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HomeMy WebLinkAboutBuilding Permit #547-2017 - 42 LACY STREET 11/21/2016ukdiV 444 L � Permit No#: S 'f 7 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION'-- Date XAMINATION'-- Date Received r_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building aOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic 1Nell . ❑ Floodplain � Wetlands Q. Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 'Identigeation - Ylease Typ"r Print OWNER: Name: Address: Yo( Contractor Name Address: sAF 59e>-, Supervisor's Construction License ., /O r-�'� Exp. 'Date..//.). _ F Horne Improvement License: _��,,. �- :._ Exp. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE; BULDING PERMIT.• $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. ,.,__,Total Project Cost: $ cs�' �r FEE: $ Check No.: Receipt No,: 3 1 ;-a-7?> NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund Sigriatiire of_Agent/Owner Signature of contractor'' Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑ IYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming ming 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 & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Signature COMMENTS w HEALTH COMMENTS. Reviewed on nature Zoning 7Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 6M FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 1244 Main Street Fire Department signature/date COMMENT Street limension 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doe.Building Permit 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 o 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 o Photo of H.I.C. And C.S.L. Licenses o 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 40TE: 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: Building Permit Revised 2014 Location 4 v9C 1--i S'f r No. Sal 7 - 2 CA. -7 Date 0- ;L t - d of 6 Check #� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ lor— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ v Building Inspector in r L = Q 2 u. D O m L Y LL i N N 0 �- W tan Z Z =� m C t0 U- K a1 C u LL O W N Z Z m J a t LL O tJJ tan Z V ~ u W t K U N Li oC 0 v ua a Z Q (D L K LL Z W Q ui W 5 LL L Ql m Z - N Y Y N n - O ca O v ee � 1^x,1 •� � �+ O: CD CL to CD m :t tr W O v E cm a 0 tNG0 �P J: t0.� i y�0 CD 0° a L O toID •CDO a E •0 0 a 0 CL 0 N z a' U) 10- m a, > o = �►,■. a: o m d m (^ 0 v.1�$�Un oma= S F- _ Q i cc=a o = NCD N H' O to CD coCc W p -0-- O .0- w uj z Li y m N C O �= O v = v O W E V N p Q 010 N N .0 %*-O O W � 1— t - CL OV > O W U) V m C noF- O z V Cl) CL Cl) w0 Lu to LU Z �l ilc- w 5 W O O O z N OD CM0 c C a o .� m m CL ^WO, �+ + O Vca O CL a CL a� Q 04, - Cc0 �CL O (1)z O U cU ca c Q 0 Cell-. 603-236.6731 Submitted to: Michael Watson 42 Lacy Street N Andover, MA 01845 Job Location: ♦, 6y Jonathan N. Lee 215 South Broadway, # 145, Salem, NH 03079 M!c ih riWvw.premierroofingnh.com We hereby submit specifications and estimate for the following: Offlce-. 603-890-9019 Date: 10-12-16 Home: Cell: 508-380-6204 E-mail: Michael.lowell.watson@gmaii.com Roof repair: • Strip roof of 1 layer of shingles. • Re -nail all loose sheathing. • Replace plywood as needed for an additional cost of $40.00 per sheet installed. • Apply GRACE Ice and Water Shield 6 feet up from edges of roof. • Apply paper to remaining roof surface up to ridge. Type: IKO Cool Gray • Install 8" aluminum Drip Edge. Color: White • Cut open ridge in preparation for ventilation system. • Replace 1 pipe boot. Size: 3" • Reroof with IKO Cambridge Lifetime shingles. • Install Lomanco ridge ventilation. • Re -lead Chimney. • Clean up and removal of waste and debris. • Magnetic sweep of property. • Walkways and drive ways swept of debris. • Dumpster provided and included in job price. Notes: We Propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of: Eight Thousand Seven Hundred Fifty ($8,750.00) Payment is to be made in full upon completion of job. (Make check payable to Premier Roofing & Painting.) All material is guaranteed to be as specified. All work to be completed in a workmanlike manner Authorized according to standard practices. All agreements contingent Signature upon accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. This company is covered by General Liability and Worker's Compensation insurance. Certificate of insurances will be sent directly from insurance agent to ensure validity. (Note: This proposal may be withdrawn if not accepted within 90 days) Acceptance of Proposal - The above price, Specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as spe,;T,,ed. Pay . ent will be made as outlined above. Signature � ��' � _ Date of Acceptance `4� l VCT- t e1 Please sign and return one copy. 7 d'iM SVty`o we kers, Compensation ]assurance Affidavit: BnUders/Contractors/Electricians/Plnmbers. TO BE FILED WITH TRE ]?Mff 'NG •AUTHORTI f. — - _ - n_-_4. r Name (Business/Orgariizaiiontlndividual)' Address: City/State/Zip: 6m" Axe yon an employer? Check the appropriate box: Phone #: q 1.Q I am a employer with employees (full and/or part-time), am a sole proprietor or partnership and have no employees Working forme in 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. 5ANI am 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.1 6. Q We are a corporgiou and its, officers have exercised their right of'exemption per MGL c. 152 §1(4) and We have no empldydes. [No workers' comp. insurance required] Type of project ()Vetluired); 7. ❑ Nev1 constrdction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition I l.❑ Electrical repairs or additions nZIPlumbing repairs or additions 13frepairs 14.[] Other *Any applicant that checks bbk #1 must also fill out the section below showing their workers' compensation policy information ' t Homeowners who su... t, his affidavit -ndi king they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check This lioX must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing -workers) coinpensation insurance for my employees. Below is tllepolicy and)0h site information. Insurance Company Naive: N/V �// — Expiration Date_ J Policy # or Self -ins. Lic. �— C, �� �'`�/ City/State/Zip: �Fq lob Site Address: � showing thepolicynumber and expirati as date). Attach a copy of the-Qvoxkers compensation policy declar o page ( Failure to secure coverage e required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year coveimprirage as r as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Iuvestigdtion s of the DIA for insurance coverage verification. X do Hereby certify under thepains andpenalties ofperju�aat the information provided shove is true and correct. /,e- / i — 4 Official use only. Do not write in this area, to he completed by city or town offaciaL City or T'ov u- Permit/License # Issuing Authority (circle one): iIns 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing pactor 6. Other Phone #: Contact Person: The Commonwealth of Massachusetts Department of Industrial Accidents _ QW X Congress Street, Shite 100 Boston, MA 02114--2017 www mass.gov/dia 7 d'iM SVty`o we kers, Compensation ]assurance Affidavit: BnUders/Contractors/Electricians/Plnmbers. TO BE FILED WITH TRE ]?Mff 'NG •AUTHORTI f. — - _ - n_-_4. r Name (Business/Orgariizaiiontlndividual)' Address: City/State/Zip: 6m" Axe yon an employer? Check the appropriate box: Phone #: q 1.Q I am a employer with employees (full and/or part-time), am a sole proprietor or partnership and have no employees Working forme in 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. 5ANI am 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.1 6. Q We are a corporgiou and its, officers have exercised their right of'exemption per MGL c. 152 §1(4) and We have no empldydes. [No workers' comp. insurance required] Type of project ()Vetluired); 7. ❑ Nev1 constrdction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition I l.❑ Electrical repairs or additions nZIPlumbing repairs or additions 13frepairs 14.[] Other *Any applicant that checks bbk #1 must also fill out the section below showing their workers' compensation policy information ' t Homeowners who su... t, his affidavit -ndi king they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check This lioX must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing -workers) coinpensation insurance for my employees. Below is tllepolicy and)0h site information. Insurance Company Naive: N/V �// — Expiration Date_ J Policy # or Self -ins. Lic. �— C, �� �'`�/ City/State/Zip: �Fq lob Site Address: � showing thepolicynumber and expirati as date). Attach a copy of the-Qvoxkers compensation policy declar o page ( Failure to secure coverage e required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year coveimprirage as r as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Iuvestigdtion s of the DIA for insurance coverage verification. X do Hereby certify under thepains andpenalties ofperju�aat the information provided shove is true and correct. /,e- / i — 4 Official use only. Do not write in this area, to he completed by city or town offaciaL City or T'ov u- Permit/License # Issuing Authority (circle one): iIns 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing pactor 6. Other Phone #: Contact Person: 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, 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 ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receivefor trustee 6f 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 b6 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 applicaintwli.o has not produced -acceptable evidence of compliaucewith the insurance coverage Aq Ered." 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=contractors) name(s), address(es) and phone number(s) 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 workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. 13e advised that this affidavit may be submitted to the Department of Industrial Accidents for confiimation 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 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. A new 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 0-c. a dog license or permit to burn 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 02114-201.7 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617.727-7749 Revised 02-23-15 wwwmass.gov/dia -rom:Nicole Boudreau FaxID:Santo Insruance Page 2 of 2 Date: 11/21/2016 09:39 AM Page:2 of 2 PREMI-3 OP ID: NB '4`c,�R� CERTIFICATE OF LIABILITY INSURANCE 1121/20DATE 6 1112112016 1 1121 /201 6 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 Planright Insurance -Salem 224 Main Street Suite 2A Salem, NH 03079 James A Santo NAME: James A Santo PHONE 603-890-6439FAX AIC No Ext : Arc No):603-890-6521 A DRESS: jam ie@santoinsurance.com NN651127 05/24/2016 INSURER(S) AFFORDING COVERAGE NAIC 0 INSURERA:Northfield Insurance Company O PREMISESEa occurrence $ 100,000 INSURED Premier Roofing & Painting INSURER B: Travelers Indem nity Com pany 25658 Jonathan N Lee dba 334 North Broadway, Apt #307 INSURER C GENERAL AGGREGATE $ 2,000,000 Salem, NH 03079 INSURER D: INSURER E AUTOMOBILE INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FXI OCCUR NO ANDOVER, MA 01845 NN651127 05/24/2016 05/24/2017AMAGE EACH OCCURRENCE $ 1,000,000 O PREMISESEa occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PES F—] LOC OTHER. GENERAL AGGREGATE $ 2,000,000 PRODUCTS- COMPIOP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEREXECUTIVE Y 1 N OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A I I 6JUB-465OP25-5-13 3A NH 05/25/2016 05/25/2017 I X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 IT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Jonathan Lee has elected to be excluded from workers compensation coverage CERTIFICATE HOLDER CANCFLLATIf)N TOWNNOA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NO ANDOVER, MA 01845 ACORD 25 (2014101) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD