HomeMy WebLinkAboutBuilding Permit #810-15 - 38 COPLEY CIRCLE 4/16/20154Wi� A -Q 4
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No# O Date Received
Date Issued: �/&
PORTANT: Applicant must complete all items on this pag
y�1 r
LOCATION
Frim
PROPVNER 1VI , £.x5r�C1Print 100 Year Structure yes
MAPARCEL. ty ZONING DISTRICT: Historic District yes
Machine Shop Villaqe yes
p�tLEn ib'�N O
o
TYPE OF IMPROVEMENT
PROPOSED USE
Exp.
Date: 3A
Residential
Non- Residential
❑ New Building
A One family
Date: I / (( y i
0 Addition
❑ Two or more family
❑ Industrial
S:Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic 0 Well
❑ Floodplain 0 Wetlands
❑ Watershed District
❑ Water/Sewer
11
OWNER: Name:
Address: 3
Contractor Name
Email
Address: 3
DESCRIPTION OF WORK TO BE PERFORMED:
- Please Type or Print Clearly
i nA, SrO
Lv1011 er Phone: Ci 7�' ' - S`I;; .. C` •/ Gi 7
Supervisor's Construction License:
( C)5 `i'7�
Exp.
Date: 3A
Home Improvement License:
(770575- S
Exp.
Date: I / (( y i
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: $ q 4C)- FEE: $ IQ
Check No.: � a q 1C1
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acc
, ignature of Agent%Owner
Signature of contracto
'und
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
r
Other Permit Fee $
TOTAL $
Check #
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Taming/Massage/Body Art ElSwimming
Pools ElWell
❑
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
Reviewed On Signature_
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osqood 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
Doc.Building Pennit Revised 2014
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
❑ Floor/Cross Section/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 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
Doe: Building Permit Revised 2014
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Customer: �.._,----
W,,,r k A {ov'er` I�� �`iG'�?Q`�
Description of work Performed:
CD Roofing
Vincent Colangelo
3 Hodgson St.
Tewksbury, Ma 01876
978-656-8497
vincentcolangelo@sbcglobal.net
HIC Llc # 170575
CSSL Lic # 105943 i
OWENS CORNING
PREFERRED CONTRACTOR
Obtain required town permits & provide certificates of insurance & workers compensation
Provide Dumpster set on planks *for contractors use only (materials all recycled)
Attach Large Tarps to protect adjacent finishes, landscaping, and property.
Strip -off ( / ) existing layers of roofing on complete house & re -nail any loose decking
4A Install flinch Aluminum Drip edging / Owens Corning Starter Shingles
Install Owens Corning Ice & Water shield Eft at eaves, Win valleys, around all penetrations
(Install Synthetic felt paper to entire roof Gf-+
0J; Install Owens Corning LifeTime warranty TruDefinition Duration shingles
Install neW neoprene vent pipe flashings on all plumbing pipes
`Install Owens Corning VentSure ridge venting with moisture guard
(� Install Owens Corning ProEdge hip & ridge cap shingles
Completely re -flash chimney with lead
Owens Corning Preferred contractor installation with full warranty
All work will be completed according to state and manufacturing codes and specifications. Every day we will have the
roof water tight, clean gutters, completely clean the job site, and use a magnet roller to collect scattered nails.
Additional work to be performed � 6"pt, �Q �y yce- I,�f ter Doc'Mg(',5"'
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 ($�,,.,,). Said amount shall be paid as follows:
J 00 0.
Note: This proposal may be withdrawn by us if not accepted within (Z/ 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 THE HOME SOLICITATION SALES
ACT AND THE HOME IMPROVEMENT ACT THIS INSTRUMENT IS NOT NEGOTIABLE.
Work will not begin until your right to cancel has expired and you -have pai 47dep t}it of
dollars ($ ), unless this agreement provid4s oth�l
Signature of Contractor or authorized representative:
*(I/We) have read the terms stated herein, they have been explained to (me/us), and (I/We) find them to be satisfactory
and hereby accept them.
Signature of Homeowner(s):
he Commonwealth of Massachusetts
Department oflndustrialAccidents
i -:. a X Congress Street, Suite 100
F
Boston, MA. 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Name (Business/Organization/ludivi/dual): �JI
Address:
City/State/Zip:
Are you an employer? Check tfie appropriate
Phone #: 978— 6 5-6 " b `/ � -7
1.❑ I am a employer with employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.Ilam a general contractor and I have hired the sub -contractors listed on the attached sheet.
'These sub -contractors have employees and have workers' comp. insurance.#
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and weave n' employees. [No workers' comp. insurance required.]
Type of project ()required):
7. 0 New construction
8. Remodeling
9. ❑ Demolition
10 E] Building addition
11.❑ Electrical repairs or additions
12. E] Plumbing repairs or additions
13. [] Roof repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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-coritraciors have employees, `they must provide their workers' comp. policy number.
X ain an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site
information. A / X
Insurance Company Name:
/tv
Policy # or Self -ins, Lie. #: L 0� ! cyj,
A.
Expiration Date:
Job Site Address: 79 G?pkK U(_ City/State/Zip:
Attach a copy of the workers' compensatidn policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance
coverage verification.
X do hereby cer�y and pgAs 0dpenalties ofperjury that the information provided above is true and correct.
Phone #:
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 #:
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 liire,
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 commomyealth 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-'contractox(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 may be submitted to the Department of Industrial
Accidents foi• 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 Jinei.
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. 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NTASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
A� �® CERTIFICATE OF LIABILITY INSURANCE ��`' 3°,° ;;'15
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 thiscertificate does not confer rights to the
certificate holder in lieu of such endorsemen s).
PRODUCER
Agency An ela Westen Insurance A
557 Central Street 9 Y
Lowell, MA 01852
CONTACT
NAME:
PHONE FAX
N 978 735-4094 N : (978) 735-4095
(AmE-M
IL
ADDRESS: angela@awesten.com
INSURE S AFFORDING COVERAGE NAIC#
INSURER A: ATLANTIC CASUALTY INSURANCE CO
3/18/16
CURED
INSURER B: HARTFORD UNDERWRITERS INS COMP
FO CONSTRUCTION CORP.
40 READ ST.
LOWELL, MA 01850
INSURER C:
INSURER D :
INSURER E:
INSURER F:
PRODUCTS - COMP/OPAGG $ 1,000#000
COVERAGES CERTIFICATE NUMBER: RFVICInN NIIMRFR-
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
AML
SUBR
POLICY NUMBER
POLICY EFF
MIMN
POLICY EXP
MM/DD/YYYY
LIMITS
A
GENERALLIABILIY
XCOMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 1-1OCCURMED
L021008696
3/18/15
3/18/16
EACHOCCURRENCE $ 1,000,000
DAMAGE TO RENTEDEa occuneno) $ 100 ,000
EXP (Ary one person) $ 5 000
PERSONAL& ADV INJURY $ ] 000 000
GENERAL AGGREGATE $ 2,000,000
GENTAGGREGATE LIMITAPPLIES PER
POLICY PRO- LOC
PRODUCTS - COMP/OPAGG $ 1,000#000
$
AUTOMOBILE LIABILITY
ANYAUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS _ AUTOS
C NIBINdEeDt INGLELMIT $
BODILY INJURY (Per person) $
P id
BODILY INJURY (Per accent
( ) $
PROPERTY DAMAGE $
eraccident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
B
WDRKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNY/NE
OFFICERIMEN®EREXCLUDED?
(Mandatory In NH)
IfESCE.L.
Yyes describe under
DRIPTION OF OPERATIONS below
N/A
2E112068
3/30/14
3/30/15
wC STATu- OTH-
I FR
E.L.EACHACCIDENT $ ZOO 000
DISEASE -EA EMPLOYEE $ 500Sddescribe, 000
E.L. DISEASE -POLICY LIMIT $ 100,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101, Additional Rene rksSchedule, Ifmore apace isrequred)
L,rn I IrII.A 1 t nut_utm T'_AW'1171 I ATMKI
u 1Vt5U-ZU1U ACORD CORPORATION. All rights reserved.
ACOR0 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
3 HODGSON ST.
AUTHORLZED REPRESENTATIVE
TEWKSBURY, MA 01876
u 1Vt5U-ZU1U ACORD CORPORATION. All rights reserved.
ACOR0 25 (2010/05) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E -Mail: VINCENTCOLANGELO@SBCGLOBAL.NET
feg�i
OfSccof Consumer Affairs & BusinCTOReulation
E IMPROVEMENTCONTRA Type:stration: 170575 DBA
pration: y 11%102u,
y i
CD ROOFING
VINCENT COLANGELO
3 HODGSON ST g—
TEWKSBURY, MA 01876
Undersecretary f
Massachusetts - Depart:Trent of Public Safcty
Board of_Building Regrllations13nd Standards
1(onstraetign Su
peri isur Spcciallj
License: CSSL-105943 I'
8 �.,t � 1 � ♦i 11
VINCENT COLANGELO
3 HODGSONSTREET S
Tewksbury MA 01876 r _
c
e
I —Expir.
--�'' r 03/09/20165