HomeMy WebLinkAboutBuilding Permit #298-2017 - 894 GREAT POND ROAD 9/9/2016 ` ( i NORT►y
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 7°
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Permit No#: Al? 9017 Date Received ��' -�`�t
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Date Issued: �.9 /a'0' to
IMPORTANT: Applicant must cco-mplete all items on this page
LQCATION
` Pint
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PROPERTY OWNER ` kfa I oac
Print- 100 Year Structure yes -no
MAP JO PARCEL. Z o ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
.R
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial 1
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition _ ❑ Other
7,Septic Of 1Nell ❑ F�lootlpl n []`Wetly Vis;` ^' ❑,:1%Uaters.hed District
•Water/Sewe`r ' � `' a � °'
DESCRIPTION OF WORK TO BE RFORMED:
{
Identific tion- lease Type or Print Clearly
OWNER: Name: M(-)kff rK knno ►'Y10 jo Phone:(D(�
Address: 0(1
J �8. ft6Af_DL_Rr HA
Contractor ame: one:
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Contractor �: . ,
Address:
Supervisor's Construction License: S', Exp:: Date: :
HomeIm rovement License: Exp. Date.
p l�'1
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: $ �, cJ�` FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access ranty fund
'7777 - i
Plans Submitted ❑ Plans Waived ❑ Certified Plot PlanT] Stamped'Plans ❑ ' , t �'
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnxuning Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dwnpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
R
COMMENTS
� f
CONSERVATION Reviewed on Signature
t
COMMENTS 4 °
HEA LT W Reviewed on ,
Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: '- Comments
a
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp ®ump77
sterons tees
Located at 124 Mam Street " '° `� �,
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Fire Department signa .ure/date
tne
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'!:$a "� Se '' ,'F "-ca,c '�J a .•; -. L
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
i
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
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Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes N®
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
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® Notified for pickup Call Email
Date Time Contact Name
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
4. Building Permit Application
4 Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
4 Engineering Affidavits for Engineered products
OTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
i
I
Building Permit Application
4 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)
i Copy of Contract
2012 IECC Energy code
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
Location 69( rA T
No. -g a i'? Date
• - TOWN OF NORTH ANDOVER
• K Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
Building Inspector.
r -I - V F NORTH .,q
ve' '*
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No.
LAK, h ver, Mass, q q ob'016
A- coc"IC.l WIC. y�.
7�A�RATEo
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BOARD OF HEALTH
Food/Kitchen
PERMIT- T LD Septic System
.410 Q0O • I� .......................... BUILDING INSPECTOR
THIS CERTIFIES THAT ....................................... ............... ...........
has permission to erect buildings on ....... fy Foundation
Rough
to be occupied as
.............�.rr ...� ..........,..�.............�..K ... ...................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT STAR Rough
Service
...... ... ............. .... ... ................ ................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough _
Display in a Conspicuous Place on the Premises - Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
EIN#51-0503313 T Haverhill MA 978-374-9224
MA Reg.HIC#149221 member Lawrence MA 978-687-7339
_t2. MA Lic.UCS#78130
Hampton NH 603-929-9224
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BBBohing Hampstead NH 603-329,8200
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Toll Free 1-888-SOS-ROOF
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Www.LAMBERTR OOF I NG.COM
265 Winter Street Haverhill MA 01830
-•
Name: I Moira Goodman I Date: 19/8/2016
Telephone: 617-851-6461 Cell Phone: Click here to enter text. Email: Goodies6@comcast.net
Billing Address: 894 Great Pond Rd City: N.Andover State: MA
Job Address: 894 Great Pond Rd City: N.Andover State: MA
Scope of Work
®Strip and Re-Roof El Re-Roof Approximate Roof Area:
®Prepare for re-roofing by ensuring all safety measures in accordance with OSHA regulations and landscape is properly protected.
M Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site.
®Inspect wood deck,if we discover any rotted wood,replacement will be performed at*$3.95 per LF for roof deck boards. If substantial deck
rot is discovered,re-sheathing of roof deck can be performed at*$1.25 per SF. If individual sheets are found to be rotted/or de-laminated,
removal,disposal and replacement will be performed at*$65.00 per sheet.If any trim boards are rotted,replacement will be performed at
*$12.00 per LF 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*$12.00. If wood deck,siding and flashing is sound,we will re-nail any loose wood to rafters,
sweep deck,and prepare for roofing.
®Install 8"drip edge to all rakes and eaves.Color:
®Apply ice&water shield(UNDERLAYMENT)as per manufacturer's specifications and/or
®Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck.
M Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
Z If upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$450/ea
ZInstall a new:Year ❑3 Tab MArchitectual El Designer Color:
9Furnish and install anew shingle over style ridge system Soffit vent system *$n/a
9AI1 debris generated by Lambert Roofing Co.will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances
vill the watertight integrity of the building be compromised.
special Notes:6'of ice and water shield to be installed to entire building. Synthetic paper to be installed above ice and water shield. 40 yr
architectural shingles. Ridge vent all applicable areas.
)PON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORKMANSHIP WARRANTY GUARANTEE FOR PERIOD OF 10 YEARS
IONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND LIMITED LIFETIME YEARS HONORED AND ISSUED BY THE SHINGLE
AANUFACTURER MANUFACTURER'S UPGRADE *$N/A
Denotes potential additional costs above the total estimated price.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
he Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of:$ 16,500.00(*)
ixteen Thousand,Five Hundred (Dollars)
Payment will be made according to the following work schedule
5,500.00 deposit upon signing contract
by or upon completion of
3olonce upon completion of completion.
(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 attached notice of cancellation for an explanation of this right.
DO NOT GN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Acc tante of the Contract Proposal
rme Owner(s)Signature:
Date: ` L
ntractor's Signature: Date: ill C} 1`
www.lambertroofi com ( se see reverse side)
The Commonwealth of Massachusetts
Department of Industrial Accidents
h
Office of Investigations
e
1 Congress Street, Suite 100
. ,W` Boston,MA 02114-2017
wives mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): `,-�
Address: A(.Q CS 1 n
Ci /State/Zi - �.Q,i' 1 1�/�Ql Q) �_;a) Phone#:
Aree on an employer? Check the appropriate box: Type of project(required):
lir
am a employer with 4 ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]Now construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have
8. E] Demolition
working for me in any capacity. employees and have workers'
insurance.* 9. E]Building addition
comp.[No workers' comp. insurance
+required.] 1 5. E] We are a corporation and its 10.E]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13-Lb/Other
comp. insurance required.]
*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-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,
Policy#or Self-ins. Lie. #: 105AQQ aoW)G-a' 1(6 Expiration Date: ° •t�
Job Site Address: �"t
`l &Pen�ry� City/State/Zip: �3• &10•&,W ka-
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 5250.00 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.
I do hereby certify under the pains ties of perjury that the information provided above is true and correct.
Si ature: Date:
Phone#: - 31�A• `t a'
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 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 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 perfonnance 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-contractor(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 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 Departrnent 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406'or 1-877-MASSAFE
Revised 7-2013
Fax # 617-727-7749
'
www.mass.gov/dia
016-Sep-20 10:32 AM Allan Insurance Agency Inc. (978)745-5483 1/1
CERTIFICATE OF LIABILITY INSURANCE D9/20IDD0
o /2o/21616
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONNCItS 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder i9 an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain pollolee may require an endorsement. A statement on this certificate dons not confer rIghtc to the
certificate holder In lieu of such endomemen a),
PRODUCSR CONTACT
Jerrold Memeras
ALLAN INSURANCE AGENCY INC. P °Ne (978) 745-5905 (6701 715-3093
63 1/2 Jefferson Avenue 2nd Floor Jerrold@ allaninsuranoe.com
P.O. 13OX 511 INSURERS)AFFAFFORDING COVERAGE NAIC9
SALEM MA 01970-0511 iNeugeRA Associated Ind Ins Co.
INSURED INSURER Safe Insurance CO.
TGLRC iNsugeRciNational Union Sire Iris Co.
dba: Lambert Rooting co. INSURERDAcQ American Insurance Co.
265 Winter Street: INSUk4RE-AG1e American Insurance Co.
Haverhill MA 01830— INSURERF
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTUNTHBTANDING 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.
TYPE OF INSURANCE AVDL VOK POLICYNUMBER LIMITS
GENERALUA131UTY / / EACH OCCURRENCE 8 1,000,000
X COMMERCIAL GENERAL LIABILITY / / / / IIAMAUBTORINTPF—
P ® 50,000
A CLAIMS-MADE ®OCCUR RES102029 02 1/12/2013 1/12/2016 MED EXP one arson 3 1,000
X per progeot Aga NIRtiO71151 Roofers ASSOC. / / / / PERBONALAADV INJURY a 1,000 000
GENERAL AGGREGATE 5 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMPIOPAGO S 2,000,000
POLICY 7 P LOC / / / / L
AUTOMOMILB LIABILITY / / eaS 11000.1
ANY AUTO / / / / BODILY INJURY(Par parson) E
B ALL OWNED BCHSDULED 6203819 7/16/2016 7/16/2017
AUTOS x AUTOS BODILY INJURY(Pereeeldent)
X HIRED AUTOS X AU OSWNED / / / / OPER 8
X UMBRELLA UA9 X OCCUR / / EACH OOOURRENCE 6 5,000,000
C EXCESSLIAa F I CLAIMS-MADE 11111018335633 1/12/2013 1/12/2016 AGGREGATE 6 S,000,000
DED R / /
WORKERS COMPlINVATION / / / XTATU• 0
AND EMPLOYERS'LIABILITYTORY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN 6862Ua-2L0887S-2-16 MA 3/25/2016 3/25/2017 C.LEACH ACCIDENT S 1 000 000
OFFICER(MEMBLR FXCLUDEDT a N I A
D (Mandat,o
eery
y�in NH) / / / / E.L DISEASE-EA EMPLOYE S 11000,000
'D dfF�710N OOP2RATI0NS / / / / E.L.DISEASE-POLICY LIMIT 6 11000,000
T Worker'■ Cc mpansation NH / / / / Same li O of 1,000,000
6962UD-SD81311-16-13 Na 2/22/2013 2/22/2016 policyebove 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANaoh ACORD 101,Additional RemerM Schedule,It mars space to required)
CERTIFICATE HOLDER CANCELLATION
( ) - (978) 688-9542
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICES WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
1600 Osgood St.
AUTHORIL EPRF09NTATNE
North Andover MA 018413- (� "11� J ArntrIL-lul:,
ACORD 25(2010105) ®1988.2010 ACORD RPORATION. All rights reserved.
IN9026 i2tHoos),o( The ACORD name and logo aro r 1912red marks of ACORD
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Massachusetts Departmeht of Public Safety
Board of Building Regulations"and Standards
License: CS-078130
Construction Supervisor
RICHARD J LAMBERT
t Y
266 WINTER STREEL {tl
HAVERHILL MA:01830
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Co ,.M ..CIS_
Expiration:
missioner
06/02/2018
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= Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Co It
e...i
I Registration: 149221
a - Type: Private Corporation
T.G.L.R.0 dba Lambert Roofing Company, Expiration: 12/6/2017 Tr# 273093
} +
RICHARD LAMBERT -r -
265 WINTER STREET "
HAVERHILL, MA 01830
U
SCA pdate Address and return card.Mark reason for change.
Ca 20M-05/1 i 'Address ❑ Renewal Employment Lost Card
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