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HomeMy WebLinkAboutBuilding Permit #367-13 - 217 WINTER STREET 11/5/2012 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 3 Date Received Date Issued: I v IMPORTANT: Applicant must complete all items on this page lkXT PR®PERTiY�® NER�:� Prost, 100YeaOltl Structures- ye no•- MAPNCtFARC.EL ONINGD,IS�TRICTHist©ncDistnct Sr nor i p:y es no) Sh �Mach'ir% o illage�_ _ TYPE OF IMPROVEMENT PROPOSED USE { Residential Non- Residential ❑ New Building ?One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial I ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑UVell ❑:Flood,plamx << El Wetlands ❑ Watersheds®ist_rct DESCRIPTION OF WORK TO BE PERFORMED: M Identification Please Type or Print Clearly) OWNER: Name: ),tAVn s':gotexsl 1-17— Phone: Address: 1G NTR,`QT :R' Name': �t IQ CI�lP_1Z:il0Y,t Phone T 3_ I- 5upervlsor"s Construcfionl License:' rJ 5 _ Exp Date 1 }- ' Home ImprL:iCI_ " " 1 ARCHITECT/ENGINEER Phone: I Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST 8 ED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ l) Check No.: Receipt No.: Qv' ' / NOTE: Persons contracting with unregistered contractors do not have access to the guaran and . .. rtteof cgent/0-WherA _"."" gnantartaT'sc;Y to„ r _ _ - Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stam d Plans ❑ I � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r r- i Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ ❑ Tobacco Sales Food Packaging/Sales ❑ I, .Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM l DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i CONSERVATION Reviewed on Signature j� COMMENTS HEALTH Reviewed on Signature COMMENTS i i 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 p Dum sten on site yes no Located at'124 MainStreet Fire Departr'rient 9i§nature/date { COMMENTS i 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 chop requires approval of Electrical Inspector Yes No DATER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use II ® Notified for pickup - Date I � Doc.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 � o Building Permit Application ! j o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses I ' ❑ Copy of Contract o Floor Plan Or Proposed Interior Work Li Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I Addition Or Decks Id ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 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 o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract Li Mass check Energy Compliance Report Li 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 submated with the building application Doc: Doc.Building Permit Revised 2012 Y Location J < ' No. G��♦ � Date ` e TOWN OF NORTH ANDOVER =i e £ Certificate of Occupancy $ a, f Building/Frame Permit Fee $ ? + a� Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ q 'S Check# � 25907 Building Inspector k NORTH Town of 7,1, Andover o yr. No. _ iR Z - h • ver, Mass, I t COCHICHIWICX 1' �•9 �4ATED `��5 S U BOARD OF HEALTH T T LD Food/Kitchen Septic System ' THIS CERTIFIES THAT ................................... BUILDING INSPECTOR . PERfig . .... .... .... ..*. ..... Foundation has permission to erect . .........................buildings on .ato:�v....... .I.M�.. ... ........... � Rough to be occupied as .......... .... � .... .. .............. ......'.' ......... aly ................ ................................. 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 MON S ELECTRICAL INSPECTOR UNLESS CONSTRUCT S TS 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 The Co>,:rnonwealth ofMassaehusetts Department oflndustrial Accideit:ts Office ofInvestigations 600 Washington Street Boston,MA 02.111 Workers' Cwwwanass govldia ompensation Insurance Affidavit:Builders/Contractors/Blectricians/piumbers App Iicant Information Name Please Print Le M (Business/Organization/fndividual):. `•�l� Address: City/State/Zip: ' Phone.#:_ Are yyf an employer. Check"the appropriate box: 1.ERI am a employer with 2 '4. [1 I am a general contractor and I Type of project(required):- 2 Elemployees(full and/ part time).* have hired the subcontractors 6- ❑New construction I Ora a tole proprietor or pa-mer_ listed on the-attached sheet 7. 0 Remodelutg ship and have no employees These sub-contractors have working for me in any capacity- employees and have workers' 8. ❑Demolition [No workers'comp,insurance comp-insurance.#' 9. ❑Building addition 3.❑required j -S_ Q We are a corporation and its 10Q Electrical repairs 1 am a homeowner doing all work officers have exercised their - - or additions myself[No workers'comp. — ':} right of exemption per MGL 11-�PI . • ng repairs or additions insurance required.]t c.152,§1(4),and we have no 12.0 oofrepairs employees_[No workers' 1.3- Other oomP-Insurance required.] Ho eowne s that checks box affidavit must also fill out the section below showing their workers'compensation policy information. t ------ Homeowners who submit this aifrdavit indicating they are doing all work and then kine outside con (Contractors that check this box must attached an additional sheet allShowing the Mors must submit a new affidavit indicating such. employees. if the sub-contractors have to nam of the subcontractors and state whether ornot those entities have P yees,they must provide their workers•comp.policy number- I am an employer that is providing workers'compensation insurance for my infornrution. employees Below is the policy and job site Insurance.Company Name:_;"'�¢,� -l�ci Policy#or Self-ins.Lic.#: jh( .. Expiration Date Job Site Address:2 J� L City1State/Zip:__ W M� Attach a copy of the workers'compensation,policy declaration page-(shor ing,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 fine t t$$1,500a d and/or one-year imprisonment;as well as civil penalties in the form imas STOP Wcriminal ORK ORDER ties of a of up to$250.00 a day against the violator. Be advised that a copy of nisi s in the mayof be forwazded to the Office and a fine Investi tions of the DIA for insurance cov a verification. ce of Ido hereby certify der the d penalties of perjury that the MtMnation provided above is true acid correct Si ture: . • Date- i �� 2 Dacia!use only. Do not write in this area to be completed by city or town offmiaL City or Town- ' Permit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3.Citi/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Ofher Contact Person: Phone#: . •A`oRv® CERTIFICATE OF LIABILITY INSURANCE I DATE(AUDI)N"'"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE EXTEND C,ONOTW0.ALTER BETWEEN THE COVERAGE AFFORDED By THE POLICIES } REPRESENTATIVE OR PRODUCER,AND THE NOT HOLDER THE ISSUING INSURER(S), AUTHORIZED . IMPORTANT Ifthe ceoffigte holder is an ADDITIONAL INSURED,the t�olicy(ie8)must be endorsed, ff SUBROGATION t..WAIVED,subjectto ifie < terms and conditions of the Polley,eorb n pofc%s may"Woe an endorsement: A cerK$cate holder in lieu of such endomement(s� rnerlt on this certificate does n PRODUCER. at confer rights to the ACT Emond 23<Assoaabes M►chael Emond 857 Tumpike Street PRONE FAX Suite 133 AEMAIL No North Andover MA 01845 AFFORDING c�ovERAc� NAtc s INSURED UMRERA:Farrtr Famil Casual Insurance Com a HRH ConsbuctiorT KWRERB 80 Campbell Road nasi ftm f!: INSURER D- North Andover MA 01845 INSURERE- COVERAGESCERTIFICATE NUMBER DaIR> F: EA THIS tS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED gE!_OW HAVE BEEN ISSUED TO THE INSURED NAMREVISIED ON NUMB FOR THE POLICY PERIOD CERTI T@_ NOTWlTHSTANOING ANY REQUIREMENT,TERM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY eE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE T13ttJIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS n'PEOFtN.sURANCE MF505?EFF POUCYErIP LUMs-TY POUCYNUMBgt uMlrs X COMMERCuu-GENERALUmLrryAm' EACH Es 171 000000 CLAIM-MADEI OCCUR PREMISES ooaurenoe S 50 000 A 2001X0726 MED EXP(A"y O1B�") s 5000 11/2012011 11120!2012 PaM0NALSAovINJURY sIncluded GENIAGGREGATEUMITAPPUESPER GEt1ERALAMREGATE S 2,000,000 X RC1' m OC PROCUTS-COMP/OPAGS000 000 AIriOMOBILE LIABILITYS ANYAUTO 17In. SNGLEUMrr ALLOWNEO S1,000,000 USCF SCHEDULED LY INJURY(PerP�) $ A X HIREoaUTOS X A WNED 200104287-4A 03/16/2011 03/16/2012 sao�Y INJURY lPeraardeny S 0' PPROFE�RTY[1AMAGE S X UMBRELLA LIAB OCCUR S A Lug CLNnES MADE 2007 E1169 EACtI �ce s 1 000 000 1211412011 12!14/2012 q� DED REreMoNs is 1.000,044 WORKBMCompauSgnaN LIABILITY A, ANYPRMOtBPR1N�T!ARTDVi1V_E.Y/NOFIRCeWC A S ❑ N I A 200SM827 E L EAcri ACCIDH3F Ul m yesdescribeundw 12/0712011 1210712012 $500-000 EL.DISEASE-EA EMPLO S 500 .,000 EL DISEASE-POUCY UMM $5,0 _ I __.0(I0 I I DESCRWMN OF C"'EM rONS/LOCA'nONSI VEMCLm(Atffich ACORD ten,Add t,Ives!ria �t�V mac space is Operators by named insured .eaulred) CERTIFICATE HOLDER CANCELLATION HRH Construction SHOULD ANY OF THE ABOVE 80 Campbell Road DESCRIBED POLICIES BE CANCELLED BEFORE THE RDANC7111T THE F. NOTICE WILL BE DELIVERED IN ACCORDANCE Wliti THE CY OVISIONS. North Andover MA 01845 ArrrtwR® , ,ACORD 25(2010f05) 01988-201 ACORD CORPORATION. All rights reserved; The ACORD name and logo are reglshwed marks of ACORD ,s Massachusetts -Department o; ?uoilc Safe;; Board Of BuildingRegulations 9 ons and Standards (nn.tructinn Supcn i.401. License:C"57754 WELL D HOPE 80 CAMPBELL RD - N ANDOVE#MA 01845 = Commissioner =<P:-r-1`; n 03/04/2014 _..-_._................. l e .a�iln�oinvca U a. -- 1 l.Vl/�JJ!/CI1.!lJC Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: .101730 Type: Office of Consumer Affairs and Business Regulation xpiration: 6/29/201.4..-. Private Corporatict- 10 Park Plaza-Suite 5170 HRH CONSTRUCTION INC: Boston,MA 02116 r William Hope 80 CAMPBELL RD NORTH ANDOVER,MA 01845 Undersecretary 4—alid without Miature n i natio 1a'gro Conner a Q i THE POWER OF ACTION non U j Services Group This service is brought to you through su port from your local utility This Agreement is made by and among and Conservation Services Group(CSG) ALtn RCS David Leibowitz 50'Washington Street, Suite 3000_` 217 Winter St Westborough,MA.01581 North Andover,MA'01845-1307 Rei.!No. 120837 • Custotner ID:C00000092151 Contract Ek 20120831 WORK Federal ID No.222457170: Site FHD-500002082124 4%ai1 completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED v r ^^✓ _ _ .w _ - 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 the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: • Description Quantity Location Attic Floor Open Blow Cellulase 6` 668 living Space $895:12 Damming 120 N/A $222.00 Propavent 2'or 4' 54 Attic $189.00 Vent bath fan to roof flapper 2 Attic $236.00 Sub Total: $1,542.12 Energy Efficiency Incentive $1,156.59 Net Sales Tax After Incentive $0.00 ® Total $385.53 • k w • Printed:=1/2012 Page 1 of 1 IL PAYMENT Customer agrees to pay,Contractor for the Work,the Customer Share of the Contract Price as follows: ® Payment#1::$ 1 a<. :�: f as a Deposit payable to CSG upon signing the Contract(not to exceed U3 of the total retail costs or actual costs of special orders,whichgver is greater).Mail check&contract to CSG,:Attn:RCS,50 Washington St,Ste.3000,Westborough,,MA 01581. Final Payment:S. ,I 7, G as the final payable pendent lnstallatiorf Contractor {� payment for the Work shall be due and a able to the Inde ("lIC")upon satisfactory completion 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 ge purchased and/or prior incentive utilization.Changes to individual line items and/or previous The Utility Incentive Share is dependent upon the packa incentives may increase or decrease the size of the Utility Incentive Share. You may cancel 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 ay following the signing of this agreement. ` ®O NOT S C THERE ARE Y BANK SPACES. Custom r ignature ate Indicate your selected IIC here,if applicable �oF) Initial here if you want Y,//�/ !� /r ^ the Program to assign a - v /3- l — i 6 a� Particaoatm2 Contractor LnaTionalgn THE POWER OF ACTION Conser aY Services Group This service is brought to you through support from your local utility This Agreement is made by and among - 1 _.::......._...... .. ._.. _., :.::: ::. .. :..:::and Conservation Serv'lces Group(CSG) Attn:RCS David Lel'bowitz 50 Washington Street,Shite 3000 Westborou -*MA 01581 217 Winter St . Reg. .. o Aiiover,3V 61U54307::. ::.:: 0::1.20837 e Cast®mer ID: 0000009215i Contract ID:20120831 ASEAL. Federal ID No.2224.57170 f ® Site I D:SOM208212A (Mail completed contract to address above) _........._............ 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perforin 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 the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: a Description Quantity Location Attic Stair Cover Thermal Barrier with carpentry._..__u—_..___.......____ Living Oe ....�.—_.. $237.65 Perform Air Sealing at Estimated 625 CFM50 Per Hour 6 Living Space _.._........_..._.�.-------...__.___ $462.00_ Door Sweep___________._ ___....__ 9 NIA $21.97 Exterior Door Weather _ StriPPm9._._..---- ............ -—..........--.....- .. 1 NIA ----_....._...__----..._.__....._..._ .__.._.__._._.....-_..._._....__..---5'20--- Sub Total: $746.02 Energy Efficiency incentive $746.02 Net Sales Tax After incentive 50.00 Total $0.00 a iR m o Printed:8/31/1012 Page I of 1 11. PAYMENT Customer agrees to pay&ntractor for the Work,the Customer Share of the Contract Price as follows: ® Payment#1:$ as a Deposit payable to CSG upon signing the Contract(not to exceed W of the total retail costs or actual costs of special orders,whichever is greater).Mail check&contract to CSG,Atilt:BCS,50 Washington St.,Ste.3000,Westborough,MA 01581. Final Payment-$_G as the final payment for the Work shall be dee and payable to the Independent Installation Contractor ("IIC")upon satisfactory completion 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 The Utility Incentive Share 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. You may cancel 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 y f Ilowi g e signing of this agreement. DO NOT C IF TH AWANBNK SPACES.,��f� Ca.✓SJnlJ�/B� (oe) Custom Signature Indicate your selected IIC here,if applicable Initial here if you want J //��� oI�f�{��- / the Program to assign a _ ���— ���!' /' ca— G�CLLr Participating Contractor �7i f �7 1a Q ruse save PERMIT AUTHORIZATION FORM ��� � dam'/T7i owner of the property located at: (Owners Name,printed) (Property Street Address) (Cityfrown) 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. Owners Signature 1,12— 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 Rev.12132011