HomeMy WebLinkAboutBuilding Permit #840-15 - 7 COPLEY CIRCLE 4/23/2015A&Permit No#:_
Date Issued:
LOCATION
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
PROPERTY OWNER_
MAPU5I PARCE
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Print 100 Year Structure yesrnoZONING DISTRICT:Historic District yeMachine Shop Village ye
NORTH q
TYPE OF IMPROVEMENT
PROPOSED USE
v
Residential
Non- Residential
❑ New Building
El One family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Others:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
El Septic , ❑ Well
❑ Floodplain ❑ Wetlands
El Watershed District,
0 Water/Sewer --- -
Ur-Ok�rur 1 1U Ur VVUKK I U tit PLKI-OKMED:
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Identification - Please Type or Print Clearly
OWNER: Name:_ Akf -S (A�� �,I ,� Phone: g7g-6�S-S8a�
Address:
Contractor Name:
Phone: q78—G5G--?g97
Supervisor's Construction License:_1 C- S Exp. Date: 3 / q(/
Home Improvement License:
Date: )//[0
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: $_14 9) x FEE: $ (t34
)ve
NOTE: Persons contracting with unregistered contrac ot�h a�rass to the guaranty fund
Check No.: ��O R e
/1
Location 7 1--e eA
No. Date
Check #t,,2 / 0 5'
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ZZ t,59
Foundation Permit Fee $
Other Permit Fee $—I --
TOTAL $
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Taming/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 m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature.
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
.f
Planning Board Decision: Comments
Conservation Decision: Comments
Vater & Sewer Connection/signature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIREiDEPAR4TMENir Ternp Durnpsfer;on site �yesF _ _ X nog __�
LQcafedat 1w24'xMaintStreett
Fire�Departmensig;nature/d`ate_�_
_
11
Dimension
Number of Stories: Total square fleet 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 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
r. Copy of Contract
4. Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TOTE: 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
46 Photo Copy of H.I.C. And C.S.L. Licenses
:aa Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
:rF Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: 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
:rn Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
� 2012 IECC Energy code
4. Engineering Affidavits for Engineered products
OTE: 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
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Customer:
IV- An8co-r- -5-1;a
Description of work Performed:
CD Roofing
Vincent Colangelo
3 Hodgson St.
Tewksbury, Ma 01876
978-656-8497
Qq u l q (.1/q (f e r �G � VM q �l l y1
vincentcolangelo@sbcglobal.net
HIC Llc # 170575
CSSL Lic # 105943
OWENS CORNING
PREFERRED CONTRACTOR
( Obtain required town permits 8r 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.
0,Strip-off (J ) existing layers of roofing on complete house & re -nail any loose decking
Olinstall 8inch_;,U�;'>�. Aluminum Drip edging / Owens Corning Starter Shingles
Install Owens Corning Ice & Water shield Eft at eaves, 3ft in valleys, around all penetrations
Install Synthetic felt paper to entire roof
(� Install Owens Corning LifeTime warranty TruDefinition Duration shingles A CS4 w004)
O) Install new'neoprene vent pipe flashings on all plumbing pipes
M, Install Owens Corning VentSure ridge venting with moisture guard
Install Owens Corning ProEdge hip & ridge cap shingles
KCompletely 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
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 ($ ' Qoo,°0 ). Said amount shall be paid as follows:
Note: This proposal may be withdrawn by us if not accepted within �y V 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. G ,�..-TON,
�
Work will not begin until your right to cancel has expired and�ou-ha e �� eposit of
dollars ($ 1000 cam) unless this agreement provides o�the e.
Signature of Lontractor or authorized representative:!
il'
*(I/We) have read the terms st ted herein, hey have een explained to (me/us), and (I/We) find them to be satisfactory
and hereby accept them.
Signature of Homeowners) ___
IG 5o
The Commonwealth of Massachusetts
M Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dna
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Nalne (Business/Organization/Individual):
Address:
City/State/Zip: fig" KSL
Are you an employer? Check the appropriate
Phone #: g7cd_G 5-G ^ 9q9-7
1. ❑ I am a employer with : employees (full and/or part-time).*
2.❑ lam 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.Iptu a general contractor and I have hired the sub -contractors listed on the attached sheet.
ghese sub -contractors have employees and have workers' comp. insurance.#
6. ❑ 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 required.] ,
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
r
12. Q Plumbing repairs or additions
13.0 Roof repairs
14.0 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 Eve employees, they must provide their workeis' comp. policy number.
]:'am an employer that is providing workers' compensaiion insurance for my employees.' Below is the policy and job site
information. //��
Insurance Company Name: All
Policy # or Self -ins, Lic. #: L O d OQ Cno (b Expiration Date:
Job Site Address: 77 LOD 1.2 y (,.t e r City/State/Zip: &.
•
Attach a copy of the workers' c .mpe, sation 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 his statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification
I do hereby c�fy uS4PfXi e Jams andpenalties ofpeijury 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 offzciaL .
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 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 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 commonNyealth 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 -contractors) 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 for 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 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
(i.e. 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 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
2/20/2015 12:24:32 PM 8626 02/02
nco L? CERTIFICATE OF LIABILITY INSURANCE it DATE'20120IYYYY)
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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). p��T
PRODUCER 04809-001 NQNTACT _
Monica Insurance Agency J(Ay o E.q: (978) 454-2577 (ASC. No_ 19781441-1282
19 Mill Street Suite 2
Lowell, MA 01852 -MSS - -- —
INSURED
Rondo General Construction Inc
34 West 3rd Street
Lowell, KA 01850
_-wsuRERA A.I.M. Mutual Insurance Company
,-INSURERS
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.
'y TYPE OF INSURANCE -- �INSRiWVD+ POLICY NUMBER - _ .1ra�S�vv). (MMIDDY>WYV� .-� LIMITS
GENERAL LIABILITY - I FA N ~.S _ _ -
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3 Hodgson St
AUTOMOBILE LIABILITY
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DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if moll space Is required) —
a
CFRTIFICATF HOL ❑FR CANCF1 l ATIAN
CD Roofing
3 Hodgson St
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Tewksbury, MA 01876
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W 1!RS5-LU1U AGUKU t;UKI'UKA IIUN. All rignts reserVea.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
8732
��� ,arn»roxrc•.ri r rr' (rr[,.rr•�n.:rte
Office of Consumer Affairs B Business Regulation
0ME IMPROVEMENT CONTRACTOR
Registration: 170575 Type:
expiration: 1 111 01201 5 DBA
CD ROOFING
VINCENT COLANGELO
3 HODGSON ST
TEWKSBURY, MA 01876
Undersecretary
.� oa lcl o^
Cunstructigkj tiuperN i.„r Spriiall�
_. c 21 CSSL-105943
'VINCENT COLANGELO 11 �b.
3 HODGSON STREET
Tewksbury MA 01876
I
03/09/2016