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HomeMy WebLinkAboutBuilding Permit #404-14 - 1907 SALEM STREET 11/1/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1.� I Date Received Date Issued: 1 1172 IMPORTANT:Applicant must complete all items on this page LOCATION E073- SALE:Y _ gr Print PROPERTY OWNERt1{�1 LIi�3z#ci+CV-A 1- Print 100 Year Old Structure yesCno MAP NO: PARCELO/2- ZONING DISTRICT: Historic District yes 7 Machine ShopVillage es 9 Y TYPE OF IMPROVEMENT PROPOSED USE ResiRrential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic D Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DE*RIPTION OF WORK TO BE PERFORMED: fZ L 14ko !&(n k V --q>A2 vo Lss Identifica ion Please Type or Print Clearly) OWNER: Name: �1 ' Phone: Address: 101 b-+ ,- 1A CONTRACTOR Name: Phone: 31A —+2143 Address: Supervisor's Construction License: C'} - Exp. Date: 3 - - t Home Improvement License. LO Z3 Exp. Date: 6 . 2-cl 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: $ t3 t5 - FEE: $ :�,Z>o Check No.: , Receipt No.: 2--7 NOTE: Persons contracting with unregistered contractors do not have access to the gu fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 11 Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 - 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 Towpa Engineer: Signature: Located 384 Os ood 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 Ll Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract La Floor Plan Or Proposed Interior Work u 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit Li 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 L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cas€s 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 2012 Location AO 9 ' 5�IL- ► No. Date Ir • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# G 1 J Jwilding Inspector CONTRACT FOR Conser atlon PRODUCTS / SERVICE WORK ConsVeration Services Group This service is brought to you through support from your local utility This Agreement is made by and among and John 1leydenreich Conservation Ser0ces Group(CSG) 1907 Salem St Attn:RCS North Andover,MA 01845-3330 50 Waslwlgton Street.,Suite 3000 Site ID:S00002164878 Westborough,DIA 01581 Project 1D:P00000169613 Reg. No. 173484 Customer ID:C00000174930 Federal ID No.222457170 Contract ID:20130919 ASRAL (Afail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be perfumed the following work on these"Premises"in a professimial maiuier and in accordance with the terms of this Contract,including the attached recomnendationsAvork order describing the work in detail(the"Work")which are incopoated herein by reference: Description Quantity Location Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 6 Living Space $462.00 Door Sweep 4 N/A _ $84.68 Exterior Door Weather Stripping 4 N/A $100.80 Sub Total: $647.48 Utility incentive Share $647.48 Customer Contribution $0.00 °�ff0 For office use only Printed:9/19/2013 Page 1 of 2 II. PAYMENT Customer agrees to pay Contractor for the Rork,the Customer Shue of the Contract Price as follows:Papnent#l:$ as a Deposit payable to CSG upon signing the Contract(not to exceed 1R3 of the total retail costs or achral costs of.sporders,whichever is greater).Atail cheek&contract.to CSG, Attn:RCS,50 Washington St.,Ste.3000,Allestborough,AIA 01581.Final Payment:$ V as the final payment for the NVork shall be due and payable to the Independent Installation Contractor(91C")uponsa sfaeto•y completion of the'Work.Customer widerstands that he/she«ill not be required top-ay the Utility Incentive Share of lire Contract price in the amount of S _•The Utility hicentive Sprue is dependent upon the package purchased and/or prior incentive utilization.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION lire 11C and Ci s-tomer lierebv nnrtuilly agree in ach•.uice that Ln the event that the RC itas a dispute concenwng tltis Contact,(lie liC ruav submit Stich disl)irte to a private arbitration service which has been approved�b%,the �1Office of Con nstuner Again-,and Business Regulation and Customer shall be required to submit to such mtrihation as provided in M.G.L.c 142A. Customer 1^/A fn{ `"1 '' _"l`^�" bF� Contractor.—. You mayQancel this a regiment if it has been signed b a art there to at lace other than an address of the seller, Y g g Y party p which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this aigreetnent..DO NOT SIGN 7Dt C NTRACT IF THERE ARE A�I Y BLANK SPACES. Ria r. rtt t�v ti I I ?N Cnhsi ru.t,*vt7 c. tomer Signatu Indicate vour.e ec le 1]IC here,if applicable (Olt) h»hal here if you Avant xi /}j /� e'_:'_-'A the Program to assign a CSG Signature Dae Fame of CSG Repres itathve(Printed) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. Ula AvAr G CONTRACT FOR Conser anon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among � 1 07 and John Heydenrcich Conservation SeMces Group(CSG) 1907 Salem St Attn:RCS North Andover,MA 01845-3330I� 50 Washington Street,Suite 3000 YIV Site 1D:S00002164878 Westborough,MA 01581 Project ID:P00000169613 OCT 0 4 2013 Reg. No. 173484 Customer ID:C00000174930 Federal ID No.222457170 Contract 1D:20130919 WORK ()Ilail completed contract to address above) 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the foltoeirtg work on these`Premises"ui a professional manner and in accordance with the terms of this Contract,including the attached reconmiendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location Hatch:Thermal Barrier Polyiso 2 inch(Attic) 1 Hallway $38.09 Damming __ 38 NIA 570.30 Attic Floor Open Blow Cellulose 6' _ 418 Living Space $560.12 Sub Total: $668.51 Utility incentive Share $501.38 Customer Contribution $167.13 [oil For office use only Printed.9119/2013 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ as a Deposit payable to CSG upon signing the Contract(not to exceed 113 of the total retail costs or achral costs p(�Pecial orders,whichever is greater).Mail check&contract to C.SG, Attn:RCS,50 Washbigton St.,Ste.3000,Westborough,DIA 01581.Final Payment:$ Il!.uz as the final pa}orient for the Work shall be due and payable to the Independent Installation Contractor("11C")upon satisfactory completion of the 11'ork.Customer understands that he/she M11 not be required to pay the Utility Incentive Share of the Contract price in the amount of$ �V/•�Ir' .The Utility Incentive Share is dependent upon the package purchased and/or prior incentive utilization.Changes to indh4dual Pure items and/or pre%ioas incentives may increase or decrease the size of the Utility incentive Share. III. DISPUTE RESOLUTION The FIC and Customer hereby mutually agree in adwince that in the event that the 11C has a dispute concerning this Contract,the i1C may subunit such dispute to a primte ruttitr.tion seivice which has be�ernl approved l>.y t ie 011 ce of Coisw[uier Affairs aril BiLsiness Regtdation and Cilsteltner•shall be rrgtiired to submit to such aniritration as prntided in DLG.L c 142A. Customer. N tt^^ Ge]Lr tnt/rLt tJ't Contractor. y You may ncel this agreement if it has been signed by a party there to at a place other than an address of the seller, which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of th's agreement. DO NOT SIGN THI C NTRACT IF THERE ARE ANY BLANK SPACES. f-1. 4 i k R H CU 1151lruc,4-�on toR) t -tomer Signature to indicft your selected IIC here,if applicable Initial here if you want q �� r'. EZ� the Program to assign a ��/ Participating Contactor CSG Signature V D.to Name of CSG Representative(Printed) TERDIS AND CONDITIONS APPEAR ON THE REVERSE. 1/13 i �a�7 �1�� PARTICIPATING r CONTRACTOR V�, PERMIT AUTHORIZATION FORM I, John Heydenreich ,owner of the property located at: (Owner's Name,printed) 1907 Salem St 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 4 � Ot n is signature / 91' 1/13 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 Contractor Date C]�rL For office use Only Rev.12132011 IQ The Conintonlvealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 ' www.tnass gov/dia Workers' Compensation Insurance.Afridavit: Builders/Contractors/Electricians/Plumbers APPlicant Information ` Please Print Legibly Name(Business(Organization/Individual): �. lf� Address:_ r City/State/Zip: ObVIM.-Wk 0)64Sphone.#: 9( Are P16an employer?Check the appropriate box: 1. I am a employer with, 4. F1 -Type of project(required):.I am a general contractor and I _ employees(full and/or part-time).*. have hired the sub-contractors 6. ❑New-construction 2.❑ I ant a•sole proprietor or paxtn6r- listed on tho-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors haveg_ ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.#" 9• ❑Building addition required.] 5. ❑ We'are a corporation and its 10.11 Electrical repairs or additions 3.01 am a homeowner Join all work officers have exercised their $ 11.❑Plumbing repairs or additions myself.[No workers'comp. right df exemption per MGL insurance required.]t c. 152,§1(4),and we have no 12. f repairs employees.[No workers' 1-3.9 Other t comp.insurance required] 'Arty applicant that checks b-ox#1 must also fill out the section below showing their workers'congmsation 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-conhwtors and state whether or not those entities have employees. If thesub-contractors have employees,they trust provide;their workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees Below is thepolity and job site information. _ Insurance Company Name:_ '�l�?� Policy#or Self-ins.Lie.#: Expiration Date: ,Job Site Address: 1aQ�, l�tl�r+( cC. City/State/Zip: 4-ax 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 lip 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 maybe forwarded to the Office of _Investigations of the DIA,for insurance coverage verification- -T do erification.Ido hereby certify under th pains-a alttes of perjury that the information provided Bove is true and correct Signature- Date: W Phone#: Official use only. Do not write in this area,to be completed by city or town o icioL .ff �. 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#: NORTH Town of t ndover 0 10 No. 404-o- H - ver, Mass, o . 1 > M �,�A�R�TEO ►•Pp�,�y S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ........................ .. ... .............. .. ...... .. .�. ... ......................... BUILDING INSPECTOR has permission to erect ......... g la Q a,0w&w*,w. � r.......... Foundation ................. bulldm son .... ... .. ........ ..... Rough to be occupied as ..........Al-t-cft........5 ......................................................................... 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 MO HS ELECTRICAL INSPECTOR 3o UNLESS CONSTRUCTIO ARTSt..... 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 Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Massachusetts_De Board Of BUi - Partment ar auoi:.: 5ai Idtng Regulations and Scanctardz, Can+tructi„n Sglum i,,,r License:C&05T754 NAf 0vVWA 03845 — nr Commissioner 03/0412044 Ottwl:�-�� . �Iafio l�t1ENTCONTIZgCTOR License or�tstration vald for individul ase on)y 40 1730 Type_ beforethe expirationdate. If found return to: 6I9%21l4 Private o Office of Consgmer Affairs and Business IRH CON "=' tatict� 10 Park Plaza_Suite 5170gutation STRUC:TION. ` '� Boston,MA 02II6 Wi iam Hope i 0 CAMPBELL RD ORTH ANDOVER,MA 09645 � IIndersecreta�y _ Notvalidwithoutst re ACb v® CERTIFICATE OF LIABILITYDATE(MMIDDNYYY) INSURANCE 07/05/2013 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 fights to the certificate holder in lieu of such endorsement(s). PRODUCER Michael Emond Emond&Associates PHONE FAX 857 Turnpike Street EaNAItEM 978-208-471-'A a Ne Suite 133 (NSU S AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURER A: Farm Family Casualty Insurance Com an INSURED HRH Construction INSURER B: 80 Campbell Road INSURERC: INSURER D: North Andover - NorthAndover MA 01845 INSURERS- asuaet 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 AUDLSUBR POLICY NUMBERPOLIIC EFF. POUDYYY1 EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000.000 X COMMERCIAL GENERAL LIABILITY PREMISES fEaoeamance $50,000 CLAIMS-MADE a OCCUR MED EXP(Ary one person) $5.000 A 2001X0726 11/20/2012 11/20/2013 'PERSONAL&ADV INJURY $Included GENERAL AGGREGATE $2,000,000 GEMLAGGREGATE UMITAPPLIES PER. PRODUCTS-COMPlOPAGG X $2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITYr tA8MBIN�EDn1SINGLE LIMIT S1,000-000 00 O t) 1 ANY AUTO BODILY INJURY(Per penton) S ALL OMED X SCHEDULED A AUTOS AUTOS BODILY INJURY(Per accident) S X HIREDAUTOS X �O ED 2001C4287-4A 03/16/2013 03/16/2014 PROPERLY DAMAGE Peracddend $ S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS Llae � : CLaMSMAOE 2001E1169 12/14/2012 12/14/2013 AGGREGATE $1,000,000 DED X RETENTIONS $ WORKERS COMPENSATION WC STATU OTH ANO EMPLOYERS'UASUMY ::. LIMITS ER_ A ANY CEIMENET0' Y/N EJ_EACH ACCIDENT $ OFFlCE&t9NBER EXCLUDED9 N/A 2005W6827 12/07/2012 12/07/2013 500 000 (Mandatory In N ti yes.describe under EL DISEASE-EA EMPLOYEE $500 000 OPERATIONS belowr r EL DISEASE-POLICY OMIT $500,000 4 t DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Sdwdute,K more space Is required) Operations by named insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, M0710E WILL BE DELIVERED IN ACCORDANCE WITH THE LACY P�toVlsloN& h ? AUTHORRED 11 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Clear Ali