HomeMy WebLinkAboutBuilding Permit # 6/22/2015 I NORTH
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BUILDING PERMIT ,�� tet:: ,6 OL
TOWN OF NORTH ANDOVER °
°� APPLICATION FOR PLAN EXAMINATION H
H
Permit N 7 Date ReceivedCHU
Date Issued:
IMPORTANT: A22licant must com lete all items on this 2aae
LOCATION,"
PR(,PERTY QWN RNxdll
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MAP NCt i'ARELZCNINt DISTRICT, His# ric D�str� tes
Mahrn hop Vll�age yes ca
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
Ci Septic 0 We'II ❑�Floodplain El1Netlands CI W�tersh�d Drs#rrct
Q W8ter/Sewer,
1-15 Ir-n1,11 C '.' <:,4 r 51-,, --Tos4o)
Identification Please Type or Print Clearly)
f
OWNER: Name: 7:1uuislhoAPhone:
Address: \L�C) 2CQ-Scny� e�* "-L DQA oy�er
CONTRACTfJR Name: Phone " ?
Mdress4911,
Supervisor's;Corisfrttetion License. , {
~�
Home fmpraVemerit License: Ex Date
";
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: $ 1(D L- FEE: $
Check No.: Receipt No.: Z:)(- . s
NOTE: Persons contracting with unregistered contractors do not have access to uaranty fund
Signature of Agent/Owner Signature of contractor I
F NO)RTH
Town of It
17',
Andover
0
No. ® _ _- a
T Z h ay2Z
T ® LAKE ♦ Vl ' Mass,
COC MSC KlwWK ��'
,p A04ATED
`r U
BOARD OF HEALTH
PERMIT T L Food/Kitchen
i ` Septic System
THIS CERTIFIES THAT .............pn�A4........�.� ...... J.t1.(- !.! -:...k .' - -............................. BUILDING INSPECTOR
has permission to erect .......................... buildings ons��...... ..............,..................... Foundation
Rough
to be occupied as ......... ,,, .... r... ...........:... ...... .......................................................... Chimney
provided that the person accepting this permit shall in ev 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
I , -- PERMIT EXPIRESMONTHS ELECTRICAL INSPECTOR
LESST Rough
Service
.................... .. .....................7T:�.......................,
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Bu 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 the Building Inspector. Burner
Street No.
Smoke Det.
EIN#51-050-3313 Havedrill M.'k 978.374.9224
MA Reg.HIC zr 149221 i.:awrence MA 97&687.7339
SIA Lie.UCS 4'+8.139 } Hampton NII 603,919.9224
BBB Single-Ply License#1711 r y Hampstead NI-1 603:329.8200
__ Sian X 9'2 i y. Toll Free 1.88830S.R0017
1
265 Winter Street
Haverhill MA 01830
icensed a+I tred .:Factory Trained ::Factory Certifie a ,
Name: i Date:
Telephone 'Z :2c ` ��I ��Alt.Telepho e "A�'� 7`=f�t`"�j '�r�"�h a Email:
Billing Address:, ' °Ir J -a '�___— --- City:�f. �r �, tli (`:lt =' S#ate: Ef`t�l('i,..
Job Address: e" City: State:
Scope of Work AStrip and Re-roof ❑Re-roof Approximate Roof Area:____
❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected,
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from die job site.
❑ 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-sheathing of roof deck can be performed at*$--I, per SR If individual sheets are found to be
rottedfor de-laminated,removal,disposal and replacement will be performed at*$ "=per sheet.If any trim boards are rotted,
replacement will be performed at ._='' 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'f'$ ( 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 manufacturers'specifications and/or C '
❑ Apply premium(UNDERLAYMENT)to(he balance of the exposed wood deck.
❑ Re-flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure>water tightness,
❑ If upon inspection, e discover clAmDey lead to be worn or deteriorated veplacement will be performed at*$ Y
o_. Install a new; Year Traditional rArchiternaral ❑ Designer C or ��.�..r'.: r•,.,{_. _, I
❑ Furnish and Install a new shingle over styli ridge vent system ❑Soffit vent system
❑ All debris generated by Lambert Roofing Co.,Inc,will be cleaned up and disposed of from the job site in a legal fashion.Under no
circumstances will the watertight integrity of the building by oippromised. r ti
Special Notes l {. �: C� ,ti4~at `' _ + / t a 1 °= 1� 7ti ti 1 c`�1 `, l j j C' ..y
"t�t.A:!"`.`a o'�i.4�^—='�l t''"K;� ,�„�''•,�g�.� e'P.6�' ts'; ,,� 4( ,fg r.. +i:.d'' :-�}.-,,t r' ��� �`j�r`�I ti i!.•�t a "+
UPON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORKMA SHIP GUARANTEE FOR APERIOD OF
YEARS HONORED AND ISSUED 13Y THE LAMBERT ROOFING COMPANY AND 1 f=,YEARS HONORED AND ISSUED BY THF.
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ "
-I'Denotes potential additional costs above the total estimated Brice.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work, furnish the materials and labor specified above for the total sum of:
` (.Dollars)
Payment NAB be made according to the following work schedule:
$ deposit upon signing contract
$ by_/_/_or upon completion of
$ 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 snail 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 for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Canf,ract Proposal
Home Owner(s)Signatures): r' Date:-/ l_ _
Contractor's Signature:, i'i:�1 Date: I t j
r -
alI" � eCIII (Please see reverse side)
^` The Commonwealth of Massachusetts
1 Department of Industrial Accidents
14 J. + l' Office of Investigations
600 Washington Street.
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Puliders/Contractors/Electricians/Plumbers
Applicant Information / ' / Please Print Legibiy
Name(Business/Organization/Individual): /o / k z A/—"1,?v
4611
Address:---t% �� / ��,/�
City/State/Zip: e. Gids" /Gf� r &cP Phone#: i''
A e you an employer? Check the appropriate box: Type of project(required):
I. I am a employer with W 4. [:] I am a general contractor and I
employees(full and/or part-time),*
have hired the sub-contractors 6. F-1New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g_ Demolition
working for me in any capacity, employees and have workers'
9. F-1 Building addition
[No workers' comp.insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑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 11D Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box 41 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 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.
X am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and jab site
information.
Insurance Company Name: 0_T4b l)'(m)
Policy#or Self-ins,Lic.#:i ` `+ �' `1 � Expiration Date: t � p
Job Site Address: �Ck uk C - 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 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.
X do hereby certify under th d penak�,Aofperjury that the information provided above lips true and correct.
Signature: Date: T c
Phone#: LAI
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#: .
DATE(PMIDD/YYYY)
04/07/2015
CERTIFICATE OF ILS
TMS CERTIFICATE IS FFIRMATVELYEOR NEGATIVELYI AMEND, EXTEND OR ALTER TIHE COVERAGE AFFORDEDABY THE POLICIEGHTS UPON THE CERTIFICTE HOLDER. THIS
CERTIFICATE DOES NOT dT A
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 OlicAic
the certificate holder is an ADDITidAmaNSF2E an endorsenrenm a skat meust be a Gndthis certifRiaate does not Wconfer Drights)4o the
the terms and conditions of the policy,certain polis yrequire
certificate holder In lieu of such endorsement(s). CONTACT 7errold >zBmeras
PRODUCER NAME' FAX
PNONE (979) 7$5-5905 .(970) 745-5993
ALLAN INSURANCE AGENCY INC. EMAIL .Jerrold@allaninsurance.com
63 1/2 .7efferson Avenue 2nd Floor INSURERS AFFORDING COVERAGE NAIC0
P.O. SOX 511
SALEM mAA 01970-0511 INSURERA:Assoicated Ind Ins Co
-----®® — INSURERO:Safet IIlESLlY 1100 Co
INSURED
INSURERc:National Union Fire Ins Co.
TGLRC
mai Lr1TOIJert ROO$inG� Co. INSURERD Ace AILIeriCiUn IY1Stlrnce CG7.
265 Winter Street INSURERE:ACe Americaxl Insurance_.go.
1'I�Verkl4 1 1 MA 01830- INSURER F:
COVERAGES CERTIFICATE IUUMBER:
RE11181dN NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THNTRACT OR E INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED CERTIFICATE NOTWITHSTANDING
TWITHMAY BEST LADED OR Y REQUIREMENT,
TERM OR CONDITION INSURANCE AFFORDED BY THANY E POLICIES DESCRIBED[HEREIN IS SUBJECT TO ALL CUMENT WITH RESPECT O THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RPD
DL CYEFBFY PPO—LldAID LES
XPLIMITS
ILSR TYPE OF INSURANCE POUCYNUMBEF2 MMIn6/YY Y MMI 1,000,00
/ / EACH OCCURRENCE $
GENERAL LIABILITY ,' 5 0,0009
/ / P EMISES Ea occurs rce S
X
COMMERCIAL GLNLRALLIABIIJTY 11/12/201411/12/2015 MED EXP( one person) S 1,000
A CLAIMS MADE FOOCCUR 81028029 1,000,000
/ PERSONAL 5 ADV INJURY $
X Per project Agg / / / / GENERAL AGGREGATE $ 21000,000
PRODUCTS•COMPIOP AGG S 2,000,000
GEN't AGGREGATE LIMIT APPLIES PER , / / / S
,
POLICY X PRO- LOC / / / / C MBINED 'INGLE LIM 1 000 000
Ea awd
AUTOMOBILE LIABILITY / / / / L30DILY INJURY(Par person) $
i
B ANY AUTO UODILY INJURY(Per accident) 3
ALL OWNED X pU70SUlLD 6203819 7/15/2014 07/16/2015 PROPERTY DAMAGE $
AUTOS X NON-OVJNEU (Pe.r ssrsiden'
$ HIRED AUTOS AUTOS
X UMBRELLA LIAR X OCCUR E18430331
EACH OCCURRENCE S 5,000,000
11/12/201411/12/2015 AGGREGATE S 5, '000
C EXCESS LIAR CLAIMS-MADE / / / / S
DED RETENTION 5 / / / / 3{ Wi'S7ATU- GTH-
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITYE L EACH ACCIDENT S 1,000,000
ANY PROPRIETOR/PARTNERIEXECUTIVE� NIA 03/25/2015 03/25/2016 EL DISEASE-EA EMPLOYE $ 1 000 000
OFFICERIMEMBER FACLUDF.D+ S62UB-2E09875-2-19 MA
D (Mandatory In NH) f / I / E L.DISEM E-POLICY LIMIT S 11.0 0
000
1(yes descolao under
DESCRIPTION 01 UPLRATIONS Lelw, 1,0 0 0,000
12/22/2414 12/22/2015 samaLmdsas
W Worker's Compenstaion NH6S62UB-SD81311-6-14 NFI pokcyabove 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) '.........................
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TGLRC rlba Lambert Roofing THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
265 Winter street AUTHORI E REPRESENTATIVE %3
vq nI t
Haverhill
PdA 01830-
Cc71988-2010 ACORC4 CORPORATION. All rights reserved.
ACORD 25(2010!05)
INS026(201005101 The ACORD name and logo are registered marks of ACOFID
CS-078130
WCHARD J LANOERT
265 VVIRnR STWEET
HaverWR MA 01030
0610212016
Office.of Consumer.Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 149229
Type: Private Corporation
Expiration: 12/6/2015 Tr# 245813
T.G.L.R.0 dba Lambert Roofing Company
RICHARD LAMBERT
265 WINTER STREET
HAVERHILL, MA 01830
Update Address and return card.Mark reason for change.
Address R Renewal Employment R Lost Card