Loading...
HomeMy WebLinkAboutBuilding Permit #1100-15 - 21 CLEVELAND STREET 7/27/2015 NoRTH BUILDING PERMIToF-.,,.Eo TOWN OF NORTH ANDOVER 3a y� _,�,.6 0 0 APPLICATION FOR PLAN EXAMINATION b�- 1 Date Received a,�qo" Pa`^5 Permit No#: q �TEo SSACHUS Date Issued: IMPORTANT:Applicant must complete all items on this page j S� LOCATION Print PROPERTY OWNER &1c-A- r e6 r'e.A - Print 100 Year Structure yes n MAPQ4&q3PARCEL�J ONING DISTRICT: Historic District yes no i 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 0'Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watery .ed Distract., Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: C-7t tG 19- A e-6('Q-&, Phone: Address: Contractor Name: li 06 15 El1P/6 fz Phone: / 4 FF6 Email fav A, Address: ao At ow /h o Supervisor's Construction License: Q!,Z) 7�L/� Exp. Date: Home Improvement License: Exp. Date: 7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED SEED ON$125.00 PER S.F. Total Project Cost: $ �-, �60 FEE: $ -i Check No.: �Zy- oq -12:4 Receipt No.: Z � 2- NOTE: Persons ntYacting with unregistered ontYactors au not have access to the uaYanty fund ev wnature.of Aqent/Q��—­ Location No. �� Date `F' . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �� Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check#'L L �)?1j,2-4 2 BuPP�s ildInspect in or Plans Submitted ❑ Plans Waived ❑ Certified Plot flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ I 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 e Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes (h Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street ,FIREiDEPARENT�TIIl1TempDumpster onsite ,yes .::_ ' F,if ig r>latu re/date; i 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) -�A 6 . ® Notified for pickup Call Email Date Time Contact Name ---------------------- Doc.Building Permit Revised 2014 i i i 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 4� Building Permit Application 4. 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. Building Permit Application 4. Certified Surveyed Plot Plan Workers Comp Affidavit �6 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) 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 NORTH Town of 2 t EAndover o - �+ No. 1166— Alt t - h ver, Mass, (Aj%t �� o coc NICKf WICK ST U BOARD OF HEALTH Food/Kitchen PER kilT LD Septic SystemTHIS CERTIFIES THAT ....... icA Q BUILDING INSPECTOR ................. .............H.e .......................v..................................................... has permission to erect ........... buildings onA�..�./..�e. o Foundation .............. .... . . .... . .... ............. Rough to be occupied as .......�.. !�... t.....4.....�l....' . ..... .. . �.......................... 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONST ION TARTS 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. a Federal ID# ITT RISE Engineering RI Contractor Registration No MA Contractor Reglatratlon No A division of Thielsch Engineering CT Contractor Registration No t 60 Shawmut,Canton,MA 02021 CONTRACT�+ _. 339-502-5197 FAX 339-502-6345 CONTRACT R I S E Page I � ENGINEERING PROGRAM�'� TfpS COniRACrp FNTEgEp aJ}p vn: aErEN Salt CMA-HES �a�ED cusrouExwnwoarcws ELOW vxo++a DTE CUENTa WORK ORDER Erica Megrew ! U tJ~a. X101)680-0567 03/16/2015 406429 00002 SERVICE siREEr __--...ai 21 Cleveland Street [i ' & 2015 T 1 Cleveland Street SERVICE cnr.STAMzly '_ _�.__ _-- — BUM ctn.srATE.aa Notch Andover,MA 018 North Andover,MA 01845 JO SCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage.This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for scaling include air leakage to attics,basements.attached garages and other unheated areas(windows are not generally addressed.) (8)working hours. At the completion of the wentheriuttion wort:,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. AIR SEALING ADDER: (2)working hours. 5680.00 5170.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaccd fiberglass baits to(30)square foci for damming purposes. $61.50 ATTIC FLAT.Provide labor and materials to install a 10"layer of R-35 Class I Cellulose added to(390)square feet of open attic space. 5573.30 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(180)square feet ofkneewall area. 5630.00 KNEEWALL FLOOR:Provide tabor and materials to install a 6"layer of dense packed R-22 Class I Cellulose added to(168)square text of kneewall Door. 5299.04 ATTIC ACCESS:Provide labor and materials to insulate(4) back of the kncewall hatch with 2"rigid Thcnnax board,and seal the edge of the hatch with weatherstripping S240.00 VENTILATION:Provide labor and materials to install ventilation chutes in(43)rafter bays to maintain air now. $86.00 BASEMENT DOOR:Provide labor and materials to insulate the back of the basement door leading to the bulkhead with 2"rigid board that Meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all edges and seams with FSK tape. $72.22 10 RISE Engineering RI Cont a RContractor Registration No MA Contractor Registration No �— A division orThielsch Engineering CT Conbzctor Registration No t i 60 Shawmut,Canton,hiA 02021 339-502-5197 FAX 339-502.6345 CONTRACT R I S E Page 2 ENGINEERING PROGRAM TMS CONTRACTt3 ENTERED WTO BETTTEEM Wit CMA-HES ENDaEERBIOA►bTT�cusTaTERFDRWoaTAs EVVECUSTOMER oElerDe>m goer DATE 4TENTS WORK ORDER Erica Megrew /{t (401)680-0567 03/16/2015 406429 00002 /Sj}1 -}tJ 415 A MUM STREET - —'- _ - 21 Cleveland Street t 3 2-1 Cleveland Street __ __. aERincE urY,srATt;aP BILLIIiT1 CITY.STATE,aP - North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,812.06 Program Incentive: $2,321.55 Customer Total: $490.51 WE AGREE HEREBY To FURNISH SERVICES-COMPLETE IN ACCORDANCE WRH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Four Hundred Ninety&511100 Dollars $490.51 UPONFMLMPECTIONAROAPPROVALDYRISEEIf MERMCUSTOMER.AOREESTOREMTTAMOUNTDUEHFALL NrERESTOF,%WRLBECNARGEDMDNn YONANY .UNPMDBATANCE �DAYS.lEE REVERNFORTYPORTANTYWORNATNMt ON GUARANTEES.MOMOFRWMN.apIEDDLMAMMURA MFW:OWTRATIOM _ _ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 1UTUH SIDNA RISEEAOUepinO NOTE-TM CONTRACT MAYBE WITHWAWN BY US IFHOT EXECUfWWMQN DATEOFACCEPTAN E 3Q ACCEPTANCE OF CONTRACT.THE ABOVE PRIOMSPECRCATIONS AND CON1XnO SARE DAMSATdFACTORY To ua aRo ARE HEREBY ACCEPTED,YOU ARE AUTNORM TOGO THE WORK AS SPECUTED.PAYMlNT WR.L BE MADE AS OUTI,ITEDABOVE The Commonwealth of Massachusetts „ . Department of IndustrialAceidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): U ky r ev 5v 16 Address: � w City/State/Zip: k/1-z& /'Yl ia- Phone#: / G Are you an employer?Check the appropriate box: Type of project(required): 1_T2tn a employer with 6r� -ployees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8, 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14Other !_fa V 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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: !7'PI U Policy#or Self-ins.Lie.#: (D Expiration Date: Jam` ���jv Job Site Address: -21 5� • "#-C State/Zip\6, 4�ex MO''N Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under lie pai s a d penalties of perjury that the information provided above is true and correct. Si natur Date: to Phone#: 72 —1,U 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia TDINS4 OP ID:MR CERTIFICATE OF LIABILITY INSURANCE IM-M(MmDDty" kh� I O611012016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AI=FIRMATIVELY 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 pollcy(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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CT TYG Insurance Agency,Inc. PHONE 7g1-641-3002 68 Freeman Street AIC No At No:781-641-3009 Arlington,MA 02474.6614 ADDRESS. INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Scottsdale Insurance Company INSURED TD Insulation,Inc. iNsuR6Re:AmGuard insurance company dba Hugh's EnerIW 259 Milton Street INSURERc:Arbella Protection Ins CO. 41360 Dedham,MA 02026 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER-- THIS UMBER:THIS IS TO CERTIFY THAT THE.POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINO.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 MID MM POLICYLICY EFF LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 11000,0 CLAIMS MADE 0 OCCUR CPS2020992 08!1412014 08/14/2015 PREMISES Ea occurrence S 50,00 MED EXP(Airy one person) S 6,00( PERSONAL&ADV INJURY S 1,000,00 GEN1 AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,00 POLICY JET ❑ 7 LUC PRODUCTS-COMP/OP AGG IS 2000,00 OTHER: S AUTOMOBILE LIABILITYMBBIdINED SINGLE LIMITffa S 1,000,00 C ANY AUTO 1020032764 08/14/2014 08114/2015 BODILY INJURY(Perpom) S ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) S NON-OVINED PROPERTY DAMAGE S HIRED AUTOS AUTOS Peracc Iden 5 UMBRELLA LIAS X OCCUR EACH OCCURRENCE S 1,000,00 A EXCESS UAB CLAIMS-MADE XBS004"10 10107/2014 08/14/2015 AGGREGATE $ 1,000,00 DED X RETENTIONS 10000 S WORKERS COMPENSATION PER TH- AND EMPLOYERS'LIABILITY YIN STATUTE ER B ANY PR PRIET ER PARTNERIEEXCLUDEDECUTItfE NIA R2WC641650 05/30/2015 05/3012016 EL EACH ACCIDENT S 500,00 OFFICE(Mandatory In NH) EL DISEASE-EA EMPLOY S 500,00 Ifyyes,tlascribe under DESCRIPTION OF OPERATIONS We F-L DISEASE-POLICY UWT S 500,00 Commercial Appiica DESCRIPTION OF OPERA'nONS/LOCATIONS!VEHICLES(ACORD 101,Additional nwnarls 8ehodul%%nay b*&U=had irmom Wac to m ryl,eq Conservation Services Group,ilnc,National Grid NSTAR and WMEC are added as additional insured as their interest may appear for work contracted with the named insured. CERTIFICATE HOLDER CANCELLATION CONSWES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE 08JIMED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR®R�E�PR�ESSEENfTATNE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD :t d z r 1. } f Massachusetts -Departr gin{or Public Safety Board of Building r=yuiat'; ,rs an,&Standards .y?4+� O.Utlltl ill.11lJ Jl JUfJi"i S 1101 �'. �� License: CS460784 Thomas P Dromgogre 259 Milton Street Dedham MA 02026 c )1-0 P-Piration Commissioner 101222016 ` - - = Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement-Contractor Registration Registration: 104800 Type: Supplement Card Expiration: 7/15/2016 HUGH'S ENEIRGY CORPORATION THOMAS DROMGOOLE 259 MILTON 'STREET DEDHAM, MA 02026 Update Address and return card.Mark reason for change. SCA 1 20on-05/11 �] Address F-1 Renewal 17 Employment 17 Lost Card - Mce of Consumer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR P Office of Consumer Affairs and Business Regulation " Registration �p4g00 _: Type: 10 Park Plaza-Suite 5170 Expiration::_7/15/20;1E Supplement CE!, Boston,MA 02116 HUGH'S ENERGY CORPORATIO)V THOMAS DROMGOOLE"- _r 259 MILTON STREET DEDHAM,MA 02026 Undersecretary Not valid without signature