HomeMy WebLinkAboutBuilding Permit # 11/17/2015 ,%OerH
BUILDING PERMIT ®�RR��o ,b06
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION -
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Permit No#: �Ce) Date Received ��ss acHusti��5
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
int 1
PROP RTY OWNER Print 100 Year Structure yes / no
MAP __PARCEL:_ZONING DISTRICT:- District yes' no �`
Machine Shop Village ye no
TYPE OF IMPROVEM��TReside,ntial
OSED USE Non- Residential
❑ New Building family ❑ Industrial
❑Addition o or more family ❑ Commercial
Iteration of units:
❑Assessor Bldg [I Others:
[I Repair, replacement y g
. [I Other
El Demolition ,,, „ „r ,i u,/ �a;�,/ „„ir✓�r�r/,;�r�rrr/%/OXfv<�O(/i /, Q1 r, . ,I N,/,1�, acl�� r�//,///
,,r c{� r ✓,oi �/c o/„iI/ / / � rv„ � JNJi t n�+��� r r � ,���6
DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly Phone:
OWNER: Name: \
Address:
Contractor Name: Phone:
Email: a t tc
Address:
Supervisor's Construction License: t r _Exp. Date: 6 °f
Home Improvement License: 1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDINO PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $
FEE: $ k
�. mac; ,
Check No.:
Receipt No.: ��
NOTE: Persons contracting with unregistered contractors do not have access to t ze guaranty fund
0 Z
m /o „ 11
��ti
Town
®
aNo. ��_ �
C, h , SSS, ��
COC LAKI ,
RATED
S C
VBOARD OF HEALTH
Food/Kitchen
PERM ,IT T L �ID Septic System
THIS CERTIFIES THAT ..�. -0.. .. ......................... BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ..q.lDfV.ald ............ . .t........................
l� Rough
tobe occupied as ..............(, .. .........r....................r�.. . ..... ........................................................ 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
L PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS C STRU CTIOT TS
Rough
I
Service
................... .. ... ... ............................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BuildinY Rough
i
1
Display in a Conspicuous Place on the Premises — Do' Not Remove Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
050-3313 Haverhill MA 978.374.9224
EIN#51-
MA Reg. 050 3 149221 be Lawrence MA 978.687.7339
HICMALic.UCS#78130 Hampton NH 603.929.9224
�ofan Hampstead NH 603.329.8200
BBB Single-Ply License#1711
-5i�,,,,�1932 O.
Toll Free 1.888.SOS.ROOF
265 Winter Street
Haverhill MA 01830
---� ;,�L!icesed r;Insured :;Factory Trained ,,Factory Certified �•
Name: i is /al(V Date:
Email:
Telephone:
Telephone: Alt,Telephone:
f�� ? f" ^, , G,, Cit f rlr�ini -��C�C'.�r State: f a
Billing Address: y
Job Address: City: State:
Scope of Work ❑Strip 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 the 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*$ �_10 per SE If individual sheets are found to be
rotted/or 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*$ 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
❑ Apply premium(UNDERLAYMENT)to the 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 ensureyatebtightness.
❑ If upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$
❑ Install a new: Year ElTraditional 1�Architectural ❑ Designer olor
❑ Furnish and Install a ew shingle over style 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 bu'lding be compromised.
Special Notes LAX 1� t' �� c ^t :fes ?{ j v v t11. S
1 r U� � 1 Xi
tr
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UPON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF.,,/!)—
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND YEARS HONORED AND ISSUED BY THE
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ � i � ' VCS J ,4,r-
*Denotes potential additional costs above the total estimated price. u'
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 will 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 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 for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Contract Proposal
-N l L < £^ Date:
Home Owner(s) Signature(s):
Contractor's Signature: Date:
HA76AMAY In1_"h91Vii"nnfi"0_[•'nM (Please see reverse side)
Company Insurances
TGLRC Inc.DBA Lambert Roofing Company will provide certification of insurances,demonstrating that we are fully insured for worker's compensations,
general liability,automobile liability and an umbrella policy.This documentation will be sent through the US mail to the above named parry if not already
provided.
TGLRC Inc dba Lambert Roofing CoMDany agrees to:
Commence the described work on or about
Complete the described work in approximately days.
Not be held liable for delays due to circumstances beyond our control.
Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control
Not be held liable and not covered under the workmanship warranty,for pre-existing conditions including but not limited to:
Mold and or wood rot,defective,faulty,rotted or worn building counterparts such as,but no limited to:siding,roofing,masonry,
plumbing and windows,all of which may jeopardize the watertight integrity of the structure.
o Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the
residence.
This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc.DBA Lambert Roofing
Company and the Homeowner/Business Owner or Agent.
Permits
A building permit may be required to remove and replace your roof.It is our obligation to secure these permits if required as the home owner's agent.Note:
Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A.
Accelerated Payment
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be
financially insecure.However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds
not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the
signatures of both parties.
Payment Terms
A finance charge of 1.5%a month(18%per year),will be added to all invoices on the 31"day.All legal and or collection fees will be paid by the binding holder
of this contract.
The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before work begins may not exceed
the greater of-
1/3 of the total contract price or:
0 The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule.
Arbitration
The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this
contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs
and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A.
Owner: � e . Date:
Contractor: Date: .
Contractor Registration
All home improvement contractors and subcontractors must be registered,any inquiries about a contractor or subcontractor relating to a registration should
be directed to:
Contractor Registration:
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place,Rm. 1301
Boston,MA 02108
(617)727_-3200
Home Improvement Contractor Law:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulations
10 Park Plaza,Rm.5170
Boston,MA 02116
(617)973-8787
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
Better Business Bureau
(508)652-4800
(508)7S5-2548
(413)734-3114
Cancellation
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be in the main office or branch
thereof,provided you notify the seller in writing at the main office by ordinary mail posted,by telegram sent or by delivery,no later than that midnight of the
third business day following the signing of the agreement.
( IN TIALS
4.
AC tp? DATE(MM1DOrv'YYY)
CERTIFICATELIABILITY 08/13/2015
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 CONTACT Jerrold Kameras _
._--_FAX -` .......,..-.-s-r—.._._.-......
ALLAN INSURANCE AGENCY INC. {'NONE (978) 745-5905 A,C !+tl; ;45.54a3
63 1/2 Jefferson Avenue 2nd Floor AI)DR ,Jerroldr,)allan9.nsurance.com
P.O. BOX 511 INSURER(S)AFFORDING COVERAGE MAIC r{
SALEM MA 01970-0511 INSURERA:Associated Ind Ins Co
INSURED INSURERB:Safety Insurance Co
TGLRC {NSURERC:National Union Fire Ins_ Co.
dba: Lambert Roofing Co. INSURERD•Ace American Insurance Co.
265 Winter Street INSUREP,E:AC_e_American_ Insurance Co._._--
Haverhill MA 01830• e!suRER F: —
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
IMS l:; TU CERTIFY THAT THE POLICIES Of INSURANCE (_IST ED BELO !HAVE BEEN ISSUED TO EHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
!NDI1;ATl f? NOTWHISTAJDING ANY REOUIRENIENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT I0 WHICH THIS
CL.E:T1EiCATE MAY BE ISSUED OF: MAY PERTAIN THE INSURANCE AFFORDED BY T•HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE fERmS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES U0.11TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
_ —
INSRPOLICY EFF POLICY EXP --- --_-^�— -�—
LTR ' TYPE OF INSURANCE POLICY NUMBER 64At1DD,YYYY !Aldr D!YYYY LIMITS
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AI `11,-iuRE{ZI ) �� 50,000
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DESCRIPTION OF OPERATIONS!LOCATIONS r VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required)
CERTIFICATE HOLDER CANCELLATION
TGLRC Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
dba: Lambert Roofing
265 Winter St. AUTHORIZEO111JPRE5ENTATIVE
i .•
Haverhill DSA 01830-
ACORD 25(2010/05) i 1988-2010 ACORD CORPORATION. All rights reserved.
INS025 . . .- , The ACORD name and logo are registered marks of ACORD
Nov. 17. 2015 10 :57 LAMBERT ROOFING CO. 9785215791 PAGE. 1/
■
' Qo OAT(:(MMIDDIYYYY)
colla CERTIFICATE OF LIABILITY INSURANCE 11/13/2015
fHIS CER'rIFICATE 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 Iiou of such endorsement(s).
PRODUCER
CONTACT Jerrold TCamerae
NAME:
._...... .._.....---- —.-__.. .....-----FAX---- _
-..—_......... .....
ALLAN INSURANCE AGENCY INC. PNONE . (97B) 745-5905 I rsTel !t9-sae3
63 1/2 Jefferson Avenue 2nd Floor EMAIL JerrGldGdallaninouranCe.com
P.O. BOX 511 —•___-_-__•,•__.••,•.. •,INSURF.R(S)AFFORDING COVERAGE N-^-_ _-_NAIC 11•._
SALEM MA 01970-0511 INsU119RA:Aor3ociatet7 Ind Ina Co. —
INSURED INSURERO:Safet _InRuraxiCeCo.
TGLRC INSUHERc_.National Union Fire ins Co—__
dha; Lambert Roofing Co. INSURFRD:Aca American Insurance Co.
265 Winter atr®et IN5uKeRt_Ace American Inaurance Co.
Haverhill MA 01.830- tNsuR[R�: uy '
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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wsFi( ' •__.._. _......: —-- S6tbl,i15R'""' POLICY EFF POLICY EXP- -----_ — LIMITS
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CERTIFICATE HOLDER CANCELLATION
-
• SHOULD ANY OF THE ABOVE OESCRI9E0 POLICIES HF,CANCELLED BEFORE
TGLRC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
dbaT Lambert Roofing Co.
265 Winter Street AUTIIORIZ EP48gNTAT1Vt
Haverhill MA 01830•
ACORD 25(2010105) / 0 1986-2010 ACORU ORPORATION. All rights reserved.
The ACORD name and logo are ragiso red marks of ACORD
The Commonwealth of 1Vlassochusetts
Department oflndustrialAccidents
qt m� X Congress Street,Suite 100
Boston,MA 02114-.2017
www.mass.gov/dia
f. Workers' Compensation Insurance Affidavit:Builders/Contractors/Electiicians/Plumbers.
TO BE PILED WITH THE' PERMITTING AUTIfOIRJTY-
Applicant Information Please Print Le ibl
Name (Businesslorganization4ndividual); "
Address:
City/State/Zip: at...., Phone#:
Are you an employer?Cheelc the appropriate box: Type of project(required):
1.❑I am a employer with : employees(full and/or part-time).* 7. Q New construction
2.❑I am a sole proprietor or partnership and have no employees Working for me in 8. []Remodeling
any capacity.[No workers'comp.insurance required.] g, ❑Demolition
3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 n Building addition
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 11.❑Electrical repairs or additions
proprietors with no employees. 12.F]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.EJ Other
6.Q We are a corporation and its offigers have exercised their right of exemption per MGL c.
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*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
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-coniracfors have employees,lliey must provide their workeis'comp.policy number.
Y ant an employer that is piovidirag workers'compensation insurancefor nay employees.'Below is the policy and job site
information.
�.
Insurance Company Name:
ry
Mx��
Policy#or Self-ins.LIc.#: ° � � n a
�,. � �. � � .. Cz /state/zip:
�I
lob Site Address:t" 1 .Ir, R c tyw
Attach a copy of the workers' compensatio 0Hey declaration page(showing the policy number and expiration date).
Failure to secure coverage as required imder 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 DIA for insurance
coverage verification.
X do hereby certify under the pains andpenalties ofper jury that the information provided alcove is true and correct.
Signature: Date:
Phone#:
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CS-078130
RICHARD J T
265 VAMR SMET
HaverhIn MA 01
OMM1
Office,of Consumer Affairs and.Business Regulation
10 Parr Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 149221
Type: Private Corporation
Expinsdton: 12MO15 Tri 24013
T.C.L.R.0 dba Lambert Roofing Company
RICHARD LAMBERT
265 WINTER STREET
HAV RHILL, MA 01630
Update Address and return card.Mark reason for choose.
p Addrmss p Renewal p Employment ® Lost Card