''.. A OFHCh6B HIMMtH�XCLDDI=D9 N/A NIA NIA AWC40070259002015A 05/11/2015 05/1112010 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 140,000 It yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 NIA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sahedula,may ha attaahod If mora spaaa Is roqulrod) Workere'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B;no authorization is given to pay ejaims for benefits to employees in states other than Massachusetts if the insured hires,or hes hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the data 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.mase.govtlWdtworkerecompenastonfnvestigationa/. 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 TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET BUILDING 20 SUITE 2035 AUTHORIZED REPRES ENTATNE NORTH ANDOVER MA 01845 �D_'j Daniel M,Cr y,CPCU,Vice President—Residual Market—WCRIBMA (�)1968-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ® • Dec/23/2015 10:24:57 AM Degnan Insurance 978-327-6558 1/1 DATE 1MrWVDDM'YYI COREY CERTIFICATE OF LIABILITY INSURANCE 12/23/2015 HIS 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(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone; 878-588-4474 Fax: 970.327.8558 CONTACT DEGNAN INSURANCE AGENCY NAME: DEGNAN INSURANCE AGENCY PHONE BTB-688474 IFAx 978-327.6558 85 SALEM STREET E4 Nn P.I) roc.Not EDDR cde nan de naninsurance.com LAWRENCE MA 01945 AOORE89: g � g INSURER($) AFFORDING COVERAGE NAIL 9 INSURERA : NORTHLAND INSURANCE COMPANY INSURED DEBRECENI,JAMES D!B/A FAMILY ROOFING AND PAINTING '"SURER s 2 TANAGER WAY INSURER c ; LONDONDERRY NH 03053 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25820 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 TYPE OF INSURANCE ADD SUER poll"Billy POLICY 11X► LIMITS LTR INPOLICY NUMBER A GENERAL LIABILITY WS230277 03/06/16 03/06/16 EACH OCCURRENCE S 600,000 '.. DAMAGETO RENTED $ 100�Opp COMMERCIAL GENERAL LIABILITY PREMISES(Ea daDwendel CLAIMS-MADE F1 OCCUR MED.EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 600,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 '.. POLICY PECTRO- LOC S J AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea aDDIdelttl $ ANY AUTO BODILY INJURY(Per pereon) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per eCCldenrf $ HIRED AUTOS RNON,OWNED PROPERTY DAMAGE S AUTOS (Der aocldenq $ UMBRELLA LIA& OCCUR EACH OCCURRENCE $ IXCI$$ LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION S $ STATU- 7 WORKERS COMPENSATION WC AND EMPLOYERS' LIABILITY TORY LIMITS ER $ ANY PROF RISTORMARTNIA11XlCUTIVIf YIN E.L.EACH ACCIDENT $ OFFICER/NIEMBER EXCLUDED? NIA E.L.DISEASE-EA EMPLOYEE (tdrindatoryinNl) $ If yea,describe under DESCRIPTION OF OPERATIONS bol.w E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schvduly,if more apace is roquirvd) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD STREET BUILDING 20 SUITE 2036 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MAO 1845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: Elizabeth J. Chavez ACORD 26(2010/06) ©1889.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-099685 Construction Supervisor Specialty JAMES J DEBRECENI 2 TANAGER WAY LONDONDERRY NH 03053 - �n ` a (� l� Expiration: Commissioner 12/06/2017 Ufze pay inzancaeczll�a1C�tajj cXW41 J? Office of Consumer Affairs&Business Regulation jrME IMPROVEMENT CONTRACTOR gistration: 12385 Type: piration 8!267201$,, DBA J4 D WEATHERSEAL ; - �_ JAMES DEBRECENI' \ s 2 TANAGER WAY LONDONDERRY,NH 030513 - ` j f Undersecretary