Loading...
HomeMy WebLinkAboutMiscellaneous - 37 STONECLEAVE ROAD 4/30/2018Date 1:4V5, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -' t This certifies that ........k #yn.Pr- P has permission fornsta lation 71`.a ...... inthe buildings of ............................ . ........................................................................... at ...... .......... !!:� .. .......e—k!..., North Andover, Mass. Fee.�.5 ........ Lic. No..16.Z.2 . ....... ..................................................................... GASINSPECTOR Check #0— -7 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 0 MA DATE P i5 PERMIT JOBSITE ADDRESS S OWNER'S NAMEn.f GOWNER ADDRESS _ �� _ a TEl _ FAX TYPE OR OCCUPAN Y TYPE COMMERCIAL EDUCATIONAL PRINT [� RESIDENTIAL CLEARLY NEW: RENOVATION: Q REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES - �OOOD©00000®®�' • : fail11- f 2[�8111 t-Fi --ire-- li r-[11 r-r�l I BOOSTER I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR ts�r:�Arn^ GRILLE �— INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substaF'ZE meets the requirements of MOL. Ch. 142 YES 1[3 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYR TYPE INDEMNITY ® BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [7— AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compf ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #I SIGNATURE -–_-- MP 0 MGF 0 JP ® JGF Q LPGI Ba*�–CORPORATION ©# = PARTNERSHIP 0#= LLC E]# COMPANY NAME: A_ ADDRESS - N CITY c ✓-✓r-tk!1 C P _ I STATE C � ZIP Cole=TEL FAX CELL�'Q MAIL T^ O z 0 H U a ' 1 O❑ a z O y❑ W } 0 a Z w :* W 5 cn aCf) Ll oLU w � CO o a a a U J E. a a C w x w F- LL H zz 0 H U a L�7 c�h a The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: ,, I ✓1 City/State/Zip: w ,tA4 Phone #: Are you an employer? Chec the propriate box: 1.Iaam a employer mployees (full and/or part-time). 2. ❑ I am a sole proprietor or partnership 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 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.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporatiofficers on and its ocers 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. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs I f 14. ❑ Other �GS lo- 4r *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif 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:. Policy # or Self -ins. Lie. Expiration Date: Job Site Address:20 4 C F ,Cs:L�e iL' J City/State/Zip: /u o {"i ajw-6r �-)- Attach a copy of the workers' compensation 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 of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certyy nder the painsAd penalties of perjury that the information provided above is true and correct. Signature'./A /l4V Date: K Phone #: 7 � 3( C� ' `o 26 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 #: l 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 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-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 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 OF �:,:: l.a/'�" 4w -a Sa,.y � r ✓'",_x fi 4� t �. ', � � a Y,; ' .y �. "'�y", aC ', z � t G + "^ `+y; +w?"Y' .: f� R,� y,� � `C,:. •'+R .cam. n �f s `t ,..et .. f .t,{r .4'��Y'� � is �`. &•yy a•, a �\� f"::.. �•, �t' � s .,r s !�,,. .a . - r e«. r�,�� t�S PIF+ �.'.�' ,y '�ia��'u �v �S�'a• � ��'h yv,;, -si :� f t 4- , . &� � � a y fit; ''` .! , .•-�*�� , 4 mss$,. 3� '�' r }s"�'� .s -r -!.>y 4'a ' �%,'•� .. '. � < T 3a�,�y�,� �. ,r r. a. s4: �„ 4'-' ,'•�� k , f x �. 'e .�• � OY�1F � 'c.4�.+j � as . +.K � `� �' v. '•.7 i •a�«#re �'�'� iE''a�aS. .. �i .s. z." ;t �, S•wi'•.-„ "� 111 � k � �.��u ,.,`r a r `�. ,tz �. • .� "'¢' `� �,: �, iR ate � �f T..a • t,o-:. s ' . >'�, ' � __y s• � :t�t+P : ra :.,� - fie' � �i��e. S � -. -$ �`. � a e� � *�" �, � `e ✓� _ : d. " .oft . LL ?� n . Y +r !p "^ h -� -wi. • _ +`t- ,. .�- ,.. � . r �5 ,tr` ,t.r .-"+� f � 1 � 11 k �] 0 -I Nf - como r Ln o N m v D c < to Q: �o v c LA 2 �* c O ( N ttn O fD to 3 N 7 O =;4 to r D r ,, Location 4 No. p S Date d NORT1y TOWN OF NORTH ANDOVER _ o Certificate of Occupancy $ 41 �� s��•�„5 t`� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ / a TOTAL $ la Check # 3 v 6555 l'Building Inspector CI7j')36r - 62Y,9 C (1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T r F x TI i�tOle�`>rROM C Y BUILDING PERMIT NUMBER: D DATE ISSUED: -� -d 3 SIGNATURE: ZU Building Commissioner/I TeRfor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: / 1.2 Assessors Map and Parcel Number: 62.5 L414 Map Number Parcel Number 1.3 Zoning Information: Zoning Dist c ­t Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO 2.1 Owner of Record e 6 Z> IZi-'-v►-1 �i .5'� S��nct.- /eev,.P, Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: _ Si natu Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: aV `1 & > �`„ , / Address l� l S Telephone Not Applicable ❑ License Number 9 Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name /1 3 �' �� U S -—�j✓� (�t l �, Registration Number ` Address Expiration Date Si re Telephone 1 0" O z M go 0 rM M _r Z G) J SECTION 4 - WORKERS COMPENSATION (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 5 Description of Proposed Work checkall applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - F,STIMATF.T1 CONCTRUCTInN r,ncTQ 1 Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (e) X (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total_ 1+2+3+4+5 S C-' Check Number 3r,a..11U1'4 14 vVV1'NEX AU 1n%JK1L.AttLM IUBt UUM-FL1','1'ED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _ - ! G 4 4t 14�, as Owner/Authorized Agent of subject property Her�beha �-,_ to act on My �towork authorize wilding permit application. nahueTer Date SE ON 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Na rafra7e of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlMBERS IST 2 ND 3 RD SPAN WMENSIONS OF SILLS , DfWNSIONS OF POSTS DIMENSIONS OF GIRDERS IEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMdNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) of Permit Applicant ?, (:� �P `0 7) Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector LAMBERT ROOFING CO., IN V In burin TTN: MR- ED RIEMITIS, PHONE: (978) 686-3204 since 1932 v SUBJECT: (REF#00071) PROPOSAL FOR 37 STONECLEAVE ROAD N. ANDOVER, MA 01845 APPROX. ROOF AREA: APPROX. 2,400 SF. We hereby submit specifications and estimates for the following roof construction on the building @ the above address as per detailed description listed below. 1) Pre -pare for re -roofing by ensuring all safety measures are taken in accordance to OSHA standard regulations and landscape is properly .protected. 2) 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 @ $2.95 per SF. If wood e, sound we will re --nail any loose wood to rafters, sweep deck and prepare for roofing. is 3) Install custom shop fabricated metal (Aluminum) drip edge to all roof rakes`and eaves of roof (perimeter) as required. 4) Apply ice & water shield (UNDERLAYMEM) to the entire balance of the wood deck. 5) Install anew 25 -Year Traditional style shingle roof system. Color and manufacturer to be chosen by owner. 6) Cut in and install a new "Owens Corning" continuous shingle over style ridge vent system. 7) Re -flash all stack pipes and/or any roof penetrations as required and dictated by good roof practice to ensure water tightness. All debris generated by the Lambert Roofing Co., Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstance will the watertight integrity of the building be compromised. �P_W00(9_ 2 _k, I �,t THIRTY SEVEN STEVENS ST. HAVERHILL, MA (978) 374-9224 (FAX) 521-5791 OR VIA E -MA LAMBERTROOFING@AOL.COM OR VISIT US ON THE WEB @ WWW.LAMBERTROOFING.NET MAY 15, 2003 Al'� -2— MAY 15, 2003 ON COMPLETION AND PAYMENT IN FULL ROOF SHALL HAVE A WARRANTY FOR A F,IOD OF TEN YEARS ISSUED BY THE LAMBERT ROOFING CO., INC. AND TWENTY FIVE ARS ISSUED BY THE SHINGLE MANUFACTURER. The total cost for all tax, warranty, labor & materials. $6,350.00 (Payment terms: TBA) Acceptance of propos Signature 2/5 A Z Please sign and return one copy upon acceptance. this contract may be withdrawn by us if not accepted within 30 days. "Quality Workmanship You Can Trust" Our Proof is on Your Roofl Sincerely, DECOITO /Firm Manager I —2— MAY 15, 2003 UPON COMPLETION AND PAYMENT IN FULL ROOF SHALL HAVE A WARRANTY FOR A PERIOD OF TEN YEARS ISSUED BY THE LAMBERT ROOFING CO., INC. AND TWENTY FIVE YEARS ISSUED BY THE SHINGLE MANUFACTURER The total cost for all tax, warranty, labor & materials. $6,350.00 (Payment terms: TBA) Acceptance of proposal: Signature Date Please sign and return one copy upon acceptance. NOTE: this contract may be withdrawn by us if not accepted within 30 days. "Quality Worlananship You Can Trust" Our Proof is on Your Roofi Sincerely, LAMBERT ROOFING CO., INC. RICHARD j DECOITO Vice President/Firm Manager • ���. CERTIFICATE OF LIABILITY INSURANCE DATE IM"D/YY) FROOUCER - l O 6/ 17 / 0 2 THIS CERTIFI BOYLE INS AGENCY INC OF ONLY AND CONFERS ISSUED NO RIGHTS MATTER THE INFORMATION CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 445 MAIN STREET COMPANIES AFFORDING COVERAGE WOBURN MA 01801 ALL OWNED AUTOS X SCHEDULED AUTOS X HIRED AUTOS . K NON -OWNED AUTOS GARAGE LLABILITY ZANY AUTO E"S"IL1Ty UMBRELLA FORM OTHERTHAN UMBgELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ PARTNERWEXECUTIVEINCL OFFICERS ARE: EXCI OTHER 179406250 05/28/02 05/28/03 DESCRIPTION OF OPERATIONS/LOCATIONBMEMCLE34PECIAL ITEMS BODILY INJURY COMPANY INSURED A C N A LAMBERT ROOFING CO INC COMBPANY MERRIMAC VALLEY ROOFING CO INC TRANSCONTINENTAL INSURANCE 37 STEVENS ST COMPANY HAVERHILL MA 01830 TRANSPORTATION INSURANCE CO COMPANY COVERAGES 0 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 REOUIRF.MENT, TERM OR CQNDIT!ON OF CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TME INSURANCE AFFORDED AND CONDITIONS OF SUCH POLICIES. LIMITS ANY CONTRACT 09 OTHER DOCUI.ICP:T WITH RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE ^EXCLUSIONS SHOWN MAY TERMS, HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE LTR,; POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL LIABILITY C 10 7 4 0 2 9 9 5 8 ' DATE (MM/DD/YY) DATE (MM/DONY) LIMITS 05/28/02 5/ 28/03 XCOMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE s2 000 O O O CLAIMS MADE OCCUR PRODUCTS • COMPIOP AGG 61 000 000 OWNER'S i CONTRACTOR'S PROT PERSONAL A ADV INJURY $1 000 000 EACH OCCURRENCE sl 0 0 0 000 FIRE DAMAGE (Any am Ip) A 50 000 3 4MED AUTOMOBILE LJABYJTY 9981905/28/02 EXP (Any — PNfon) i 5 000 5/28 03 ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS X SCHEDULED AUTOS X HIRED AUTOS . K NON -OWNED AUTOS GARAGE LLABILITY ZANY AUTO E"S"IL1Ty UMBRELLA FORM OTHERTHAN UMBgELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ PARTNERWEXECUTIVEINCL OFFICERS ARE: EXCI OTHER 179406250 05/28/02 05/28/03 DESCRIPTION OF OPERATIONS/LOCATIONBMEMCLE34PECIAL ITEMS BODILY INJURY (P"P"i01) s 500,000 BODILY INJURY (P" aackwn') s 1 000,000 PROPERTY DAMAGE : 500,000 100,000 500,000 100,000 O rrcz 0 M M W •� O cQ 00 O O � U O a CC13 U O 04 p� w U o03 0 to o 0 o Mo O I\� C O 0 PL 0 �Vo h > Ln Ln .- CL o o >;p cc j- m h x crW z o 0 C7 Lp1 U " ' CY) O •w 00 'C a) T- \+ 1� O y ��y..0 wQ d W W v'O r, n. ~J C� ? o o ? W .0 �L c'o m O m Nom' N O W N% U' Q O r, J�cM2 �> w ra = 0.' LL y ao 0 E N H N C WC > ' g IX X .. . .. loo ow, � �w � Mn �k i:4 LU ■moo § k < .3 2 ,cl � 6 c i:4 Q k k M @ § 5 i W3 W 4 o p CL 0 H w a o C 7 ro 0 � W Qr m u W w W i, x o c� SP m z a w N z cn v o v O cn �: co c � C N O V V 4: CLC O O _C O O � yam"' m o a y mCL E m m a y m r .� m O � . Z C ` y O C E m Cc= .: m r _ = o «.+.-= c cue ISO a0c0s m � fV' y zcc C = m CD a d.=.p N CO2 m = .. LJJ O = LL F� .y .Z. c Z m 'y 8 LU •E V V o os QJ COD a = eyv y'� O r- .aimF. Z 0 W 2 O a z 0 U Cf) f M, 0 0 v I C� _ � Q � M E m m 3� O Q O Cc Cl �Q O C cc d O ,� ca C Z CD V CO)CL O C C cc d CO) Q 0 U) crW w crW U)