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HomeMy WebLinkAboutBuilding Permit #026-15 - 151 RALEIGH TAVERN LANE 7/9/2014 ORT BUILDING PERMIT °�N.e° sgtio TOWN OF NORTH ANDOVER °� 0 APPLICATION FOR PLAN EXAMINATION Z —�` Permit No#: X40 1 Date Received "meq rE, "e5 �gSSACHUS�� Date Issuer., t IMPORTANT: Applicant must complete all items on this page f LOCATION' � C �� _r.G(� —tomb _ _ t n _- r Fant PROPERTY OWNER,_ Pnnt x 100 Year Structure yes no: MA= d PARCF � ZONING DISTRICT Historic Distract yesfi no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ;;One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other E Septic ❑1Nela� ❑ Floodplain q Wetlands _Watershed District: Water/Sewer _ - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: pckU�ee� �,Pn S®-n Phone:q 2 – W- ( V03 Address: t 5—t fit` jLT _ P 4 Contractor Name /� �h.one: � � y Address:_ ,_= CSort Supervisors Construc_tion,Liden8e Date: =r _ — Home Improvement License _-[.(.!to. 1 :Exp.. ,Date:_. 1-1../ty_It Y 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. s-r co CJV Total Project Cost: $ gt�'QO - FEE: $ - Check No.: — "42 Receipt No.: 2�� NOTE: Persons contracting with unregistered contractors do not have access tot u r ty fund Signature of Agent/Owner_ - _ Signature of'contracr__ __ . 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_ i COMMENTS I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments �F Conservation Decision: Comments - Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street `FIRE+DEPARTM,ENT - Temp fDumpster,ons site yes Located at 12:4..Mainn;Street Fire De pa,-rt mentaigha-ture/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 i NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I, i i 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 ❑ 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/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 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 I ❑ 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 I 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 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 Location No. (O 1 Date + . - TOWN OF NORTH ANDOVER , . e - Certificate of Occupancy $ rte" Building/Frame Permit Fee $ Foundation Permit Fee $ 4kN Other Permit Fee $ TOTAL $ E fR • Check# tt � 2 7 / 5 4 Building Inspector s NORTH own of ndover 0 11- 1: _n No. bZ4 ,, I C, ver, Mass, A� coc�icNew,c� 1. X1,95 RAreco) U BOARD OF HEALTH Food/Kitchen PERMILDSeptic System THIS CERTIFIES THAT .............Dom� . N S0� BUILDING INSPECTOR ............. .. . . ....., ......................................... Foundation . has-permission to erect .......................... buildings on . .�..... .. .�... ...... .. � • Rough to be occupied as ...."accepp .....A... ......................................................................... Chimney provided that the perg 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 IPERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 1 . UNLESS CONSTRUCTI ST R Rough Service .................... ........... ..... ........................�...�........... Final BUILDING INSPECTOR 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. CDROOFI-01 BTAZZARA ,a►a►�oR®@ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYI� 4/8/2014 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(les)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 CNAOMNEACT Brtttany Tazzara John M.Glover Agency PHONE 860)485-9730 aC No):(860 485-0075 A.C.Piccolo Agency c " P.O.Box 65 ADDRESS:btazzara@johnmglover.com Harwinton,CT 06791 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Mesa Underwriters Specialty Ins.Co. 36838 INSURED INSURERS:Massachusetts Workers Comp Vincent Colangelo dba CD Roofing INSURER C: 3 Hodgson Street INSURER D: Tewksbury,MA 01876 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 TYPE OF INSURANCE DLSUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER M/DD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 -DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY TBD 1234 4/27/2014 4/27/2015 PREMISES Ea occurrence $ 100,00 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 7X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIASOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATIONX WC STATUTH- AND EMPLOYERS'LIABILITY TOCRY LIMI - OER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A C-20-20-003639-01 5/14/2013 5/14/2014 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 Uesdescribe under RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLESAttach ACORD 101 Additional Remarks Schedule If more a required) ( space is req red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Tewksbury THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow TowMain Street ACCORDANCE WITH THE POLICY PROVISIONS. Tewksbury,MA 01876 AUTHORIZED REPRESENTATIVE e. ua"'— I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Goff monfB o4k of tbl'assach.usetts De,�art�n�nto,f. ndifstri(lAcczelenf Office o,flnvestigations 600 Washington Street .Foston,M4 0.2111 www.mass.gov/ciza workex'S'Compensation Insurance Affidavit:Builders/Cont°actore)Electr cians/PI*bera A�pp�(cant Inforanatiton Please PrintLebXY Name(Business/Organizationlfndzviduat): mit .A.ddress: �qr"7 5� _ City/State/Zip: �2w CS n/ Phone : tel'��-�05 � `c�Gl q Are you an.employer?Check the appropriate box: Type of project(required): 1.❑ I am.a employer with �• ❑I am a general contractor and I g. [New'c6nstruction f employees(hu and/or part-time).* have nedthe sub-contractors a sola proprietor orpartner listed on the attached sheet. 7• ❑Remodeling ship and`haveno.employees These sub-contractors have 8. [(Demolition workiug for me in.any capacity. workers'comp.insurance, g. ❑Building addition [No workers'comp.jnsmauce 5. ❑We are a corporation audits 10.E]Electrical repairs or additions ' xegtraxed.a officers have exercised their 3.El Zama homeowner doing all work right of exemption per MGL 11.Q Plumbing,repairs or additions myself LToworkers'comp. c.152,§1(4),and wehave no 12.pRoofrepairs insuran.cere ed. employees.[No workers' ' comp.insurance required.] ME]Other zAny applicant that checks box#1 must also fill outthe section bel6w showingtheir workers'compensationpolzcyinformation. Homeowners who mbmitihis affidavit indicatingthey ke doing allwork and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the suh-contractors and their workers'comp.policy information. I am an employer that ispraviding 1porters'compensation insurance formy employees Bellow is thepoliey ancijoh site infarrmallon. Insurance Company Name: C� !n, 4A -- r W Z Policy#or Selz ins.Lic.#: tj ? Expiration Dato: 1 P lol 7[15 Tob Site Address- 157 IC I G —City/state/Zip: Attach a copy of 00 workers'comp ent atlonBoliey declaration page(showing-the policy number and ex piratiou crate). Failure to secure covexage.as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/axone year imprisonment,as well as civil penalties in the foam of a STOP.WORD ORDER and a fine of-up to$250.00 a day against the violator. B e advised that a copy of this statement may b e forwarded to the Office of Iuvestigations of the DIA for" ur ce,coverage verification. I do Hereby a pai s andpenaldes of eP'u that the in,for•madon,provided above is true and correct. Si afore Date: Phone#• official use 0.81Y. DO not write in this area,to be completed by city or town official. City or Town: PerralflLicense# Issuing.Authority(circle 6110): 1.Board of health.2.BuildingDepartnment 3.CityMown Clerk 4.]Electrical Inspector 5.PlunablugInspector f.Other - - - nx.,�o fix. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an e�r�,ployee is defined as"...every person iri the service of another under any contract ofhire, express or plie�oralorwritten.» An enTloye is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo ormore . of the torQ9Amgengaged inajointenterprise,and includingthelegalrepresentatives ofa`daceasedemployex,.orthe receiver or'-6&o.of�au individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant ofthe 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 bean 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b a On 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 nocedsaty,supply sub-contractors)name(s),addresses)andphonenumber(s)alongwiththeir certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation,insurance. If an LLC orLLP does have employees,a policy is required. Be advised thatthis affidavit in be submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should b e returned to the city or town that the application for the permit or license is being requested,xtot the DO'artment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain.a*orkexs' compansatfonpollqy,please call thaDepartmentatthpituniber listed below. Self-insured companies should enter I* 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 fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill inthe pemsit/Iicense number w ichwill be used as a reference number, Iwaddition,an applicant thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessaty)and under"Job Site Address"the applicant shouldwxite"all locatioirs in (city or town):'A copy of tho 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-ii on file for future p exmits or licenses. Anew afffdavit must be.filled out each year.'Whore,a home owner or citizen is obtaining a license oxperrnit not related to any business or commercial venture (i.e,a dog license orliermit to burn leaves etc.)said person is NOT'xequired to complete this affidavit. The Office of Investigations would like to thank you in advance fox 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: Tho ItlaofM.?S�z.,chU Pti� QfCe offmostxwaowq BostQn, .02111 TO- GM-2,Z49 0 0 e 406 Qx 1.-87-7- MA Revised 5-26-OS a � 74 CD Roofing Vincent Colangelo 3 Hodgson St. Roofing Tewksbury,Mallw -$ p®�k THERE'S NO ROOF CAN'T COVER 978-656-8497" vjnc 978-656-8497 HIC Lntic# L 05,ngdl- aft�Cgl� o net CSSL Lic# 105943 Davr d �►n So n oo Customer: -� .T- OWENS CORNING PREFERRENO iTRAG Norsk X,c&�f' 781 -a3y -L/16Y Description of work Performed: `1�8-�81 Gq(+�b n P(Obtain required town permits& provide certificates of insurance&workers compensaQQ (4 Provide Dumpster set on planks*for contractors use only(materials all recycled) ,f-Attach Large Tarps to protect adjacent finishes, landscaping, and property. ..Strip-off(Q) existing layers of roofing on complete house& re-nail any loose decking Install 8inch .Q Aluminum Drip edging/Owens Corning Starter Shingles Install Owens Corning Ice&Water shield Eft at eaves, 3ft in valleys, around all penetrations Install Synthetic felt paper to entire roof A Install Owens Corning LifeTime warranty TruDefinition Duration shingles Install new neoprene vent pipe flashings on all plumbing pipes hK Install Owens Corning VentSure ridge venting with moisture guard Install Owens Corning ProEdge hip& ridge cap shingles 11 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 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 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,tornado and other necessary insurance.Our workers are fully covered by Worker's Compensation ti 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. f-A) We propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of: dollars($,-9 f(y% m ). Said mount shall be paid as follows: 7 Sy�wwoo Note:This proposal may be withdrawn by us if not accepted within days. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT INY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. THIS SALE IS SUBJECT#TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS;/NOT NEGOTIABLE. Work will not begin until your right to cancel has expired and you h p ' a posit of dollars($ ), unless this agreement provides o Signature of Contractor or authorized representative: *(I/VUe)have read the terms stated her ,th`y have pr)'ZiEplained to(me/us),and(I/We)find them to be satisfactory and hereby accept them. Signature of Homeowner(s): iai�' Massachusetts-Department of Public Safety Board of Building Regi l.,jtion9 and Standards n�trttctios)l Supercisur SpeciaJti ,, License: CSSL-105943 , .,t 1 1.1, tjlflll �'ll VINCENT COLANGELO !. 3 HODGSONSTREET f r Tewksbury MA 01876 { i QJ',,lr,,,, J1ast �' , Expiration' Commissioner 03/09/2016 j �� �: ,• .'(92e �Pan��aaruuea�Cf a� cusaac arleCt� _4L�\_ Office of consumer Affairs&Business Regulation j' ME IMPROVEMENT CONTRACTOR Type. W-egistration: 170575 DBA piration 11/10/24, .z CD ROOFING c 5E ti VINCENT COLANGELO l j 3 HODGSON ST j, TEWKSBURY,MA 01876 Undersecretary