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Home My WebLink AboutBuilding Permit #118-14 - 1 Stacy Drive U-1 8/5/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION PROPERTY OWNER -._-- in 100 Year Old Structure yes no MAP NO. PARCEL: NG DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: � Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: S CONTRACTOR Name: Za�.r Phone: Address: ZIO/ 1 � 7/ Supervisor's Construction License: �( Q Exp. Dater LHome Improvement License: Z �' � Exp. Date: r 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: $ �c � FEE: $ Check No.: �j Receipt No.:_ ��g� v NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund Signature of Agent/Owner4 Signature of contractor Plans Submitted ❑ Plans Waive Certified Plot Plan ❑ StampedPlans Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF.SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS -CONSERVATION Reviewed ori Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS z Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW To vo Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Mair,,Street Fire DepartmeNt signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use EJ Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Tine fol.o. wing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:tted with the building application Doc: Doc.Buhding permit Revised 2012 Location S' / ' — DIL " No. Date . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ 7 7 7D— Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# a r � " J `� ' Building Inspector r 1 ttORTH ve" '* 0 No. — Iq ver, Mass, ' l �/� COC-01C Ml WICK ��• 7.95 RgTEO '-*' �S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .......400.f N...N........Q...0. r ............................... ......................... BUILDING INSPECTOR has permission to erect buildings on `..........STtri... P Foundation Rough to be occupied as f y .............. .. .... . ................... ................ .......... .....�................................. Chimney provided that the person accepting t s permit shall in every respect co nfo 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 CONSTRU ST Rough � + Service .......... ... ...... ............................................. Final "" BUILDING INSPECTOR GAS.INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE CERTIFICATE OF LIABILITY INSURANCEz -DATE(MbIJIDLttYYYY) `(38/27;'2012 ;,HIS, CEI TiRCATE "IS ISSUED AS A MATTER OF INFORMATION ONLYL AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 31Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER. ------------ UVI-VI11ANI: it tive certificate holder is an ADDITIONAL INSURED,the policyti—es)-must be endorset�.. If SUBROGATION IS WAIVED,subject to VICterms and conditions of the policy,certain policies may require an endorsement. A statement on.his certificate does not confer rights to the celtificate holder in lieu of such endorsement(s). Jerrold Kameras F& INTS1_73ZAINCE AGENCY INc. PHONE (978) 745-5905 FAX Jefferson Avenue 2nd Floor ldftllaninsuzance.ca INSURER)AFFORDING COVERAGE NAiC iV MA 01970-0511 INSURER A:SeUeca Specialty ins. Co. wsugeRs:S-afety Insurance Company ZC, ::I-,C LNSUREPC A- 1terra. Excess .&.. Surplus Ins.R 0 g Company INSUREPo:Ace American Insurance Co7 Wintevz- Street INSURER E: ve,rh MA 01830- rl"IURER F CERTIFICATE NUMBER. REVISION NUMBER: C) CEP.TIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY P_ERIO,_) __1, N070,AIT,HSTANDING ANY-REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VTITH RESPECT TO VvHiCH. �,HHs i ER•TIFICATIE ,'VIA'BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEP&i& E—LUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYrE OF E AO wV0 POLICY EFF POLICY EXP PORKY NUMER ly-M-122-fy—y-y—yi (MMI—ODAlyyy) UP41ITS GENERAL UABiLITY EACH OCCURRENCE X CON-TMERCIAL CENETAL L iAMI ITY DAMAG PREMISES fEa azI."encel a CLA*,?AS-N1:b*,DF. L.-25�j OCCUR iL-CGLOGGO00069 11/12/2011 11/12/2Cl2 WIED EX0;Ary We On) = 11000 PERSONAL,&ADV INJURY S 11000,000 GENERAL,AGGREGATE I c 2 n 000 1,00 ,C AGia REG:'ATE x-fitAi-i'APPLIES PER PRODUCTS-C(A?P!OP AGG JOL 0 ' i POLICY (Loc 7,(—)MB*4FD SINGLE AU. UARII-IT BODILY INJURY(Perper5on) ALL SP_HEOVLFD AV70S AUTOS I 07/16/2012 7/16/2013 Bogg y INjURy, 'pu cCFNjI S "D A:,� NCNNO�NNED PROPERTY DAMAGE ALI' Ape,��_Vftd I ':_Ica y 1 i O'CCUR Oi:�:;URRENGC EXCESS IAF CL.AffASAIADE "_333CS0000040 AGGPEC-,A.TE RETF-7'I f;,- 11/21/2011 11/12j2012 tVOPKERS COMPENSAVON AND EMPLOyJw LWYERS'LIASILI�. TORY I T,' x NIA E.L.EACH AMGEN' it.0001000 OFPCERAMEMEPIR FXCUJDFD�, .wndaw i , 1 4 1 L142954 8/28/2012 8/2812013 i. 4e E-L DISEASF EA EMPU'Wt-9 5 000 _yeS�, _mc DESCRip"i(I"0_1 OPFRIATIONS E.L.DISEASE•110uCY LIrAr, S_ 1,000,0C_0 DEZRCRIPT'IiON OF OPE RA—IIOKS;LOCATIONS I VEHICLES (Attach ACORD 101,AddRiaoal Remarlis Schedule,i£mato space Is reqtdredy RTIFICATE HOLDER CANCELLATION -_,GLRC.. Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICEIL L BE DEUVERED IN ACCORDANCE WITH THE POLICY PROMiONS. DBA Launbert Roof ing Co. 265 Winte_- Street AUTHORIZED REPRESENTATIVE Haverli-Lil KA 01830- ACORD 25(2040/05) 1988-2010 AC09D CORPORATION. Aft rights reserved.33 The ACORD name and logo are registered marks of ACORD C"78130 RICHARD J UMB]ERT 245 WINTER STREET Haverhill MA 0If 202014 Office of Consumer Affairs anduszness Regulation js a 10 Park Plaza o Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 149221 Type: Private Corporation Expiration: .121602013., Tr# 218746 T.C.L.R.0 dba Lambert Roofing Company RICHARD LAMBERT 265 WINTER STREET HAVERHILL, MA 01830 — — Update Address and return card.Mark reason for change_ �� Address ; Renewal —1 Employment F ' lost Carr T. IN`5' 0-)0-33'3 Haveftll MA 978,374.9224 klA Peg. Fig:# 149221 araabert Lawrence MA 97&6V.7339 Li U(:5- 8I30BBB, Hampton^H 603-:929.9224 l _e se, 17r l oohing Ha rigstead �H 603.3293200 �. :. - SCvece.Z93z CO- Toil Free 1,888.SOS.ROOF 265 Winter Street Haverhill MA Oi830 �. r7i t :Licensed Insured Factory Trained Factory Certified Date: `I ;jklt.Telephone: Email: rrl +�i !`,A �,, _ ': si.�g Add :r�.SS: 0 ttv: Siat�: :& i r 3'S:— .A.l I A t a S _ _a lt}': jJo,4 E%1-- State: (Y14A i Scope of Work .Strip�rsd Re-roof i Re-roof Approximate Roof Area: - Prepare for re-rbolin-by ensuring all safety.measures in accordance with OSHA standard regulations and landscape is properly protected. cer-Eove existing layers of shingles down to roof deck and dispose of in a legal fashion from die job site. in-pect wood deck, if we discover any rotted snood, replacement will will performed at*S1 -5_per LF for roof deck boards. If sumstantial deck rot is discovered,re-sheathing of roof deck can be performed at per SF.If individual sheets are found to be r itedlor de-laminated,removal,disposal and replacement will be performed at*S ?per sheet. if any trim boards are rotted, rt lacenaent will be perfor-ned at*S ff per LF for nese pre-primed pine.Inspect siding at roof line and all flashing behind siding,if we discover any damaged flashing tar sailing at the roof line,replacement will be performed at*S�� '�`2 . If wood deck,siding,and ?_<shing is sound,we will re-nail any loose wood to rafters,sweep deck,and prepare for roofing. -: h1s€all 8"drip edge to all rapes and eaves.Colori �)Ln,;bo Appis ice&water shield(UNDERLAYMENT)as per manufacturers`specifications andfor S ter C Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck. J` Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof_practice to ensure Umeter tightness. 7 If upon inspection,we discover chimney lead�to be worn or deteriorated,replacement will be performed at*5 3 __. I?stall a ne-w: Year s,Traditional c Architectural D Designer Color u t n Furnish and lnsta a new shingle over style ridge vent system 0 Soffit vent system*S _.: Ali debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no circamstances will the watertight integrity of the blllldin be compromised. pecial Note i 'p3 r ! r r�4tt 1 t/+ f �i � 3 F 3, UP0 COMPLETION AND PAYMENT IN FULL.ROOT=SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND PEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. °uMANUFACTURER UPGRADE *S *Deriotes potential additional costs above the natal estirnated price. TOTAL.CONTRACT PRICE AND PAYMENT SCHEDULE a .'hc t Parttractcr agrees to perform the.+ork,furnish the maaerials and labor specified above for the total sum of:$44 ( t (Dollars) P3vm,ent w1l(be;rade according to the following work schedule: -- -deposit upon si�uraatIV contract --by or upon completion of upon completion of contract. (Law forbids demanding fall 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 vote notify the ;_-,onTactor in s,ritipt, at hivber 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 Acceptance of the Contract Prop al I,F. s= � l nL Ou ne-(sj u?;na.ure(s) iQ ` ' '`�f.t.� !J _ Date: (If J09i' G � � f- Date: wI�.E�?2 'U1� orsiractor's Sigr•,a°:ire; G . aIX be rtroofing.Coln (Please see reverse side) e The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: „�� 5� City/State/Zip: /&, /�, Jam-/�',��1/� Phone#: eV3�G Are you an employer?Check the appropriate box: Type of project(required): a employer with ;�b 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).” have Hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 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.]t employees.[No workers' 13J]Other 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 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 their workers'camp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: (�� c/� Expiration Date: , �? Job Site Address: a City/State/Zip:21AO Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify andpenalties ofperjury that the information provided above is true and correct. —Signature: Date: Phone#: 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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or.written." An employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation-affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CoMiAozlwealthofMassachusetts Department of l adustrial Accidents Office of Iovestigatitons 6.00 Washington Street Boston,MA,02111 Tei,#61.7-7274900 at 406 or 1:-877,7MA.SSAFB Revised 5-26-05 Fax 4 617-727-7749 www-wass,govldia