HomeMy WebLinkAboutBuilding Permit #528-2016 - 31 BRADFORD STREET 10/29/2015Se4ivve b
Permit NO
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
-� Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Date:
4-0 -2C
Resi
Non- Residential
New Building
One famil
Y—[ -7
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
e flair, replace e -
Assessory Bldg
Others:
Demolition
Other
Septic '"Well , s'_;
Floodplain Wetlands
Watershed District
Water/Sewer, ��
v
DESCRIPTION OF WORK TO BE PERFORMED:
`Q Ef7 C,rt- e •r.6ct' LsL,���
Identification Please Type or Print Clearly)
OWNER: Name: d/
Phone: 7k •4
Address:
Supervisor's ConstrutEon
Home Improvement.0der
ARCHITECT/ENGINEER
Address:
'Licensers
Exp.
Date:
4-0 -2C
se f' 7
Exp.
Date:
Y—[ -7
Phone:
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: $ 0,6 FEE: $
LO
Check No.: I (D� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ignS atur�e7of Agent/C Pune ., - �. `. Signa ure of contractor , A
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
Location
No.. S 2ok �a Date
TOWN OF NORTH ANu\,(0,k R
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Location
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 Reviewed on Signature
COMMENTS
,
)TE
"HEALTH Reviewed on Signature
:. .
Vn
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
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
I
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
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
NOTE:
❑ Building Permit Application -
o 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
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
L3 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 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 2008
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DISPUTES
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 ARBITRATION AS PROVIDED IN M.G.L.c. 142A
Pella Windows & Doors
Contractor
� v
Homeow
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.
NOTICE OF CANCELLATION
Date of transaction: 10/10/2015
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 agreement,
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 retain 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
transaction above).
10/14/2015
I hereby cancel this transaction.
(Date)
(Buyer's signature)
(three business days from the date of
it.
The t✓ommonnedalth of Massdachieserls z�
Department of IndustrialAccidew
Of e of Investigations
1 Congress Street, Suite 100
Boston, mil 02114-2017
taw rtaass govIdiaa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizationgadividuat): clIA �. &I �glg � b,]�O gc UC
Address: 4S- r--,Dr 9C!
Phone #:
Are you an employer? Check the appropriate box:
1.04 am a employer with 7-S 4. [] I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ® I am a sole proprietor or partner-
ship 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.]
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.*
5. ® 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'
coma. insurance reauired.l
Type of project (required):
b. ❑ New construction
7. Wemodeling
S. 0 Demolition
9. ❑ Building addition
10.® Electrical repairs or additions
11.® Plumbing repairs or additions
12.® Roof repairs
13.❑ Other
=Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 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-coatmctors and state whether or not those entities have
employces. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I ares an empkyer that is providing workers' compensadon insurance for my eniplopees. Below k the policy aced job site
information.
Insurance Company Name: [4
Policy # or Self-ias. Lie. #: 4060 Ll 010 @ Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and eiptration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido Drerebp certify tender the pains card erralties of perju>$� Cleat the ieeforenation provided above is trite and correct
Phone #: ,S_-Q7a ' ;-
Official use only. Do not write in this area, to be completed by city or town official.
City or Tov%%:
Permit/License 9
Issuing Authority (circle one):
L Board of Health 20 Building Department 3. City/Town Cleric 4e Electricarl Inspector 5. Plumbing Inspector
h. Other
�"'CL.V CERTIFICATE OF LIABILITY INSURANCE 06/9"015MMIDD/YYYY)
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 NTA T
Fred C. Church, Inc. Dorothy A. Corlett, CIC, RPLU
NAME:
41 Wellman Street PHONE978 3227231 FAX
Lowell, MA 01851 C No AIC No : (978) 4-54-1865
(800)225-1865 E-MAIL
AnnRFCC• dcodett@fredcchurch.com
-- wrcnnuc NAIL#
INSURER A : Citizens Insurance Company of America 31534
INSURED
New England Window 8 Door LLC
INSURER B New Hampshire Employers Insurance Company 13083
45 Fondi Road
INSURER C
Haverhill, MA 01832-1302
INSURER D:
INSURER E:
COVERAGES CERTIFICATE NUMBER: 54457
INSURER F
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW
REVISION NUMBER:
HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE
INSR _DL
BEEN REDUCED BY PAID CLAIMS.
TD_ SUBR
LTR TYPE OF INSURANCE POLICY NUMBER
MM/DDY EFF Pym OLICY
GENERAL LIABILITY
EXP LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS -MADE OCCUR
100,000
PREMISES Ea occurrence $
q X CG0001
MED EXP (Any one person) $ 10,000
ZBN8161407
7/1/2015 7/1/2016
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,000POLICY
X PRO- X
PRODUCTS - COMP/OP AGG $ 2,000,000
LOC
AUTOMOBILE LIABILITY
$COMBINED
SINGLE LIMIT
ANY AUTO
Ea accident
ALL OWNED ED
BODILY INJURY (Per person) $
AUTOS AUTSCHOSULED
NON-0WNED
BODILY INJURY (Per accident) $
HIREDAUTOS AUTOS
PROPERTY DAMAGE $
Per accident
UMBRELLA LIAR OCCUR
EXCESS LIAB
CLAIMS -MADE
EACH OCCURRENCE $
DED RETENTION $
AGGREGATE $
WORKERS COMPENSATION
$
AND EMPLOYERS' LIABILITYYIN
X I OTH-
B ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑ N / A 400040101
T1§"FR 500,000
7/1/2015 7/1/2016 E.L. EACH ACCIDENT $
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - EA EMPLOYEE $ 500,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if
more space is required)
CERTIFICATE HOLDER
CANCELLATION
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
Client # 29'0Met
# Cert Holder#
ACORD 25 2010/05
( )
�
O 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are
registered marks of ACORD
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