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HomeMy WebLinkAboutBuilding Permit #873-15 - 15 COPLEY CIRCLE 5/4/2015 BUILDING PERMIToNo DT",�� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Receivedrep �gSSgcHus �y Date Issued: —9 N P ANT:Applicant must complete all items on this page // LOCATION [S (00ff &"r- Print PROPERTY OWNER 01t 54AZ1 -/- - Print 100 Year Structure yes Gno MAP 00PARCELD0��ZONING DISTRICT: Historic District yes Machine Shop Village yes 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: 5���r Identification- Please Type or Print Clearly OWNER: Name: 4 r- Phone: Address: t Co 1� C `r Contractor Name: Co rti Phone: Email: Address: s n G`L --r4eA4X ,7e Supervisor's Construction License: 10 Sc'`a` 3 Exp. Date: Home Improvement License: 1705-7 Exp. Date: tdlolls- 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: $ /��RQC? - FEE: $ Check No.: �i4 l Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access a toy f d Location I i3 rO P 6:�� t No. — B Date . - TOWN OENORTH ANDOVER TUD, � Certificate of Occupancy $' Building/Frame Permit Fee Foundation Permit Fee $_ ` 10, Other Permit Fee TOTAL $ Check# o Building Inspector T 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Penning Board Decision: Comments Conservation Decision: Comments Wafter & Sewer Con nection/Siqnature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street _ FIRE'.DEPART,MF,T - Tempi®umpster o.n,site eyes L_ocatediat 12.4dMbin.8treet Fine Repar�tmentsgnature/date; COMMENT'S 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pelmit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 Building Permit Application 4. 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 OTE: 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORTty own of ndover 0 0 No. - �513 I - ° h ver, Mass, COCHIC"IWICK( �•9 A°RA rE 0 AI*0 (5 S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ...............0... ...... If ? ........................................................... has permission to erect .......................... buildings on ... �,., Foundation �.. .......... O.P. ...... ` Rough tobe occupied as .............. .. ...... .... � ................................................................... Chimney provided that the person accepting his permit shall in every pect 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 MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUCT is S TS Rough ...................... Service .............. ........... .............. BUILDING. . . INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. CD Roofing Vincent Colangelo 3 Hodgson St. • . Tewksbury,Mo 01876 • 978-656-8497 ® 656-84-97 vincentcolongelo@sbcglobal.net HIC Llc# 170575 CSSL Lic# 105943 Customer: OWENS CORNING t Copley 6,'r. PREFERRED CONTRACTORIc q_-K IJ - A'ido' ver 478--(oBS-sy83 ! Description of work Performed: ,Obtain required town permits&provide certificates of insurance&workers compensation Provide Dumpster set on planks*for contractors use only(materials all recycled) Attach Large Tarps to protect adjacent finishes,landscaping,and property. JfStrip-off(/ )existing layers of roofing on complete house&re-nail any loose decking Wnstall 8inch Aluminum Drip edging I Owens Corning Starter Shingles fA Install Owens Corning Ice&Water shield 6ft at eaves,3ft in valleys,around all penetrations Install Synthetic felt paper to entire roof (Install Owens Corning LifeTime warranty TruDefinition Duration shingles t�lnstall 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 `}Owens Corning Preferred contractor installation with full warranty All work will be completed according to state and manufacturing codes and specifications. Every day we will have the roof water tight,clean gutters,completely clean the job site,and use a magnet roller to collect scattered nails. Additional work to be performed All material is guaranteed to be as specified. All work to be completed in a workmanilke 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 and may become an extra charge over and 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 damages incurred by contractor.Full Payment Is due upon completion of work We propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of: dollars($ /p/c700,`�-, ), Said amount shall be paid as follows: Note:This proposal may be 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 DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEG I BLE. Work will not begin until your right to cancel has expired and yo e p ' a po t of dollars($ ), unless this agreement provid othe Signature of Contractor or authorized repr a tative: *(I/W/e)have read the terms statedh r ,they have explained to(me/us),and(I/We)find them to be satisfactory and hereby accept them. Signature of Homeowner(s): I The Commonwealth of Massachusetts F Department of Industrial Accidents a i d I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia 5V• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibtvl Name(Business/Organization/Individual): �( �!�Q Address: City/State/Zip: n Phone#: � g5-6 --?((q 7 Are you an employer?Check the appropriate box: Type of project(required): Ln I am a employer with employees(full and/or part-time).` 7. ❑New Construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.[]Plumbing repairs or additions 5. am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 14.❑Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no 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. Homeowners who submit this affidavit indicating they aze doing all work and then hire outside contractors must submit a new 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A1Q4e Policy#or Self-ins.Lic.#: ,fNi-_f Expiration Date: Job Site Address: l e City/State/Zip: /\ pen ation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers'co 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. I do hereby certi un th ains nd penalties of perjury that the information provided above is true and correct. Date: S-�4t X Signature: � Phone# Eenonly. Do not write in this area,to be completed by city or town official. n• Permit/Licensehority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: 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 employer is 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-contractor(s)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. A new 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NlASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �`�® CERTIFICATE OF LIABILITY INSURANCE ��(�4/23)15 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 policy0es) 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 Angela Westen Insurance Agency NAME:PHONE FAX 978 557 Central Street E�AAIL 978 735-4094 N ( ) 735-4095 Lowell, MA 01852 ADDRESS: an ela@awesten.com INSURE S AFFORDING COVERAGE NAIC a INSURER A:ATLANTIC CASUALTY INSURANCE CO INSURED INSURER B:HARTFORD UNDERWRITERS INS COMP F O CONSTRUCTION corporation INSURER C: 119 FARMLAND RD . APT 1 INSURER D: LOWELL, MA 01850 INSURER E: INSPIRER 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 AWL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M/DD/Y MM/DO/YYYY LIMITS A GENERAL LIABILITY L021008696 3/18/15 3/18/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea no) $ 100,000 CLAIMS-MADE 7 OCCUR MED EXP(Ary one person) $ 5,000 PERSONAL&ADV INJURY $ 1'0 0 000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PROi F LOC $ AUTOMOBILE LIABILITY COMB INEDISINGLELIMIT $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PRerOPE 'Y tDAMAGE $ HIREDAUTOS _gUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 2E112068 3/30/15 3/30/16 1 WC STATU- DTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERMIEMBEREXCLLDED? N/A (Mandelory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 N yes describe under E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rerrerks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LARRY AND NANCY HOPP ACCORDANCE WITH THE POLICY PROVISIONS. 16 AVALON ROAD STONEHAM, MA AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD dame and logo are registered marks of ACO RD Phone: (781) 665-7740 Fax: E-Mail: to ciinircirtrrrr r r, rr,rir ra,r Office of Consumer Affairs&Business Regulation � ME IMPROVEMENT CONTRACTOR 5 _Registration: 170575 Type: expiration: . 11/10/2015 DBA ® 3 CD ROOFING VINCENT COLANGELO 3 HODGSON ST TEWKS BURY,MA 01876 Undersecretary .RG^r `'' k.. 'C`un,trurti�r,� Supci+iti��rSprci:elt� ., /� ' CSSL-105943 }j VINCENT COLANGELO 3 HODGSON STREET ; Tewksbury MA 01876 03/09/2016 a;