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HomeMy WebLinkAboutBuilding Permit #875-13 - 826 DALE STREET 6/14/2013Permit N0: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 'r 1MPORTANT: Applicant must complete all items on this paize MAP- NO, I� _ - . ,PARGEL1 yes �rloj yesj no) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0,'Septic ®�Well�+Floodplain ®1Netlands I' Watershed Districts . t ❑ Water/Sewers DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name:�� Lzo&,7 PI Address: �� /�C� S%^ xl 4i�JGteu CO:NTRACTO.Ri 'Name:.; Za1Vb4iq -7—l�G,!'s`=� , � __ _ Phone 'Address::/?3:2 -, S.upervisor,'s C:gnstructi m License: -_ i 1 Home;ImprQvemenQticense. / _ _ _- Expa ©'.a_ter 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: $ FEE: $ Check No.: ��S Recei t No.: NOTE: Persons contracting with u rn gasterec�contractors do not have access to the JuqWAtvf#nd tSignature `of Agent/Owner x . , ;r __ ` S�gature :of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Ttamped Plans ❑ Location No. Date v Clec, 265'i 9 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes •' Planning Board Decision: Comments Conservation Decision: Comments Water & Severer Connection/Siqnature & Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMF.NT - Temp Dumpster on site yes no Located at 124 Main Street Fire Departmet t-signlature/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 NOTES and DATA — (For department use B Notified for pickup - Date Doc.Building Permit Revised 2010 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L: Licenses Li _ Copy of Contract Li 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) E3 Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 app, al 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.Bui?ding permit Revised 2012 E9 * r �I Z • • J LU m =J Nm L +u 0 O u Z C Y T O a Z Z d cc O a Z V W J W ��o C C "JIE oG O a Z 0 Z 2 W 0 LU Q: LL \ O LCL Ln U Q ul - .-a _ O7 LCL L W C U C LL L O w C LL L = K UL {n C LL O 1' C LL i M.0 V �, Q. w =a o H V E Q. Z., 9 07 w N 'M7 r ca 0 O O CL Q � Q C � � O J � O ) z� N U) W W ce W U! L <� W y°+ O ��o C C "JIE 0 L Z., 9 07 w N 'M7 r ca 0 O O CL Q � Q C � � O J � O ) z� N U) W W ce W U! T: EIN # 51-050-3313 Haverhill MA 978.374.9224 MA Reg. HIC # 149221 56be Lawrence MA 978.687.7339 MA Lic. UCS # 78130 Hampton NH 603.929.9224 BBR Singes -Ply License# 1711 Roofing Hampstead NH 603.329.8200 .0— __- Sii1932 Toll Free 1.888.SOS.ROOF 26S Winter Street M1< _ Haverhill .MA 01830 c� 1 ` ,,.,Licensed *Insured 4actory Trained. trFac ory C� f14.f � �ir �1 01F0?13 - TiAiP.• . Telephone rv'? Alt. Telephone: Email: ri Billing Address. f F : .. City: t' f a �� � Stater- Job Address: City: State: Scopeof Work Strip and Re=roof ❑ Re -roof Approximate.Roof Area: ❑., Prepare for re -roofing by ensuring all safety measures. in accordance with OSHA standard regulations and) andscape is properly protected. 0 Remove existing layers of shingles down to roof deck and dispose of in a:legal fashion from the 'ob site. D,Inspect wood deck, if we discover any rotted wood; replacement will will performed at *$ _ per LF for roof deck boards. If substantial deck rot is discovered, re-sheathingof roof deck can be. performed at *$, ' per SE If individual sheets are found to be rotted/or de -laminated, removal, dispos and replacer fent will be performed at *$:_. 454r `"`" per sheet. If any trim boards are rotted, replacement will be performed at *$.�'� �"` per LI+. for new pre=primed pine. Inspect siding at roof line and all flashing behind siding, if we discover any damaged flashing or siding at the roof line, replacement will be performed at *$ If wood deck, siding, and flashing is sound, we will re -nail any loose wood to rafters, seep deck, and prepare for roofing. EI Vstall 8" drip edge to all rakes and eaves. Color: D ­ Apply ice & water shield (UNDERLAYMENT) as per:manufacturers' specifications and/or Apply premium (UNDERLAYMENT) to the balance of the exposed wood deck. 0 -Re -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to .ensure water tightness. 0 -if upon inspection, we discover chimney lead to be worn.or deteriorated, .replacement will be. performed at *$ ) Q Install a new:i, ctectD Designer Color 0 Furnish and Install a new shingle over style ridgevent:system . 0 Soffit vent system *$ O�All debris generated by Lambert Roofing Co., Inc. will be cleaned up and'disposed. of from the job site in alegal fashion. Under no circumstances will the watertight integrity of the building be compromised. Special \Notes ~~s UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF ,"e -Z YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND .YEARS HONORED'AND ISSUED BY THE SHINGLE MANUFACTURER. ❑ MANUFACTURER UPGRADE *$ *Denotes potential additional costs.above the total estimated price. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE -> The Contractor agrees to perform -the work, furylsh the materials and.laboopecif�ed above for the total sum of $ �� (*) /1C&_i` 1•,. r"'� . s' 1 (Dollars) Payment will be made according to the following w $ c <,.a _ . .__&deposit upon signing contract . $ by __J_/_ or upon completion of $ ; c'= ` upon completion of contract. (Law forbids demanding full payment until. contract is:completed to both party's satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram. or by delivery, not later than midnight of the third business day following the signing of this agreement. See attachednotice of cancellation for for an explanation of this right. DONOT SIGN.THIS CONTRACT IF THERE ANY BLANK_ SPACES cceptance of the Contract Proposal Home Owner(s) Signature(s):Date Contractor's Signature: f I -w':% 1 Date:" Company Insurances TGLRC Inc. DBA Lambert Roofing Company will provide certificationofinsurances, demonstrating that we are fully insured for work general liability, automobile. liability and an umbrella policy. This documentation will be sent through the US mail to the above named pa, provided. TGLRC Inc dba Lambert Roofing Company agrees to: • Commence the described work on or about ' • Complete the described work in approximately days. �. • Not be held liable for.delays due to circumstances beyond our control. t • Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control. • Not be held liable and not covered under the.workmanship warranty, for pre-existing conditions including but not limited to: ' • Mold and or wood rot defective, faulty, rotted or worn building counterparts such as, but no limited to: siding, roofing, masonr : ' jeopardize the watertight integrity of the structure. plumbing and windows, all of which may • Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed oct.` residence. • This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc. DBA Lambert Roofing Company and the Homeowner/Business Owner or Agent. &hermitsp q g .:and replace your roof. It is our obligation. to secure these permits if required as the home owner's agent. Note: A building permit may be required to removeyt Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A: Accelerated Payment A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herse3f to be financially insecure, the contractor may require that the balance. of funds site continuing the contracted work: Withdrawal of funds from said account would require the not yet due be placed in a joint escrow account as a prerequi signatures of both parties. Payment Terms A financecharge of 1.5% a month (18% per year) will be added to all invarces,on the 311' day. All legal and or collection fees will be paid by the binding holder of this contract. • The law requires that any deposit or down payment required by TGLRC Inc. dba Lambert Roofing Company before work begins may not exceed the greater of - 0 1/3 of the total contract price or: 0 The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule. Arbitration The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute .to a ptivate arbitration service which has,been approved by the Office of Consumer Affairs and Business Regulation and c er shall bis required to:.submit to such arbitration as provided in MGIC 142A. -.� Date:' Owner: i'•� , �. F , �^ " 7 A— Date: Contractor: > Contractor Registration All home improvement contractors and subcontractors must be registered, any inquiries about a contractor or subcontractor relating to a registration should be directed to: Contractor Registration: Director of Home Improvement Contractor. Registration Board of Building Regulations and Standards One Ashburton Place, Rm. 1301 Boston, MA 02108 (617)727-3200 Home Improvement Contractor Law: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulations 10 Park Plaza, Rm. 5170 Boston, MA 02116 (617) 973-8787 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Cancellation You may cancel this agreement if it has been signed by a party thereto at a place other than an address of seller, which may be in the main office or branch thereof, provided you notify the seller in writing at the main office by ordinary mail posted, by telegram sent or by delivery, no later than that midnight of the third business day following the signing of the agreement. INITIALS �� �:�J l ,�t'%% z� Office of Consumer Affairs and Zuslness Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 14922 Type: Private CorDoration Expiration: ;.12/612013 Tr# 218746 T.(..L.R.0 dba Lambert Roofing Cofnpany RICHARD LAMBERT 266 WINTER STREET HAVERHILL, MA 01830 Update Address and return card. Mark reason for change. Address -j Renewal 71 Employment j_ i Lost Car: CERTIFICATE OF LIABILITY INSURANCE 3 2 C A 'S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 2012 UPON THE CERTIFICATE HOLDER. THIS n?IFICATE 'DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ACTE THE COVERAGE AFFORDED SY THE POLiCiES R '3 Q W - 'HE IS CERTIFICATE- OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED R"Pr T TNE OR PRODUCER, AND THE CERTIFICATE HOLDER, I -ESEN!A the certificate holder is an ADDITIONAL INSURED, the poh ICY(ies) must be endor,sd. If SUBROGATION IS WAIVED, subject to ,,--rnsand "'n"ifions of the policy, certain policies may require an endorsement. A statement o"is Certificate does not confer rights to the hFlFft Of such endorsement(s). NAME: aerrold Kameras AGENCY INC PHONE pm(978) '745 -5905 Na I tAX AfC erson Avenue 2=1 Ploor gmko"t.jerrold@allaninsura.-ice.coio. ... . .......... 04SURER(SLAFFOROMG COVERAGE JAM 4 MA 03-970-0511 _jNSURERA:Seneca S2ecL��!.t�Ins. Co INSURER B,.Saf ety. insurance Company iNsuRER c..Al terra Excess r Surplus Ins. Company MSUR'ao.-Ace Ameri _�rica�Llnsuranc�eL INSUR k E -Xli, 01830 - INSURER F RAG;E: CERTJFIC ATE NUMBER. REVISION NUMBER - Tr TH'A T ?'HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOHE INSURED NAMED A80VE FOR THE POLICY PEMOD HSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT' WITH REcSPECI To'%riii­IjCii, BE ISSUED. *OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEIREM IS 3U8jECT TO ALL TFIE: T E R k,, L iJS �O---`-NS ND CCIN n -MONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVS-nrrm Pgzni jr-cvi ov in OF I' NSURANCF ADDL�Uf� kLICY Poucy EFF POLICY r;xp I _NUMBER UWTS OCCURRENCE is GOD, �.70 0 1 GENERAL COMO F, j occuii 11/12/201111/12/2CI-2 blED 'Ar., - ------ 3 AD V fNjkj,-,' 1, DQ(j, 00() ... .......GENERA1. AGGRVGAT[ 2,000,000 -!"GAT' (';-I APPLAF:S PFR PRiDDUCIFS - C0,1APICIPAGG S 00 L LOC _7 80DILY INjURY Ift persnri+ X 3CHEOULED 203819 7/16/20!201/16/2'013 -PR-(;PF-RTr Or: AUT05 10CCUrRENCER E_Xc=35 _'AF1 Ci AIMSAIADE 3EC50000040 AGGRFGATE 1 5, UIF z L_L�.,4 11/21/2011 11/12/201.2 i ­0KrPS CGYAPEPESATION DwIPLCM L'.R3'LfAWU1`Y ------- TSIx f N _iVE N i A 142954 108/28/2012109/2612013 L L EACH 000 000 C_L SEA 000 000 EA F.L. DiS SE POLICY 1.101-1 j 000 j­­­wnv iui. AuaruGnaj Nemarks UtnedWO,ffMOrespacois required) 1 F iC AT w. DB� _'-Furfibert, Roofing Co. MA 01830 - Ha SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNIEREaN IN ACCORDANCE WITH THE KiLtCY PROVISIONS. AUTHORIZZED REPRESENTATIVE 1988-2010 ACORD CORPORATION. A-fif rightsreserved­&-9 AfIf%mm The Commonwealth of.tiMassachusetts Department of IndustriqlAcclknts Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leafty Name Address: City/State/Zip:/ Ut W(1,��J Phone #:. Are you an employer? Check the appropriate box: t;f r a employer with c90 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. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors 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 required.] % 07 Typo of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. F1 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. I Homeowners who submit this affidavit indicating they ire 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 their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:r� 4' r Policy # or Self -ins. Lic. #: C Expiration Date: Job Site Address: ��6� S� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. X do hereby certio under,tlins andpenalties ofperjury that the information provided above is true and correct. 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 commonwealth for any applicant who has not produced -acceptable evidence of compliancewith 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 maybe 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The GoxnMO.Umalth of Massachusetts Department of fadustrial Accidents Office olIavestigatioas 600 Washtngtoa Street Boston} MA 02111 Tel, # 617-727-4100 ext 406- oz 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 vc ww_mace unuM.;a