Loading...
HomeMy WebLinkAboutBuilding Permit #818-14 - 306 MARBLERIDGE ROAD 5/13/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: r�s 1 IMPORTANT: Applicant must complete all items on this page LOCATION_30'� _ int, PROPERTY OWNER_ c�Print 100 Year Old Structure MAP NO: V � PARCE--- L ZONING DIS,TRI:CT: -_ _- Historic District _w Machine Shop Village yes,no yes no yes( _ no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ,<One family ❑ Addition ❑ Two or more family 0 Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other O'Septic 0 Well E Floodplain 0 Wetlands ❑Watershed District ❑ Water/Sewer ' ESCRIPTION OF WORK TO BE PERFORMED: C S411",,/0 `l:PP 4 PErn4r- c/_ 1 Ind Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: �� } -� CONTRACTOR Name:._ _ iJ�.C�,-� _ n �Za L 'Phone:... q712 �65`6 ~ 'g Y9 7 ic��iSon Address. Supe-rvisor's;Construction.License _ 105�_Y413 - _`Exp. Date:_ Home Improvement License: _ _ ,% 76,S7 5- Exp. Date` .. //. Acl. r/`5 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. O� Total Project Cost: $ %, q00- ' FEE: $ Check No.: e2-677 1 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce o t ty fund SignatureofRAgent/Owner Tab of contract" u Plans Submitted �J Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -r Building Department 1 -he fo[iowing is'a list of the required.forms to be filled outIor.:the appropriatepermit tube obtained. R.00fivg, Siding, Interior Rehabilitation Permits o ' Bluilding Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or G.S.L Licenses o Copy of Contract o 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 ❑ Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit D Photo Copy of H.I.C. And C.S.L. Licenses Li 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) o 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) Li Building Permit Application Li Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract Li 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 casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Plans Submitted: ❑ Plans Waived ❑: ..Certified Plot Plan ❑ Stamped Plans ❑ :T'I'PS OF:;SEWER:AGEDISROSAL 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 Reviewed on Sianature COMMENTS HEALTH Reviewed on _ Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes - Planning Board Decision: Comments Conservation Decision: :Comments G' Water & Sewer Connection/Si_gnature & Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPAftTM:ENT-::-:Temp Dumpsteron site yes. no , Located- at',124tMain Street'--:. Fire'Depar"tme►it signatu"re/date " COMMENTS �`' -- .-Dimension.- Number - imension Number of St o ies: Total square re feet of floor area based on Exterior dimensi o n s. _ Total land area; sq. ft.: ELECTRICAL: Movement o.f.Meter, locatibn,'ryiasft or service drop requires approval of Electrical Inspector Yes No DANGER.Z®NE LITERATURE: -Yes No MGL Ctiapter166.Section 21 A, and G min.$100=$1000:fin.e NUTES and DATA — (dor department use B Notified for pickup - Date Doe.Building Permit Revised 2010 Location `,o `n �(L. 0—j No. U 19— �`i v Date q t3 1`4 Check #7 6,771 27570 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee i $ Foundation Permit Fee $ Other Permit Fee $_ TOTAL $ Building Inspector CD Z VOL CD 0 CL r VOL CL D to 0 00 CDCD Cr CD 0 CD W W CL v S' CC CD Cn a CD 0 VOL0 n LU 0 n' r_ U) tv n CD CD CD a U) CD U) v z CD a CD tp Z m cnO cn n 0 Z N D Cl) Z Z cn a O m X in Z 0 VI O D 0 Z O_ 5 CD N (O O S. to M <D to0 U) O U) rt 0 0 O N < c cn O m n0 0 � CLC.)m C - �. O CD T 0 0r+ Q m cn W a O y p O CD (DCD 2 -% -% O O CD C7 � O_ =r .� C O <D S CD -40 10 0 CC N ? 0 0 :G h= CD : O O a a°N CL CL0 Co O CL —N <�S:A O CD < ., Q: W" :O � y CD r� N 0 ZM c rt =r :�• cot; CD C=D cn(D 3. O N s aCD (D a a) : C N N co TZ1 T N :O T Z7 T n 7o T N T - C M 0 5. p (D N C d � C N C fu C C _0 O 7 — 3 _ 3 _ _ 7 Q r'. \ m N S n o 0 n r- w (D m m r- C 3 3 G1 C O o N 0 z C) N C) C) D Z m m O m D z _ O The Commonwealth of Massachusetts , DepartmentoflndustYialAccidi nts Office of Invesfigations 600 Washington Street Boston, MA 02111 www.mass gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricxans/Plii hers Applicant Information Please Print Lem 1y Name(Busnnos/Organizationftdividual): tf oce t loiiley . City/State/Zip: P,w K S u� �/ Phone #: q Are you an employer? Check the appropriate bo • Type of project (required): 1. [] I am a employer with 4. Sam a general contractor and I 6. Now cbnsfruction ` t tim employees (full and/orpare).* 2. ❑ I am a sole proprietor or partner- have ned the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and1ave no employees These sub -contractors have 8. ❑ Demolition woxking forme in any capacity. workers' comp. insurance. g, [I Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised.their right of exemption per MGL , 11. [] Plumbing repairs or additions myself. [No workerscomp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurancerequired.] i employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicantthat checks box#I must also fill outihe section be16w showingtheir workers' compensation policy information. i'Homeowners who submit this affidavit indicatingthey tie doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees Below is thepoliey andjob .site information. A r !, Insurance Company Name: /-AA Q-eis J_IJ e S r n Policy # or Self ias. Lic. #: (2a 1 co 66 q G Expiration Date: Job Site Address,, �0(. 6,4g r W e r-'City/State/Zip: A nCC, Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1, 50 0.00 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 "in �urance coverage verification. I do Hereby u be and penalties ofperjury that the information provided above/is true and correct. Rio-nnfi,rn- Date: Phone #• — a 7L 5�6- G Y 9 7 Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. BuildingDepartment 3. City/Town Clerk 4. EIectrical 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 iii 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 trdstee 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 bean 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 tho workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if iiecessary, supply sub-contractor(s)name(s), address(es) and phone numbers) 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 au LLC or LLP does have employees,apolicyisxequired. Be advised that tbisaffidavit may besubmitted tothe Department of hidustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 7:he affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of IndustrialAccidents. 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 thatmust submit multiple permit/license applications k any given year, need only submit one affidavit indicating current policy information (if necessary) and under "lob Site Address" the applicant should write "all locations in (city or town)" ffi A copy of the affidavit that has b eon ocially stamp ed ox marked by th.e city or town. may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 bum 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, please do not hesitate to give us a call. The Department's address, telephone aid fax number: The Com- of:Massac&v.:seits Department of TndwWal Accidenta Offtoe offAvestigatx 6bQ Wash ag o a Steet Boston,, MA 02111 T01#617-'�4�QQ et4g6 qx-Q:lY!}�`fi Revised 5-26-05 Fax 0 617"727'77¢9 �w'.�xtass,g4vfcli.a A� V CERTIFICATE OF LIABILITY INSURANCE FDATE(MM14/2/'14 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 policyfies) 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 endorsemen s . PRODUCER An ela Westen Insurance A enc 557 Central Street g Y Lowell, MA 01852 CONTACT NAME: PHONE TAX c. N 978 735-4094 N ; (978) 735-4095 � ADDRESS: an ela@awesten. com L021008696 3/18/14 INSURE S AFFORDING COVERAGE NAIC# INSURER A: ATLANTIC CASUALTY INSURANCE CO DAMAGE TO RENTED $ 100,000 INSURE INSURER B: HARTFORD UNDERWRITERS INS COMP FO CONSTRUCTION CORP. 40 READ ST. LOWELL, MA 01850 INSURERS: INSURER D: INSURER E: INSURER F: COVERAUE5 CERTIFICATE NUMBER: RFVI.%inN NLIMRFR- 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF M/DD/Y POLICY EXP MMIDD/YYYY LIMITS A GENERALLIABILITY }( COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E OCCUR L021008696 3/18/14 3/18/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 MED EXP (Arryone person) $ 5,000 PERSOINA L&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AG GR EGA TE L IMI T APP LIE S PE R POLICY PRO- LOC$ PRODUCTS -COMP/OP AGG $ 1,000,000 AUTOMOBILE LIABILITY ANYAUTO ALL O W NED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS COMBINEDSINGLELIMIT N $ BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) PROPERTY DAMAGE $ araccdent $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTIONOFOPERATIONSbelow N / A 2E112068 3/30/14 3/30/15 WC STATU- DTH - PR EL. EACH ACCIDENT 100,000 EL. DISEASE -EA EMPLOYEE $ 500,000 EL. DISEASE -POLICYLIMIT 100,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mon: space is required) �93ZSlldL9L\I SGLPJ 1451A 1!355-LUTU ACURD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: VINCENTCOLANGELO@ SBCGLOBAL . NET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CD ROOFING THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. VINCENT COLANGELO AUTHORIZED REPRESENTATIVE 3 HODGSON ST. TEWKSBURY, MA 01876 1!355-LUTU ACURD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: VINCENTCOLANGELO@ SBCGLOBAL . NET Massachusetts - Department of Public Safety Beard of Building RegGlptions end Standards r. `.6)n.strn Stion Superl isur Sprcial� License: CSSL-105943 .,r_I i.5 U,. VINCENT COLANGELO 3 HODGSON%STREET Tewksbury NSA 01876 Expiration 1oG ntnussioner 03/09/2016 . V 1Le �JLY/97///ZM?.GIK'CL.L�>Z 6�U(�QOQ:GIZU/JP.�\ Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR !'a 1 . istration: 91'705.75 Type: i xpiration r--11/10/201-5 DBA CD ROOFING 15,2- VINCENT COLANGELO`ti�` >>' 3 HODGSON ST TEWKSBURY, MA 01876 i Undersecretary 3 Hodgson St. Residential/Commercial Tewksbury, MA 01876 Masonry 4mo Ph: (978) 656-8497 Vincent Colangelo Free Estimates. Lic. #170575 ROOFING Fully Insured Proposal Submitted to Homeowner Work To Be Performed At Name Street A 1 w Street © r 4" ` City r State City State - Date / Telephone � �3 — $fig Telephone Complete Description of Work to be Performed: o S`f'r ? -. � rS G�4 W 1' S e's- 4 f ' _ -2 .� f ` • �l Ci s Q, � 7t C 5 r sl 14, IF I14 �P It 9-01 5LjP- qj _aP S 1 f`cr p S b. S UJ x . Date work will start Date work will be completed All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications must be made in writing on an Add-on/Modification of Contract form and may become an extra charge over and above the amount stated herein. This agreement is contingent upon delays beyond our control. Owners to carry fin:, tomado and other necessary insurance. Our workers are fully covered by Worker's Compensation Insurance. Homeowner agrees to pay for all work as set forth below. if the homeowner defaults, homeowner agrees to pay all costs of collection, includingreasonable attorneys fees, in addition to other damages incurred by contractor. Full Payment is due upon completion of work . We. propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of. G— ! dollars ($ �t qpm_ Said amount shall be paid as follows: G ® 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 PROVISIONS OF TME. HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEGOTIABLE G,� 1 Work will not begin until your right to cancel has expired and you ha dollars ($ � 50 ), unless this agreement provid erwi Signature of Contractor or authorized representative: *([/We) have read the terms stat ereii , b explained to ( us), a (I/We) find them to be satisfactory and hereby accept them. Signature of Homeowner(s) DI s1 - \