HomeMy WebLinkAboutBuilding Permit # 6/28/2016 BUILDING PERMIT ®� tLORT6y 6
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TOWN OF ORT ANDOVER `46
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
ss�ca+us�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION '
not
PROPERTY OWNER` S C6`1Z
/� Print 100 Year Structure yesOno
MAP PARCEL: 61 ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ane family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
-ug,g" a"',
epi elU f; Flood Iam � QlWetlantls, Wa ershed.D,stncfi
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: �(n�r �/t ��' Phone:
Email: Ah,
Address:
Supervisor's Construction License: -Exp. Date: 1 Z
Home Improvement License: S Exp. Date:
ARCHITECT/ENGINEER _ Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ S ° r �' ° FEE: $ 4�
Check No.: -0 Receipt No.:
NOTE: Persons contracting with unre 'stered contractors do not have access to the guaranty fund
{ --
FttORTH
Town ofe
ndover
�,.
";'' 0%
C%o LAKE
ver, ass,
COC N'CNEw'Ca
�AO
U BOARD OF HEALTH
Food/Kitchen
P T LD Septic System
THIS CERTIFIES THATC BUILDING INSPECTOR
................. ..... ....... . ...... ................................................................
has permission to erect ...... bu' dings on ,,.... .... Foundation
........... ........ .... .......................... . ............
re raq)C
. Rough
tobe 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS Rough
Service
.... .. .. ........ ..... ...... ......... Final
B L INSP CTOR
GAS INSPECTOR
cc acv Permit Required t® Occupy Building Rough
Displayin a Conspicuous Place on the Premises — Do Not RemoveFinal
No Lathing Or Dry Wall ToBe One FIRE DEPARTMENT
ntilInspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
A
LL UMIMEIW
Chimneys Residential & Commercial Roofing All Types Of
SidingCHIMNEYS POINTED-REBUILT-CAPPED 9p
- Expert Masonry Work
Mass Toll Free '� �a Leaks Experts ] Licensed& Insured
1-800-WAIT-4-US ® Loca//y Owned& Operated Sirce 1976 ;'q p License#034200
(924-8487) IKO azee woz n or We Work Year Round
. _
Proposal To: Scott Cooke Date $6/13/2016
Street: 61 Forest St. scookesk8@aol.com
N. Andover, MA
Roof proposal 781-710-6880
Certainteed Landmark
1. Extra caution will be taken to protect house and 12. Removal of all work related debris. Planks will be
landscaping as best as possible. (tarps etc.) placed under dumpster to prevent any damage to
Magnets run at final clean up. driveway.
2. Remove all shingles from entire house. 13. Building permit included.
3. Inspect and re-nail any loose or lifted plywood. 14.Contractor workmanship warranty: 10 years under
Any compromised plywood will be replaced at an normal wind and rain conditions.
additional cost of$70.00 per sheet of 1/2" CDX.
4. Install heavy gauge 8" aluminum drip edge to all Total roof cost: $ 7,500.00
eaves and rakes. White,brown or mill finish
5. Install 6' of Certainteed Winter Guard ice and
water shield along all eaves. Certainteed 3Star extended direct MFG warranty
v 6. Install Diamond Deck synthetic underlayment to A fully transferable 100% coverage against
J remaining sheathing up to ridge. material defects for a fully non pro rated period of
7. Install all new pipe boots. 20 years. Please refer to pamphlet left in estimate
8. Install Certainteed Swift Start starter shingles to folder. Offered to our local referrals and included
all eaves. in this proposal at no additional cost.
9. Install Certainteed Landmark Limited Lifetime
architectural shingles to entire house. 10 year Balance due upon completion
material MFG. warranty. (See extended warranty)
All shingles will be installed and fastened References available upon request
according to mfg. specs.
10. Cut and install new GAF Cobra ridge vent and cap Highly rated member of the accredited BBB and
with color matched Certainteed Shadow hip and Ancie's List
ridge shingles. (MA code)
11. Counter flash existing chimney flashing and all Thank you!
roof protrusions with ice and water shield, tie into
new shingles and seal with clear Geo-Cel sealant.
L �2
Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and are herby
accepted. You are authorized to do the work as specifi d. Payment w4ill ' de as outlined above.
Date of Acceptance: Signatur
The Commonwealth of Massachusetts
f Department of IndiustriadAecidents
Mi -:• : /d I Congress Street,Suite 100
Boston,AM 02114-2 017
www.mass.gow/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY. .
Annlicant Information Please Print Legibly
Name(Business/Organization/.Cridividnal): (f,�11;7<4 Oki< Y-),z6 V
Address:
City/State/Zip: yw✓l
ITh e r'( GMfrJJ Phone#:
Are you an employer?Check&e appropriate box: Type of project()required):
L❑Tama employer with employees(full and/or part-time).'` 7. 0 New construction
2. 1 am a sole proprietor or partnership and have no employees working for me in 8. Remo delirig
any capacity.[No workers'comp.insurance required.]
3.F]I am a homeowner doing all work myself.[No workers'comp.-insurance required.]f
9. El Demolition
10 []Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.C1 Electrical repairs or additions
proprietors withno employees. $
12.[J Plumbing repairs or additions
5.�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.t 13.[�Roof repairs
6.E]We area corporation and ifs officers have exercised their right of exemption per MGL a 14.4a Other If's`/1
152,§1(4),and we have ncl 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 subniif this affidavit indicating they are doing all work and then hire outside contractors iAust submit anew affidavit indicating such.
#Contractors 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-coritracfors fiave employees,they must provide their workeis'comp.policy number.
Iain an employer that is pioviding workefs'compensation insurance for my employees.'Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lic.#: Expiration Date:
Job Site Address:_.l2 �'�� j/ City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration(late).
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 DLA for insurance
coverage verification.
I do hereby certlJy under th, gins andpenalties ofpe�jury that the information provided a/_hove/is true and correct.
Signature: Date:
Phone#
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/'I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone##:
WORKERS COMPENSATION AND EMPLOYf RS LIABILITY INSURANCE POLICY
iNFORMATION PAGE
AJ-M. Mutual Incural ce Company
64 Third Avenue, Burlington, Ma ssachusetts 01803.0970
(800)876-2 rGS NCCI NO 26158
POLICY NO. C-400-700!
.1
PRIOR N0, !WC-400.70094t34.2014A
ITEM
1, Tho Insured; Ail under One Root
DBA;
Melling address; e!O John Lon:tafame FEIN:+=*••8261
Methuen,eMA 01844
Legal Entity Type; Sole Proprietor
Other workplaces not shown above; see Location
2. The policy period is from i 1!09/20 5 to 11/0912b16. 12;01 cm,standard time at the Insured's mailing address.
3. A. Workers Compensation Insurance;Part One of the policy i pplios to the Workers Compensation Law of the
states listed here.: MA
S. Employers'Liability Insurance;Part TWO of the policy applies to work in each state listed in Item 3.A.
The limits or Irablilty under Part Two are; Bodlly Injun by Accident S 100 000 each accident
Oodlly Inju by 01sease S "--""' 0 `�Pppcy ilmit
Bodily Inju by Disease S "':""`" 1QO;000 each employee
C Other States Insurance; Coverage Replaced by 8ndorserr ant WC 20 Oa 00 B
0. This Policy Includes these Endorsements and Schedules; SEE SCHEDULS
4. The premium for(his pollcyy,will be determined by our Manuals f Rules,Classifications,Rates and Rating Plans.
All information required below is subject to verification and chs go by audit.
�C�sslfic_efions _iir`em u ass " "11i1es'
Code Eptime id PAP rS100r t±sUmated��
No, Total An ual Annual
Remuner tion or
~•-- -•----• Romuner:Itlon Premium
INTRA 174366 i t
• INTER I I
SEE-CLASS CODE 801-1E01
Minimum Premium 9liidp
--•--�•---....� Yc at Estimated Annual Premium
ow
STATE'Cis de Posit Prertuum no
. 5414
Sti to Assessments/surcharges
$1 .00 X a 7500% $1
This poiloy,Iaoluding all endorsements,is hereby countersigned by '"•~•'
t or a pnq utZs" 1C100a5/200?�$
Service Orilee:
64 Third Avenue P irry Insurance Agency LLO
Burlington MA 01803 51 Chickering Rd,Rt 126
N 2rth Andover, MA 01646
WC 00 00 01 A(7-11)
InctuUsad es eopylipht*dmRtarial ortho Havon•r Counall on Companattlton b►ouronoe, ,
uaott with its p�rmI..r
11/18/2015 LVED 11166 FAX 781 598 6430 DAVID ZELLER INSURANCE
0001/001
i
ACOR CERTIFICATE OF LIABILITY INSURANCE
111102015 I
THIS cERTiP1CAT8 1t;ISSV90 A8 A MATTER OF INFORMATION ONLY AND CONFER8 NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE:DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THR POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT. If the Cartilleate holder is an ADDITIONAL INSURED,the POROypee must he endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain po11e1vs may require an endoroamant. A statement on this eertilleate doe:not cooler rights to the 1
aerti6cate holder in lieu of such andorsemenl(s),
PaooucER1ADMITMa elian Goodwin
DAVID E.ZEL,LER INSURANCE AGENCY INC °lk 7a� tsetszot�
DR ma *Ilan davidzeller,Donn
370 LYNNWAY '
LYNN "'� o' A NAICir i
MA 01001imVmAj ACE AMERICAN INSURANCE CO 22667 i
IN°VRED
IND R i
BERRY FRANK&BERRY JAMES DBA FRANK&SONS su 1
46 WINBROOK DRIVE auROM
EPPING NH 03042
COVERAGE$ CERTIFICATE NUMBER: 1314 REVISION NUMBER:
THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE L18TED BELOW HAV&SIM.1991.10 TO THE IN3UREO NAMED ABOVE FORT
H@POLICY PERIOD
INDICATED, r'IOTWITHSTANDINO 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 SUBJt:
EXCLUSION$AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS. CT TO ALL THE TERMS,
7CLAIMMOE
'EOPINSURANctr l
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CULOENERAL LIABILITY
EACHOCCURRENCE 7
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DESCRIPTION OF OPERATIONS ILOCATIONSIWHICLaa(ACORD1a1,AddltiontlRemukaaotudutgmeybaatuehulifmueeµ�eisrequlnd)
employees In states ofharrthenNMasaachusone it the insurted hirci or hit hired U�osre employenei outside o Massacchui ono authorization to giren to pay calms for benefits to
This el)AROAts of Insurance shows the polloy in force on the dela that this certificate was issued(unless the explrsttOn dale on the eboYe policy precedes the Issue date et Ihle
certificate of Inaurance). The status or this coverage can be monitored Qally by accusing the Pmoroloov a Pfr•Coverage Veritdbove olicyh fool at I
www mass,govAwdAvorks*oompens*UOAMVD$ilgetioMl. t
No partners have elected coverage.
t
CERTIFICATE HOLD CANCELLATION I
SHOULD ANY OF THE ASOVR DESCRIBED POLICIES Be CANCELLED B
EFORE0 L16
1
THU EXPIRATION DATE THEREOF, NOTICE WILL A DBL D BHD IH !
ALL LINGER ONE ROOF ACCORDANOTWITHTHEPOUCYPROV1StONS.
30 TEMPLE DRIVE
AUTs O?tIZcoagPRBSeHTATM
METHUEN MA 01844 Dental M,Cr
V.CPCU,VIC*President-Residual Market—WCRIBMA
ACORD 25(2014101) (D 1988-20114 ACORD--CORPORATION.kj[-rjjht$1`41040,
The ACORD name and 1090 Bre registered marks Of ACORD
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Maeer+ohusotts.
Board Of Building Repularlail a ouS:a
ClawtPudlon gUPQrvl„rt1
license;03.009120
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