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HomeMy WebLinkAboutBuilding Permit #283-12 - 1 Stacy Drive U-1 10/4/2012 TOWN OF NORTH ANDOVER pAPPLICATION FOR PLAN EXAMINATION Permit NO: O /, Date Received Date Issued: c- /ti IMORTANT:Applicant must complete all items on this page LOCATION S `f A=L y D k) bbl r x-K Print PROPERTY OWNER Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no R l o l O u o — 001q - 0000, 0 Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial air, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑'Septic 0 Well El Floodplain �O Wetlands 0 'Watershed District D'Water/Sewer DESCRIPTION OF WORK 0 BE PERFORMED: L . C- �A- t 6 V\J (Identification PI se Type or Print Clearly) OWNER: Name: "�4 iZC� v�ti�v Phone Address: l f1�' �� /-f�i1 , ✓�.� "�/} C�l 9VY CONTRACTOR Name: % �� C,,st ,vu,�- Phone: 96?`)63,�7 Address: v CG C-4 yl `( <` Supervisor's Construction License: 9 /�� S �- Exp. Date: Home Improvement License: Exp. Date: �✓ �rir� 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: $ r �` /, �� FEE: $ �:6 Check No.: %' ;2 '/ Receipt No.: j°� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature;Q.TA ent/ r d -- Siahature of.contra" or .._ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunrrimg Fools, ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 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 square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: 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 - Date DocAuilding Permit Revised 2011 June/mi 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 ❑ 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 Permi Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ f=loor/Crossection/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 ❑ 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: Doc.Building Permit Revised 2008mi Location/ 57ecy /)/' No. Z- Date b L �aRTM TOWN OF NORTH ANDOVER a Certificate of Occupancy $ • i CMUs,<� Building/Frame Permit Fee $ so— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24656 wilding Inspector AORT#q TO'" Of . Andover .. . . , O dover, Mass.,LK E COC HIG HE WICK It. ADRATED PP�,��� S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................. 7 / � ........................................................................................ Foundation has permission to erect..................................... . .on .... buildings ./..... ��G.... ......y! �r............................................ Rough Chimney to be occupied as .................. Ns .... ..... ..... `1....................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final' 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ....................... ........ . ...... .............. .................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocayy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. OP ID:SS '4 CERTIFICATE OF LIABILITY INSURANCE 0312( 24MI 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: U the certificate hokler an ADDITIONAL INSURED,the policy(les)must be endorsed. ff SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement an this certfiexte does not confer rights to the certificate holder in lieu of such endorsement(# PRODUCER 978468$-7000 CONTACT Durso&Jankowski Iris Agcy LLC 198 Massachusetts Avenue 978-688-7007 PHONE Fax Nor North Andover,MA 01845 1 . Charles S.Randone c=aPRO �w,POL.AR-7 INSURi3WAFFORDINGCOVE RAGE rim 04SURED Polar Blur Insulation Co.Inc. INSURHZA:Penn America 32859 P O Box 958 WSURER 8:Safety Insurance Co. 33518 Andover,MA 01810 INSURIatC_ INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE POLICY NUMBER POLICYGF POLICY EXP { !mIaTS GENERAL UABRM I EACH occuRRENce s 1,000,000. A X coMMERCIAI Gear RAL LIABILITY PAC6864084 03!24!11 03124h12 5 50,00 CLAIMSfiMDE n OCCUR MED EXP(Any ane Person) $ 5% PERSONAL&ADV INJURY S 1,000,0 GUEffALAOGREGAM Is Z0001 GITPLAGGREGATE LIMIT APPL�fESPER (� PRODUCTS-COMPOPAGG $ 1,000,0 POLICY JECT PRO- l i LOC 1 g AUTOMOBILELIABILrY COMBINED NEDSINGLELIMIT S 1,000,000 B ANY 100926 0IRM11 i 01J04M2 BODILY INJURY(Per Pte+) S ALL OWNED AUTOS t BODILY INJURY(Per aenq 1 S X SCHEDULED AUTOS PROPERTY DAMAGE s X HR®AUTOS (Peracadenl) X NON-OWNED AUTOS E s 5 UMBRELLA UAB X OCCUR � EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE PAC6864084 03/24!11 03124!12 AGGREGATE $ DEDUCTIBLE iJ f $ RETENTION $ !f 1 1 1 $ WORKERS COMPENSATION YIN X TORY�LIMf�TS � AND EMPLOYERS'LJABILTTY ANY PROPRIETN=-R EX t7f DED?ECUiTVE + I I S OFFICERA�lEM6ER EXCLUDED? � NIA! E.L EACH ACCIDENT (MarlddMin" I El DISEASE-EA 2n24 S DESCRIPTION OF OPERATIONS below El DISEASE-POLICY LIMIT S I � f DESCRIPTION OF OPERATIONS I LOCATION I VEHICLES(ASach aCORD t01 AdManai Remarks ScheAWe,ff more space Is regairedj G.L.CA.C.,National Grid Corporate Services LLC DBA National Grid,Action Inc,Boston Gas Company,Colonial Gas Cny,Essex Gas CompatLSr&Bay State Gas Co.;are additional insured for generalollaGty With respects to work performed on their behalf by the above. CERTIFICATE HOLDER CANCELLATION GLCAC11 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCB_LED BEFORE G.L.CA.C. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN &Bay State Gas Co. ACCORDANCE WITH THE POLICY PROVISIONS 350 Essex Street Lawrence,MA 01840 AUTHORIZED REPRESENTA?IVE AMIJIL ©1988-2009 ACORD CORPORATION_ All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD N - AghtFax N1-1 1/19/2011 1.0:14:22 AM PAGE 2/002 FaX Server ACORD. CERTIFICATE OF LIABILITY INSURANCE DATe(mw Drrmr} oinmoll 'MS GERTIRCATE IS ISSUED ASA AWITER OF INFORMAIM ONLY AND CONFERS NO RKGS UPON'THE CWMCATE HOLDER.THIS CERTIFICATE ODES ND'T AFFUMtATWELY OR NBGAIIVELV AURID,EXTEND OR ALTERTHE COVERAGE AFFORDED BY THE POLICIES BELO W. TUNS CE RTIFICATE aF MSURANCE DoEs moT camsTnu,tE A c owmc r aErmEm miE LgwA NG INSURi72(Sj AUTHORIZED REmmE#TA,nts OR PRODUCER,AND TETE CERRMATE HOLDER. PAPORTANL-NlAe calf c o!aider b m ADDRAONAL RISUB M6 ttw pdIcj(ws)!Nast be arak rzed.H SUBROGATION IS WAIVED,suigeato Cha tRualcw4 aarldida m a#U»policy,ewbin po5eies=W R eiI aDa«,dorsea y A s�hmerB Nit this eRx55eate does Iaot confer rrgfds to 8ro , to, hIuwofsuch ar>darsemenl4 PRODUCER CONTACT NAME- PHONE FAX DURSO&JANKOWSKI INS (AIC,No,Ems): FAX 148 AdASSACETUSEM AV194M E-MAIL ADDRESS: PRODUCER NORTEI ANDOVER.MA 01845 CUStOMM ID& 22P'I I. INSURER(Sj AFFORDING COVERAGE MAIO* INSURED INSURER A: TRA-YELTD.tS IlV>l>Ir34 NM COMPANY INSURERS: POLAR SEAR INSULAMON CD INC INSURER C: INSURER D: P.O.BOX 958 INSURER E: ANDOVER,MA 01810 INSURER F: COVERAGES CERTIFICATENMBER: Ravin 1iNUt em- TMISTOCOMFYTHATTLEPOLICESOFJISURANCELWED BELOW HAVEBEENI= DTOTHEINSUREDNAtIEDABOVE FORTHEPOUCYFER80DMOCATEG NOTMTHSTANOING ANY R8WXR6lffST,TELIV6 OR COMMON OF ANY CONrRACrOR OTHER DOCt1 &iT WITH R£SPECrTO WMCR THIS OERTW=X'TE MAY 938 MWJM OR MAY PL3RTm Ttm mwRAwCE AFFORDED SYTHE POUCH 089CMM MMmNS SU8.RCTTO 3LLT%ETElWS FxCL UMOM AND CONo;nm4S OFSUc*(POUCIES. LiNTSSHOWN WAY KAVE 8594 REDUCED BY PAID CLARAIS. MR ADDL.SUSR POLICY EFF DATE POLICY EXP DATE TYPEOFUGUlZ 4CE POLIcirrviu ER D Y7YYI (r3 MIAYTM uurrs LTR 84SR WVD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL L A LMY DAMAGE TO RENTED S CLAWSMADE OCCUR PRE ISES{Eaoomorrenee) MED EXP WW one person) S PERSONAL&&ADV MIRY $ GSN%AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ POLICY PROSECT LDC PRODUCTS-CONFJ0PAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LMT(Ea acoderd) ALL OWNED AUTOS 90DILY Iirl.IIRY $ SCHEDULE AUTOS (Pet pMI=) HIRED AUTOS BODILY INJURY S (PereccidenQ NOL!- WNED AUTOS PROPERTY DAMAGE 5 {Par accident} UMBRELLA LiAB OCCUR EACH OCCURRENCE $ EXCESS LL48 CLAM-MADE AGGREGATE $ DEDUCTIBLE s RETENTION S $ WC$TA7IAORYLbi7S OTHER WORKER'S COMPENSATION AND EMPLOYERS LIABILITY YIN U9-9ML09&11 01/012011 411012012 E.L EACH ACCIDENT $ 1,000,000 ANY PROPSUTOFNPARTNERIEXECMM Y El-DISEASE-EA EldPLOYEE$ 1,000,000 OFFICEFUME343MOCCW0®7 (montatory trs NHl E.L DISEASE-FOLICY LIMIT $ 1,000.000 tryea.Cea mmunder DE9r3SPnO,VOFOPEPJaX Sootoar DE'Sr OPTION OF OPEIRA7ION5AOCA71ONSIVE N O alloposimpECIALM319 IMS REPLACES ANY PRIOR CERIMME ISSUED TO THE CERTIRCATEHOLDER AFFECIEW WORRE RS COMP COVERAGF— CERTIMATE HOLDER CANCELLATION G L C A C&BAYSUM GAS CO SHOULD ANY OFINE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETH MSOF,KV=WILL BE DEL(VERED IN ACCORDANCE 350 ESSEX STREET Vm THE POLICY PIiOVIMONS. AUTHOR REPRE$EIMATIVE LAWRENCE,MA 01940 Charles J Clark ACORD 25(2009M) tsea zoos AcaRD c:oRRoRATION. All rights Dred. Office of� o;�ST3L' er Affairs and Business Re ation i o Fark Plaza.- Sit€5170 -16 Bo-sum,Massachusetts 02.1 Hone Improvement Conn-actor R4strafion Re isiratiorr102721 Type: DSA Expimtlo r: 7MO12 Tr# 298S38C! POLAR BEAR INSULATION CO. -- Vincent LeBlanc _ — P.O. BOX 958 ANDOVER, MA 01810 -- Upftte AMrm and return card.Xark rem-a for d=r- Ad&ess - Renewal _ Empioymeai 77 jart cera r=: ` - f nasi CAM- T xmnse or Yim�aNd iE}F in me�v Office of c{1�er BIRD Bushress R Dn -7-F4-- YL 1i}vm Types iQ park 1222-S 51?8 _> aTiraftm 7=2 ESA Bose 3&i 82116 D R BEAR ISSULATI UCO_ VincerA LaBla= 51 Sfl_CANAL ST. 5A -- - �_ _ - -- LAWRENCE,MA 01841 rnclersecr+'tarr tintrand without signature "-"s..j' Misr. :-i! o C-S SL 99352 RR t VINCENT LEBLANC 24 LANDING DRIVE METHUEN,MA 01844 axpiraucm: 4.0412£?i2 99352` 3DAAA Golum� GasR- of Vasshuwm A Prigwrm Coups" 79 Gas Account Audit Request go 175 /" PRELIMINARY AGREEMENT READ THIS AGREEMENT ANDNIAJKE SURE YOU UNDERs,rAND IT BEFORE SIGNING. NuKE SURE ALL BLA-NXS ARE COMPLETED AND ALL PROVISIONS THAT DO NOT APPLY ARE CROSSED OUT. THIS AGREEMENT HAS LEGAL FORCE MND EFFECT ANID BINDS THOSE.WHO SIGN, This Agreement is made on �, / "� / /,/, between Hoae),welll of 65 Shawmut Rd, Suite 4, 2 d n0ff, Canton. N-lassachusetts 02021.(800-2474112)hereafter called"Administrative Contractor" "Honevivell"'and ti l ter C of 'Address) 01(—,M (Address cont) ;Telephone) Hereinafter called"Customer."The Customer is the Owner I Tenant of the above-mentioned Premises. DESCRIPTION OF WORK TO BE PERFORINIED In consideration of the Administrative Contractor's agreement to select a qualified Installation Contractor to perform in a good workmanlike manner all work("the Work")set forth in the attached Work Order(s).the Customer agrees to the terms and conditions of this Agreement No Work may be performed without the Written consent of Owner- Customer-understands that calculated energy savings are estimates only and are not guaranteed. PRICE For field technician use onto: For the Work described in the Work Order(s)and shown on COMMENTS: the accepted Offer Sheet,attached hereto, 0 SEE HEALTH AND SAFETY FORM the Total Estimated Cost is$ 0 OTHER The Total Due at the time of Installation from S I the Customer or the orto e performed i Cfor Wk bfd i i If the Installation Contractor determines that the Work cannot be provided for the Price quoted above,alt parties will have the right to terminate this Agreement Price quoted is valid for 90 days. • Owner of the Premises agrees to payt prior to the commencement of the Work,and-Administrative Contractor accepts, in fall satisfaction for the Work.the Price set forth above. Tenant agees to pay, prior to the commencement of the Work, and Administrative Contractor accepts, in full satisfaction for the Work the Price set forth above. RIGHT TO CANCEL 'THE CUSTOMER MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED AT A PLACE OTHER THAN AN ADDRESS OF THE ADMINISTRATIVE CONTRACTOR, WHICH MAY BE ITS MAIN OFFICE OR BRANCH THEREOF PROVIDED THAT THE CUSTOMER NOTIFIES THE AWMINISTRATIVE CONTRACTOR IN WRITING AT ITS MAIN OFFICE OR BRANCH By ORDINARY MAIL POSTED. BY TELEGRAM SENT OR BY DELIVERY.NO LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGRFEMEN-I,SEE NOTICE OF CANCELLATION(IN DUPLICATE)ANNEXED FOR AN EXPLANATION OF THIS RIGHT. IMPORTANT:ADDITIONAL TERIMSNND CONDITIONS ARE ON,THE REVERSE SIDE By signing below you,t siomerrepresents that(1)You read and understood both sides of this Agreement before you signed . 1�u, it,(2)You a t ,-the terms and conditions set forth on the front and back of this Agreement;(3)The agree n agree You 9 Atimm' ' e Co_ or{directly or indirectly)has made no representations or warranties regarding the Work,other than those is conn .=rms ont, n this menta(4)That at the time you signed the Agreement,it has been signed by the Administrative Contractor i't' _iv or administr mative,there were no blanks that had not been completed and that the W9jJ<you requested was p perly above C lioneviv Signature Date WnarK Signature Date Tenant's Signature Date MAIL THE SIGNED AGREEMENT TO: HONEYWELL 65 SHAWMUT RD,SUITE 4,2ND FLOOR CANTON,MA 02021 Honeywell-White Installation Contractor-Yellow Customer-Pink Revised 1012010