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HomeMy WebLinkAboutBuilding Permit #650-13 - 25 ELMCREST ROAD 4/8/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION L Permit NO: �� S �' `4_ Date Received 9 Date Issued: IMPORTANT: Applicant must complete all items on this page �► �sP st LOCATIONi 1 PROPERTY°OWNER, �a'1 D 0 Ao-V`i-1 _ Print; 90owear,61diStructure yesno,- MAP NO": PARCEL:ZONING DISTRICT: Historic District yes no, Machine_,Shop, Village yes no, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial RRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic, Well ❑ Floodplain, ❑ Wetlands ❑ Watershed�District` Water/Sewer, . DESCRIPTION OF WORK TO BE PERFORMED: dentificatio OWNER: Name: �cr l �c Address: C� `r �rM C ne Please Type or Print Clearly) 9A0v.r4,1 e CONTRACTOR' Name: Phone.-. Address:Sf_ olg 7c. Supervisor'sConstruction License: " Exp Da._t_e: _36/1J, Soo d 3 Y -5 - Home Improvement License: I -7o -5--7 -5- Exp. Date: t f l/G /15 ARCHITECT/ENGINEER Phone: 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: $ FEE: Check No.: / Receipt No.: f? NOTE: Persons contracting w' pnrg,tered contractors do not have accessto the tyfund of Agent/Ovvr er Signature`of contracf0 : r% Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans 9 Location �2 No. 10� Date I TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check# ,45 26259 Builaing Inspector 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 COMMENTS CONSERVATION COMMENTS HEALTH j COMMENTS DATE REJECTED DATE APPROVED ❑ 1❑ Reviewed on Signature Reviewed Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sevier Connection/Signature & Date Driveway Permit DPW Tow; Engineer: LOcatea ;R54 uS ooa Jtreet FIRE DEPARTI MENT - Temp Dumpster on site yes no Located at'124.Main`Street.. Fire Depaqnier�lt�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 iso MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The foliowing 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 app:.al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm;ated with the building application Doc: Doc.Bui?ding Permit Revised 2012 I Anmm m m m y m y U N ="• < m U rMl.O, O 0 �vQ-0 t/1z o � � vi � N p O tR ,O,r �' TI C O_O a 0 m N �• O 2 O Q pO U3 (O 11. O N, O O o v S CD eZ CD CD . ZN C CD S 0 to —•_ Cl) Cro. pzp� a (�0 'y: ;:L C O X v��` V Z < QQ o Cl) o CD o Z porn yCD 71�, � .L � • C CcD ou 0 CA � cc �, Z C CL Nm It to t lcnCl) CD D 0 Nom: N C Z �• C CD y �' .f : p --h : 0 70 c CD n C czn: CD -0 a n: c 2) O ; au O 0.7 m ;v O A N 3 o rDr+ O ID F KW CD m z O C M m 70 3 m T O' wago :O O S H vZ, m O T j m Ln < w O opo S m � Z m 0 T j �7 O S � C W �_ Z 'O m 0 T n ? 7 .Z7 O S T O 3 a - ��* O W C v z O Z m 0 N fD ° f7 < 3' T O oa \ S M W > v O T m 2 Z` �O Vq CDROOFI-01 RWALKER CERTIFICATE OF LIABILITY INSURANCE DAT1262D/YYYY) 412 612 012 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 License # PC -904790 John M. Glover Agency P.O. Box 700(AIC, Norwalk, CT 06852 CONTACT NAME: PHONE FAX AIC No Ell: (203) 838-5554 (FAX No): (203) 857-7848 AD RIESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Montpelier US Insurance Co INSURED Vincent Colangelo dba CD Roofing 3 Hodgson Street Tewksbury, MA 01876 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES 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. INSR L. TYPE OF INSURANCE ADD INSR R POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx] OCCUR X $1,000 Per Claim Ded TBD 4/27/2012 4/27/2013 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X I POLICYPRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY t DAMAGE $ Per acc den $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatoryin NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Tewksbury ry 1009 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Tewksbury, MA 01876 AUTHORIZED REPRESENTATIVE CK . Q0_ ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,Y www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers )r Name (Business/Organization/Individual): t / C /l CQ'1 Address: City/State/Zip: L Please o/67(6 Phone #: G178 -C 5^6 qc, Y9 Lre you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I , ,,employees (full and/or part-time).* have hired the sub -contractors `[�i I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ty applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. w irn employer that is providing workers' compensation insurance for my employees. Below is the policy and job site �rmadon. arance Company Name: icy # or Self -ins. Lid. #: Expiration Date: Site Address: City/State/Zip; ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIAJgHi "nce coverage verification. 0 hereby cer, ' nndder ze p t andpenalties ofperjttry that the information provided above is trite and correct. iafirr late �/L ��� ne #: ct 7A C )fficial use only. Do not write in this area, to be completer) by city or town official. Aty or Town: Permit/License # ssuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other 'nnfarf Parenn• Phnna #i- 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 receiver 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 carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 bur leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ?lease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. ## 617-7274900 eyt 406 or 1-877-MASSAFE Pax:E Al7_7?7-.7749 •�1 Massachusetts _Department . =° Board o$ Buildiri of Public Safety 9 �eg.dl�tion5 and Standards ' Cunstr'qYiun Super isu+' Specialh License: CSSL-105943 VINCENT co \k 3 HODGSON%S Tewksbu TREET t, ry D, A 01876 t Commissioner Expiration . 03/09/2016 z Office of Consumer Affairs & Bu iness Regulation HOME IMPROVEMENT CONTRACTOR Registration: 170575 Expiration: 14t 013 Type: DBA CD J r LANA p VINCENT CO '�! L-J d . ,•.� .'ff 3 HODGSON ST TEWKSBURY, MA 0187 Undersecretzry 1' i i - F. 3 Hodgson St. Residential/Commercial Tewksbury, MA 01876 Masonry 41mo Ph: (978) 656-8497 Cell: (860) 712-8279 Vincent Colangelo Free Estimates Lic. #170575 ROOFING Fully Insured Proposal Submitted to Homeowner Work To Be Performed At Name �' c) 4 a I A A Street '-- It I (- Street Art f r e.4 `vl -- City State City ��rll� A r* State A _ Date Telephone Telephone Complete Description of Work to be Performed: o I e e' � %� c Ir 00'Fo 0a //l I J F7i1 %IN IQ P n Se Ct r' _ - Q - f r". D +. I n r /1 1.1.3 (— t, r 1 n 0 VP � 'i%e, T" ,D. ,QP `'' no - t r I -f 1,U (�e r.44 i I Date work will start Date work will be completed 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 specifications 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 ($ 5-r 161Dp. cO ). Said amount shall be paid as follows: Note: This proposal may be withdrawn by us if not accepted within days. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. THIS SALE IS SUBJECT TO THE PROVISIO-,NS?OF THE HOT,SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEG I'4►BLl. Work will not begin until your right to cancel has expired and you,have �d a d oslt of dollars ($ a ), unless this agreement provides�6th Ise. �-760. ,;. Signature of Contractor or authorized representative: *(VWe) have read the terms stated},erein, they have been explained to (me/us), and (VWe) find them to be satisfactory and hereby accept them. Signature of H eowner(s)-