HomeMy WebLinkAboutBuilding Permit #952-15 - 250 MIDDLESEX STREET 5/21/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date issued: " ' ZA �—
ANT: Applicant must complete all items on this
LOCATION 50
Print
PROPERTY
Print 100 Year Structure igi.
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
Orr
6 0 -
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
[I Addition
El Alteration
0 One family
El Two or more family
No. of units:
0 Industrial
El Commercial
0 Repair, replacement
El Demolition
0 Assessory Bldg
Other 'Tq0v4 �-i'o n
El Others:
-0
,F Rri
7
DESCRIPTION OF WORK TO BE PERFORMED:
5eaq 1-1`442 )9 ;-C-- V ta )4- il Ili 4
Identification - Please Type or Print Clearly
OWNER: Name: ho,%Aty io n uic Phone: f>
7—
Address: Ad re 5,fl
Contractor Name: t -f V- ly Phone: �?tFL %to
E Mail:
Address: �5 7— e -
Supervisor's Construction License: C5,51 /bG of�? Exp.. Date:
Home Improvement License: Exp. Date: 0>106-IdOI&
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.'$1200 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $— 50
CheckNo.: a�/k Receipt No.: a&b /
NOTE: Persons" con'tr—acting with unregistered contractors do not have access to the guaranlyfund
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
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
16 Copy of Contract
4� 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
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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4� Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
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
Doe: ]Building Permit Revised 2014
Plans Subrnitted 11 Plans Waived 11 Certified Plot Plan 0 Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer.
Tanning[Mas s age/13 o dy Alt
Swimming Pools El
wen El
Tobacco Sales El
Food Packaging/Sales 11
Private (septic tank, etc. El
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature'
Reviewed on Signature
Reviewed on
Sianature
qg Board of Appeals: Variance, Petition No: 7oning Decisionfreceipt submitted yes
A_,
Planning Board Decision:
Comments -
Conservation Decision: Comments
Water & Sewer ConneGfion
]DPW Town Engineer: Signature:
LOcatea ;Jd4 USgOOa zjtreet
MRS
6nT:
ER'N, TT,
M1
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
U Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
we
Location,15? 1!tJ44��
No. Datei
Check 4t
28811
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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Federal 11) 9
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division ofThicisch Engineering CT Contractor Registration No
60 Shawmut Unit #2, Canton, MA 02021
CONTRACT
339-502-6335 PAX 339 -502 -&MS
Page 1
R I S E PROGRAM
TM CONTRWr tS EMERED ORD BETWEM FUSE
CMA -HES ENWOMR04 AM VW CUSTOMER FOR WORK AS
ENCINEERINC; DUMBED BELM
CUSTOUT-A PHONE DAU cueff 2 V10"OrMER
Nancy Dowe (978)685-5772 0 1/29f201 5 409689
00002
Serom STRMT BRI= STRMT
250 Middlesex Street 250 Middlesex Street
SERVICE CffY.STAWnP SUM CIM STAV- ZIP
North Andover, MA 0 1845 North Andover, MA 01845
Ir E C I g V F -EE
Mnn
JOB DESCRIPTION
I
n
n
BARRIER. A Blower Door Test ivill not be conducted at your home, due to the prcscnsc ofasbesios.
Lu1j
$0.01
AIR SEALING: Provide labor and materials to scal areas ofyour home againstwastcK excess air leakage. This work wijI be
performed in concert with the use of special tools and diagnostic tests to assure that your homewill be left with a health a4 -
air exchange and indoor air quality. Materials to be used to scal your home can include caulks, foams, weatherstripping- and oth
products. Primary areas for scaling include air leakage to attics, basements, attached garages and other unheated areas (windows are
not generally addressed). (7),Avrking hours.
At the completion or the weatherization work, and at no additional cost to the homeowner, a final blo%vcr door and/or combustion
safL,ty analysis will be conducted by the sub-contructorto cum the safety ofthc indoor air quality.
$525.00
DAMMING: Provide labor and materials to install a 12" layer ofR-38 unfaced fiberglass haft to (40) square feet far damming
purposes -
$82.00
ATTIC FLAT. Provide labor and materials to install a 10" layer ofR-35 Class I Cellulose added to (416) square feet ofopen attic
space-
S592AO
SLOPES: Provide labor and materials to install a 6" layer ofR-21 Class I Cellulose added to (128) square feet orsiopc am
WIum-cr possible baffles will be installed to the entire length ofeach bay to maintain ventilation space.
$238.09
ATTIC ACCESS: Provide labor and materials to insulate the back of (1) attic hatch with 2" rigid Thcrmax board. Wcatherstrip the
perimeter.
S60.00
VENTILATION: Provide labor and materials to install (I)insulated exhaust hose vAth gable wall mounted flapper vent to exhaust
existing bathroom fim(s).
$118.75
VENTILATION: PTovidc labor and materials to install ventilation chutes in (32) rafter bays to maintain air flow.
$64.00
BASEMENT CEILING: Provide labor and materials to install (112) linear feet orR-19 unlaced fiberglass insulation to the perimeter
ofthe basement ceiling at the house sill.
$196.00
BASEMENT DOOR: Provide labor and materials to insulate the back of the basement door leading to the bulk -bead with 2' rigid
board that meets the sections R-316.5.4 and 3 16.6 requirements of building code. Sea] all edges and scarns with FSK tape.
$72.22
WHOLE HOUSE FAN: Provide labor and materials to fabricate and install a rigid foam insulating cover for the whole house fan.
S209.21
RISE Engineering will apply all applicable, eligible incentives to this contracL You'will only be billed the Net amount. Currently,
for eligible measures, Columbia Gas offers 75% incentive, not to exceed S2,000 per calendar Inear, and an incentive of I 000K for the
Air Sealing measures up to $900.
Federal M #
RISE Engineering R! Contractor Reffistration No
MA Conbzctor Registration No
A division of7lictsch Engineering CT Contractor Registration No
60 Shawmut Unit #2, Canton, MA OMI CONTRACT
339 -502 -WS FAX339-92-6MS
Page 2
RI S E PROGRAM TIRSCONTRACTMENTEREDNTOBETINEENRIM
CMA -HES ENWIEER04ANDINECUSTOMM FORWORICAS
ENGINEERING DESCRIMBEIM
CUSTOMER MORE DATE CLIENTS VOORKORDER
Nancy Dowe (978)685-5772 01/29/2015 409689 00002
s8MCE SUME. B�Ijujmkwa
250 Middlesex Street 250 Middlesex Street
SERVICE CITY STATEZW BB.L= CITY. STATF, ZIP
North Andover, MA 0 1845 North Andover, MA 0 1845
JOB DESCRIPTION
For the sahty and health oryour homes indoor air quality, we will be conducting a blower door diagnostic orthe available air flow in
your home both before the work is begun, and after the weatherization work is complete. We will also conduct a full assessment of
the combustion safety oryour heating system and water heater. 11fis has a value of$90 and is at no cost to you. Total allowable
weathefization. incentive is $2,990.
$90.00
u v k,
FEB 4 ('_ U -D
Total: $2,237.66
Program Incentive: $1,831.99
Customer Total: $406.67
VWE AGRM RSUBy To FUMM SER=ES CoMpLM IN ACCORDMCE WrM AWVE SpecIFICATIONS. MR.ME SUN OF
'Four Hundred Five & 671100 Dollars $405.67
UPON FINALOMPECTfONANDAPPROVAL By ME ENGINEERING. CUSTOMAGRM TO RMTAUMM DIJE NRML WTERESTOF 1%WXL BE CHARGEDMONYMYONANY
UWMBALANMAFrM30DAMSMIMEMERMMWOWAWWOMATMCM GUARANYMS�RMTSOFRECMION, romw�
100 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
CUSMER ACCE51
NOTE.' TWS CONTRACT MAY BE VOTHDRAWN BY US IF NOT EMCUTED V� DATE OF ACCBITA14M
ACCGIFANCE OF CONTRACT -THE ABOVE PRICMSPECMICATIONS AND COMMONS ARE
30 SATMFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORRED TO DO THE WOW
DAM AS SPEOMM PAYMENT WML BE MADE AS OUTLINED ABOVE
T
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
rcycy lzsp -
,K
Address)
XJO 1-141 4 ki 19,-7,ro / Ma - a "
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.
Owner's
The Coninionivealm of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washing
ton Street
% Boston, MA 02111
ivivittinassgovIdid
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (BLisiness/Or�panizatiorLtindividual):
Address: r,
Phone #: Q 7
Are you an employer? Check the appropriate
box:
1. Z I am a employer with —7 .
4- C] I am a general contractor and I
employees (MI andior part-time).*
have hired the sub -contractors
2 C3
- 1 am a sole proprietor or partner-
listed on the attached- sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have xvorkzers�
[No -workers' comp. insurance
comp. insurance.*.
required.]
S. We are a corporation and its
3- 0 1 am a homeowner doing all work
officers have exercised their
myself. [NO workers- comp.
right of exemption per MGL
insurance required.)
c- 152- § 1(4). and we have no
employees. [Noworkers�
-A 1
comp. insurance required. I
ef S --
Type of project (required):
6. E] \-ew construction
7. n Remodeling
8. 0 Demolition
9. n Building addition
10.0 Electrical repairs or additions
I Ln plumbing repairs or additions
12-[] Roof repairs
.3.N -Other 4 �1441
- TA!L
*Any applicant that checks box:i I must also fill out die section below showing their workers- compensation policv infortnation
4 - - -
I lomemmers whO submit this affidavit indicatina thcv are doine all work- at -
�Contractors that check this box id then hire outside contractors must submit a new affidavit indicating such.
. must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees- ir the sub -contractors have emplovees- they must provide their workers' conip. policy number.
I am an e1RP10Ter that ispropidiEng workers'compens,714011 insurancefor mg- eniployee.L Below istliepoligandjob sire
information.
Insurance Comparty'Narriv
Policy 41 or Self -ins. Lic. ft: PC LAIC— 50r—eq v S— Expiration Date:
Job Site Address- City/State/Zip-.
Attach a COPY Of the workers' compensation policy declaration page (showing the POI!cY.number and expiration date).
Failure to secure coverape as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1 1500-00 and/or one-year impnisonment. as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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.
I do hereby cerdfi- tinder the pains andpenaldes ofperimy that the hiformation provided above is trite and correct
Qffidaluseazr�r. Do not wrile inthis area, [a be COHIPletedby city ortoum official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of licalilb 2. Buildina Department 3. City/Toll-ri Clerk- 4. Electrical Inspector i. Plumbing Inspector
6. Other
Contact Person: P h o n e -fur:
ACbRbP CERTIFICATE OF UABILITY INSURANCE
DATEMMIDDIlf"
1 0110612015
THIS CERTIFICATE 18 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. certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUSROGATION IS WAIVED, suFj-9ct to
the terms and conditions of tha policy, cerlain policies may require an endorsement A Statement on this ceMcde does not confer rights to the
cartilicals holder In lieu of such endorsement(s).
PRODUCER
Automatic Data Processing Insurance Agency, Inc.
I Adp Boulevard
Roseland, NJ 07068
CONTAUT
NAM
No:
POLICY EKP
INSUMP)AFFORDINGCOVOME NAICS
VMNERA'. NorGMDlrmnnc* Company 31470
INSURED POLAR BEAR INSULATION CO INC
51 S CANAL ST
PO Box no
Lawrence, MA (KN3
VISUFMB:
RISUratc:
INSURERD:
INSUREIIE:
RGURERF: .......
COVERAGES CERTIFICATE NUMBER: 295670 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 18 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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CPLUMBIA GAS
195 FRANCIS STREET
Cranston. R1 029`10
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
AMORIZEDREPRESENTATM
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on Massachusetts 02116
Bostc , Registra#on
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Ilome ImPrOv on: 102726
Regidmtl
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Type- Tr# 252249
n* 7WO16
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LATION CO.
pOLAR BEAR INSU
Vincent LeBlanc
p.O. BC0(958
n for change
ANDOVER, MA 018`10 return card- mark re"so
date Addressas eat [3 Lost Card
Up —1 Employm
Renewal -�-j
Address
ops -CAI a 50M44M4.Gj0I2I6
Massachusetts -'Department of Public SafetY
Board of Building Regulations and Standards
Construction supervisor Specialt-Y t -17-A
License: C!AL-106017
pETER A LEBLANC
2 EAST ME jjjjEET. P
plaistow NH 0386
Expiration
514— 0412812018
commissioner