HomeMy WebLinkAboutBuilding Permit #872-15 - 23 COBBLESTONE CIRCLE 5/4/2015Permit No#: N I'L"
Date I
BUILDING PERMIT
TOWN OF NORTH ANDOVER
,YLICATION FOR PLAN EXAMINATION
Date Received "
�Qq°RAreo
gSSACHUSS�
i I Il}WORTANT: Applicant must complete all items on this page
LOCATION t r
Print
PROPERTY OWNERCf( c 'Ag4t
Print 100 Year Structure' yes no
.MAP _PARCEL: _ oy ZONING DISTRICT: Historic District yes' no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
}Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
b Septic E! Well
❑ Floodplain ❑ Wetlands
❑ ;Watershed District
❑ Water/Sewer:
-1de
OWNER: Name:
Address: a3 co We
Contractor Name: U4
012
nt rficationn Please Type or Print Clearly
rrQ� V rQ�GIIZ �
Supervisor's Construction License: �6—q�t 3 'Exp. Date; � �C
Home lmprd,Vement Licenser 1,70 -75'- Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �lI`tdd �� FEE: $
Check No.: M13 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have accgss to u fund
Location a3 0
No. Date
, -7
Check # ,
TOWN OF NORTH ANDOVEA
Certificate of Occupancy $
Building/Frame Permit Fee $443
Foundation Permit Fee $
Other Permit Fee $
TOTAL
A� T�1�
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF. SEWERAGE DISPOSAL
Public Sewer❑
Tanning/Massage/Body Art ❑
Swimming Pools El
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
COMMENTS
Reviewed On Signature,
CONSERVATION Reviewed on Signature
COMMENTS,
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wafter & Sewer Connection/Signature & Date Driveway Permit
DPW Town'Engineer: Signature:
_ Located 384 Osgood Street
FIRE DEPRTME-N TernDu �ster`�on si e y s to
�Lo ated at1�2�4 Main Streets mp
-
F�ire Depart�menKi- tune/date
T - i.�.r
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
I ❑ ' Notified for pickup Call Email
Date Time Contact Name
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
OTE: 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
OTE: 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
2012, I ECC Energy 'code
Engineering Affidavits for Engineered products
TOTE: 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
Doe: Building Permit Revised 2014
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Customer: 3 �� sfa� G t Ir'
)IIJ- AAdotAr 018L(5- q,7 3-6K-03(19
Description of work Performed:
CD Roofing
Vincent Colangelo
3 Hodgson St.
Tewksbury, Ma 01876
978-656-8497
vincentcolangelo@sbcglobal.net
HIC Llc # 170575
CSSL Lic # 105943
00
OWENS CORNING
PREFERRED CONTRACTOR
Obtain required town permits & provide certificates of insurance & workers compensation
'Provide Dumpster set on planks *for contractors use only (materials all recycled)
( 'Attach Large Tarps to protect adjacent finishes, landscaping, and property.
o Strip -off ( I ). existing layers of roofing on complete house & re -nail any loose decking
(*Install 8inch t ) Aluminum Drip edging / Owens Corning Starter Shingles
0, Install Owens Corning Ice & Water shield 6ft at eaves, 3ft in valleys, around all penetrations
Install Synthetic felt paper to entire roof
9 Install Owens. Corning LifeTime warranty TrulDefinition Duration shingles
(,)'.Install new neoprene vent pipe flashings on all plumbing pipes
( Install Owens Corning VentSure ridge venting with moisture guard
0 Install Owens Corning ProEdge hip & ridge cap shingles
y. 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
6o AA e -e(/ CI- tjcl ' sdi,'e 14( Ftgf Koo�S,
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
specittications 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
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.
We propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of:
dollars ($ j [ ! , ). Said amount shall be paid as follows:
Note: This proposal may b.e withdrawn by us if not accepted within 30 days.
YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT-:W_:JHE THIRD BUSINESS
DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED -NOTICE ?_ OF CANCE11ATION 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, C� #'
39 �
Work will nVtbegin ur t our right to cancel has expired and you -hive p a d gg
of
dollars ($ d (7p0 . ), unless this agreement provides other 'i e. if
Signature of Contractor or authorized representative(
*(I/We) have read the terms stated herein, they -have been explained to (me/us), and (I/We) find them to be satisfactory
and hereby accept them. ' �j '
Signature of Homeowner(s): ` t `( �t C �) , �` 5�'t ' �•
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
5�• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:_ `"I�P,til i.ci
Are you an employer? Check the appropriate
Phone #: 7� Pvtf�'7
1.❑ I am a employer with employees (full and/or part-time).*
2.❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either, have workers' compensation insurance or are sole
proprietors with no employees.
S.i am a general contractor and I have hired the sub -contractors listed on the attached sheet.
tom'` These sub -contractors have employees and have workers' comp. insurance.1
6. FJ 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):
7. ❑ New construction
8. ❑ Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
12.0 Plumbing repairs or additions
13. ❑ Roof repairs
14. ❑ 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 a new 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
C N
Insurance ompan y __ LExpiration Date: 3
/ - -
Policy # or Self -ins. Lic. / ACX W
Job Site Address:
5 n g fir(— 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this sthement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify
Phone #
of perjury that the information provided above is true and correct.
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and 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 legal representatives of a deceased employer, or the
receivbr'or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
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 be an 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 of public work until 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy workers' compensation 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 insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to 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 legibly. 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
AO CERTIFICATE OF LIABILITY INSURANCE
7(MMWYM)
4/23/15
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(es) 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 thi s certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Angela Westen Insurance Agency
557 Central Street
Lowell, MA 01$52
CONTACT
NAME:
PHONE(978 735-4094 FAX N ; (978) 735-4095
ADM'DRESS: angela@awesten.com
INSURE S AFFORDING COVERAGE NAICA
INSURER A: ATLANTIC CASUALTY INSURANCE CO
INSURED
F 0 CONSTRUCTION corporation
119 FARMLAND RD . APT 1
LOWELL, MA 01850
INSURERS: HARTFORD UNDERWRITERS INS COMP
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES I 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.
INSRADDL
LTR
TYPE OF INSURANCE
SUBR
POLICY NUMBER
POLICY EFF
M/DDK
POLICY EXP
MM D/YYYY
LIMTS
A
GENERAL LIABILITY
X COMMERCIAL GENE PAL LIABILITY
CLAIMS -MADE F OCCUR
L021008696
3/18/15
3/18/16
EACH OCCURRENCE $ 1,000,000
DAMAGE MISEMENTED $ 100,000
MED EXP (Arty one person) $ 5 000
PERSONAL& ADV INJURY $ 1,006,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMITAPPLIES PER
17 POLICY PRO LOC
PRODUCTS - 00 MP/OP AGG $ 1 000 000
$
AUTOMOBILE LIABILITY
ANYAUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
NON OWNED
HIREDAUTOS _AUTOS
CONS INEDLSINGLE LIMIT $
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPEERdnTeYDAMAGE $
Per
UMBRELLALIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
B
WORKERS COMPENSATION'
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTNE Y�
OFFICERIMEMBER EXCLUDED?
(Mandat'ory in NH)
If yes describe under
DESG�RIPTIONOFOPERATIONS below
N/A
2E112068
3/30/15
3/30/16
WC SLI r 01R
—'
E.LEACHACgDEN1T $ 100,000
E.L. DISEASE -EA EMPLOYE $ 00,000
E.L. DISEASE -POLICY LIMIT $ 500F000
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES.(Attach ACORD 101, Additional Reim rks Schedule, if more space is requi red)
LARRY AND NANCY HOPP
16 AVALON ROAD
STONEHAM, MA
ACORD 25 (2010/05)
Phone: (781) 665-7740
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
v iyna zu It; At,unu t,unrunm I ium. All nyrus reservCu.
The AC ORD name and logo are registered marks of ACO RD
Fax: E -Mail:
I -__
• C��e a�ra�u.�ruacci r n 'G trJJuc�rr.:c�1'�
E?Mee of Consumer Affairs & Business 13e;ulation
ME IMPROVEMENT CONTRACTOR
egistration: 170575 Type:
xpiration: ; ;.Tih0%2v95 DBA
CD ROOFING
VINCENT COLANGELO'":_'':� "'
3 HODGSON ST
TEWKSBURY, MA 01876 Undersecretary
9%lassachusetts c,?lr'. a? ` 4 Pub'iC +3fCt'r
.3oarrifuiir!inraegi�l+t`cn5=a-c� S*arr�iards+
- . _ `E`,�tiitrHctiw� .r^iui�ciry i�ur Si�eci.lt� . .
cense: CSSL-105943t
105��lit
'VINCENT COLANGELO
3 $ODGSON�STREET
Tewksbury MA 01876
• ��r+.: �+. .- - rah,*
ni•» a; .ane` 03/09/2016
