HomeMy WebLinkAboutBuilding Permit #1086-15 - 115 MOODY STREET 6/23/2015 NORTk
BUILDING PERMIT
TOWN OF NORTH ANDOVER
J0
APPLICATION FOR PLAN EXAMINATION w
/ itW. _
Permit No#: 'xvl jjUU Date Received �y A�'>�reo
SSACHV`-'�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION ./lS— eiadY 51` /'ndtf
Print
PROPERTYOWNER T�ewrQ�$m
Print 100 Year Structure yes no
MAP PARCEL: Z�o ZONING DISTRICT: Historic District yes no
Machine Shop Village 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
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
S�pttc ❑Well ��Floodp ain} Wetlantls. ❑a Watershed�iDist
W�Rfe
DESCRIPTION OF WORK TO BE PERFORMED:
}cTr C,h Lp- tj!l J1 2ri5v/4L?77?V0
Identification- Please Type or Print Clearly
OWNER: Name: Sti elle y 7hprA e714 Phone: 9-os--90 -/AF6
Address: L16— Al _ 4 h ig dt�
Contractor Name: ?eTc r— t e 8 f4 Kc Phone:
Email:
Address: a. . e457- Qr.4e ST 2445-" cJ W
Supervisor's Construction License: C$9z- /06 o r,*) Exp. Date: D y�sP/,Qb/x
Home Improvement License: 6 Exp. Date: a'- x016
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: $ 3 ,T--00 -Oa FEE: $ �•�
Check No.: (.p?C1 Receipt No.:
NOTE: Persons contracting with unregistered contra ors do not have acces the guaranty fund
J
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
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 m U FORM.
i
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
i
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: Signa6re:
FIREDEP�AR� T Er �r Located 384 Osgood Street
-ti
' Sb.. \ tt L ` r t t..ti k -�►+wyr�
d ys _� f.,p IVTr tTernDumpsferRortse� yes
Lrocated at 12k4 Main Street; --
Fire Department sign lure/ -9)22
r l`i-Y`v.�i�,l�L�,�..�.1 i? t � {ti,tiA• r `?1 -�r'`� '4,.� � � � ' �, a
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)
LJ Notified for pickup Call Email
Date Time Contact Name
Doc.Buildin;Pennit 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
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4; Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
4. Certified Surveyed Plot Plan
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
16 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Location
No. 1 U� �j Date lP
• - TOWN OF NORTH ANDOVER
. Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $ S�
Other Permit Fee $
TOTAL $
Check#Ito
� A
r `p d Building Inspector
� NORTH
Town of t ndover
0
No. -
h ver, Mass,
coc«ic«ew.c«
�d A04ATEO ►'PP,��(5
1S U
BOARD OF HEALTH
Food/Kitchen
PERMIT LD Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
................... twi c. .. ........... .... ..............
has permission to erect ............... buildings o Foundation
....... I.J..5......... o. .... ...E)r ...........
Rough
�� �j� � ��1�
to be occupied as ....... ����R1. ... ...............,.��!!� �..................................... 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
PERMIT EXPIRES IN 6 MON S ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION Rough
...................... ......................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Building 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.
Smoke Det.
CONTRACT FOR
e� afiVn --
- —PRODgCTS ! SERVICE WORK
e®ration
tvlces Group/"
• This service is brought to you through support from your local utility
7`hi3 ^ et rite I ��i?�7i -�3Yi� - -
:� �h..•��- y:. f arnoil9: -
-:;•Shelly'r�otn 96ri .:.: = --- \`- Conselr�afaonSen�iccsGrrl (CSG)
o;txAr,�lo��i_r: -o�sasa7�3
_. ... ... --. � �'SEY�V�,�Itin�;t(iriStxnet,Siaite301)(�--
- Site ID:99DM3338610 - Westboro%igtt,N[AUln8l
pr:ectfD P00000350%7 :.
- ...., -No.=113484 •
. . lqu$p tierlD.COODO034$919 No ZL`L9�
Fedel.�aM 7170
Col raA ID;201517324 t VO Es; (]UfaileompletPtl contractto addrt'ssahove}
1. DESCRIPTION OF WORK TO BE PERFORMED
Contractorwill perform or cause to be performed the following work on these"]?remises"in a professional manner and in acmonlance witit the ternis of
this Conitact,including rhe adtaehed recommendationsAvork order describing the work in detail(the"Wnric")which arc incorporated herein by reference:
Description Quantity t-ocatlon
Insulate Wood Shingle Sided Wall tNtth 4"Dense Pack Cellulose 1,000 Living Space $2,160.00
Insulate Rim,foist With 2"Thmmat Barrier Potyiso 58 Living Spam $255.20
Insulate Overhang With 2"Thermal Barrier Polyiso 7 7 Living Space $338.80
Insulate Interior Guffvred Walt With 4"Dense Pack Ceuutose 112 Living Space $268.72
Insulate Open Ovetbang tiiI'tb 67 Fiberglass Balling 77 Living Space $170.94
Insulation Removal 77 NIA 588.55
sub Total: 43,27221
Utility Incentive share $2,000-00
Customer Contribution $1,272.21
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Q ••
Porof lee use only Printed:4/1/2018 Page 2 of 2
11. PAYMENT �7L�_ ��
Ct"
tlstoluer M_ to pay unntractor for the Wn lrx the Customer Stare of the Contract Pike as follows-Payment 91:g L as a Deposit
payable to CSG upon signing the Coatract(not to e'ceed V-13 of the total retail costs).Maeheclt&contrtet to CSG,Attn;RCS,BO Washington St.,Ste.
:3000.WL'StbOrl)U+1,17A Ol:rI31.Fms►1 Payment:$ �)K.. j`'1 as the final paynent fnr the Work shall be payable to the Independent Installation
Contractor("HC")upon satisfactf ry�',cro�mpletion of the Wort:- Customer understands that helshe will not be required to pay the Litility Incentive Share of the
(:ontractpri(tein the an)onnt or$�f} _,Changes to individual line items u)Alor prrtlottsineeultt es may intmew or derrense the size ofthe Utility incentive
Share.
111.DISPUTE RESOLUTION
7 hP Ttr ouch t rcctootcr luemby nuun:dty aLrPe in a(lvat)cc that hi the mwt that The tit:h.•ts a&1mio roneentitig(IQs cunrrart,Ilio.n(.•may sabmR such diq)ute to a pA%,aie raimnitinn
serf ive which Irz liven al>nroved by the Office of Consumer Alt;Qts runt Btisiness Regulation alit](le-tomer sitall he mptltvd to suhrnit utsurh:ubur;uitm ae ptnvi(tt?d in XG.1-e 1421
You may cancel this agreement if it has been signed by a party at a plate other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
/usine d following the signing of this agreement. DO WT�IGIY THIS$NTR6CT, IF THERE ARE ANY BLANK SPACES.
Apr 2015 Yo ar tjear n
2su a#lon
Shelle,D-TI1cnP3on(Apr p '
F1 s ' Date Indicate yoursdected C here,if applicable (oR) Initial Itere if you trant
--I V'" �r � . It-( the n'oyratu to assign a
-j-�s
CS mature Date Name of CSG Representative( rinied) — Participating Contractor
TEAMS AND CONDIrM0165 AYPEAR ON TEtZ 7L]SVEXSZ. 3114
0110t loargy Set`i
h y�
mass save PARTF6fPATiNG
CONTRACTOR
PERMIT A U T H 0 R 12!Aj ON FORM
l� SHE LEY THOMPSON �ow-er of the property located at:
(l wner`s.Name,printed)
115 MOLDY ST NORTH ANDOVFR
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
beft,ia:to art on inv Lehaif and obtain a building perrnit to perform insWation and/or weatherizatlon
work on my property.
X Shelley D T,ompson(Apr 2,2 15)
Ow ne's S'an atur e
Apr 2, 2015
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Coriiiaoi:vr Date
Sid°rL�LU
so
;:_-r C'tice Use Orly
Rev_12132011
Flee Conunotnvealtie of Hassadirtsetts
_- 1 EPartnment of Industrial Accidents
'x _ Office of Investigations
600 Fiesltitton Street
Boslou,MA 02111
tvlvlu mass g ov/did
Workers' Compensation Insttrattee Affidax t: BuilderslContraetrors/E:Ieeteicians/Plumbers
Aprplicarit information Pleftee Print I.eoibl�
lame($asinrss/OrganizatioanndWidual): O I dtr ec.J" ryx5 y L4�-?k?g g ;'ti �,
Address: �v 0), rs—a
CittlState/Zi9&m Phone 4-- `/ �� �1497
Are you an ernploee.?Cheep the appropriate box: T-
I
ogl, sect(required):
l. •I am a employer ninth_ 77 4-Q I am a general contractor and I
ernplot ees(full and/or part-time).* have hired the sub-contractors 6- ❑Xety construction
?Q I am a sole proprietor or partner- listed on the attached.sheet. 7. Q Remodeling
ship and have no employees These sub-contractors have
S. Q Demolition
tiorkitts far me in atnr capacity. employees and ha-ve workers-
j\o.crkers`comp.insurance comp.insurance= 9 Q$ttildittg addition
o
required.] $.Q We are a corporation and its t 0.0-Electrical repairs or additions
3.Q I am a homeowner-doing all ttvrk officers have exercised their I LM plumbing-repairs or additions
mt=self.(No workers'comp- right ofecemption per MGL 12_Q Roofrepairs
insurance required_] c-152§1(4).and%ve have no
employees.�ottorkers' i3- Other
comp.insurance required]
aAm applicant that drcc(s box=t must also fill out thescuion beton S10%%ing iheirunrt:ers-compensation poli-infvnantion.
14o ,.Wxs txho submit this afda it indicating they are doing all s+tisk and then hire outside contractors must submit a new afkidatit indicating sueh-
'Contractom drat check this box must attached an additional sheet shoeing the name,of the sub-conuaetor and state-witmberor not those entities have
tmPl%x1 s- If the std/-contractors have emplaves-they must proride their porkers-comp policy number.
1 am trey esnploygr that zc providing workers'compensadvir insttratece for 1U emploives. Below is the polier and job site
infortnatiotr. -
Insurance Compamratrre �.3 f-,a O Q rJ
Policy-or Self-iris.Lic.-: 0 DAC- —too&S7- &pitation Date- l �
Job Site Address ,� ,o-t 1'I9 f T d`y t Cit//State 4
Attach a copy of the workers'compensation police declaration page(shooing the golict number and eXpiration date).
Failure to-secure coverage as required under Section aA of MGL c-M can lead to the imposition of criminal penalties of a
fine up to S1.500-00 andlorone-year imprisonment as t+ell as civil penalties in the form of a STOP`]YORK ORDER and a fine
Of up to S250-00 a day against the violator Be advised that a copy of this statement may be fonvarded to the Office of
Investigations ofthe DIA for insurance coverAgge verification-
1 do kerebt•certijj•under lite pains and penalties o,fperjttq•Mot tke infatnealian provided above is here and eorreel.
Sisnatttre:
Date:
Phone= 4l D
Official ase 00k. Do not it-rite in tlris area,to be carrrpleted 6r cih•or tots o Bial
Citi or Tait zay: Permit/Licensed
Issuing Authority(circle one):
L Board ofIlea lth ?Builth-;Degartntent 3-Cttilron-a Cleric -l.Electrical inspector i.Plumbing Inspector
6.Other
Contact Person- Phone
CER-RFOCATE OF UABOLRY UNSUM E ams ss
Tim Tf G I ED AS A MATIIER OF OW&WATM EINLY AM CONFERS 00 RMM UPON TRE COMF=7E IIf"at Tin
CERTMUE O OWS =AFFUMTAFELY OR NEUTWMV AII ,SUM OR ALTER THE COVERAGE AFFaEDW 8V THE pOLrim
8EL(M TKS CEff rVCWE OF 925MCM 0M DW CONsilg M A CONM T SMUM TRE UWMG B SURER t AWfM)AZMp
Wmium—p holder is ADDtttONAt. , P } e3tdaa�d, if S➢iBRATtOR!Ea�iiANEq to
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ANY R8QUIRP&iB11r TEM OR COMMON OF ANY CONTRACT OR OTHBR DOCUASUr VjfH RST'TO WHICH THIS
CMUMAM LAY BE BMW 032 MAY P&MM 7W!l1SS MMCE AFFORM BY THE POLICIES DEMMM Ham}is SUBJECT TO ALL THE TERA
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Office of Consumer Affairs�
10 Park Plaza- Suite021 b
Boston,Massachusettsfor Registration
Home Improvement Contract Regiatration: 102726
- TYPe: DBA Tr# 262249
- - ExiA Mtion- 7!2!2016
POLAR BEAR INSULATION CO.
Vincent LeBlanc
P.O. BOX 958 -
ANDOVER, MA 01810 __ Mark reason for change-
update Address and return Emplo�ent [1 t�Card
# Address Renewal
0Ps-CA1 is SUM-CW04-MOIZ16
• � C=,u �. ��..,.... Wit' ....__,,..., _..._. � _......_-. '.S
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a cSSL-106017 "
PETER A LEBLANC
2 EAST PINE STREET
Plaistow NEI 03865
�. 04/2812018