HomeMy WebLinkAboutBuilding Permit #466 - 174 JOHNSON STREET 12/8/2011Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER.
APPLICATION FOR PLAN EXAMINATION
Date Received
must complete all items on this
LOCATION 1 i 4
Print
PROPERTY O WNER '644r -.S
Print
MAP NO: o V. o PARCEL: 000 ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
Lk ee"amily
❑ Addition
❑ Two or more family
❑ Industrial
p.A�#sration
No. of units:
❑ Commercial
p,Repatr, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
_
❑Other -- -
- -
�r' " r ' ' `'L ` j
Septic a A
' ; Filo dplainlf'`�Weflands;'`},°pWaterslied
District`
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ON Obi WORK TO 3E PERtiO_ D:
We) s4.#i-L.�L rc L�
(Identification Please Type or Print Clearly)
OWNER: Name: tr&L^-r DA•er-s Phone:01414,7-D4ae
Address:
CONTRACTOR .1
q-je-2"--4t
Address:
Supervisor's Construction License: Exp. Date: A)
e
Home Improvement License: ) 2'�—nV Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT.• $12.00 PER $1000,00 OF THE TOTAL ESTIMATED COST BASED ON $925,00 PER S F.
Total Project Cost: $ '` - -- moo® FEE: $ �-
Check No.: -7-V 4; Receipt No.:
NOTE: persons contracting -with unregistered contractors do not h ave access to the guaranty find
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tann g/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ElPrivate
(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 on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board•Decision:
Comments
Conservation Decision: Comments
Wafer & Sevier Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COM AMNTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. i.:
ELECTRICAL: Movement of Mciter location, toast or service drop requires approval of
Electrical Inspector Yes No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine
Dox.Building Permit Revised 2008mi
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 Como 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
MOTE: 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 Cont -n -art
13Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan Arid
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
HIOTE: 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 CIerks 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: Doc.Building Permit Revised 2008mi
Location
/)-�a
Aa >-7
No. V,61,
Date
,,OSTM TOWN OF NORTH ANDOVER
L
•
Certificate of Occupancy $
'�s.�•�,;5 t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I -)I `
24873 Building Inspector
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The Commonwealth of Massaoiusetts
Department of Industrial Acdletlts
Of, face of Investigations
' a 600 Washington Street
�7 Bostailt MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Cas-tractors/Electricians/Plumbers
Name (Business/Orgaaizidontbdividual):
Address:
Are you an employer? Check the appropriate bog;
1.51am a employer with
4. I am a general contractor ad[
employees (full andlorpart time).*
have hired the sub-condactaYr
2.0 I am asole proprietor or partner-
listed on the -attached sheet.
ship and have no employees
These sub -contractors have
worl&g -for me in any capao ty.
employees and have workers'
insurance.#
(No workers' comp. insurance
comp.
iequirad.] -
3. [1 I am a homeowner doing all woric
myself. NO workers' romp.
insurance required.] t
Q we arl"..orporaho= Mud it,
officers have exercised tt:sir
right of atsmption per MGL
o.152, 11(4), and we have ac
employees. [Ni workers'
coria. inane required.]
-Type of project (required):
6. Q New construction
7. ❑ Remodeling
a. ❑ bemontion
9. ❑ Building addition
10.[] Electrical repair's or additions
11.Q Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
"Any applicant thatehecti box#1 must Am Fill 042 the cempr.Ytan taCscyinfmmaflan.
+:Homeowners who dubmit this d5davit indica ft they are doing all work and then hire outside contrators must submit a new affidavit indicating such.
tcontractors that check lis box must attaehad an additional sheet showing Ulu name oMIe sub-aontaden and,fate whether or not those a0deshave
employees. If the sub -contractors have employes,, they must providb their workers' camp. policy nether.
X atK a!L employer that is providing workers' eompensoiion itasurance for my err<,ilayees, Beluw is tate policy and job site.
informadon. i 1
insurance Company
Policy # or Self -ins. Lic. #: b�A 11p.A�� T �" Etpiratiori Date: — / i r
Joky Site A&Lass: Cly. /State/Zip;
Attach a copy of the workers' compensation policy declaration page (sbowiagtbe policy number and expiration date).
Fail -are , 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 ana'or one-year imprisonment, as well as civil penalties in ite form of a STOP WORM ORDER and a fine
of up to MGM a day against the violator. Be advised that a copy of this statement may be forwarded to the Offlce of
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sidgnature:;�i,�.:��-
use
area,
or town official
City or 'Gown: _ _ - Permii/Licerise 4
Issuing .Authority (circle one):
1. Board of Health2. Building Department 3. City/Town Clerk 4. Elect lospector 5. Plumbing Inspector
6. othe4-
Contact Person: P1Eoac t'
A� ®® CERTIFICATE ®F LIABILITY INSURANCE
07/0612UE1MMIDDIYYYY)
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.
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).
PRODUCERNTA
T Dorothy A. Corleft, CIC, RPLU
NAME:
Fred C. Church, Inc.
41 Wellman StreetPHONE
978 3227231 FAX (978) 454.1865
a AIC No :
Lowell, MA 01651
(800) 225.1865
E*MAILdcchurch.cam
dcorleh@fre
ADDRESS:
_ADDRESS:
INSURERS AFFORDING COVERAGE NAIC N
EACH OCCURRENCE 5 1,000,000
INSURERA : Citizens insurance Company of America 31534
INSURED
Hanover Insurance Company 22292
INSURER e :
New England Window & Door LLC
Massachusetts Bay Insurance 22306
i
INSURER C:
45 Fondi Road
Haverhill, MA 01832-1302
Employers Insurance Company of Wausau 21458
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 7`1781 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.
ILTR
TYPE OF INSURANCE
ADDL
SUER
POLICY NUMBER.
MMIOD EFF
MMIDD EXP
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE 5 1,000,000
MERCIALGENERAL LIABILITY
CLAIMS -MADE M OCCUR
i
I
0 a TED 100,000
DAMAqnoh
PREMISES
PREMISES Ea occurrence' S
MED EXP (Any one person) S 10,000
A
ZBN8161407
71112011
I
71112012
PERSONAL & ADV INJURY 5 1,000,000
GENERAL AGGREGATE 5 21000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS -COMPIOPAGG $ 2,000,000
POLICY X PRO- FELOC
$
AUTOMOBILE
X1
LIABILITY
ANY AUTO
I
I
(Ea ac ED SINGLE LIMIT 1,000,000
BODILYINJURY(Per person) i $
C
AUTO OWNED AUTOSULED
ADN8162169
7;112011
7112012
BODILY INJURY (Par accident) S
NON -OWNED
HIRED AUTOS X
PROPER cIen DAMAGE S
S
XI
XUMBRELLA
LIAR
X
OCCUR
EACH OCCURRENCE S 9.000,000
AGGREGATE 5 9000,000
B
EXCESS LIAR
CLAIMS -MADE
UHN8167305
7/1/2011
I 71112012
dED I X RETENTIONS
$
M
WORKERS COMPENSATION
I
i
X t VJC STATT- 6TH-
D
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NN)
NIA
I ,
WCCZ.1269957011
!
711!2011
I
I
71112012
O LIMI—
E.L. EACH ACCIDENT S 5001000
500,000
E.L. DISEASE- EA EMPLOYEE S
If yes describe under
DESCRIPTION OF OPERATIONS below
I
E.L. DISEASE - POLICY LIMIT S 500,600
t
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101, Additional Remarks Schedule, If more space is xqulred)
Proctor Insurance
Clir
SHOULD ANY OF THE ABOVE DESCRIBED POLiC1ES BE CANCELLED BEFORE
45 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
n7ndi Road AC=RDANCE WITl1 THE POLICY PROVISIONS,
Hav5rhl;l, ARA 01&30
AUTHORIZED REPRESENTATIVE
e
„W,u ' R � • --v cv —ownW v><ry zn; rv:y. mii rignts race: vea.
ACORD 25 (204,,0105) The ACORD name and logo are registered marks of ACORD
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N
PELLA WINDOWS AND DOORS CONTRACT
1. TERMS AND CONDITIONS
These Terms and Conditions are an integral part of the contract set forth on the
Product Order (the "Contract") between New England Window and Door LLC
dba Pella Windows & Doors, Inc. ("Pella") and the person(s) identified on the
Product Order ("Owner") to supply the products (the "Products"), and perforin
the work (the "Work") described or referred to in such Contract. For Product
Only purchases, a signed "Product Only Addendum" is a required part of the
contract.
2. OWNER
Pella is not responsible for any existing security systems. Owner shall Temove
all shades; verticals, blinds, curtains, drapes or window mounted air
conditioners, prior to the installation of the Products. Pella's installers are not
responsible for the removal or installation of these types of items. Pella is not
responsible for pre-existing window coverings fitting on newly installed Pella
windows.
The Owner shall provide complete access to the work site between the hours
of 7:00 a.m. and 6:00 p.m. (Monday through Friday) for Pella's installers to
deliver the Products and perforin the Work.
3. PELLA
Pella will be responsible for and have control over construction means.
methods, techniques, sequences and procedures and for coordinating all
portions of the Work. Pella will be responsible for the Work of its Pella
Contractors who will install the Products.
Unless provided otherwise in the Work description, Pella will provide and pay
for all labor, materials, equipment, tools and machinery, transportation, and
other facilities and services necessary for the proper execution and completion
of the Work.
The materials and equipment furnished under the Contract will be good quality
and new unless otherwise required or permitted, the Work will be free from
defects not inherent in the quality required or permitted, and the Work
conform with the requirements of this Contract. Pella shall not be responsible
for damages or defects caused by abuse, modifications not executed by Pella,
improper or insufficient maintenance, improper operation or normal wear and
tear. Pella will keep the premises and surrounding area free from
accumulation of waste materials or rubbish caused by performance of the
Work.
4. CHANGES
The Owner may order in writing changes in the Work consisting of additions,
deletions, or modifications ("Change Order'). Any Change Order shall
include an adjustment to the Price and the Substantial Completion Date, as
determined by Pella. Pella reserves the right to approve or disapprove any
Change Order and any such Change Order must be signed by both Owner and
Pella to be effective.
SUBSTANTIAL COMPLETION
Owner understands and agrees that the Substantial Completion Date is an
estimate only and that the actual date on which the Work is completed may be
extended to allow for Change Orders requested by Owner or if the time to
complete the Work is affected by conduct of the Owner, weather, labor
disputes, availability of subcontractors, acts of God, fire or other causes
reasonably beyond Pella's control. If for any reason the Work is not fully
completed by the Substantial Completion Date (including any extensions
contemplated above), but is substantially completed by such date, i.e., the
Product has been installed, but minor parts or components are missing or need
to be replaced or repaired, a hold back proportionate to the cost of remaining
parts or work to be completed is acceptable. However, the holdback will not
exceed the amount of the completion costs or 10 % of the remaining unpaid
balance of the Price, whichever is less.
6. FINANCING
if payment of the Price is financed with a financial institution through Pella, all
financing paperwork must be completed upon signing of this Contract and the
requisite approvals and authorizations for the full amount of the requested
financing shall have been received firom the financial institution.
�MZV"I
Pella shall be entitled to stop the Work upon written notice to Owner for any
material default or failure by Owner, including but not limited to, the Owner's
failure to pay Pella the amount due within seven days after the date payment is
due.
CORRECTION OF WORK
Pella shall correct installation Work not in conformance with the requirements
of the Comet, if notified in writing by the Owner within two years after the
Completion Date or, if earlier, the date on which the Work is substantially
complzted and payment of the Purchase Price made subject to a holdback as
provided above. Correction of Work as herein provided shall be Owner's sole
remedy fm defective workmanship, and is provided in lieu of any and all other
remedies_ Pella's obligation to correct Work is conditioned on Pella's prior
receipt of ail payments then due.
LI?tiIITED PRODUCT WARRANTY
Pella shall w�am all Pella products, but only in accordance with the Pella
Window; & Doors Limited Warranty. THIS LIMITED WARRANTY SHALL
BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND
PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES,
EXPRESS OR LIPLiED, WRITTEN OR ORAL (INCLUDING WITHOUT
LIMITATION AN -Y W.AARANTY OF MERCHANTABILITY OR FITNESS
FOR A PART ICL LAP, PURPOSE).
10. NO CONSEQUENTIAL. DAMAGES
UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR
CONSEQUE—\7L L —INCIDENTAL, INDIRECT, OR SPECIAL DAMAGES,
WHETHER FORESEE,; OR UNFORESEEN.
11. HOME LNIPROVE]IENr CONTRACTORS
Ail home fin"i ti'CITIC- eantractom and subcontractors shall be registered with
the director of the Hone hmaroy-ement Contractor Registration Program
administered by the Berard 4Buiiding Regulations and Standards. Pella and
any of its subcoauactms idemined in ti> s asr4nnem have been registered.
Any inquires abotn Pella or anry afi - subcanaactors relating to registration
should be directed to: Director, Home firm., emeur Contractor Registration,
One Ashburton Place. Boston, MA vmi. 617-727-3548
12. PER'>II s'S (NLA customers only)
PAis obligated toapd will obtain the following permits for this project:
Oq /i%) //1 L --Homeowners who secure their own nermits will be
e c uded $ora the guaranty fund provisions of Massachus= Czese,al Laws.
chapter 142A.
In addition to the rights and warranties enumerated in this agreement, you may
have additional rights under Massachusetts General Laws, chapter 142A and
730 Code of Massachusetts Regulations R6.
13. NOTICE OF 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 his main office or branch thereof, provided you notify
the seller in writing at his main office or branch by ordinary
mail posted, by telegram sent or by delivery, not later than
midnight of the third business day following the signing of this
agreement.
See the attached Notice of Cancellation for an explanation of
this right.
Do not sign this contract if there are any blank spaces.
i
Cust , �;r aru fi
J /
Date
NOTICE OF CANCELLATION
Customer Name: p/�&s
(Please print)
Date of transaction: �V,/V
You may cancel this transaction, without any penalty or obligation, within three business
days from the above date.
If you cancel, any property traded in, any payments made by you under the agreement,
and any negotiable instrument executed by you will be returned within ten business days
following receipt by the seller of your cancellation notice, and any security interest
arising out of the transaction will be cancelled.
If you cancel, you must make available to the seller at your residence, in substantially as
good condition as when received, any goods delivered to you under this agreement; or
you may if you wish, comply with the instructions of the seller regarding the return
shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up
within twenty days of the date of your notice of cancellation, you may retain or dispose
of the goods without any farther obligation. If you fail to make the goods available to the
seller, or if you agree to return the goods to the seller and fail to do so, then you remain
liable for performance of all obligations under the contract,
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation
notice or any other written notice, or send a telegram to
Pella Windows and Doors, at 45 Fondi Rd., Haverhill. MA 01832
not later than midnight of J/ (three business days from the date of
transaction above).
I hereby cancel this transaction.
(Date)
(Buyer's signature)
DISPUTES
Job Name P jM-. 5
Date
THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE N
ADVANCE THAT N THE EVENT PELLA HAS A DISPUTE CONCERNING THIS
CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE
ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY
OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINT-SS
REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO
SUCH ARBITRATION AS PROVIDED N M.G.L.c. 142A
Contractor
Hom'901<vner
NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE
AGREEMENT OF THE PARTIES TO ALTERNATIVE. DISPUTE SETTLEMENT
INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE
ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT
SEPARATELY SIGNED BY THE PARTIES.