HomeMy WebLinkAboutBuilding Permit #615-11 - 30 VEST WAY 3/16/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: 'Ir //
Date Issued: 2- 7
IMPORTANT:
Date Received
must complete all items on this
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LOCATION. :30 VF -5-f- \JAci
Print
PROPERTY OWNER FYZANk b),F—AL&Lr--,4
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MAP NO: PARCEL: ZONING DISTRICT: Historic District yes cao-1)
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
&Family
0 Addition
El Two or more family
0 Industrial
El Alteration
No. of units:
0 Commercial
P-Rig`p—air, replacement
El Assessory Bldg
0 Others:.,
0 Demolition
0 OIter
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W®Well
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DESCRIPTION OF WORK TO BE PER -FORMED:
0
Identification Please Type or Print Clearly)
OWNER: Name:F2A-,,,k. Keysj&ieti. Phone:
Address: W��4
CONTRACTOR Name: CW% IS A)(14,-CPhone:
--5 4-4-Z�Ls
Address:
Supervisor's Construction License:Fxp. Date: 16—z -r.
Home Improvement License: l-f77C/ _Exp. Date:
I
ARCHITECT/ENGINEER Phone:
Address:
Reg. N
FEE SCHEDULE: BULDING PERMIT -7$1Z 00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: FEE: $
Check No.: Receipt No.: 9 3J
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
COMMENTS
HEALTH
r
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
weoi,
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer igature:
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 2008
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
o 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
(VOTE: 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
❑ 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
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
Chat 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 .- ?2Q
No. Date
40RTN TOWN OF NORTH ANDOVER
Certificate of Occupancy $
?-2 C>
Building/Frame Permit Fee $ %12
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
1-1 -
Check# 4;;Flr la �6?
23959
Building Inspector
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
o VJ S +- 'D-oo Q1_ S LLL
Address: 4 5- F:0AL0 r— Ro
City/State/Zip: ItM F-2 t�c k mA DI t3Z Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1.01 am a employer with 7-5—
4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g. ❑ Demolition
workingfor me in an capacity,
Y P tY•
employees and have workers'
comp. insurance J
9. ❑Building addition
[No workers' comp. insurance
required.]
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
3. [1 1 am a homeowner doing all work
officers have exercised their
11. ❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12. ❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13. ❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
f 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.
Insurance Company Name: FYIEf) L' Cl t2C-dr
Policy # or Self -ins. Lic. #: 0 8W 6Al L !�_ 7 7 c_�- Expiration Date: -7-1-11
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si!nature �Date:
73 —f6Phone#: 9_7e-ZAoS�--7&5_r y _
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 #:
ACORD,M CERTIFICATE OF LIABILITY INSURANCE
DAT20100:50
07/02/2010/DDN
PRODUCER (800) 225-1865
Fred C. Church, Inc.
41 Wellman Street
Lowell, MA 01851
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSRDD'
LTR
800-225-1865
OF INSURANCE
POLICY NUMBER
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Citizens Insurance Company of America
INSURER B: Wausau Underwriters Insurance Company
New England Window & Door LLC
45 Fondi Road
GENERAL LIABILITY
Haverhill, MA 01832-1302
INSURER C:
INSURER D:
EACH OCCURRENCE $ 1,000,000
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRDD'
LTR
INSIZTYPE
OF INSURANCE
POLICY NUMBER
POLICYEFFECTIVE
DATE 0
POLICYEXPIRATION
DATE (MMIDDNYI
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100,000
X
COMMERCIAL GENERAL LIABILITY
PREMISES Ea oCcurence $
MED EXP (Any one person) $ 10,000
CLAIMS MADE Fk] OCCUR
PERSONAL &ADV INJURY $ 1,000,000
A
ZBN8161407
7/1/2010
7/1/2011
GENERALAGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY X PRO LOC
JECT
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
X
ANY AUTO
(Ea accident)
BODILY INJURY
$
ALL OWNED AUTOS
A
SCHEDULED AUTOS
ADN8162169
7(1/2010
7/1/2011
(Per person)
BODILY INJURY
$
X
HIRED AUTOS
X(
NON -OWNED AUTOS
Per accident)
(
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $ 9,000,000
AGGREGATE $ 9,000,000
X OCCUR CLAIMS MADE
$
A
UHN8167305
7/1/2010
7/1/2011
$
DEDUCTIBLE
$
X RETENTION $
X{ WDRYC STATUS OTH-
WORKERS COMPENSATION AND
LIM TS
E.L. EACH ACCIDENT $ 500,000
B
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE
WCCZ11259957010
7/1/2010
7/1/2011
E.L. DISEASE - EA EMPLOYEE $ 500,000
OFFICERIMEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
Proof of Insurance
CERTIFICATE HOLDER CANGtLLAIIVN
w England Window & Door LLC
Fondi Road
verhill, MA 01830
ACORD 25 (2001108) Client # -)orn Mst # 10-11 GL, UMB, WC, Cert #
Auto
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTATIVE /�
rt"
U ACUKU CUKFUKAI IUN IVtStl
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PELLA WINDOWS AND DOORS CONTRACT
1. TERMS AND CONDITIONS
These Tenus 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 (-Owncr'') 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 detects 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 adjustni mt 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 pars or components are missing or need
to be replaced or repaired, a hold back proportionate to the cost of remaining
parts or work to he 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 alter 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 he Chmer'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 Warrantv. 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 bnprovement 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 Conti -actor Registration,
One Ashburton Place. Boston, MA 02108, 617-727-8598
12. PERMITS (MA customers only)
Pella is obligated to and will obtain the following permits for this project:
. Homeowners who secure their own permits will he
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.
Cuslorircr signa�iule _:7 � �� � C.i (.�
Date / j J
DISPUTES
Job Name �,cle t k/i zlg
a '
Date Cif
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 ARBITRATIO;:gROVIDED IN M.G.L.c. 142A
y✓rr
ontractor
P
�l
-LL
Homeowner
Homeowner i
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.
NO ICE OF CANCE1 I.ATI®N
�`ustomer Nacre:
iPlcusc print)
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 a reement,
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 i etain 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 (three business days from the date of
transaction above).
I hereby cancel this transaction.
(Date) (Buyer's signature)