HomeMy WebLinkAboutBuilding Permit #715-14 - 432 WAVERLY ROAD 4/15/2014Permit NO:
Date Issued:}�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION 1
Lt Print.
PROPERTY OWNER C`
Print 100 Year Old Structure yesCn
�
MAP NO: 7PARCELM9 ZONING DISTRICT: Historic District yes
Machine Shop Villaqe yes
TYPE OF IMPROVEMENT,
PROPOSED USE
Residential
Non- Residential
❑ New Building
0 One family
0 Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
❑ Demolition
0 Other
p Septic 0 Well
0 Floodplain 0 Wetlands
0 Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
C
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
ArIHrAcc-
CONTRACTOR Name:
Address:
12
Supervisor's Construction License: Exp. Date: �
Home Improvement License:
. Date:
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.
do
Total Project Cost: $ 1o' I FEE: $
Check No.: (l Receipt No.:_0 7 71
_
NOTE: Persons contracting with unregistered contractors do not have access to the kyarantyJundli
Signatureof Agent/Owner Signature of contractor
Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stam
4414 -
ns ❑
Plans Submitted ❑ -Plans Waived ❑ _ .:`.:Certified Plot Plan ❑ Stamped Plans ❑
-TI'Pl✓_O1 �-SEWEBACE..DiSPOSAL- .:..
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
.Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private:(septic tank, etc.. ❑...-:..:Permanent
D'iimpster on -Site ❑
THE: FOLLOWING SECTIONS FOROFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
i
- 2 --"DATE REJECTED .-
PLANNING & DEVELOPMENT ❑El
DATE APPROVED
COMMENTS
CONSERVATION Reviewed on Signature
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
!Nater & Sewer Connectiotl7S_ignature &Date Driveway Permit
DPW 'Tow. Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAR 6 l,, N : Temp Dumpster on site yes... no
. Located ate, 4 _Mair, Street
Fire Departure►itsignature/date
COMMENTS � _
I
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
:_Total land area; sq. ft.;
{ -ELECTRICAL: Movement of Meter. l.ocat'ian-,'-r last -or service drop requires approval of
.Electrical Inspector Yes No
DANGER..Z®NE LITERATURE:. =Yes No
MGL -Chapter 966. Section 21A._F and G min.$10011000.fine
Doc.Building Permit Revised 2010
r—
Building Department
:'.—The following is -'a -list of,the *uired.forms to be filled outfor.:the appropriate. permit to'.be obtained.
Roofipg, Siding, Interior Rehabilitation Permits
o : Bgilding Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or G.,S.L: Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Li 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/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
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
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
o 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 casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apo•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building Permit Revised 2012
IM
j, Y7
-Location V
Na < k Date
r -
r • - TOWN OF NORTH ANDOVER
sz
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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CHAMP 104 Our Source 2 You
Premium Quality...
Windows • Sunrooms • Roofs • Home Exteriors Wholesale Value"
To 21
Address(�L 1
City L� 00O&y - State_ Zip L9�3J
WHOLESALE & RETAIL
ROOFING CONTRACT
Date 4,1014
Home Phone ro/%- —?Cell/Other
32 Elm St Marlboro MA, 01752 • .75 Stockwell Dr Avon MA, 02322 • 508-580-3.119 • 877-946-3699 • Fax 508-580-6064 • GetChampion.com • HIC 127179
-\CGk C-C\--kQ \ 1`1`, C\uIA
Your Champion Roofing Frrojec� Includes the Following:
21 Complete roof tear -off and replacement
0 Leak Barrier... protects areas vulnerable to shifting
�1 Roof Deck Protection... protects from extreme weather
�l Starter Strip ... helps prevent "blow offs"
�l Drip Edge... corrosion resistance at rakes and eaves
?I Ridge Cap ... premium appearance and protection
?I Ventilation... assure air intake and exhaust
Fastening... special ring shank nails, 6 per shingle
Obtain all necessary state, county and local permits and bonds
for work requires at your home
J Job site clean up and removal.of visible debris at projegt completion
ihingle Type —� ' 1��� C,A A7
Ihingle Color
)ptions: ❑ Solar Powered Vent: Qty Location
f Anything Changes:
t
eep existing gutters �\�\eplace existing with:
Color Size Gutter Guard Style & Down Spouts
Structural Concerns:
• Scope of work shall not include detection, abatement, encapsulation or
removal of asbestos or similar hazardous substances. Champion has the right
to discontinue work if"and when hazardous materials are discovered and shall
be entitled to receive compensation for change in scope of work.
• Champion not responsible for structural soundness and shall have no liability
whatsoever for the failure of the supporting structure to support men,
materials, equipment, ice, snow and water whether it occurred before during
or after the outlined work.
• Champion is not responsible for interior damage resulting from structural
deficiencies as outlined above.
le will provide written notice if any, extra costs beyond this written estimate are required. Your verbal or written approval will allow us to proceed with extension
this contract. The most likely modification would be if portions of the roof deck require replacement.
oaf dark rennir/ranMn--*...:u
amplon.snall not be held responsible for time and materia delaysMstrikes, �acts of Godlor any other matters ike manner beyond its to conirol, Buyerand Owner agreeractices. This contract is s that he eh
u' roper signatures.
Security for this contract. Since this contract calls for mil �rder goods, it is not subject to cancellation except as stated above. Start instalation on or aboutove date. Estimated date of substantial com letion is 3 �qweeks from
in this property
contractors and subcontractors must ar registered by he Bolof Buiillding Regulations and St ndards and anyion to remove dinquiries elatinall g orregistration nshoulld be and discounts allotted.
a provision
shall obtain any and all necessary permits as the Owner's agent unless otherwise directed by Buyer. If Buyer secures permits, he or she may be excluded from the guaranty
rd provision of G.L. c. 142A. If Champion must pursue Buyer for collection of amounts past due, Buyer will be liable for Champion's reasonable fees and costs, encllud ng attomley's fees.
:INANCE CHARGE calculated at the rate of 1-1/2 percent per month (18% ANNUAL PERCENTAGE RATE) will be added to delinquent accounts. All installation and completion dates
approximate and subject to change without notice. Verbal promises can cause misunderstandings, therefore this contract constitutes the entire understanding of -the parties, and no
er understanding, collateral, verbal or otherwise, shall be binding, unless signed by both parties. Thank you for your .order. Do not sign this contract if there are any blank spaces.
I r r r1
uv ver\ li-,r') UI(
Office
PC
' aiHOME IMPROVEMENT CONTRACTOR
Registration:127179 Type=
e?� l±xpiratwn 9/.1542014 Ltd Liability Cotpor
CRPi<fJli'ION WINDOW"A. WJO ROOM SOUTH
ANTHONY COVIELLO=
75 STOCKWELL DR:
AVON, MA 02322
Un:dcrse.cretary
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suitc 5170
Boston, MA 02116
4tv id ithout signature
Massachusetts:- Department of P=ublic Safety
Board of Building Regulations and Standards
Construction Supervi.car
License: CS -097226
tilt U
ATMIONY J C &jEj" :-f
27 Colonial IivQ ' •`:
Clinton MA j15IU
Commissioner
Expiration
05/06/2014
CHAMPIO-01 PTUSSEY
ACOR'O"
CERTIFICATE OF LIABILITY INSURANCE
E (MMIDDNYYY)
71T1126/2013
TYPE OF INSURANCE
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(les) 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
Neace Lukens - Dayton/ Assured NL Insurance Agency Inc
6651 Centerville Business Pkwy
Dayton, OH 45459
CONTACT
NAME: Karen Mullins
HON 937 435-4788 4220 A/c No,: : 937 435-7395
( )
no E-MAIL karen.mullins@neacelukens.com
INSURER(S) AFFORDING COVERAGE NAIC #
TB5-Z91-461753-033
-
INSURER A: LM Insurance Corporation 33600
12/1/2014
INSURED
INSURERB:Liberty Mutual Fire Insurance Co 23035
Champion OPCO, LLC
Champion Window Co. of Boston South, LLC
75 Stockwell Dr.
INSURERC:Ohio Casualty Insurance Co 24074
INSURERD:Sentry Insurance a.Mutual Company 24988
INSURER E:
Avon, MA 02322
INSURER F
$
GUVtKAUt5 CERTIFICATE NUMBFR* RPVI¢Irl Al All IMRGR•
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
SUBR
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
-
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
TB5-Z91-461753-033
-
12/1/2013
12/1/2014
EACH OCCURRENCE $ 1,000,000
DAMA E TO RENTED
PREMISES Ea occurrence $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY . PRO X LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
$
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OS SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
AS2-Z91-461753-013
12/1/2013
12/1/2014
COMBINED tSINGLE LIMIT $ 1,000,000
BODILY INJURY (Per person) $
BODILY INJURY Per accident $
( )
PROPERTY DAMAGE
Per accident)$
$
C
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
USO(14)55279295
12/1/2013
12/1/2014
EACH OCCURRENCE $ 10,000,000
AGGREGATE $ 10,000,000
DEDTX RETENTION $
$
D
WORKERS COMPENSATIONWC
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑.
(Mandatory in
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
90-16232-01
12/1/2013
1211/2014
STATU- OTH-
X TORY LIM TS ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
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
v -1!100-ZULU AGUKU UURPURATION. All rights reserved.
AC -ORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts Nnnt rl
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Champion Windows of Boston South
Address: 362 Elm St.
Citv/State/Z1D: Marlborough, MA 01752
Phone #: (508) 580-3119
Are you an employer? Check the appropriate box:
1.0 I am a employer with 10 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
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.] t
have hired the sub -contractors
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'
comp. insurance
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ 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 -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: Sentry Insurance
Policy # or Self -ins. Lie. #:90-16232-01
Job Site Address: 432 Waverly Rd
Expiration Date:
12/1/2014
City/State/Zip: No. Andover, MA 01845
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.
Idoh
that the information provided above is true and correct.
Phone #: v / bar S_eo - 3 ff 9
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
/Y/ /
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 #:
4LN The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
4'32 VJA\r L-)( 20. rte. oou u%L MA,
1.2 Assessors Map & Parcel Numbers
Map Number Parcel Number
Lla Is this an accepted street? yes no
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.6 Water Supply: (M.G.L c. 40, § 54)
Public ❑ Private ❑
1.7 Flood Zone Information:
Zone: _ Outside Flood Zone?
Check if yes❑
1.8 Sewage Disposal System:
Municipal ❑ On site disposal system ❑
SECTION
2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: AA 11 _
CL'If=t go Ka'L Wae
Name (Print) City, State, ZIP
ASL WA,\faLU-f 2C, N l&,NUVLV
No. and Street/Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ (check all that apply)
New Construction ❑
Existing Building❑
Owner -Occupied ❑
Repairs(s) ;9Alteration(s)
ElAddition
❑
Demolition ❑
Accessory Bldg. ❑
Number of Units
I Other ❑ Specify:
Brief Description of Proposed Work2: S4-YZ-W � (LC- - �tGo F
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Labor and Materials
Official Use Only
1. Building
$ r5-7 y, �
1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
❑ Total Project Costa (Item 6) x multiplier x
2. Other Fees: $
List:
2. Electrical
$
3. Plumbing
$
4. Mechanical (HVAC)
$
5. Mechanical (Fire
Suppression)
$
Total All Fees: $
Check No. Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
6. Total Project Cost:
$ 15-179
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
R- V" 4' - (, I tt
Aw7-44o m,-t Qy 1 cc-LO
License Number Expiration Date
List CSL Type (see below) 0
Name of CSL Holder
�� CG�o � t AJ—
Type Description
No. and Street
U Unrestricted (Buildings u to 35,000 cu. ft.
C o �� , n O (S' Q
R Restricted 1&2Family Dwelling
City/Town, State, ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
'�0�3«�t/[�LE�er CtEi(�MP(aN�C0u1
I Insulation
le hone Email address
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
t�Leldty �tNDOiwS Gp51 S�fiirl
t 2� l�� iS 1�
HIC Registration Number Expiration Date
g�Nsou���C�E7cNAM�taN. ,
HIC Company Name or HIC Registrant Name
75- MCV—wE—c- 00
No. and Street
/\votes NIA 02322 (5t)b)5g0-3119
Email address
Ci /Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize O1-tA,OAP(Ol J (OWDO JS
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name (Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
conta2s ap ' a•iois true and accurate to the best of my knowledge and understanding.
� --- Av,-,qoJ.- Oow&Zco ► V l
Print Owners r A orized Agent's Name (Electronic Signature) Oate
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"