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Home My WebLink AboutBuilding Permit #117 - 21 STACY DRIVE 8/1/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received DateIssued: 6- 1 —y IMPORTANT:Applicant must complete all items on this page LOCATION vZ �-C vcK S Print PROPERTY OWNER �� A N t A 6 P e-) Unit# Q Pri t MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no lit 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 CX,Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other EI'Septic 0 Well ❑Floodplain 0 Wetlands 0 Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: t (Identification Please Type or Print Clearly) OWNER: Name: n V //1 "�.[� /*d PC-' Phone:22B SCSb9) Address: C o Ltt ( �i CONTRACTOR Name: c- E P o . K C-Yl Phone: 9>2 VD�2(03.� A Address: "Al-K"ez, lel�'`/ e- ('m ISS,-Y ' Supervisor's Construction License: �� Exp. Date: d-30 0 Home Improvement License: D� '? 6 (. x 96OLExp. Date: it 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: $ b o�a� in�� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agerit/Ovvner Sigriafure of�contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ t ' TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnnmmg 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 p- Building Permit Application 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pern 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 Permi 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 o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perm 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 `i Date...,.7. .. .... . .. ....... . Of,NpRTM TOWN OF NORTH ANDOVER Or °` 4 pL MS PERMIT FOR MECHANICAL ITALLATION f .i P �'ISS ACHU5Et This certifies that has permission for mechanical installation . . . . . . . . . . . . . . . . . . in the buildings of . .ta `� !`�.!�. . .,X 1 f ,U . !. . . . . . . . . . . at !�/. . . r��.�I . t.?/' ... . . . . .. North Andover, Mass. Fee..,�'C). . . . Lic. No.�� S^. . . . . . . . . . . . . . . . . . . . . .(is . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer &Iuiig-a Gas-, of Mass d usetts / A NSource rompmy l Gas Account ft Audit Request 116[7 l �(, f PRELIMINARY AGREETNIEW READ THIS AGREENJE1'T AND MAKE SURE YOU UNDERSTAND IT BEFORE SIGNING. MAKE SURE ALL BLANKS ARE COMPLETED AND ALL PROVISIONS THAT DO`NOT APPLY ARE CROSSED OUT. THIS AGREEiiENT HAS LEGAL FORCE A,4D EFFECT AMD RENDS THOSE WHO SIGN. This Agreement isde on 5 �aI�f3 / �t bet ee+oneywell of bS Shawmat Rd,Suite 4, 2"a floor, Canton, Massachusetts 02021,(804-241-4112)hereafter called-Zrnintstiattve Contractor"or"Honeywell"and COLO pet bI.ttIYl of 01 _ r, (Customer) lu (Address) V, uec MR 656 -0370 (Address cont.) (Telephone) Hereinafter called."Customer.'The Customer is the Owner Irenant 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),�e Customer agrees to the terms and conditions of this Agreement. \o Work may be performed without the written consent of Owner C� calculated energy savings are estimates only and are not guaranteed. tomer understands that PRfCE For&d ftftirianase oNr For the Work described in the`York Order(s)and shown on COMMENTS: the accepted Offer Sheet,attached hereto. 0 SEE HEALTH AND SAFETY FORM the Total Estimated Cost is S 01 OTHER The Total Due at the time Of Installation from S I the Customer for the Work to be performed is: Joe L3 If the Installation Contractor deterarbus that the i fork cannot be provided for the Price quoted above,all parties will have the right to terminate this Agreement Price quoted is valid for 90 dayx OKmer of the Premises agrees to pay,prior to the commencement of the Work,and Administrative Contractor accepts, in full satisfaction for the wort:the Price set forth above_ • Tenant agrees to pay, prior to the commencement of the Work, and Administrative Contractor accepts, in fttll satisfaction for the Rork the Price set forth above. RIGHT TO CANCEL THE CUSTOMER bL4Y CANCEL THIS AGR€r&_M& 7' IF IT HAS-BEEN SIGNED AT A PLACE OTHER THAN AN ADDRESS ADMINISTRATIVE CONTRA OF THE CTOR, WHICH MAY BEI PROVIDED TS W- Ar_N OFFICE OR BRA IUTIFIE$THE AD1tINISTRATTVE COQ"CRACTOR IN VLIWM AT rrS MAIN OFFICE OR BRANCR BY ORDIUNARY MAIL POSTED,BY TELEGRAM SEir'T OR BY DELIVERY,'�O LATER THAN MIDNIGHT OF THE THIRD BI _'NESS DAY'FOLLQiVING THE SIGtiIhG OF THIS AGREEMENT.SEE NOTICE OF CANCELLATION(Iii DUPLICATE)ANNEXED FOR AN EXPLANATIO;t OF THIS RIGHT. IMPORT-AN-F.-ADDITIOINAL TERMS AND COpfDITIOf:NS ARE OiN THE REVERSE SIDE By signing below yon,the Customer.represents that(1)You read and understood both 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 this3 ice rmetlt;( }T Administrative Contractor(directly or indirectly)has made no representations or warranties regarding the Work,other than those contained m this Agreement:(4)That at the time you signed the Agreemenk it has been signed by the Administrative Contractor or its administrative representative,there were no blanks that had not been completed and that die Work you requested was properly described above_ Honeywell Signature Dke w _ s Signature ��Date Tenant's Signature Date AVAIL THE SIGNED AGREEMENT TO: HONEYWELL 65 SHAWMUT RD,SUITE 4,2a'FLOOR CANTTON,MFA 02021 HoneyweA-White Installation Contractor-Yefrow Customer-Pink Revised 1012b10 RE9WEa_DAW7781s02M Office of Consumer €airs and$usines�s Regulation -- _ 10 Paris Plaza- Suite 5 170 =tea Boston,Massachusetts 021 16 Home Improvement Contractor Registration Registration: 102726 Type: DSA Expiration: 71212012 Trir 29848Q POLAR BEAR INSULATION GO. -- Vincent LeBlanc — P.Q_ BOX 958 ANDOVER, MA 01810 Update Address and return card.Mark reason for change. -' address - Renewal EFnpioyment lost Card License or ration T21M for individul use ordF y' MIA'? before the expiration date_ If found remora HOME MaMVEMENT CONTRACTOR oBice of Consumer Affairs and Business R ulstion Rsgtshaffom 102-728 Type: -170 > F irarom 7=012 DBA 1#!Part:PEaza-Suite.5 ' Boston,YU P-116 O R BEAR INSUlAt ION-CC. Vincent LeBlanc is t 51 SO-CANAL ST..#.5A LAWRENCE,MA 01841 -- --- Lnc3ersecretan `Not valid tsi#hont siagaature -77 �- _._t.moi........�. ...�j��.._..�,.3: CS Si- 99352 - - VINCENT LEBLANC 24 LANDING DRIVE METHUEN,MA 01844 Expiration: 1/30120/2 Tr= 99352 T-6fhtF&X N1-1 1/19/2011 10:14:22 AM PAGE 2/042 FaX SerVOr ACORD. CERTIFICATE OF LIABILITY INSURANCE DA'TE(MM!#iI111'1 m 01n9mil V"CERTS"TEMISSUED ASA MATTFR OF 04:010IAIM ONLY AND CONEERSHO RtBIM UPON W CESTWICATE MOM 7M CHRWICA7E DOES NOTAFnRMATWMT OR HEOATIVELV MOM EL:THID OR ALTERTrW OOVERAGE AFFORDED BY THE POUCIES BELOW. TM CER'DRWM OF DANCE DOES NO T CONSTITUTE A CONTRACTBETVI/FF11 Tamst o;GNStiRiBi(S).AUTHORIZED REPRESENTATIVE OR PRODUCEK AND IES l CATEHOLDEiL IMPORTAAR Ndo e me' cap h*Mw k en ADWTIIONAL "pdkjCwA saustbeatdomed.8 SUSROGATIOM 19 WANED,subOdtDOW bnatcad 12iaisaithep cwbjnPoSei,,saw, q-SaudenQoA staftumWenMiseor65edodeesnot eonfarzightcID930 eerhtieatstuddrtibumOtsttdterd (2} PRODUCER CONTACT NAT . PHONE FAX DURSO&1ANKOWSK1 VIS (Arc.W.FA): FAX WC.Me); 198 AVENUE E•1011. ADDRESS: PRODUCER NORTH ANDOVER.MEA 02845 cLISTOI m 22PIL DlSURER(s"')A tSRD&NGCOVERAGE IfAIG# INSURED 94SURER A: 'TRAVUJMS DM9WWI Y CAMf'ANY U45URER W. POLAR SEAR INSULAnON CO INC INSURER C. $iSIIRER D: P.O.BOX 958 INSURER E: ANDOVER WA 01820 uNsoRETt F-. COVERAGES CERINWA'TE NUVAM RErISION 10mo tI: THE JSTO CE1MPrTNAT7W POUCW OFMSURANCE LWED BELOWHAVE BEEM iSSMOTOTMEt MPAD NAHW ABOVE FORTHE POUCYOEMOD SOCATED NORL0TINEiANUMANYPOQUIN W WT;TERNORGO>fDifIONOfANYOONTRAOrOROTHERDOCUNEftTiIYIrHR ?EC7IOWFSCNTHIVCQlifglG6TEl6AYSEtSIUEO OR MAY MrARL IM WSDRANCE AFFORDED BYTHE POLICE&DIS NEM tSStI&MM€ TO ALLTIMTWdM MMLt AND TIONS OFSUC14 FOUCiL-. LWr$-%@OWI I i10.YMAVE B%1 REDUCED BY PAID CLAN @TSR ADDL.SUBR POLICY OF OATS POLICY EXP DATE TYPEOFUISURANCE PoUCYNtA ER YYYlO II DD[YYYTI uwrs Mt ffmwVD C,ENERAL LIABt M EACH GUCl E $ C IALGENFRJALLIRBH.ITY DAMAGE TOREFtFED $ CLAWSMADE OCCUR. PREM1SES(Ea*=wmrwe) IWED�(Atry otte persacl) 3 PERSONAL 8&AOV NJURY S GDM AGGREGATE LIW APPLIES PER: GENERAL AGGREGATE $ POLICY PRO.IWr LOC PRDDt=M-COMPMPAGG S AUTOMOBILE UABILITV COMIRDIED SKSLE $ ANY AUTO LWr(Ea aead-d) ALL amwAUTOS GODILY94JURY S SCHEDULE AUTOS (Pet om m) HIRED AUTOS BODILY INJURY S (Per a=kfenf) NON-OWNW AUTOS PROPERTY DAMAGE s (Par acdderC UCLA LIAR OCCUR EACH OCCURREMM S EXCESSLIAS CLARA4AADr- AGGREGATE $ 99DUCTIBLE S RETENTION S S 4rC SWErr(MLAYIS OTHER WOWERIS COMPENSAIION AIS EMPL40YEFM LIABILITY YIN U09905LUM11 OVQW2011 0110I 012 I-L.EACH ACCWEINT $ 1�=A00 AttY Y E.C.DISERSE-ICA EMPLOYEE S 1,000,004 o EMWOMa 1 01,in ro:I EI DISEASE-POLICY LWIT S 1.004.000 S yea.aesama aa. VESCRIPnON OF OPBtAnOf1Sbdcw o1TOrL CFO �A E'ClAE ITEMS IIilsI FIAMANYPRiORCERMFW.MISSUOEDT07MCOCrERMMBOLtMRAFFBCMWWOPJMMCOMPCDVERAGE CERTMATE HOLDER CANCELtArtON G L CA C&BAYSM GAS CO SNOW.D ANY OFTHE ABOVE DESCRIBED POLICIES BE CMILE.IED BEFORE 1TeEWIRATION DATE TH8WOF.NOTICE MI.BE 08JVERBs IN AC00ROANCE 350 ESSEK STREET VMHTrfE POLICY PONS AUTHOROM REPREMrATWE LAWREMP,NIA W940 Charles 3 Clark P=RD 25 V-MM) 1988.2009 ACORD CORPORATION. M tights reserved 11 _- -*'*j OP ID:SS A�>fl° CERTIFICATE OF LIABILITY INSURANCE DATE(M07/228/1811YYI� 1 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 rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 978-688-7000 NAME: Durso&Jankowski Ins Agcy LLC PHONE Fax 198 Massachusetts Avenue 978-688-7001 A/c No Ext): A/c No): North Andover,MA 01845 E-MAIL Charles S.Randone ADDRESS: PRODUCER POLAR-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Polar Bear Insulation Co.Inc. INSURER A:Penn America 32859 Dan Kiley INSURER B:Safety Insurance Co. 33618 P O Box 958 Andover,MA 01810 INSURER C: INSURER D: INSURER E: INSURER 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. ITYPE OF INSURANCE POLICY NUMBER MPM/DDI EFF MWEXP DD LTR LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY PAC6906385 03/24/11 03/24/12 PREMISES Ea occurrence $ 50x00 CLAIMS-MADE n OCCUR MED EXP(Any one person) $ 5,00 PERSONAL BADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO 2100926 01/04/11 01/04/12 (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LUAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ A PAC6906385 03/24/11 03/24/12 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remaft Schedule,N more space is required) Insulation Work-Mineral CERTIFICATE HOLDER CANCELLATION PRESCOT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Prescott Village Condo Assoc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. Stacey Drive North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts Department ofIndusttWAccidents Offrce oflnvestigadons 600 Washington Street Boston,MA 02111 www.massgovldia A 'Workers' Compensation Insurance Affidavit:Builders/ContractorsfElectricians/Plumbers pplicant Information L Please Print Les=lbly Name(Business/OTmization/lndividual):Ll h f L1vE jL,stcts Z n �,J� 8,n.x A�c-t4 lxc. Address: ` (�Ll, \. . City/State/Zip: Phone#: 7 7� Q 7 - 03 17 [EII an employer?Check the appropriate bog: a employer with 4. ❑ I am a general contractor and I [7E project(required): loyees(full and/or part time)* have hired the sub-contractorsew construction a sole proprietor or partner- listed on the attached shget.temodeling and have no employees These sub-contractors haveemblition ing for meis any capacity. workers'comp.insurance. workers' comp.insurance 5. WWe are a corporation and its uilding addition ired] o$2cers have exercised theirlectrical repairs or additions a homeowner doing all work right of exemption per MGL umbing repairs or additions lf[No workers'comp. c.152,§1(4),andwe havenoofrepairs ance required.]r employees.[No workers' comp.insurance required,] her )US ¢K *ArY aPPlicant that checks box#1 must also fill out the section below showing their workers'compensation.Policy information T Homeowneas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContract`that check this box must attached an additional sheet showing the name ofthe sub -contFactois and their woriors'comp.policyinformation. Iam an employer that fsproviding workers,compensation amt insurance for my employees Below is thepolicy job site informaation. Insurance Company Name: ±VL.4y ttc�iLS U6 q({0 5 L Policy#or Self-ins.Lic.#: Eviration Date:_j bj At ID Job Site Address:_ .d_E c� • '-City/State/Zip:_ 9/ �� 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 [nvestigations of the DIA for insurance coverage verification, do hereb certify u r e sins and P Penaltlff ofperjury that the information provided above is true mad correca: �i afore: - �� Date: — f hone#: O,ffacial use only. Do not write in this area,to be completed by city or town offacld City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.CRY/Town Clerk 4.Electrical Inspector 5.PlumbingInspector 6 Other Contact Person: Phone#: