HomeMy WebLinkAboutBuilding Permit #215-13 - Exception 9/18/2012 TOWN OF NORTH ANDOVERL —
APPLICATION FOR PLAN EXAMINATION
Permit NO: /J Date Received a I
Date Issued:
IMPORTANT: Applicant must complete all items on this age
= P
int,
`PROPERTYRa
-OWN
/1
7 z nfl 100W&i4QldiStructure, no:
MAPNO'�_i L_-_ PARCELZ�-,Z_ONINGD;ISaTRIC�T;h �HistoncDlstnct" nog
;Machine Shop)VdI,-- � yes' no
I _
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 0 One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ ,Repair, replacement ❑Assessory Bldg 11 Others:
P
❑ Demolition ❑ Other
Y
❑aSe tic ❑;We 11 ❑ Floodpl11 ' ❑1Netlands� Watershed�District3
f
POP,
e
❑=Water/S;ewerl..
DE RIPTION OF WORK TQ� PERFORMED:
Ea
Identification Please Type or Print Clearly)
OWNER: Name: L144 d, a d' s �'�``� Phone:
1
Address:
a / � ��2 i
C®NTRACTOR' Name � _C _ z `I ✓ --- Phone =? `"' -
co J7
Address:
,14
Supervlso(ss)Constructorn Licens"e ��d �� Expid
-
_ - -
HomeImprovernent�Lleense._ - ri E:xp Date Y7J
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PE MIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. —
Total Project Cost: $ �/ �!' _FEE: $ - '00
Check No.: ` y Receipt No.: 2 7z L
NOTE: Persons contracting with unreff' tere Tactors do not have access to the gu ant.v fund
Signature of Erb _1.' S gnatu.re�ogntractor
Plans Submitted
❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL 1
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent DumP ster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED r
PLANNING & DEVELOPMENT n ❑
COMMENTS
i
I
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
A
}} Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
II �
Planning Board Decision: Comments
1
Q54nservation Decision: Comments
411-titer & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at-'124,Main Street-
Fire Department
COMMENTS
Location
No. V/Sr AC3 Date �....
e - TOWN OF NORTH ANDOVER
. � Certificate of Occupancy $
Building/Frame Permit Fee $ dd
t Foundation Permit Fee $
` Other Permit Fee $
TOTAL $
Check 4j&3�
25720 Ui1 ing Inspector '�
NORTH
own of _ ndover
No.
h ver, Mass, �-
toc.uchew�cK y1'
A04A-rED
S V
BOARD OF HEALTH
PER I T T D Food/Kitchen
Septic System
// BUILDING INSPECTOR
THIS CERTIFIES THAT ..... r%�!.�5...:':I �...........................................................................I........
Foundation
has permission to erect .................... buildings on ... .��..../47Z .....?............... .......................
---
out -
to be occupied as....... ..W'... . ....................��.f��1. `. ...... h-
...............................
to �ferfney
provided that the person accepting this permit shall in every respect worm to the terms o -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.
�A
MONTHS
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TARTS 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.
SEE REVERSE SIDE
is i in agreement between i
assic Metal Roofs, LLC • Toll free 1-866-660-6668 F or Office Use,only
X64 Gleasondale Rd. (Rte 62) Stow, Massachusetts 01775
-70A Contractor Regi# 144235 Rl Contractors Lic##26528 • CT Contractors Lien 1410 O6(l5 till
'And
;Name— C✓'`d��_�T � _ -:���� �_ -- —
Hereinafter will be referred to as�l� Buyer
f
Address... A-1
'City/Town � �'.' ..
State. Zip
'Phone P Flume r ell
,lob Site Address (if different): „f �..- ':`
Entered into on
Vic Buyer is the recorded owner of the property described in the Job Site address above,said hereby contracts with Classic Metal Rooi's,UC
(hercinaller the"Contractor")and authorize:%the Contractor to supply!all necessary..materials and labor to install,construct,and place the
improveniertts according to the following specifications,terms,and c6,nditions(hereinafter the"Speciticat'sont")rt the Job Site.
Specifications: '
Classic Metal Roof Shingle: Rustic olor:SG NIB DC CB B5 F(; TR Bit.
Oxford Colo AV TR 1\'[B S(;
Premium jEzlar i 'w AB CP CU
Finish: Staffdai•d Thet•mo __
Yes No hoofing accessories o
Plashing sl.��lights-number
_ sheathing 4'r 8CDX
--- Underlaytnent type-__-.-.—__. —_ Exisfing Roof material removal&disposal
-- - Vent pipes,size ,number __ _ Strip existing.hoof t#layers_
�^
Snow Guards# . Remove and dispose
Note:Place dumpster `?1: ly
Buyer will:
• Supply adequate electrical power for the Specifications.
a Be responsible for all rot damage and any other necessary sub roof repairs not stated Hi the Specifications.
• {agree to compensate the Contractor for any additional work perfonned by the.Contractor at a cost that is mutually agreed
upon by the Buyer and the Contractor before the work is started.
Special Instructions:
au
6 log-,
- - Contract Price$._�� -�
1
p Sales Tax fi
Sub-Cotal
Down Payment(U3)$_"W '-`W''
When work Begins Payment(1/3)$_-- �_--�-
Balance on Completion(1/3)
Make all checks payable to Classic Metal Roofs.LLC Do not sign this agreement if there are any blank spaces
In witness whereof:the Buyer and Contractor have hereinto tre`1y°signed their names this, day of �� of 20/
The Co,nlractor and the Buyer hereby inutuallr-agree in advance that in the event that the Contractor has a dispute concerning,
r—hitra#inn eorvice which has been annroved by the office of
�• s .€�' yunN .
"AtQr! ��3 j. 0
44,111
l a, s
Z'lic t dyer is(lite recorded o-vvner Of the Property described in the Job Site,address above,and hereby contracts with Classic Metal Roofs,LLC
(hereinafter the"Contractor")and authorizes the Contractor to supply all necessary materials and labor to install,construct,and place the
improvements according totilefiollowiug specifications.ternis,Yand conditions(hereinafter€he"Specifications")at the.lob Site.
Specifications: ��f/ ,�` {G t lz`'Ae—, t' r
Classic Metal Root Shingle: Rustic 'Dior: SG f41B UC CB BS
F TR BK
r
Oxford Colo 1i 'I R 1 A413 [�.G--l?G SG
Premii i f IV AB CP CU
Fililsh: 5ta•tt1li#id T rertno` y r
'Mn�
N'0 hoofing accessories
t°
Hashing skylights
—number �_•�� .� f it� ��'�&`�y �r�� r���X���� �r � x;:., y�
t hr derlayment type w „w .w —
w 'y a ,
Y r� n, ( {��q�5, s+ ,l : ,
91 t,Pilwa'.. ize, ^r.�'!�t'Lfni 1
Sf d'v^ GAW—U Y h t
m
� n �
1 YE 7777,
A i1
xe.
�r. s
A Pa
4,4
�4 ya• '''.+ .,wr �r�. y}.+_' 2r��C},.y(ry Fir
`y7•'' PY a�u.,y
j4+E" ( „S��i4riJ. Y.
itt
tit
�.� Y"t F: '�g a'3.y, Ny �'I"
x.
3 _- .,.��.. •ham-phi-Y� _ i y�'C� s�y'uL 7 fi�� 'l•SY;
....a—• { � r i Rr, �,Jr� -1f �J.A+� J '�.,f to t 3' ,i
T -
t�.� plc► ___�...__
7•t;.��`_—P Contract Price$ !'
— - 1 C t ''ii ' � t, Sales Tax$_
Sub-Total
Down Payment(1/3)
When Work Begins:Payment(113),S
Balance On Completion(113) -
Make all cliecks payable to Classic Metal Roofs,LLCr _ —
Do not:st n this agreement if there are any blank spaces
In witness whereof:the Buyer and Contractor have heleintri;freely signed their names ilii day of / oy2p/Z:
The Contractor and the Buyer hereby mutually agree in advance that in the event that the Contractor has a dispute concerning
the contract,the may su1b dispute to a.private arbitration service which has been approved by the Office of
Consumer AtTairs and B inc ceulation and the 1;oyer shall�be/equirel to submit to such arbitration.
Signe . .P
l s1c,Metal Rcr ,'LLC _
Huyer
Ilu'is a bfndme aFtventent between the Buyer and the Conterclor. This is not a credit Transaction and will nen t>e liu utced by tete:('.onteaCtor, 'll financing is required;the Ru cr
hcn•h}'authonz4s the Contractor w rrbt in cwdit informarittn and the Bum hereby agrees to pawide and sign ail necessar} third required hs any tha ' }
uist Un totiiacomplete the lin(nein«htpne-thiel}'upon nxluesl. "I'hc Buyer hcrc,l+}°acknrnsrled ti;an grirutal colryr of this n,reanxnl anti to the terms and conditir n..}3tlt tcltrii.tl
All surplus material is the properly of the Contractor
I
i'
i
CERTIFICATE OF LIABILITY INSURANCEDATEOU DD""")
109113120`12
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 pal cy(les)must be endorsed. N 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 endomement(s).
PRODUCER Dacey Insurance Agency,Inc.
Dacey Insurance Agency,Inc. PHOS 401 398.8020 Fax 401 398.8017
I31 Main Street AAAtL
East Greenwich RI 02818 MaURRJUSI AFFOROM r
fINSURER A: Montpelier US Insurance Co.
INSURED INIURM .The Travelers
Classic Metal Rook LLC I .Travelers Propeft Casualty Co.of America
264Gleasondale Road -INSURER 0:
Stow,MA 01775 INSURRR 4:
811R6R
COVERAGES CERTIFICATE NUMBER: I 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 CONTRACTOR 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.
rA
TYPE OF INSURANCfi ADOLBUOR BER POLK:Y EPP POLICYEXP
Jun im GENERAL LIABILITY HOCC MENC 1 OOO 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO:a amfin RENTEDS100,000
CLAIMSMADE 0 occuR MP0038001000ti23 11123111 11123112 MED F-XP ons =p $5,000
PERSONAL 8 ADV INJURY E 1 000 000
GENERAL&MEGATE s2.000.000
GEWL AGGREGATE LIMIT APP" S PER: PRODU -COMP/OP A i OOO OOA
POL Y WrT " 5
AUTOMOBILE LIABILITY COM ED SINGLE LIKUT i'000,000
B ANY AUTO BODILY DUURY(PerFMw)
AAULTOS NED X AAUUT"o°s� EO BA 628MOO72 11118!11 11118112 BODILY DUURY(Per aWdenl) S
X HIRED AUTOS X ANOTI�WNEO PROPERTY DAMAGE War aeriami 6
S
UMBRFLLALIAB OCCUR EACH OCCURRENCE t
EXCESS LIAS LAIM MADE AGGREGATE
WORKERS COMPENSATION WC STATU- OTH.
AND EMPLOYERS'LIABIUTY
ANY PROPRIETORIPARTNERIEX
C OFFICERJMEMSEREXCLUDEDi ECuU NIA 497SP714 12122111 12/22112000
�v� E.L EACH ACCIDENT 5OO
(Mandatory Ie NN) EL DISEASE.EA EMPLY S500.00
n desodbeunder
e E.L.DISEASE-POLICY LIMB $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attseh ACORD 101.AdM#wW Rwaft Sahsdats.I oleo spew b eequlrsd)
ContractodVendor prequalification
CERTIFICATE HOLDER CANCELLATION
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1600 Osgood StrBeI THE EXPIRATION DATE THEREOF. NOTICE WALL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVMION8.
North Andover,MA 01845
AUTHORIZED REPRESENTATNE
01 2010 ACORD CORPORATION. rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and usiness Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 144235
.-:.
Type: Ltd Liability Corpor
t 4rv3
u ,; ' tT Expiration: 9/17/2014 Tr►1 229529
CLASSIC METAL ROOFS L.L.C. " t
REESA GONET = ;
264 GLEASONDALE RD ' . � k
STOW, MA 01775 r'
S4 = ;
date Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
DPS-CAI 0 SOM-04/04-GIO1216
Office o�6o Omer�,., u�in ",g ,tt'.n License or registration valid for individul use only
U!CIC
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration• , 144235 Type• Office of Consumer Affairs and Business Regulation
Expiration: :911;7/2014 Ltd Liability Corpor 10 Park Plaza-Suite 5170
Boston,MA 02116
METAL RQOFS LkL711-0"a
REESA GONET iy
264 GLEASONDALE RD # q
STOW,MA 01775
�zUndersecretary Not valid without signature
{
f
,C
1:
)V Massachusetts -department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
License: CSSL-100240 `
Qf
NICFIIAEL W.GbNET--- 7�,
264 GLEASONDALOROAD. _
Stow MA 0175 _
-1iA 1 Expiration
Commissioner 01/20/2014
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,lassociation.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 performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented Ito 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 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA Q2111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
-vised 5-26-05 Fax#617-727-7749