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Home My WebLink AboutBuilding Permit #531-15 - 1511 GREAT POND ROAD 12/9/2014 L NORTH 9 BUILDING PERMIT ° ts``° '6T �o TOWN OF NORTH ANDOVER ° >' 1 APPLICATION FOR PLAN EXAMINATION ; e Permit NO: Date Received 12 '� °9 • -- " °AA 7FU•'pP •(y 9SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION S 11 Great Pond k1wd Print PROPERTY OWNER A I 15011 Ma _ A� �� Print MAP NO:O� Z- PARCEL: 4W ZONING DISTRICT: Historic District yesno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer pGn ul C� �c%k 7,► -Fo✓ �55sf (n5-falla-h6y, 'in aAc Identificatilo_n, Please Type or Print Clearly) OWNER: Name: -) hsorl MGL►�I IYl Phone: Address: IC5I 1 Gt,,- ?ain� IZd 013J S CONTRACTOR Name: Phone: 2g3•�t�1a �NY lP,.av N►G'Nti�a. �P�t7i,M�NT" tU L Address: I2db &46NN1 NJb1PN Sfi Supervisor's Construction License: GS 0-r102,061 Exp. Date: 3/Ito/V Home Improvement License: 11755.5 Exp. Date: 1 �vI tie ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � • 7 FEE: $ Check No.: I I 'j Receipt No.: 283-z?-,q ! NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agen_t/Owner Signature of contractor 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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 o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 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 Call Email Date Time Contact Name Doe.Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPB OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinuning 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 Signature_ 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 Location 16 1� " rrl ". No. J Date • - TOWN OF NORTH ANDOVER a Certificate of Occupancy $. Building/Frame Permit Fee $ 30 Foundation Permit Fee $� Other Permit Fee $ TOTAL $ Check# 11✓J� Building Inspector (SC CONTRACT FOR Con ser atIon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among Alison Martin Conservation Services Group(CSG) 1511 Great Pond Rd Attn:RCS North Andover,MA 01845-1216 50 Washington Street,Suite 3000 Westborough, MA 01581 Site 1I1:500002280775 Reg.No. 173484 Project ID:P00000286682 Federal ID No. 222457170 Contract ID:20!14141009WWORK 002 Customer 1D:0 (Mail completed contract to address above) O I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these`Premises"in a professional manner and in accordance with the terms of this Contract,including Ute attached recommendationshvork order describing the work in detail(the"Work").which are incorporated herein by reference: Description Quantity Location Attic Floor Open Blow Ceilulose 7' 688 LhArhg Space 51.052.64 Hatch:Thermal Barrier PoMso 2 Inch(Mic) 1 Living Space $41.71 Damming 88 NIA $192.72 Propavent 2'or 4' 69 Attic $264.27 Sub Total: ($1;551.341 Utility Incentive Share ($1,163.50 Customer Contribution $387,84 r a9 For office use only Printed:10/912014 Page 2 of 2 II. PAYMENT '� C{ Q Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment,#I:S(� 7 ` V-� as a Deposit payable to CSG upon signing the Contract(not to exce 1 of the total retail costs).Mall check&contract to CSG,Attn:RCS,50 Washington SL,Ste. M 3000,Westborough, A 01681.Final Payment.;3 \2.J 4.�G, as the final payment for the Work shall he payable to the Independent Installation Contractor("IIC")upon satisfactory-coinp�letioa of the Work:Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ /[6 3• 50:Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III.DISPUTE RESOLUTION Mme IIC and Customer hereby mutually agree in advance that in the event that the HC has a dispute concerning this Contract,the 11C may submit such dispute to a private arbitration service which has been apfin ed by the office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L c 14M You may cancel this agreement if it has been signed by a party at a place 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 :busine ay f liovving the signing of this agree ent. DO NOT SIGN THIS CONTRACT IF THERE ARE Y BLANK SPACES. Lustomer Si "`-- ate Indi a your selected HC here,if applicable <Ox) Initial hem if you want the Program to assign a �. CSG SignatureDate Name of C&3 Representative(Printed) Participating Contractor TERMS AND CONDMONS APPEAR ON THE REVERSE. 3/14 vG-% ani(71 62%:t%Z�i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 177555 Type: Corporation Expiration: 1/2/2016 Tr## 247688 ENVIROMENTAL ABATEMENT, INC: GEORGE WATTENDORF III 1200 BENNINGTON ST EAST BOSTON, MA 02128 Update Address and return card.Mark reason for change. SCA l :: 20M-05/11 Address Renewal [] Employment E] Lost Card (92e Wnnw 1oaatue«ll/a/b11K'jJCFC1'("jCIGJ \ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only — OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 177555 Type: Office of Consumer Affairs and Business Regulation xpiration:. 1%212016. Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 ENVIROMENTAL ABATEMENT;'INC. GEORGE WATTENDORF III 1200.BENNINGTONST:;. EAST BOSTON,MA 02128 Undersecretary Not valid without signature u Massachusetts -Department or Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-090209 ` IT" GEORGE V WATYENDORF ,��•; �_� 14 Millett Lane. Swampscott MA 01907 %4--�� =� " "` Expiration Commissioner 03/16/2016 ' I NORTFj own of �. : _ ., ,6 , Andover �o h ver, Mass, 2d� _ C 0 44New'rK �1• S U BOARD OF HEALTH Food/Kitchen PER L D Septic System � +► . a� 1. THIS CERTIFIES THAT ........ ................ . BUILDING INSPECTOR NFoundation ....... ... has permission to erect .......................... buildings on .... .......1.1.............................. .. .."..A.. .................. Rough N to be occupied as +W!!�.�!!�.1►.�.�. .. .... � .*Al ..6 Chimney provided that the person accepting this permit shall in every respect conform t�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 MONT S ELECTRICAL INSPECTOR UNLESS CONSTRU N i Rough Service ......... ...................................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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 f Until Inspected and Approved by the Building Inspector. Burner j Street No. k Smoke Det. I I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 0 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -M-kUYC JO(.._ Address: ►2b o g�r.Nt�J -�r� S� City/State/Zip: bD t� J�,l(4 CW IJ1 Phone#: <�S 7 2 15 -9-77U Are you an employer? Check the appropriate box: Type of project(required): 1.K I am a employer with D 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New 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' insurance.$ 9 E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El 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 employees. [No workers' 13.gOther VN s.tA u&-1 04� 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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AM ANM L (fVda 2E� 1 NQ ,� ��- Policy#or Self-ins. Lic. #: W(,k/Q ( ZN 5D-D Expiration Date: 1Z 111,q Job Site Address: 1511 V YeAt -Pd r,d F•(a City/State/Zip:(V.Md YY ',N0 DI$yS 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: _—� Date: l`ZJs�'f Phone#: X81' 42N'g3(iS 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#' WORKERS' COMPENSATION AND EMPLOYERS LIABILITYTV PINSURANCE POLICY ' t Ilnforrnatlon ,f -------- __ _ -w _•�9 WC . Atlantic Charter Insurance Company VDAC NCCI Co. No.:29211 Policy Number: WCV01124500 1. INSURED: Prior Policy Number: New Environmental Abatement, Inc. Producer: 1200 Bennington Street DeSanctis Insurance Agency, East Boston, MA 02128 Federal ID Number:275382735 Inc. Risk ID Number: 100 Unicorn Park Drive Business Type: Corporation Woburn, MA 01801 SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured: Other Work Places: 2. POLICY PERIOD: The Policy Period Is From: 12/19/2013 To 12/19/2014 12:01 A.M.Standard Time 3. COVERAGES: at The Insured Mailing Address A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states liste, here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of our liability under Part Two are: Bodily Injury ry b Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates& Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications No Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $550 $1,107 Interim Adjustment: Annually Servicing Office: Total Estimated Premium $1,081 25 New Chardon Street Surcharge(s) 26 Boston, MA 02114-4721 Total Premium a Surcharges) $1,107 DEC 3 0 201; Issue Date 12/30/2013 Countersigned By: ��✓'^ �v�- %r Date Copyright 1987 National Council on Compensation Insurance Form:10L �cstsri mass save' R •• 144440opp", PERMIT AUTHORIZATION FORM I, Alison Martin ,owner of the property located at: (Owner's Name,printed) 1511 Great Pond Rd North Andover (Property Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X Owner's Signature ko t�( ( � Oate 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 Contractor Date OfrO �I ForOffice Use Only Rev (12132011