HomeMy WebLinkAboutBuilding Permit # 6/27/2016 %AO RTH
BUILDING PERMIT
D� D ,6�'t�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _ -
,� � Date Received ORATED�PPysy
Permit No#. �SSvcHus��
Date Issued:
I PORTANT: Applicant must complete all items on this page
LOCATION Nonorat
PROPERTY OWNERPrint 1oo Year Structure yes no
no
MAP � PARCZONING DISTRICT:-MachintoriceShop Village yeistrict s no
TYPE OF IMPROVEMENT PROPOSED USE Non- Residential
Residential
❑ New Building One family ❑ Industrial
❑Addition ❑Two or more family ❑ Commercial
><Alteration No. of units:
❑ BldgLl Others:
Li Repair, replacement Assessor y
❑ Demolition ❑ Other
r j '❑1Netlands �� ❑�Watershed Distract,
,, r,❑ Floodplain:, r �, �F��r �{�}����,� � ��r� �,� �, lY,
�� �YSe tic ❑ � � � ,� k � r�� � � r�r r , � t �. �� �� � � ,
�tt � !ri rt,to rnh 9 7 N F'S rr i �r:.,tit ,� �n'r�rhe::. •y t - ty ,.!r rrr tr S/:r,!/ rr 1G � f r x/ t i :ll i r, ,,,. ,r,�,.,,,,F„,.,�., ;,:
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Plgase Type or Print Clearly
J_
OWNER: NamePhone:
:
Address: J acb
Contractor Name:
0 Y� Phone: °q a
Email: VY\ o
Address: f1
Supervisor's Construction License:
CIS-0—IR l 3b 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 BED ON$125.00 PER S.F.
Total Project Cost: $
FEE: $ 22-
1--Check No.: a Receipt No.:
u
NOTE: Persons contracting with unregistered contractors do not have acces uaranty fund
Town ot4o
Andover
No. 2,61
j 4.0
n V�1r'' SSS'
O L;;s^K �-
COCMIC..w.C.(
S U
BOARD OF HEALTH
Food/Kitchen
Septic System
0000,
BUILDING INSPECTOR
ER T IF LD
THIS CERTIFIES THAT
........... ......... ... .. ........................... ..... .........................................
. ...'
has permission to erect .......................... buildings on .....to.......6. .:.. ...... ................ ... Foundation....
Rough
g
tobe occupied as .......... .. .. ....... ....... .. .. .. . ............................................................ Chimney
provided that the person accepting th 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST TION Rough
Service
m ::... Final
BUILDIN ECTO
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be ®one FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
T.G
EIN#51-050-3313
MA Reg. HIC#149221 Haverhill MA 978.374.9224
� ��
MA Lic.UCS#78130 Lawrence MA 978.687.7339
�oti� Hampton NH 603.929.9224
Single-Ply License#1711 Hampstead NH 603.329.8200
_ Si v�c�i2932 0, Toll Free 1.888.SOS.ROOF
265 Winter Street
Haverhill MA 01830
Name:_ C
„Licensed *Insured *Factory Trained *Factory Certified
�/1a/,iVYl�.irfx �� Date:
Telepho 7e e Alt.Telephone: Email:
Billingddress:.0 1�?20r?n,I �f7 City: , r l !)(20V�.r State: M/,l,
Job Address: City: State:
Scope of Work Strip and Re roof ❑Re-roof Approximate Roof Area:
❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site.
❑ Inspect wood deck,if we discover any rotted wood, replacement will will performed at * per LF for roof deck boards. If
substantial deck rot is discovered,re-sheathing of roof deck can be performed at per SF. If individual sheets are found to be
rotted/or de-laminated,removal,disposal andj replacement will be performed at*$ "v per sheet. If any trim boards are rotted,
replacement will be performed at*$ Z per LF for new pre-primed pine. Inspect siding at roof line and all flashing behind siding,if
we discover any damaged flashing or siding at the roof line,replacement will be performed at*$�_, If wood deck,siding,and
flashing is sound,we will re-nail any loose wood to rafters, sweep deck,and prepare for roofing.
El Install 8"drip edge to all rakes and eaves. Color KnE,-)4 i
El Apply ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or
El Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck.
❑ Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
❑ If upon inspection,we discover chimney lead to be worn or deteriorated, replacement will be performed at*$
❑ Install a new: a ) Year ❑ Traditional Architectural ❑ Designer of
or
El Furnish and Install S newshingle over style ridge vent system ❑Soffit vent system *$
❑ All debris generated by Lambert Roofing Co., Inc.will be cleaned up and disposed of from the job site in a legal fashion. Under no
circumstances will the watertight integrity of the building be compromised.
SpelIcial Notes r �' f �� v et<
V j
t A<CA
UPON COMPLETION A D PAYMENT IN FULL,ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY ANEZ
!�-' YEARS HONORED AND ISSUED BY THE
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$
*Denotes potential additional costs above the total estimated price.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of:$j
Payment will be made according to the following work schedule: (Dollars)
$ deposit upon signing contract
$ by_/_/ or upon completion of
$ upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
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 or by delivery,not later than midnight of the
third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptanc
f of
the Contract Proposal
Home Owner(s)Signature(s):
42 -j/Date:
Contractor's Signature: j
Date:
<1BI111hertl"nn ino-(`nm
Company Insurances
TGLRC Inc.DBA Lambert Roofing Company will provide certification of insurances,demonstrating that we are fully insured for worker's compensations,
general liability,automobile liability and an umbrella policy.This documentation will be sent through the US mail to the above named party if not already
provided.
TGLRC Inc dba Lambert Roofing Company agrees to;
• Commence the described war](on or about
® Complete the described work in approximately days.
• Not be held liable for delays due to circumstances beyond our control.
• Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control.
• Not be held liable and not covered under the workmanship warranty,for pre-existing conditions including but not limited to:
• Mold and or wood rot,defective,faulty,rotted or worn building counterparts such as,but no limited to:siding,roofing,masonry,
plumbing and windows,all of which may jeopardize the watertight integrity of the structure.
• Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the
residence.
• This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc.DBA Lambert Roofing
Company and the Homeowner/Business Owner or Agent.
Permits
A building permit may be required to remove and replace your roof.It is our obligation to secure these permits if required as the home owner's agent.Note:
Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A.
Accelerated Payment
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be
financially insecure.However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds
not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the
signatures of both parties.
Payment Terms
A finance charge of 1.5%a month(18%per year)will be added to all invoices on the 31"day.All legal and or collection fees will be paid by the binding holder
of this contract.
• The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before work begins may not exceed
the greater of-
0 1/3 of the total contract price or:
The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule.
Arbitration
The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this
contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs
and Business Regulation and the, i § r shill,bVvequired to submit to such arbitration as provided in MGL c�42A.
1' �rP3
Owner ° �> :.�:. Date: UV
Y�
Contractor• ✓
Date:
Contractor Registration
All home improvement contractors and subcontractors must be register d,any inquiries about a contractor or subcontractor relating to a registration should
be directed to:
Contractor Registration:
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place,Rm.1301
Boston,MA 02108
(617)727-3200
Home Improvement Contractor Law:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulations
10 Park Plaza,Rm.5170
Boston,MA 02116
(617)973-8787
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508)755-2548
(413)734-3114
Cancellation
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be in the main office or branch
thereof,provided you notify the seller in writing at the main office by ordinary mail posted,by telegram sent or by.delivery,no later than that midnight of the
third business day following the signing of the agreement. XT"
INITIALS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigtttions
640 Washington Street
w 4. ❑ Boston, MA 42111
-� www.tnass.,gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ARQp cant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: ,f 1 1Y1
City/State/Zip: 1 \ „ L os Phone #: ®
Ar you an employer?Check the appropriate box: Type of project(required):
14EATam a employer with 4. ❑ 1 atn a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers' comp, insurance. 9, ❑ Building addition
[Vo workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.M Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] 1. employees. [No workers' 13. Other T-9—' fbb
comp. insurance required.]
"'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information,
s l lotneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit it new affidavit indicating such,
'C'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lout an employer that is providing workers'compensation insurance for my employees. Relory is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#:( � � (�q � "a. �( Expiration Date:
Job Site Address: (� City/State/Zip: +
Attach a copy of the workers' couqAnsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tender Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine ttp to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify tendert err rdpenalties of'perjary that the information provided above is trite and correct
Signature: ,mm. Dater
Phone#:
9112s-
Official
likOfficial 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#:
ACCO CERTIFICATE LIABILITY INSURANCE DATE(MIAIDDlYYYY)
03/28/2016
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(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 NAANTACT Jerrold Kameras
ALLAN INSURANCE AGENCY INC. JQ PHONE (978) 745-5905 FAX No:(97')) 745-549363 1/2 Jefferson Avenue 2nd Floor. E'r'"'AIL JerroldCallaninsurance.com
P.O. BOX 511" INSURER(§)AFFORDING COVERAGE NAIC is
SALEM MA 01970-0511 INSURERA:Associated Ind Ins Co. j
INSURED INSURER B.Safety- I_n_s 1r ance Co.
TGLRC Irt§IJRERC:National Union Fire Ins Co.
dba: Lambert Roofing co. INSURERD Ace American insurance Co.
265 Winter Street INSURERE:ACe American Insurance Co.
Haverhill MA 01830- INsuaERF:
COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER:
1HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO:M HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
_ IND,CATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VOTH RESPECT TO VMICH THIS
CERTIFICATE MAY BE ISSUED OR (JAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERAS,
EXCI USIONS AND CONDITIONS OF SUCH POLICIES LIN11ITS SHOL'JN(:1AY HAVE BEFN REDUCED BY PAID CLAIMS
- -- - _.. - - ---
ir1SR; IADDL SU _ POLICY EFF- --PO- LICY EXP
LTR TYPE OF INSURANCE POLICY tdUk1HER (Mtd1DD YYYY) MMIDDIYYYY LIMITS
GENERAL LIABILITY ( J J rPCHOCCURREN(E 1, 000,000
I X '.t0MI N L Ni P10 I IABI�:TY ,% J / J i)! E Itti RC 1L!)
PRFru5i5ct,rx ,rrr,, 50,000
A :!!161St.+N r D!;tCtiP I IA�Si.07.UC 9 D'l 111;'12!2015 11/12/2016 ,
r--� t l 1 i<;r.p,,nn) 1, 000
MY Y1)1 X( A.r _
X per provect Agg I National Roofers nssoc. P1R,,.0NALaADV INJURY i 1,000,000 '.
_ J
G i NLPAL AGGRECAif: :; 2, 000,000
r 1L >, GRI- AIE C1rhIr APPLIES PI.R I t I J / PRODUCTS-GONIPIOP AGO -5 2,000,000
POLICY I PRG- I J J
I Or.
AUTOMOBILE LIABILITY i i j / I j ; r ommIN€D SINGLE 7MIT `
i 1'7s J riU :L 1,000 000
B r r f+TJ '} J l f J BODILY INJURY(Por Fu,ecvl
�{ SCHIDULEG6203819 ;, 7� r 9 --
1 X t ,. J.. 1�,-''..615 07, 16/2016 BJDII't IN,1t1RY (�.di,c.a6ntj
XIle{F ulCE�i:3 X A�ligS1';1rlU r j Ei'(1P1 RY DAMAGE.
I
X j UMBRELLA LIAR X %
Ocr.,!tt ircHt%a:ul¢RENt:r -_ 5,000,000
C '' EXCESSLIA6 i,AIMSIAADL, � BE01E335635 �11i1;i101s11 '12;201f. Ac;CRCGAif 5,000,000
-- i
(DEP RI--PENTIONs
WORKERS COMPENSATION , J J t!C STATH f)IH-
AND EMPLOYERS LIABILITY -
P G Rii �FmARTt ERt -r_,,, I,E IY� 6S62UB-2809875-2-16 biA )3/215,'2016 03/25%2017 E L E d H 1CCIDENT 1 000,000
i OP f';I r.EE° rh:;t t,_L�- N �N t A /
(M,ndatory in NH) t—'-1 E I DISLASL-EA FfdPI OYt1E 1,000 000
c i r
E ' Worker's�Com inrlON- 1=Talus I / P 00
CI
--_ ... is
I. DISEASE LIMIT 5 1,000,0
Compensation NH 1,000,000
III
,6s62UB-GD81311-16 15 SIH 2(22`2015;12;22;2016 .,-,raY,.,'-' 11 000,000
DESCRIPTION OF OPERATIONS)LOCATIONS I VEHICLES (Attach ACORD 101.Additional Remarks Schedule,If rnore space is required)
CERTIFICATE HOLDER CANCELLATION
TGLRC dba: Lambert Roofing SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
265 Winter Street
AUTHORIZ! RFPftE tdTATIVF
i i 1 v
Have MA 01830-
ACORD 25(2010105) 9 1988-2010 ACORD'CORPORATION. All rights reserved.
INS025 The ACORD name and logo are registered marks of ACORD
Massachusetts Deparlrnent of Pubhc "safety
Board of Hnaicling Re uIatuo ns and Standards
License: CS-078130
Ca drr»I'd°ue ion
RICHARD J LAMBERT
266 WINTER STREET
HAVERHILL MA 01830
man Expiratiory
Cor'nrnissioner 06/02/2018
t
Office of Consumer Affairs and Business Regulation
� r 10 Park Plaza - Suite 5170
Boston, Massachusetts 0211.6
Home Improvement Contractor Registration
Registration: 149221
Type: Private Corporation
Expiration: 12/6/2017 Tr# 273093
T.G.L.R.0 dba Lambert Roofing Company
RICHARD LAMBERT — ----
255 WINTER STREET ---
HAVERHILL, MA 01830 - — -
Update Address and return card.Mark reason for change.
SCA 9 ca 2crPA-0511r
Address Renewal ❑ Employment Lost Card