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HomeMy WebLinkAboutMiscellaneous - Exception (598)t I VkORTH q BUILDING PERMIT i? g6, �LEo h6 T61rQ TOWN OF NORTH ANDOVER ; Zai APPLICATION FOR PLAN EXAMINATION i Permit NO: Date Received TYPE OF IMPROVEMENT PROPOSED USE x IF 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 Septic Well.: Floodplain Wetlands Wa tershed Distrid Water/Sewer OWNER: Name: Address: l2 zq Identification Please Type or Print Clearly) 00 OG 17 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: $ 162K f FEE: $ Ir � Check No.: Receipt No.:' R NOTE: Persons con et' with unre ed contractors do not have arcWs to the guaranty fund Signature of Agent/Owtner Signature of.contrae �--c h a 1 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & 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 signature/date COMMENTS -- Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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) ❑ Notified for pickup Call Email Date Time Contact Name 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor. Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: 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 o 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 NOTE: 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 o 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) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 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 Permit No#: Date BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION IMPORTANT: Date Received must complete all items on this LOCATION Pint PROPERTY OWNER MAP PARCEL: 1 1111 i UU. rear Structure ZONING. DISTRICT:_ Historic District - - Machine Shoo Vil yes no yes no TYPE OF IMPROVEMENT PROPOSED USE ❑ New Building Residential ❑ One family Non- Residential ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units.- ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic❑ Well p ❑ Flootlplain ❑Wetlands 11 -Watershed District DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: ARCHITECT/ENGINEER Phone: Address: Reg. No. V 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.: Receipt No.: NOTE: Persons contracting w1th unregistered contractors do not have access to the guaranty fund Si -nature of A ent/Owner �g�. 9 Signature of contractor- j Location Y No02- Date Check # ` 27750 TOWN OF NORTH ANDOVER -01 Certificate of Occupancy $ Building/Frame Permit Fee $ US Foundation Permit Fee $ Other Permit Fee $ TOTAL $ A6A Building Inspector 0 Z �D O Cr 2 > co � O 0v CD CLc C .O CD CLO S• = (� CD N n O OW -A 0 a F 0 r_ n 0 CD CD3 CD U) O Z CD a CD FJ c� O < 00-0 rt = -h <. D O Q O --I 0 �• Q n O N cp O_O r- CL CD 3 --CD N N r -CD M CD 0 Q. W N C O cam. NCL O_ O W� O' C C=D' �D CD Z Q- --lo r M 0 N. C/) � c ch —� o o' 0m O O CD N Z ai = n=. < n o 70�— Q < (n m cn CD C C _s C m 0 a Z CD CD �` v, G7 n) -o rt CDN CO) Z �, : o >� (O � cn 0 O O = CD O art U) CD c' C F= C.) cn o °h z � � O D fD y : CD -0 m: c 0: � 2 0' O o CL N = N Ma .6 N 0 CD 0 • U) rt N O mc CD 91 2 CD > c .00 Oil D Ax S s I �1 VI 3 O 77 VI r m N O o] •n m z Z T R A p N n T j Vf fD < A O m m n N T O T =$ d A O M r C W z N m � T n S_ A O T O p 3 C G z z N m O W N m 3W T O Q n > p o m 2 7 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner information vu•14 - — Name 60---elL�wIS Company Name Street Ad (do not use a Post Office Box address) Connactor/ Salesperson! Utcver N G3 W ! < vvc City/Town State Zip Code Busiye�s ust nuclide a strezt Iljrf Daytime Phone s J Evening Phone (/p Cityrrowu state Zip Code ^n/ fiJ G r/ 45 l r L Mailing Address (It. different from 10 Business Phone FedoraEmployer ID or S.S. Number Htme rmpmvement Cotlrxtw RM N..k, 7?xpiaatim daft imp tetaootam m� r:«��t:coat min etmt 3 ✓ K ata �aaer=nt ht. f I X11 ��i The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if nem Required Permits -The following building permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowners agent: be adhered to unless circums ces beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will b ' contracted work MGL chapter 142A.)wmAw 3 Date w ted � ork will be stantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, finish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: upon signing contract (not to exceed 1/3 of the total contract ri cost of special order items, whichever is greater) $ 0 by —� $ 0 by 1 I_ or upon completion of .rte $t7 uipon completion of the contract. (Law forbids demanding full payment until contract is co leted to oth parry's satisfaction) The following material/equipment must be special $ to be paid for ordered before die contracted work begins in order to meet the completion schedade.(**) $ to be paid for NOTES: (*) Including all finance charges (**) taw requires that any deposit or down -payment r ed by the contractor before work begins may not exceed the greater of (a) one-third of die total contract price or (b) die actual cost of any special equipment or custom "lade material which must be special ordered in advance to meet die completion schedule. Express Warranty is an express warranty being provided by the contractor? ❑ Noes 1'211 terms or the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor Anther agrees to be solely responsible for all payments to all subcontractors for materials d labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important hiformation on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. 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 comraetor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. — 1-1-111W0111 DO NOT SIGN TKIN IMV I KA% -1 lr IMvenr. "v" tir. ya.r I— — -ate + v•• - Two idemicat co ' be completed and s,gued. One wpyshwld go to the h . The other copy should be kept bytbe cmatraemr. ere gnature Contractor's Signature Date Date C A`OOO® C `..�R �.,/ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/18/2014 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(ies) 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). PRODUCER Gilbert Insurance Agency, Inc. 137 Main Street Reading MA 01867-3922 NAME°T Barbara McDonough PHONE (781)942-2225 FAXNola (781)942-2226 EA -MIL bmcdonough@gilbertinsurance.com INSURERS AFFORDING COVERAGE MAIC # INSURER A:HARLEYSVILLE /WORCESTER INS CO. 26182 INSURED Duval Roofing, LLC. P.O. Box 637 North Reading MA 01864 INSURERB:Travelers IIIc. Co. 0031 INSURER C: INSURER D: INSURER E: INSURER F: r_nvraer,FQ rFRTIFICATF NI]MRERCL1331300142 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. INSR LT TYPE OF INSURANCE A L U POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR M Gilbert, CIC/BARBAR r7L64158G 10/23/2013 0/23/2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 PREMISES Ea occurrence $ r MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO LOC X POLICY JFCT PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED XSCHEDULED AUTOSAUTOS AUTOS X HIRED X N -OWNED BA64456G 10/23/201310/23/2014 COMBINED LIMIT 500,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ POP cidenDAMAGE $ Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAB EXCESS LIAB d OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N OFFICER/MEMBEREXCLUDED? (Mandatory In NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below NSA I I o be provided directly is Travelers Insurance /11/2014 /11/2015 WC STATU- OTH- E.L. EACH ACCIDENT is 100,000 E.L. DISEASE - EA EMPLOYEd $ 100,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Coverage ('FOTIGI(`ATF Hnl DER CANCELLATION ACORD 25 (2010/05) INSn9sinm rnrn% ni ©1988-2010 ACORD CORPORATION. All rights reserved. Tha Ai rwn names anA Inn^ ara res iafararl morke ^f A(`non SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover North Andover, MA AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ACORD 25 (2010/05) INSn9sinm rnrn% ni ©1988-2010 ACORD CORPORATION. All rights reserved. Tha Ai rwn names anA Inn^ ara res iafararl morke ^f A(`non PFUG78AL �o ee gm( '° Uc (781) 944-1994 (978) 664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvalroofing.com Page No. of Pages Builders License # 58443 Home Construction Reg. # 167338 PROPOSALSUBMITTEDTO f. I C 9N O�/ DATE STREET J J CITY, STATE AND ZIP CODE V We hereby submit specifications andestimatesfor: 3 Rip &/Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS L�7 1 layer of existing roof shingles ❑ 2 layers of existing roof shingles ❑ 3 layers or more of existing roof shingles 11 0 Replace any damaged roof decking; not to exceed 32sq. ft. (additional at $1.70 per sq. ft.) 1� Install 8" Aluminum Drip-edge/Rake-edge along entire perimeter (Choice of White, Brown or Mill) JN1ad38 'ON Cae;aaaasaapa❑ 1?98.1 dW 1S H -WON U IVAna H13NN3>1 P y Cl 4�OZi0Gl6= :uol;ea1dx3 An 01-1 g££L91 :uo!1ej1sl6q-d_� :ad�t1 ZIOlOtl2l1N001N3W3�0 o W3o aaWg30 uoUtifo%ag ssamspg1sa►c��� Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS -058443 i KENNETH P DUVA PO BOX 190 72 NORTH ST N READING MA 9186' ell )11414\ Expiration Commissioner 12/10/2015 The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations ' d I Congress Street, Suite 100 ° Boston, MA 02114-2017 swww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/OrganizationJIndividual): Duval Rooifng, LLC Address: P.O. Box 637 North Reading, MA 01864 Phone #: 978-664-2557 Are you an employer? Check the appropriate box: 1. M I am a employer with 8 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- listed on the attached sheet. ship 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 These sub -contractors have employees and have workers' comp. insurance.1 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.F Roof repairs 13. ❑ 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 anew affidavit indicating such. tContractors 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: Travelers Policy # or Self -ins. Lic. #: 7PJub-0230N91-14 Expiration Date: 3/11/15 Job Site Address: City/State/Zip:ko a4L-J_�. Attach a copy of the workers' compensation Alicy 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 $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. I do hereby ceglouv0pr the pains and penalties of perjury that the information provided above is true and correct C Phone #: 978-664-255 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 #: