HomeMy WebLinkAboutBuilding Permit # 4/20/2016 ,t%ORTH 1 16 BUILDING PERMIT " I !1. 6 ,rOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Date Received Are Permit No#: CH Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION not PROPERTY OWNER L01i 11 11 yes no PO t 100 Year Structure PARCEL: ZONING DISTRICTMachineShop MAP :— Village yes. no . TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential 0 New Building El One family El Two or more family 11 Industrial El Addition ❑ Na. of units: Ei Commercial TYPE El Assessor Bldg n Others: El Repair, replacement El Demolition 0 Other DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly— Phone: OWNER: Name: Address: 7 to Phone: Contractor Name: 6c�61A k_, 0 Email: Contractor Email:il a r Address: Supervisor up r� Exp. Date: Supervisor's Construction License: S Horne % Exp. Date: Ida, 17 ---Jl ome Improvement License: ARCH ITECT/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: $ FEE: Receipt No.: Check No.: 3 3S"c ," NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund 77%7-7�- gLu PVT g p f F,q CD Roofing Vincent Colongelo Flocig son St, Tevv6bury, Mo 01876 978-656-8497 vincertfcolrangelo@siac:globLi ,nest 1 1-11C Llc# 170575 CSSL laic# 10594:3 �° >� 4A 51 � .. .m OVENS CORNING Customer: F . wudM, .1PREFERRED CONTRACTOR A),. ,/ v �v. - Description of work Performed: (%Obtain required town permits provide certificates of insurance workers compensation Provide Cumpster set on planks*for contractors use only (materials all recycled) (Attach E arge'Tarps to protect adjacent finishes, landscaping, and property, Strip-off( )existing layers of roofing on complete house& re-nail any loose decking Install £finch '—Aluminum Drip edging I Owens Corning Starter Shingles Install Owens Corning Ice&Water shield Sft at eaves, aft in valleys, around all penetrations (y Install Synthetic felt paper to entire roof (A install Owens Corning LifeTime warranty Trul efinition Duration shingles Install new neoprene vent pipe flashings on all plumbing pipes ( Install Owens Corning VentSure ridge venting with moisture guard Install Owens Corning ProEdge hip& ridge cap shingles Completely re-flash chimney with lead � _warranty Cad a " Owens Corning Preferred contractor installation with full & All work will be completed according to state and manufacturing codes and specifications. Every day we will have the roof mater tight,clean gutter's, completely clean the job site, and use a magnet roller to collect scattered nails. Additional work to be performed /14 All material is guaranteed to he as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or,deviation from the above specifications must be made in writing on an Add-on/Modification of contract form arid may become an extra charge over arid above the amount stated herein. This agreement is contingent upon delays beyond our control.Owners to carry fire,tomado and other necessary insurance.Our workers are fully covered by worker's Compensation Insurance. Homeowner agrees to pay for all work as set forth below. If the homeowner defaults, homeowner agrees to pay all costs of collection, including reasonable attorneys fees,in addition to other darnages incurred by contractor.pull Payment is due upon completion of work. We trropose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of:_ dollars ($ f� Said amount shall be paid as follows: � � �(JC,,()" ) ��M1 Note:This proposal maybe withdrawn by us if not accepted within days. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS CLAY AFTER THE CRATE OF THIS TRANSACTION. SSE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION of THIS RICHT. THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SAFES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEGOTIABLE. Work will not begin until your right to cancel has expired and,yera"hav a�ic'/a d posit of dollars ($ ), unless this agreement proyfd"es other iso:'" Signature of Contractor or authorized representative:_ - _.- -------��� *(IMe)have read the terms stated herein,tlt y hame been explained to( ru/us),and (I/We)find therm to be satisfactory and hereby accept thorn. , �w%fix„ ... °+ K 1%wr _T��2... Signature of Horneowner(s):- The Commonwealth of Massachusetts F Department of IndustrialAceidents u X Congress Street,Suite 100 a ,BostonMA.02114-2017 M . www Mass.goh/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. , Applicant Information Please Print Le 'bI Name(Business/Organization/Individual): 'L® Address: ( 5 City/State/Zip: t 144 �Ihone#: c7 70- S`(, -- it Cj -7 Are you an employer?Check the appropriate box: Type of project()required): l.]I am a employer with employees(full and/or part-time).* 7. Q New construction 2.]I am a sole proprietor or partnership and have no employees working for me in 8• E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.-insurance required.]4 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 I L❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.P<!.am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ Other 152,§1(4),and we have naemployees.[No workers'comp.insurance requited.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i homeowners who subniif this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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-cori`traciors fiave employees,•they must provide their workeis'comp.policy number. rain an employer Mat is providing-worlies'compensation insurance for my employees.'Below is thepolley andjob site information. , Js Insurance Company Name: '' --'k,10 — ExpirationDate: >/'/k',//7 Policy#or Self-ins,Lic.#: �C�G Cha"-� fob Site Address: j _® r City/State/Zip: Attach a copy of the workers'comp nsati n 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 DTA for insurance coverage verificration I do he eh Ice -y u �eithepains andpenalties ofpeijufy that the informationprovided above is true and correct. Si nature: Date: c , G Phone#: -7 n 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#: C ® CERTIFICATE LIABILITY 1 DATE(MM/DL7/YYYY) 4/13/16 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), AU`rHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policypes) 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 CONTACT NAME: Angela WeSten. Insurance Agency PHONE FAX 978 735-4095 (978) 735-4094 No ) 557 Cenral Street E-MAIL ADDRESS: angela@aWest:en.COTR Lowell, MA 01852 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A:ATLANTIC CASUALTY INSURANCE CO INSURED INSURER B;HARTFORD UNDERWRITERS INS COMP F 0 CONSTRUCTION CORPORATION INSURER C: 4 ASTOR ST AP. 4A INSURER D; LOWELL, MA 01852 INSURER E: 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE p POLICY NUMBER MNDN MMNWlYYYY LIMITS A GENERAL LIABILITY L021008696-2 3/18/16 3/18/17 EACH OCCURRENCE $ 1,000,000 DAMAX COERCIAL GENERAL LIABILITY PR_ MMISE !.occurrence) ccENTrr EA!. ccu a ce $ 100,000 CLAIMS-MADE F-I OCCUR MED EXP(Ary one person) $ 5 000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINEDDSINGLELIMIT $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eraccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 2E112068-16 3/30/16 3/30/17 WC STATU- OTA- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOWPARTNER/EXECUTNE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD101,Additional RenarksSchedule,ifmore space isregdred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CD ROOFING ACCORDANCE WITH THE POLICY PROVISIONS. VINCENT COLANGELO 3 HODGSON ST AUTHORIZED REPRESENTATIVE TEWKSBURRY, MA 01876 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACO RD Phone: (978) 656-8497 Fax: E-Mail: VINCENTCOLANGELO@SBCGLOBAL.NET �ite (poo��raaozcae�clt�o�U<��cJd�ccic[Je� Office of Consumer Affairs&Business Regulation . ME IMPROVEMENT CONTRACTOR 170575 Type: q,Zglstratlon: Expiration: 11/10/2017 DBA CD ROOFING VINCENT COLANGELO 3 HODGSON ST '...>c,..:='_' •«:_ TEWKSBURY, MA 01876 Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-105943 Construction Supervisor Specialty VINCENT COLANGELO 3 HODGSON STREET TEWKSBURY MA 01876 Expiration: I Commissioner 03/09/2018