Loading...
HomeMy WebLinkAboutBuilding Permit #668 - 256 MIDDLESEX STREET 3/20/2012Permit N0: 6 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: IlgPORTANT: Applicant must complete all items on this pai4e Print Pr' t MAP NO: PARCEL:�ZONING DISTRICT: Historic District yes Machine Shop Village yes 100 year-old structure yes 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 0 eS pti '� Well �" �' >yqAAK oodpla ® etlands E+^1^� ♦fit „E _'i 0 Wa ershed ►—sfrict� *;�'£'.,.t 1 i of Y♦ q•. +�.eUa �] � f.Y�l .� I'� M [�] ► [�] ��d[�J ., :� 1 Cil : i � � � N ��] :� ►�i I � �� (Identification OWNER: W Type or Print Clearly) CONTRACTOR Name: % Phone: Address: Supervisor's Construction License: (0 %e��b Exp. Date: 01 - Home Improvement License:Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST``BASED ON $925.00 PER S.F. Total Project Cost: $141235 FEE: $ 1� Check No.: �-- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund s5 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 o Workers Comp Affidavit o Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks o Building Permit Application o Certified Surveyed .Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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 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 & DEVELOPMENTEl COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comm Conservation Decision: Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: . F Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS L - 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.s10o-$1000 fine Doc:.Building Permit Revised 2011 June/mi Location c25�2 S 1/ ! t&i.A� No. Date�� Check # t �—� 25114 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL M"1 136lding Inspector $ J i 9 O b co 19 ,15 O z W Cd i LL cc LL O L C H O V V •O.'O nc. ev o c p Ea o CD o n F E c _ CO: r; o _ N �C m m '= C N �p N E� }: CLU N O O o c�Q N •p_ C Z 0 0� v y z • C L CLO CD Q1 N CD C m O 0 0 CA LL m �. c •ca C4 �CL= C CJ '® v cm Col. a r m E N L O O ev cm CD m CD c m O .cm C N CD L O Z O J 0 U CO 0 w U C/) i� W O E CDL O O v O CL O y p C I cm ca O •— � p O y � m co ow O �CD � p o _O O d �Q H C� CJ J •O 0� C Z CD C.� y \Y e cc co Q. E LU 0 C= 0 LLI W 19 W 0 O CSG � 0 © , a o d w ,o f� �G C/') � c v b o cz U w a x c w a x W wo' w x w z v o cn cn i LL cc LL O L C H O V V •O.'O nc. ev o c p Ea o CD o n F E c _ CO: r; o _ N �C m m '= C N �p N E� }: CLU N O O o c�Q N •p_ C Z 0 0� v y z • C L CLO CD Q1 N CD C m O 0 0 CA LL m �. c •ca C4 �CL= C CJ '® v cm Col. a r m E N L O O ev cm CD m CD c m O .cm C N CD L O Z O J 0 U CO 0 w U C/) i� W O E CDL O O v O CL O y p C I cm ca O •— � p O y � m co ow O �CD � p o _O O d �Q H C� CJ J •O 0� C Z CD C.� y \Y e cc co Q. E LU 0 C= 0 LLI W 19 W 0 The Commonwealth of Massachusetts Department oflndustrialAccidents Office oflnvestigations' 600 Washington Street Boston, MQ 02111 S www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conilractors/EIectriciansfPlumbers Qlicant In%rmaiion Name (Business/Organization/Individual): Address: .City/State/Zip:/.Po Phone #: A - 1 VLre you an employer? Check the appropriate box: am a employer with.4. ❑ I am a general contractor and ) 2. ❑employees (full and/orpart-time).* l am a sole proprietor or have hired the sub-contragtors listed partner- ship and have no employees on the attached sheget. t These sub -contractors have Working for mein 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 MGL myself. [No workers' comp. per c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp insurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demblition 9. ❑ Building addition 10.❑ EIectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs xequtred.] Un Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensafionpolicy information. T Homeowners who submit this affidavit indicatingthey are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contracfors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' rnrnn -1 urn an employer that is providing workers' compensation insurance for MYemployees Below is the policy and job site infos�mation. Insurance Company Name: ` Policy # or Self-in.s. Lic. #: _ 2-3 �� Expiration Date: 4F-1 Job Site Address: � Attach a copy of the workers' compensation policy declaration a e showi City/State/Zip: �. P g ( ng the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL G. 152 can lead to the impositi Chic up to $1,500.00 and/or one-year imprisonment, as well as civil penaltion of criminal penalties of a as in the form of a STOP WORK ORDER and a fa Dirup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the -nvestigations of the. DA for insurance coverage verification. Office o£ clo hereby cerI y un ' s andpenalties ofperjury that the information proyicled above is true and correct. i nafure: narP• 3� /��r 0— Official use only. Do not write in tliis area, to be completed by city or• town official. City or Town: Permit/Iicense # Issuing Authority (circle one): Y. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectxicaI Inspector 5. Plumbing Inspector 6. Other 201atact Persnn 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, writte express or implied, oral or n:' 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 entify, ever the employing employees. How owner of a dwelling house having not more than three apartments and who resides therein, e the occupant 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 ofpublic 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 thaf apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphone numbers) along with their certificates) 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 wor employees, a policy is required. B e adkers' compensation insurance. If an LLC or LLP does have vised that this affidavit maybe submitted to the Department ofIndustrial Accidents for confMation.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 boftom of the affidavit for you to fill out in the event the Office of fnvesfigations has to contact you regarding the applicant. Please be, sure to fill in the permit/license number Which Will be used as a referencd number. In addition, that must submit multiple pernut/liceuse applications in any given yean applicant ar; need only submit one affidavit indicating current Policy information (ifnecessary) and under -job Site Address" the applicant should write "all locations in jcity 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 notrelated to, any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank yo -din advance 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: l✓ORIMORIW6alth oi. ilassacl u, etis ,l)ep.axiMORt of Industrial Accidents Offike Of Invotigations 600 Wasbington Street Boston M- 02111 617.-727-4900 ext 406 ox 1.~S77_mA88AF Kevised 5-26-'05 Fax # 617-727-7749 -"'1"0*1 . CERTIFICATE OF LIABILITY INSURANCE DATE{MMlOD 03/09/2012012 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(les) 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 ALLAN INSURANCE AGENCY INC. 63 1/2 Jefferson Avenue 2nd Floor P.O. BOX 51,1 CONTACT Jerrold Kameras NAME: PHONE (978IAIC, No) 945-5905 FAX till. (9'x8) 745-5463 EMAIL 0errold@allaninaurance.com ADDRESS. SALEM MA 01970-0511 INSURERS AFFORDING COVERAGE NAIC h INSURERA:Senecat Specialty Ins. Co. INSURED TGLRC Inc. Ciba Lambert Roofing Company X65 Winter Street Haverhill MA 01830- INSURERB:Safet Insurance Company INSURER c :Alters, Excess & Surplus Ins. INSURERD:Chartis Insurance Com an INSURERE: INSURER F: RCYIJIUIV I11UfVIt3r_K: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY,PERIQD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 13E 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. ADDLSUOR itrR TYPE OF INSURANCE POLICY NUMBER MM DIC/YYVY MMID21 EX v LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1; 000, 000 X COMMERCIAL GENERAL LIABILITY / / / / �Y DAMAGE A CLAtMS-MADE M OCCUR 11/12/2011 11/12/2012 Mt ES a ur nce $ 50, 000 MED EXP (Any one person) $ 1,000 J-CGLOOOOOD0696-01 PERSONAL 8 ADV INJURY $ 1, 000, 000 GENERAL AGGREGATE. $ 2,000,000 GEN'LAGGREGATE LIMIT APP_I PRO' PRODUCTS•COMP/OPAGG $ 2,000,000 $ POLICY t.00 LOC / / / % AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT B ANY AUTO / / / / sacci ti S 11000,000 BODILY INJURY (Per person) S X ALL OWNED X SCHEDULED AUTOS AUTOS 6203819 tl7/16/2tl11 07/16/2022 BODILY INJURY (Per acodent) S X HIRED AUTOS X NON -OWNED AUTOS / / / / PROPERTY DAMAGE $ er accident $ UMBRELLA LIAR X OCCUR / / / / EACH OCCURRENCE S 5, 000, 000 0 X EXCESS LIAR CLAIMS -MADE 3EC50000040 / % / / AGGREGATE $ 51000,000 DEO I I RETENTION 11/21/2011 1/12/2012 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY S WCSTATU• X OTW ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBEREXCLUDED? � NPA / J / / E.L. EACH ACCIDENT S 11000,000 D in NH) (Mandatory C001-60-2396 8/28/2011 08/28/2012 II yes, dosctitro under DESCRIPTION E.L. DISEASE - EA EMPLOYE S 1 000 000 E.L DISEASE - POLICY LIMIT S 11000,000 OF OPERATIONS below / / / / DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 141, Additional Remarks Schedule, 8 mono space Is required) New England Development LLC, Newburyport Development Holding LLC,Newburyport Operating Holding LLC, Newburyport Manager LLC, Newburyport Development LLC, NED Management Limited Partnership, New England Development Realty Advisors, Inc., NED Newburyport LLC, NED Manager LLC, NIR Newburyport Realty are listed as additional insureds. (`.FQTICICATC LIAI r1C6 - _ :. _ NIR Newburyport Realty C/O Newburyport Development 54 Inn Street Newburyport MA 01950_ 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 ACORD 25 (2010105) O 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (2atoo5).oi The ACORD name and logo are registered marks of ACORD i Board of Buildiw7 R �ztfl at;1) 11 S ivn'! tru u CS 78130 RICHARD LAMBERT 94 PICADILLY RD HAMPSTEAD, NH 03841 612/2012 30062 Office of Consumer Affairs and 2usinss Regulation 50',fi-04V-G-012`S LJ "Ns LI Kenewal LI Employment ("I Lost Card EIN # 51-050-3313 MA Reg. HIC # 149221 W, MALic. UCS # 78130 BBB Single -Ply License# 1711 LaMi 1 *Licensed T. ambe e'Ofertg " �0. 265 Winter Street Haverhill MA 01830 *Insured *Factory Trained z*Factory Certifie4 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 Telephone'"- 'V Alt. Telephone: Email,, Billing Address: 1 0 rybl b City `t ` k-; Z-1 f State: Job Address: '. - f 1 t"' Citytl f_ moi{fk Staten Scope.of Work ®'Strip and Re -roof ❑ Re -roof Approximate Roof Area: ❑A Pxepare for, re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. ❑ Remove existing layers of shingles. down to roof deck:and dispose of in a legal fashion from the job 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 *$ 6 peper SF: If individual sheets are found to be rotted/or de -laminated, removal, disposal and replacement will be performed at *$ per sheet. If any frim boards are rotted, replacement will be performed at *$ `,1- 7 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 *$ / `.P If wood deck, siding, and flashing is sound, we wt(le-nail any loose wood to rafters, sweep deck, and prepare for roofing. ❑'Install 8" drip edge to all rakes 0nd eaves. Color L� k *Ae,;, I]' Apply ice & water shield DE (UNRLAYMENT) as per manufacturers' specifications and/or ( f ,0 =�' oApply premium (UNDERLAYMENT) to the balance of the exposed wood deck. ©`Re, -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. ❑ if upon inspection, we discover chimney lead to be worn or deteriorated, replacement will be performed at-*$�.''" ❑= install a new: e in Year ❑ Traditional ❑ Architectural ❑ Designer Color ❑' Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$ D-Alfdebris 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 buil be compromised: Special Notes C: UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF. r �/ YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND . s ; 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 perfogmthe work, furnishlthe materials and labor specified above for the total sum of: $ 1Ef (*) E ._..' nle 'e L%e 3 1 (. ✓<� _ _ (Tlnllarcl Payment will be made according to the following work schedule: $ iia x� deposit upon signing contract $ by _/_/_ or upon completion of vt<_ p , $ _..:-� �-, r 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 th€ third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN -THS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal Home Owner(s) Signature(s)-= ` �- � : � _ z r Date:,/ / / t < Contractor's Signature: 10� Date:..- / www.lambertroofinp.com (Please see reverse side)