HomeMy WebLinkAboutBuilding Permit #655-16 - 22 RALEIGH TAVERN LANE 11/25/2015�eRAIM O /"� -3- /s'
Permit No#:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Q'tZyED ;by6N�\
A°Rwreo
IMPORTANT: Applicant must complete all items on this page
LOCATION - JAL- ,C,c +A -V6 LAI
Print
PROPERTY OWNERtF
Print 100 Year ,kg6tute ° - yes e
MAP 1,W –A PARCEL: 010q ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
COne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
_
❑Septic 11 Well
El Floodplain [I Wetlands
__
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF–WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: A4,4 Li fF-E&I e44144AA-m Phone: ,7 7 J -%4o -7? i q
AdrirPss J-)- R4L tf ' e --ALAI L -Al
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BSED ON $125.00 PER S.F.
7 fpTotal Project Cost: $ 4e2W — FEE: $
Check No.: Z Off & �� Receipt No.:_�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor At,-----
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
COMMENTS
Signature.
CONSERVATION Reviewed on Sianatu
COMMENTS
HEALTH
5,
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
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
Doc.Building Permit 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
❑ 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
❑ 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
VOTE: 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
LocatioQg t4 -b v I Date
No.
Check # tga& r
2100737
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
2
Building Inspector
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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 perform
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 remove
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 perform 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.
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.
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 from the financial institution.
PAYMENTS
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 Contract, 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
completed 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 for 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 all payments then due.
LIMITED PRODUCT WARRANTY
Pella shall warrant all Pella products, but only in accordance with the Pella
Windows & 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 IMPLIED, WRITTEN OR ORAL (INCLUDING WITHOUT
LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS
FOR A PARTICULAR PURPOSE).
10. NO CONSEQUENTIAL DAMAGES
UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR
CONSEQUENTIAL, INCIDENTAL, INDIRECT, OR SPECIAL DAMAGES,
WHETHER FORESEEN OR UNFORESEEN.
11. HOME IMPROVEMENT CONTRACTORS
All home improvement contractors and subcontractors shall be registered with
the director of the Home Improvement Contractor Registration Program
administered by the Board of Building Regulations and Standards. Pella and
any of its subcontractors identified in this agreement have been registered.
Any inquires about Pella or any of its subcontractors relating to registration
should be directed to: Director, Home Improvement Contractor Registration,
10 Park Plaza, Room 5170, Boston, MA, 02116, 617-973-8787, 888-283-3757
or visit the HIC website at htto://www.mass.gov/ocabar/
12. PERMITS (MA customers only)
Pella is obligated to and will obtain the following permits for this project:
Buildin . Homeowners who secure their own permits will be
excluded from the guaranty fund provisions of Massachusetts General 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
780 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.
jl�,f w4e-,* _c��
Customer signature
Date
DISPUTES
THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN
ADVANCE THAT IN 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 BUSINESS
REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO
SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A
Pella Windows & Doors
Contractor
Homeowner
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.
NOTICE OF CANCELLATION
Date of transaction:
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 further 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
transaction above).
I hereby cancel this transaction.
(Date)
(Buyer's signature)
(three business days from the date of
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 0211420.17
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiot>/Individual): 4EIIA 4, 4A16 ) S -,�- b,— r2 LLQ' _
Address: 4 rot -4 n ��
City/State/ZiU:
Phone #: q 78- -Z63—
Are you an employer? Check the appropriate box:
[jI am a employer with --,7S 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ .I am a sole proprietor or partner-
ship and have no employees
working for the in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.]
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.+
5. ❑ 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.]
Type of project (required):
6. ❑ New construction
7. D3;.[temodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 are doing all work and then hire outside contractors must submit anew 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.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: F M Q LCC •,e '7- -�N (►
Policy # or Self -ins. Lic. #:(oq Expiration Date: ._ % "' A
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure 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 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.
1 do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Phone #: 7e-. ZJ65-�7a
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Cli
CERTIFICATE OF LIABILITY INSURANCE06/2912DATE
015
(MWDD/YYY1')
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).
PRODUCER N A
Fred C. Church, Inc. Dorothy A Corlett, CIC, RPLU
NAME:
41 Wellman Street PHONE 978 3227231 FAX (976) 454-1865
Lowell, MA 01851 o
(800) 225-1865 FARAILse. dco lett@fre0cchurch cem AIC No
#
INSURER A : Citizens Insurance Company of America 31534
INSURED
New England Window✓£ Door LLC INSURER B : New Hampshire Employers Insurance Company 13083
45 Fond! Road
Haverhill, MA 01832-1302
COVFReRFS 11013
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED
KtVI51UN NUMBER:
TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR
OTHER
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES
DOCUMENT WITH RESPECT TO WHICH THIS
DESCRIBED
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
HEREIN IS SUBJECT TO
ALL THE TERMS,
INSR CLAIMS.
ADDL SUBR
LTR TYPE OF INSURANCE POLICY NUMBER MWDDY EFF YYYI MWDD EXP
LIMITS
GENERAL LIABILITY
X
EACH OCCURRENCE
g 1,000,000
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
100,000
CLAIMS -MADE a OCCUR
A X CG0001
PREMISES Ea occurrence
MED EXP (Any one person)
8
$ 10,OD0
ZBN8161407 7/1/2015 7/1/2016
PERSONAL 8 ADV INJURY
1,000,000
$
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X PRO- X
PRODUCTS - COMP/OP AGG
$ 2,000,000
POLICY LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
ANY AUTO
ALL OWNED SCHEDULED
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
AUTOS AUTOS
HIREDAUTOSNON-OWNED
AUTOS
PROPERTY DAMAGE
$
Pe accident
8
UMBRELLA LIAB
OCCUR
EXCESS LIAB
EACH OCCURRENCE
$
CLAIMS -MADE
AGGREGATE
$
DED RETENTION $
WORKERS COMPENSATION$
AND EMPLOYERS' LIABILITY
X WC1STATU- OE H.
B
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? ❑
NIA
400040101
E.L. EACH ACCIDENT
500,000
7/1/2015
7/1/2016
$
E.L. DISEASE - EA EMPLOYE
500,000
$
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L DISEASE - POLICY LIMIT 1
$ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mora space is required)
CFRTICHIATP ur11 nco
-M1V%1cLA-M r RJR
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
ant# Mst# `+,.-.u_��__u
.........R v rano-AU 1U AI,UKU GUKYUKA I IUN. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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