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HomeMy WebLinkAboutBuilding Permit #118 - 20 STACY DRIVE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION �Ac_ . ,v A Qye K. . Print PROPERTY OWNER - C Unit# Print IJ MAP NO: PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yes no it 100 year-old structure yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial B-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic 0 Well ❑Floodplain ❑Wetlands D Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: C Lms U L UK ' - 2� l�t _ f t w (Identification Please Type or Print Clearly) OWNER: Name: r�f+►vF Mc /4Fiv)LX Phone: G&;-6(l9S_ Address: CONTRACTOR Name:V /h1([-ter Li�J&W K&Av ioi n jtUS.Phone: ?2Y �C Address: 14,KfA ;,ter \2A Supervisor's Construction License: Exp. Date: jf3a ado/.L Home Improvement License: I D a -Nb Exp. Date: o SDI t 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: FEE: $ J Check No.: ��, Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of A enffr _ .Signature of co t� cfor: Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw'rnming 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 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 Doc:.Building 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 a Building Permit Application d Workers Comp Affidavit u� Photo Copy of H.I.C. And/Or C.S.L. Licenses d 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 Perry 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 ❑ Floor/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 .fermi 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 1 V Date. . /...... . pf HORTM TOWN OF NORTH ANDOVER ,e,q. 0 PERMIT FOR MECHANICAL INSTALLATION i � s AC HUSEt This certifies that . has permission for mechanical installation ....7wJ . . . . . . ^ . . . . . . . in the buildings of �Ln� . . . . r'Lf.� !`!^'j. ... . . . . . . . . . . . . at . U. . . . .tea . . .,DYk k/-. . . . .. North Andover, Mass. Fee. 17., . . Lic. . . . . . . . . . . . . . . . . . . . . . . .1 . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7/2/2012 Tr# 298090 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 _ Update Address and return card.Mark reason for change. Address J Renewal Employment I[] Lost Card DPS-CA1 0 5OM-04/04-G101216 Office of�onsu�►� ia� gu a n License or registration valid for individut use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: U!PWBEAR Registration• �0272g 72!2Type: Office of Consumer Affairs and Business Regulation Expiration: 012 DBA 10 Park Plaza-Suite.5170 Boston,MA 02116 INSUbVT40N C0 Vincent LeBlanc 51 SO.CANAL ST.#5A f LAWRENCE,MA 01841 Undersecretary 'Not valid without signature `= �l f-sNachusetts Dell:i1 t171i18t tat" 111Di1C Sail1% Board of Baiittlfl's ke�111.1um- ill{1 tt t;ill:ls 1ls k---17 i O s r tion-1 su�bervisr+CjyeC1t!0,2f L EBws ;:cern CS SL 99352 Restricted to: WS - - VINCENT LEBLANC 24 LANDING DRIVE METHUEN, MA 01844 _ Expiration• 1130/20-12 t„mn�i..,i,rn%•rs. Tr,': 99352 i i Yt� 4, Columbia Gas=of IMasskhusew A NiScurce company Gas Account�f Audit Request n / PRELLIN111 iARY AGREEMEN-f READ THIS AGREEMENT AND MAKE SURE YOU UNDERSTAND IT BEFORE SIGNING. MAKE SURE ALL BLANKS ARE COMPLETED A'N'D ALL PROVISIONS THAT DO NOT APPLY ARE CROSSED OUT. TEAS AGREEMENT ELAS LEGAL FORCE AND EFFECT AND BLN'DS THOSE MVHO SIGN'. J ]� ,11 M4�� I This Agreement is de on between(Heneyweti of 65 Shawmat Rd,Suite 4, 3°a floor. Canton. Massachusetts 02021 (800-214-7-4112)hereafter called"Administrative Contractor"or'Hweywell"and of ado 1 fCustoJ} I y fAd ss) n't-j) (Address cont.) (Telephone) Hereinafter called"Customer."The Customer is theOvine ZITenant of the above-mentioned Premises. DESCRIPTION OF WORK TO BE PERFORMED 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%q itten consent of Owner. Customer understands that calculated energy savings are estimates only and are not guaranteed. PRICE For field technician use onM For the Work described in the Work Order(s)and shown on COMMENTS; the accepted Offer Sheet,attached hereto, o SEE HEA-TM AND SAFETY FORM the Total Estimated Cost is S ,. o OTHER F&3 3 3 G The Total Due at the time of Installation from $ n i the Customer for the Work to be performed is: If the Installation Cantraetor determines that the Work cannot be provided for the Price quoted above,all parties will have the right to terminate this Agreement Price quoted is valid for 90 days. er of the Premises agrees to pay,prior to the commencement of the fork,and Administrative Contractor accepts, in full satisfaction for the'Work the Price set forth above. • Tenant agrees 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 Atli ADDRESS OF THE AD`UISTRATIVE CONTRACTOR, FYHICH MAY SE ITS M-ALN OFFICE OR BRANCH THEREOF PROVIDED THAT THE CUSTOMER NOTIFIES THE ADMINISTRATIVE CONTRACTOR IN VYRITING AT ITS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED,BY TELEGRAM SENT OR By DELIVERY,NO LATER TILA,V MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT.SEE NOTICE OF CANCELLATION(IN DUPLICATE)A.NNNEXED FOR AN EXPLA..FATIO4.OF THIS RIGHT. tMPORTATNT:ADDITIONAL TERMS AND CONDIT70INS ARE ON THE REVERSE SIRE By signing below you,the customer,represents that(1)You read and understood troth sides of this Agreement before you signed it;(2)You agree to be bound by the terms and conditions set forth on the front and back of this Agreement;(3)The Administrative Contractor(directly or indirectly)has made no representations or warranties regarding the Work,other than those containw in tWs Ag2 u=t;(4)That at the time you signed the Agreement,it has been signed by the Administrative Contractor or its administrative representative,there were no blanks that had not been completed and that the Work you requested was properly described above. _ Hane�veU Signature aremer's Signature Date ? lie 0114,N1 J"l i' T'enant's Sign9turd Date MAIL THE SIGNED AGREEMENT TO: HONEYWj-:LL 65 SHAWMUT RD,SUITE 4,!"FLOOR CANTON,SIA 02029 Honeywell-White Installation Contrachr-Yelory iustcmer-Pink Revised 10r2t}10 amw aF The Commonwealth ofMassachuseti in Department of Industrial Accidents Office oflnvestigationg 600 Washington Street s • Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information // Please Print Le 'bI Name(Business/organization&&I dual) LU h✓ L� E��Ldw C ��n lLK �:� Address• < }� (� City/State/Zip: Phone#: M q'p 7 -7 b 3 g Are you an employer?Check the appropriate box: _ 1.❑I am a employer with 4. 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 2.0 I am a sole proprietor or partner- listed on the attached sliget# 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp. ' $ ❑Demolition p insurance. [No workers'comp.insurance 5. We are a corporation and its 9' addition required.] .officers have exercised their 10.❑Electrical repairs or additions 3• I am a homeowner doing all wank right of exemption per MGL 11.El PIumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no insurance required]t employees.[No wo&ms' 12.[]Roofrepairs comp.insurance required.] 13.@ OtherIM SU f,,i�►- tet, !AnY APPhcant 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 suck Contractors that check this box must attached an additional sheet showing the name of the sub-conhaetms and their workers'comp. poficyiafor lam an employer that isprovsding workers' orf compensation insurance mation. information, my employees. Below is thepolicy and job site Insurance Company Name.-±V et e:-fcs UB q,70 5 t " Q Policy#or Self-ins.Lic.#: Expiration Date:_ Job Site Address: t WCA- A i �lt3fC7•�ck i Cit y/State/Zip:_ 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. n o the imposition of criminal penalties of a fine up to$1,500.00 and/or one-ye152 calead t ar imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine Df 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. do herek cernfify u r the pains and penalises ofperjuPy that the ix o ` f rmation provided above is true and correct .i ature: � Dt Date: hone#: (4 0-2-? .2a Offresrri use only. Do not write in tits area,to be completed by city or town t,*7da City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityPrown Clerk 4.ElectIumbing Inspector 6.Other Contact Person: Phone M OP I©:Ss CERTIFICATE OF L BIL" INSURANCE 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 CERTIRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIMATE HOLDER_ IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the por y(ies)must be endorsed If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain pokes may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder in tieu of such endorsement(s). PRODUCER 978-688-7000--Cr Durso S Jankowski Ins Agcy LLC 978-688-7001Fax 198 Massachusetts Avenue11RIft gm North Andover,MA 01845 E-MAIL, Charles S.Randone ADDRESra: s�tDDsx:ER m RPOLAR-1 assro>vla� =UIHRP Ai IG CO10tACE I NMI. INSURED Polar Bear tnmtlaftn Co.Inc. DWRM A:Penn Amedca 132859 P O Box 958 wwmat Insurance Co_ 133618 Andover,MA 01810 wsuRsx c. INSURER E: INSORERr- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMEN r TEM 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 CLAW. IL7R TYPEOF�11RANCE POLICYNU1!BER ` PINKYt3� mmnnOLICY a I Lam GENSZALLIABRiTY EACHOCCURREICE S 1,000,00 A X coMI,m mLGBgSIM—L'U'�ASUrY AC6864084 03!24!11 03124tt2 USES omar� s 50,00 CLaIMs�aaDE I--�OCCUR "LIED so,(a"g am�) S 4' P@ZSONAL&AOVMJURY $ I G8 at LAG&REGAXE S x+0001 GE?&AGWZS..-AMLffiffAPPLJEE�SPBt I PRODUCM-COMPIOPAM s 1,000, POLICY i !PRO­JECTi 1 LOG I i s TOlssoaaLfaslLrrY { CD )SIN6LELtTIflT S 1,000,000 aU I {{ B 7ANY AUTO 100926 01104111 { 01!04112 Y s (30DIL IN.rtAZY(Perpersoc:j { I t ALL OVYN�AU'� � BODILY Raw(Peramxlav{S X SCHEDULE?AUTOS ( PROPERTY DAMAGE S X WtED AUTOS i X Non#-rnnrMD aUTos Is s UMBRELLA LL48 X =UR EACH OCCURRENCE S 1,000,0 00 o=m ups CLAIMS-MADE � AGGREGATE S 03124111 03124112 A I ACS8fi4084 � � # D®UCTISLE RETENTwN 5 I S WORia:RS COMPENSUM ( t X LAIMITS ER ND AEMSPLOYE RS'LIABRA Y Y I N ANY, fi/P I N!A E L SACH ACCIDi i's OFAR EXd VDEO? (MandabNin M I E1.DISEASE-EA IRAPLOn4 S If yes.desabe[alder DESCROMON OF OPERATIONS bebw I EL DISC-POLICY LIMIT S DESCRBrn d OF OPSiAnONS I LOCATIONSI VEHICI.ES(AVacL ACORD 101,AddM0g2d Re"we4s Staed�e,If"mre space is requited} G.L.C.A.C.,National Grid Corporate Services LLC DBA National Grid,Adson Inc,Boston Gas Company,Colonial Gas ,Essex Gas Company&Bay State ppGaserrfo ed on�r befM by theabbvne��Witft respecfis to work CERTIFICATE HOLDER CANCELLATION GLCACII SHOULD AW OFT HE ABOVL DESCRMED POLICIES BE CA E r M BgaDRE THE EXPIRATION BATE THEREOF. NOTICE WILL BE DEUVERED IN 8 Bay Sta. Gas C0. ACCORDANCE WITH THE POUCY PROVISIONS. 350 Essex Street Lawrence,MA 01840 AU HORS RS+RESENrAMVE O 1988-2009 ACORD CORPORATION- All rkPubs reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD 3i, �tFBx Nl-1 1/19/2011 1.0:14:22 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF UABILITY INSURANCE oAm(mwwmm OIn9mDll IM CEfCitFiCA'MMISSUED ASA fIAWER OF 91FORNATION M&Y AND CONFERS HO RLGMS UPOK MMtr--EtTL "T-9 t'"OER TM CMnN `ATE DOSS WrrAFARLtATIVELY OR UW ATAVELY AfLBm F]C7'FAID OR ALTERTEE COVERAGE AFFORDED BY 1HE MUCIES IES BELOW 3. CERMPIOAXE OF INSiIRtANCE HOES mar COIsinUrE A COKTRACTSEiWE1317M ISSUNG OMUPJMM AUTMORUED REP RES9 AMVE OR PRODUOM ANDRE CERTIFICATE HOLDOL rtAPORTAKT Blha cwdfimta hofdes Is as ADDnWNAL tfm De- ','=A saim4 bo ormdossod.U SUBROL3 MM IS WAIVED.Z&*&tta 9-0fytmcard of tla PanM eWWM P =Y roquF=and sr do�pmart. 65ataHoes no*, m lLio �IDfdlt In ft of sob e[ (4 PRODUCER CONTACT HAM FAX PHONE DURSO&Mb[MVIM INS (AIC,ft,E;*: FAX (AfC,No); 148 AIASSACEELISEM AVENUE E MUL ADDRESS: PRODUCER NORTH ANDOVER MA 01845 0USW I M ID ft 22PTL 885URER(S)AFFORDING COVERAGE ILkIG a3 INSURED HNSIIR�A: TRAM DMOD4Nny NOWANY INSURERS: POLAR BEAR 1NSULATTON CO INC INSURER C: WISURER O: P.O.BOX 1158 INSURER E: ANDOVER PAA 01820 Ir F: COVERAGES C ICATENUMASM N �� 'iEl6 LS TD CI�tLIf•Y7HJlTT�PODQES Ofd LWW SEWW RAVE SEE46SMOTOTHER25URM NALMO ASOVH FORTLIE POLIOYPM0O9MC&TEO- NOTV�AM DIMAKY Ri:Qt1Rt T.T8O60R COt11>ittON OFANY CON[RA=ORCR73ER DOCiIILEI�iT With RrSAFLTTa Wh➢Cii3Hl9 CERS3RGATE l3AY 3£LS9GE9 ORMAYPERTAIN 7M M PAliCEAFr,OROEBF3YTIfEPOLtCISOFAFilU ISS;lg)PL7TO LLTFIETER16y At�iD T10NSOFSlJCFIPOLJd6 LMMSHOWHUffHAVEOMQEDBYPAIDCL&IM WSR ADOLSVOR POLICY EFF DATE POE=EYP DATE {JtQJt9 TYPF5 OFUdSFJRANCE PoLwrmumsm YYY!) ( + OL7LYtY71 LTR �� EACH OCCURRENCE $ GENERALUAsum COWERC-IALSENERALLIABLITY DAMAGETO RENTED S CLASAS MADE OCCUR. PREM1SM(En ) MED EXP&W cm S PERSONAL"AOV INJURY S CANEPAL GEN`LAGGREGATELIMITAPPLIESPM PRODUCTS-C0b1210PGREGATE S POLICY PROSECT LOG PRODUCTS-Chl3'lt3PAGG S AIRTONIOSILE LIABIIL71f COMBB4ED SINGLE S ANYAUTO LI�I���) ALL OWNED AUTOS (peSOr Per") RY S SMISDULE AUTOS SO '} HIRED AUTOS 9QDRY Re4 S NOt4dWNEQ AUTOS PROPER•iY DAMAGE S {Per 2cc de(4 UMBRELLA LEAS OCCUR EACH OCCURRENCE $ EcXCESSLL40 CLAVAS44ADE AGGRE3CiATE � DEDUCTIBLE $ RETENTION$ TMCSTA3M0#3YUMIiS O0$2 WDRCE R'S COMPEN"MON AND EN PLDYEfLS LIMU3Y YIN UD�0. 841 OUD'I 2011 O1MIrAl2 E.L EACH AC 309M S 1.�.� ANY PROPERFT+OW , E Y E..L..DISEASE-EA EMPLOYE-S S 1.000.004 OFRCSWiEofi3aR8CCUJOEIIT frYtoJ�cU ELDISEASASE-POLICY LBWT S 1.000.000 n�a.aeaams,■,a� DESCF11P1WW CFOPEPK 10NSbct@w OESCRP7IOM OF�PER113tOitSfLOCAtnDlL4/i/F1lFC HCfJ►LYIAts I=REP ACFSANYPRiORC CA1E753L7FDTO'tf3E?ci3nit'qCATBBOLDMAFFBCIINGWOESOMWCOVFRAGF' CERTMAM HOWER CAHCI=L"-IMN G b C A C&$AYSTAT GAS C8 SHOULD ANY OFIM ABOVE DESCRIBED POLICIES BE CM LLED B�oRE tiIEEXPLRAFtE>AI DATETLgffiEOF,MO=VML BE DELIVER IN ACCOLOAHCE 350 FSSEK STREET NIM TELE POUCY PROMOiNS. ALf HomzW JaWRESWrAME Clark TAVVjtWCE.MA 01840 Q18EICS 3 198L�2D9W,20 09 ACORL}WRFCRAiIQAL. AN rights T2S2iYFE£I. ACORO25(2Q1P M)