HomeMy WebLinkAboutBuilding Permit #763-11 - 2 PARK WAY 5/10/2011BUILDING PERMIT of No DTH q
TOWN OF NORTH ANDOVER o2 y`�t' •�;',`.6~� f
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received 4
Date Issued: ��% ��
A044re
Ssga
IMPORTANT Applicant must complete all items on this page
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LQCA�TION�
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PROPERTY OVI/NER
,`MAP,'210- `�7 PARCEL
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Historic 418NQ
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acFiEne Shop `Village
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TYPE OF IMPROVEMENT
PROPOSED USE
New Building
Residen '
Non- Residential
ne family
Addition
e family
Industrial
Alter
No. of units: _
Commercial
P air, replacement
Assessory Bldg
Others:
Demo i io
Other
Septic (Nell '
" Floodplain L'Wetlands
WatershedDistnet
Water/Sewer.
f_
v�rv�. rr\ �.,. 1 � _ .. _ BE PREFORMED. _ _
Y'oDES C IPTION OF WORK TO
• ,-.
or Print Clearly)
CONTRAGTiORr Narne Y' 'I PhoAV-
ne::
y 11 v l'•1a
;Address-
Supervisor's Construction LEx
icense:
kp Date I"
Horne Improvement License: �_. . � i Ezp We
J
ARC
H-
ITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULD/NG PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 1 y M , FEE: $_
J
Check No.: /"? A� ox Receipt No.: y/ moi'
NOTE: Persons contracting with unregistered contractors do not have access to t
fund
Signature of Ageiit/Owner77
Signature of contractor
.J
Plans Submitted Plans Waived Certified Plot Plan
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/MassageBody 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 on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted--
c
Planning Board Decision:
1
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
_.. - -
FIRE: DEI?ARTMEN'T _ " _Located
- — -- - -
Temp Duinpste on site yes _
oc
a e Osgood Street
Located 24, Main StPeet
at1 „ n
b
Fire. Depa -tsi nature/date r�� M
COMMENTS .. e ' . .
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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
Doc.Building Permit Revised 2010
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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
�hoto Copy Of H.I.C. And/Or C.S.L. Licenses
opy 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 K.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 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 2008
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The Commonwe¢lth of Afassachusetts
Department o f Industr-ial _gccidents
Office ofinvestigations
..600 Washing ton Street
Boston, MA 02111
M7WW. m.assgov/din
Workers' Compensation Insurance Aff davit. Builders/Contractors/Electricians/Plu
a Iicant Information tubers
Name (Business/Organization/individual):
Address:
City/State/Zip:
Are y u an employer? Check the appropriate box:
1.1�y 1 am a employer with ��_
4. ❑ I am a o
employees (full and/or part-time).*
• ❑ I am a sole
have hire dem contractor and I
the sub -contractors
proprietor or partner-
ship and have no employees
listed on the attached sheet x
working for me in any capacity.
These sub`cOntractors have
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation
required.)
❑ I am a homeowner doing all
and its
officers have exercised their
work
myself. [No workers' comp,
right of eXCM3ptioner MGL
C. 152 I P
' � �4)� and
instu'ance ret
q
we have no
employees. [No workers'
comp ins
Type of project (required):
6. ❑ Neuf construction
7. ❑ Remodeling
g• ❑ Demolition
9. ❑ Building addition
10. [1 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑kofrepairs
I3.
* 4-y ZPPh--nt that box.
ch— to duce required-]
Other
..�: -� tuts! s?st, tit's cet the recti„
' I9omeo ee_i s^os:r= t^ar wort comY sem* o�
wnera who suomitthis affidavit indicating e}, a*r dciug a.. wct#; and
Contractor-, that ch=ic this box m::at atm„ hed av addiiioaai sheet showing the - rV yv, y�
titan hire outside contract- :. sohm't a new
Game of the sub -c amdavn ma; sting such.
r .. onnactors and thP:r u,.,a.�.
- . "•` ""yN.yer uiar is providing workers' compensation insurance form e
informcfion y mployees.
Insurance Company Name:
Policy # or Self -ins. Lie. #.
Job Site
=r• PI—Y mrormanon.
Below is the policy and job site
Attach a copy of the workers' compensation olicy declaration page (rho C� / /Z� � �� r MQ
Failure to secure coverage as required under Section � �' the policy number.and expiration date).
fine up to $1,500.00 and/or one-year imprisonment, ass well asMGvfi penalties l ad toohee imposition
a STOP Ifr.
Of up to $250.00 a day against the violator. Be advised that a co Penalties of a
Investigations of the DIA ORDER and a fine
g urance coverage verification. Py of statement may be forwarded to the Office of
I do hereby
ofPeriurj, thQz the inform m on provided above rs true and correct
Official use only. Do not write in this area, to be completed by city or town ofjzcial
City or Town:
hsuiiza Authority (circle one):
1. Board of Healtb 2. Building Department 3
6. Other
'�'ermit/License #
Cify/Town Clerk 4. Electric:aI Inspector
Contact Persuir•
Phone 'f
5. PIumbinb inspector
Information an- d 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 Iegal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association og other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartMLents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maim9--mance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be cause of such, employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or Iucal licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to c onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coxnpliance 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 unTtl 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), addresses) and phone mrmber(s) along with their certificate(s) of
in==e. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other tim the
members or partners,are not required to carry workers' comp easation 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 hwurance coverage. .Also be store to sign and date the affidavit The affidavit should
be retjrn ,1 to the city or town that the application for the uert>:liit or license is being . re
questted, not the .Depar=ent. of
Industrial Accidents. Should you have any questions regardinLg the law or if you are;. ed . 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 legrbly. 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 Office of Investigations would is7ce to thank you in ath-Mce 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 Commonwealth ofM&_saahusetts
Department of Industrial Accidents
Office gf Iitvestte�atdons
600 Washiaaton Street
Boston, M -A 0.2111
Tel. # 617-72.7-4900 ext 406 or 1-9 —/7-M 4SS:�E
Revised 5-26-05 Pax # 617-72.7- 7749
vrvrrw-mass.. nv/dia.
]C��E •O.F•'L['.A-M.aw�•
DATE (bIM1DalYY)
NSUR CE,
='-�CEf� 1 1,1
lt:' .- 1 . 03/10/2011
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ALLAN INS13R3lNCE AGENCY 1NC .
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
63 1/2 Jefferson Avenue 2nd F
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. SOX 511
COMPANIES AFFORDING COVERAGE
SALEM MA 01970-0515
_. — —
COMPANY
A Seneca Insurance Company
WSUFiED _
COMPANY
S Safety Insurance Group
TGLRC INC db8 Lambent`'>5toofiug
__-
265 WINTER STREET
COMPANY Landmark Insurance Company
C
HAVERHILL MA. 05.830-_--
COMPANY National Union Fininsurance
R
.CQVieFiAGES �• .•. .; .
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THI= POLICY PERIOD
INDICATED, NOTVATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAK THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THF TERMS,
EXCLUSIONS AND CONDITIONS OF SUCK POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-
COPOLICY EFFECTIVE POLICY EXPIRATION---
TYPE OF INSURANCE POLICY NUMBER LIMITS
LTR. DATE (MMIDPIYY) DATE IMM10011M
GENERAL
LIABILITY
BOOILY INJURY OCC
X
COMPREHENSIVE FORM
GL3000422
11/12/2010
11/12/2011
BODILY INJURY AGG
$ 2 pOpr00D
PROPERTYDAMAGEOCG
PREMISESIOPERATIONS
$ 2 000 000
A
—
uNDERGROUNO'
EXPLOSION & COLLAPSE HAZARD
/
PROPERTY PAeeAGE AGG
X
PRODUCTSICOMPLETEDOPER
sl & PD COMBINED OCC
$
X
CONTRACTUAL
/ /
/ /
BI & PD COMBINED AGG$
- _
INDEPENDENT CONTRACTORS
PERSONALNJURYAGG
$ 1,000,000
X
BROAD FORM PROPERTY DAMAGE
/ /
/ /
-,-
Medical Payment,,,_
5,000
X
PERSONAL INJURY
AUTOMOBILE LIABILITY
BODILY INJURY
ANY AUTO
(Par Par—)
ffi
8
ALL OWNED AUTOS (PrivatsPass}
8203819
07/9.6/205.0
07/16/2011
BODILY
-
XX ALL OWNED AUTO
(Over than Private Passenger)
dd
s
X 111IREDAUT08
/ /
f /
X NON-OWNED AUTOS
_
PROPERTY DAMAGE
$
GARAGE LIABILITY
BODILY INJURY—
PROPERTY DAMAGE
$ 1,000,000
COMBINED
EXCESS LIABILFrY
EACH OCCURRENCE
$ 5,000,000
C
X �umBRELLAFORM
LBA054597
11/12/2010
11/12/2011
AGGREGATE
$ _ 5/00a 000
OTHER THAN VMSR"LA FORM
$
13
WORKERS COMPENSATION ANDWO
EMPLOYWW LIABILITY
009934145
0$/26/2010
08/28/2011
STATU. $ 0TH
IMITS..
Ei&KM., CCIDE.NT
$ 1,000,000
THE PROPRIETOR! $ INCL
PARTNERS'F*CurNE a
'
/ /
/
EL DISEASE- POLICY LIMIT
...
$ 1,000,000
..
OFFICERS AK-: IEXCL
ELDISEASF-RA EMPLOYEE
S 1 R00 ODD
OTHER
DESCRIPTION OF OPERA'nDNWLCCA'nONSNEHICLMSPECIAL ITEMS
7 -
MOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE
EXPIRATION DATE THEROF, THE ISSUING COMPANY WILL ENDEAVOR TO (NAIL
30 DAYS WRITTEN NOTICE TO THE CER-fIFICATE HOLDER NAMED TD THE LEFT,
PUT FAILURE TO MAIL SUCH NOTICESHALL IMPOSE NOOBLIGA1104 OR U"IL}TY
OF KNiq UPON THE COMPANY, ITS A EN PpRESENTATIVES.
AUTH REP in VE
ACQRa 25 f {gl9Sj: :.. ,. . `' . • : ' ``'
ACO0I3GCJRP(*ATION•1688
Da
flice of C,
Affairs andif
Lsumer A usi=ss Regulation
-10 Park Plaza - Suite 5170
Boston, Massqsetts 02116
1-iome Improvement tkodor Registration
LArV!B7E-JRT1ROOr-jN.iG CO
RICHARD LAMBERT
265 WITERSI-REET,
HAVERHILIL-., 'PAA 01830
- i
"PS-CA11 C' 5()M-04104-0101216
Reqistrafion:,, 149221
Type: Nivate Corporafion,#
Expiration: 12/6/20-11 -fr . 290268
daie Address and .return card. Mark reason for chang,
A .2-2
Li rM L -j - neuewal E] Employment [] Lost C:
W..
N-Jassachusetts - Depar-iment of Public Wet
Baht (-.-f Building Regrohitions and Standards
Construction Supervisor License
License: CS 78130
RICHARD J LAMBERT
94 PICADILLY RD
HAMPSTEAD, NH 03841
Expiration, 602012
Tr#: 30062
'k
EIole-P
-050-3313
MiHIC # 149221
MUCS # 78130
BBB. Siy License# 1711
T. G
Umber
r4ofing
SivLCei1932 CO-
265
Winter Street
Haverhill MA 01830
*Licensed *Insured *Factory Trained
Name:
Haverhill MA 978.374.9224
Lawrence MA 978.687.7339
Hampton NH 603.929.9224
Hampstead NH 603.329.8200
Toll Free 1.888.SOS.ROOF
*Factory Certified
Date:
Telephone: rte! 'eZL9Z&4 Alt. Telephone: E -Mail:
Billing Address: Job Address: Z ?(JaY- L1 OIy AJ , &106A2.r
Scspe of Work Strip and Re -roof ❑ Re -roof Approximate Roof Area:c'-
repare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
emove existing layers of shingles down to roof deck and dispose of in a legal fashion from thejob 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 *$ 2_2'' per SF. If individual sheets are found to be
rotted/or de -laminated, removal, disposal and replacement will be performed at *$ 6-0. ' per sheet. If any trim boards are rotted,
replacement will be performed at *$ 12,75 per LF for new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if
w iscover any damaged flashing or siding at the roof line, replacement will be performed at *$'—' 1-r- If wood deck, siding, and
a hing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing.
Z'nstall 8" drip edge to all rakes and eaves. Color
ply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or
Mpply premium (UNDERLAYMENT) to the balance of the exposed wood deck.
�p
�e-flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensue water tightness.
If upon inspection, we discover chimney lead to be worn or deteriorated, replacement will be performed at *$
Install a new: c- L ` 3 v Year ❑ Traditional Architectural El Designer 1-# Ea �' k,9 n a C� �' ro
�
❑/Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$ C + -
�1 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.
i�
Special Notes 13A C 1iavD ;? N"a S D i�� rYl OyfnL
Au -
UPONu -
UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND 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: $I1'�_. od (*)
Payment will be made according to the following work schedule:
$ 4-1006 . 06 deposit upon signing contract
by —/_/_ or upon completion of
66 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
Acceptance of the Contract Proposal
Home Owner(s) Signature(s): Date:
Contractor's Signature: �� Date: / / 1
Location
No. -2 0 // Date 5 1U ii
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 26 Of
i
24148
v� Building Inspector