HomeMy WebLinkAboutBuilding Permit #502-12 - 216 WAVERLY ROAD 12/23/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: bo -2 2 Date Received
Date Issued: a
MPORTANT: Applicant must complete all items on this page
LOCATION d/r1 d Zaae,2L�
Print
PROPERTY OWNER c ve, Unit #
Print
MAP NO: `PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
❑ One family
❑ Addition
0 Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
0 Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
_
{ 0]Segtic ❑ W 1
®fFlpoodplain�T��Uetlanclsj
l
ra e shADstn" cwt`
®gWater/Sewers
OWNER: N
Address:
CONTRACI
Address:
,JL aUUMF i WIN Ur wUK1K lv BE YERYUKMED:
WE
Ir
n Please Type or Print Clearly)
Supervisor's Construction License: Exp. Date:
Home Improvement License: /Y�7,Ad/ Exp. Date:
ARCHITECT/ENGINEER
Phone:
/� P13
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: $ /® e0,5 FEE: $ 7,�- o
Check No.: /4(,73 -7 Receipt No.: l
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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 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: Comme
Water & Sewer 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
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
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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/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: Doc.Building Permit Revised 2008mi
Location 1,41%
No. ' �2 Date
NORTIy
TOWN OF NORTH ANDOVER
�e
Certificate of Occupancy
$
J�CMus t�
Building/Frame Permit Fee
$ Da
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
24909 ` it ing Inspector
U
Board of Bu9ld3n'i4 R';�-Tuiatkons an(j
CS 78130
RICHARD LAMBERT
94 PICADILLY RD
HAMPSTEAD, NH 03841
6/212012
30062
Office of Consumer Affairs and 2us
MANN
10 Park Plaza - Suite 5170
Boston, IvIassacausetts 02116
Home Improvement C ctor Registration
Registration: 149221
Type: Private Corporation
Expiration: 12/6/2013 Tr# 218746
I A-).L.MA, aba Lambert Roofing Campany
RICHARD LAMBERT
265 WINTER STREET
HAVERHILL, MA 01830
Update Address and return card. Mark reason for change.
DPS -CAI -°, 50N4-04/0-"-G!012--C ❑Li ress L_j Renewal ❑F1 Employment [--.I Lost Card
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/Ac -"M" F -DATE (MMIDDNYYY)
CERTIFICATE OF LIABILITY INSURANCE
11/01/2011
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, ANDTHE 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 endorsemenqs),
PRODUCER
ALLAN INStjRANcE AGENCy INC.
63 1/2 Jefferson Avenue 2nd Floor
P.O. BOX 511
CME:Jerrold Kameras
PHONE
,,,(978) 745-5905 FAX
IAICNol- (9") 145 -5483
E -RAIL
ADDRESS: Jerrold@allaninsurance. com
INSURERS AFFORDING COVERAGE NAIC P
SALEIM MA 01970-0511
ecialty
INSURED
TGLRC Inc.
dbaLambert Roofing Company
265 Winter Street
Haverhill MA 01830-
wsuRERs;Safety Insurance Ct�mpany
INSURER :Alterra Excess Sualus Ins.
INSORERD:Chartis Insurance Company
INSURERE:
INSURER F
COVERAGES CFRT1F1rATr- tJtIMRJ=P-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANOING ANY REOUIREMFNT, 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 SMJFCT TO ALL THE TERMS,
EXCLUSIONS AND CON Di7:0NS OF SUCHPOLICIES: LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS,
IF4S—RT—
LTR I
TYPE OF INSURANCE
5DF
SUR
POLICY NOMBER
POCY EFF
MLIIOD/YYYY)
ICY EXP
jm
LIMITS
GENERAL LIABILITY
EACH OCCgRREROCCURRENCE:1 100000(
'0,
X MERCW, GENERAL LIAR xry
CLAIMS-MADF FXIOCCUR
NJ_CGL000000G676_G1
11/12/201111/12/.2012
DAMAGET RENTED
PREMISES S 5000(
MEDF.XP.(AnyDna pf)rscn) 100(
PERSONAL & ADV INJURY 100000(
GENERAL AGGREGATE 200000(
GEN'L A(�GRFPOLICY ,,'JkTf: LIMIT APPLIES PER
OL LOC
F
PRODUCTS I COIAPIOP AGO 200000(
AUTOMOBILE
LIARtUTY
=,�INGLE LIMIT
100000(
B
Px
ANY AUV' ;
ALL. OL' MED SCHEDULED
AUTOS EXI AUTOS
I
6203819
07/16/2011
D7/1612012
BODILY INJURY (Por $
BODiLY INJURY (Pwabodont) $
X
HIRED AVIDS NON -OWNED
AUTOS
PROPER AM - AGE.
,(Pp D
S
—
UMBRELLA UAB
I
OCCUR
EACH OCCURRENCE $ 500000,
C
X
EXCESS LIAO
X
CL_AIMS4AADE
KAX3=50000040
11/12/201111/1.2/2012
AGGREGATE S 5000001
DED I I RETENTION
WORKERS COMPENSATION'T
-
I 1_%,",
D
AND EMPLOYERS' LIABILITY YIN
ANY PROPFZIETOR,'PARTNEFZIEXECUTIX,--
OFFICERIVEM9ER PXCLUDEW
(Mandalory In NH)
Lies, desr6be under
NIA
08/28/201108/28,/2012
T 0 R L lh'�'T S. X
E.L. EACHACCIDENT $ 1000001
E.L. DISEASE - EA EMPLOYE S 1000001
E.L, DISEASE - POLICY LIMIT I S 100000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required).
CERTIFICATE HOLDER
ACORD 25 (2010105)
INS025(2oioo,)oi
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
C 1988-2010 ACORD CORPORATION. All rights reservec
The ACORD name and logo are registered marks of ACORD
The Commonweatth ofmassachusetts
Department of.1ndustrial.Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
yY
www.faaassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors)Electricians/I'lumbers
iplicant rnformniin„
Name (Business/Organization/Individual): �j
Address:
City,
Phone #:, ��,����/� c�f�
re you an employer? Check a appropriate box:
1
• lama pto er with
4. ❑ I am a general '
contractor I
employees (full and/or part-time).'
2.01 am a sole proprietor or
and
have hired the sub -contractors
listed
partner-
on the attached sheget. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] T
employees. [No workers'
comp, insurance re aired ]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. [] Demolition
9. ❑ Building addition
Y0.❑ Electrical repairs or additions
I1.❑ Plumbing repairs or additions
12.❑ Roofrepairs
13.❑ Other
* q i
Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy mformation.
L
wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp, policyinformation.
I am an employer that isproviding workers' Com
pensation insurance for my employees Below is the policy and job site
fOTMatloil.
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: �/ ,
City/State"ip:
Attach a copy of the -workers' ompensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofiVIGL 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA, for insurance coverage verification.
r do hereby certify er f s andpenalties ofperjury drat the information provided above is true and correct.
Offcciat use only. Do not write in this area, to be completed by city or town offcial.
City or Town: Permit/License #
Issuing. Authority (circle one):
I. Board of Health 2. Building Department 3. City/Tg" CIerk 4. Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person:
Phone #•
SEIN # 51-050-3313
S MA Reg. HIC # 149221
MA Lic. UCS # 78130
BBB.. Single -Ply License# 1711
0
1/ 11�LX
wLicensed
Narne
Telephone:
T.
mbe
Roofing
Se.ru.�1932 CO.
265 Winter Street
Haverhill MA 01830
*Insured *Factory Trained
Haverhill MA 978.374.9224
Lawrence MA 978.687.7339
Hampton NH 603.929.9224
Hampstead NH 603.329.8200
Toll Free 1.888.SOS.ROOF
Billing Address: I (" � —L )L> f�_ Ac t r City: G `� ��y t 'l State: 1�\ r
Job Address: SG1 Z~ City: el_ States _
Scope of Work rip and Re -roof ❑ Re -roof Approximate Roof .Area: a
repare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and lands ape is properly protected.
1P4emove existing layers of shingles down to roof deck and dispose of in a legal fashion froma job site.
(��spect wood deck, if we discover any rotted wood, replacement will will performed at *$- �� per LF for roof deck boards. If
substantial deck rot is discovered, re -sheathing of roof deck can be performed at *$ SF. If individual sheets are found to be
rotted/or de -laminated, removal, dispos 1 and replacement will be performed at per sheet. If any trim boards are rotted,
replacement will be performed at *$ 6 — per LF for new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if
we discover any damaged flashing or siding at the roof line, replacement will be performed at *$1. If wood deck, siding, and
fling is sound, we will re=f`iail any loose wood to rafters, sweep deck, and prepare for roofing.
titall 8" drip edge to all rakes and eaves. Color LL)�.4G ¢
ply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or
GX ply premium (UNDERLAYMENT) to the balance of the exposed wood deck.
flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
0'r
P,an inspectionw discover chimney lead to be worn or deteriorated, re 1 t will be performed at *$�;
tall a new: Year ❑ Traditional =al ❑ Designer Color
❑ Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$
❑ 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.
Special Notes
UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF—<=—)-
YEARS
F<=—)-YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND ��6�2YEARS 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 erf m the work, futnis e material d lab r specified above for the total sum of: $G''
--- J'r
a/ ' �--------- (Dollars)
Payment will be made according to the following work schedule:
$'�y� c,62 deposit upon signing contract
_cz�.
by =//_/_ or upon completion of
upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
i
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.
i
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
cceptance of the Contract Proposal
Home Owner(s) Signature(s): ZDate: AX7 O�
Contractor's Signature: