HomeMy WebLinkAboutBuilding Permit #384-2017 - 29 ANNE ROAD 10/11/2016 BUILDING PERMIT N°DT" ti
TOWN OF NORTH ANDOVER oa y� 46 0
APPLICATION FOR PLAN EXAMINATION
- h
Permit No#: Date Received /0
�SSACHU`'fc�,(
Date Issued: /0 - t 1 ' 9-01 So
IMPORTANT: Applicant must complete all items on this page
LOCATION Za 6-(\n(LQJ
Print
PROPERTY OWNER 0.f t-\-(j--
Print
1-CrPrint 100 Year Structure yes no
MAP '� PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Reside tial Non- Residential
❑ New Building One family
❑ Addition ❑ Two or more family ❑ Industrial
Iter tion No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PER ORMED:
( t LOCA tl
r
Identification- Please Type or Print Clearly
OWNER: Name: tri UJ&Jr r\Cir- Phone: 11
Address: tR tMne `
Contractor Name: V&)VI- Phone: Gi�, b 3slo • N �33
Email: Lbrn
Addres q It
Supervisor's Construction License: [0IS191 Exp. Date:
Home Improvement License: 0-3 Exp. Date:
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: $ G
Check No.: aqe*0/ Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location fi mye P, b
No. LI- G 17 Date +o • '1
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
r� .
Check# a �49 !,�
Building Inspector
v a J
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
rIDMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wafter & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
t�Locatedlattfl2}43[IVlainkESt�eet ®FIRE RTmp m
n te y.es _Q- ATono
Fire Department,si9,n-@t mate
COMMENTrS, _ _
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 Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
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
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
;rt 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)
i6 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 q
Town of ? _ 6 ndover
0
No. _ loll 4t -
�o h ver, Mass, /0 • /t 0/ $0
CONIC Nl WKK ��'
RATED
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT ,, ,,,,, ,,, ,,,,, ,,,,,, BUILDING INSPECTOR
.
has permission to erect .......................... buildings on ..�:�..... ................................ Foundation14�1!IV�..... ....�
to be occupied as Q .........5 �♦ �1.cut.....0.ftfir.......'........... Rough
1 .. .. Chimney n y
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 CON STRUCTIO START 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.
• RISE Enemmift Rl I I P I A Raghdra a No 086
(W1 C osdraadorReg�rdian No 110x79
A dM"artThlei:e9 Ln
RISE Campu7AWmas,CiyDA NN
��NW 91•
CONTRACT
F1t09 ,
PRWRAM
(� CSHA-lis
0 MRS MORIN
Men watael' �" t978}Z58-7885 07111R016 423706 04004
IUJII29 Arm Roel 29 Acne Road
-� ULM .
North Andover,MA 01 , ! North Andover,MA 01845
^� JOB DESCRIPTION
HEALTH&SAFETY:waStbui ldw work am mt proceed aulft the modem draft ism a tinsel.
son
AIR SEALDIM Provide tabes and mataiads seal atheas of yora home agatiost fid.c=m air kelmga. This work win be
I f- , to coaoat with dw on of speoW ecots and etc Was to awe that Your borne win be kft with a heats M Wd of
air e�oelhen fte aad iaQoor air gnality.Mala 6o be used to seat yarn`hosaa cea I eaatks.tbams eat pmdacet RWW
meas for salt tt dub alr icalmp to allies,bmmeM Smad ed 8roe p and other unhemed meas(wtadaws aha oat Dow*
adbem&)Thls win segaim(a)w horns.A redaatam to cubic ti!+ot per mk=(cfa)of air to aA will occam bat the aaaai
nomberofo6aisnotparsaW .
At tho camplaton of tx waadwhation whk and at no aditmd cost to do b meawaw.a Pow bower door mtd/or axaboda
satiny am d3 l k will be cortkmd by tae sadfcormracw to ahs, the satiety of the indoor airgtmlitSr.
Moo
AIR SEALM ADDER: (4)ww ft boars.
$moll
DAM►D40:Phalle ldw and mmbb to ts"a Ir WW of R-38 an6aoed Bbaq$ass balls to(60)sgame feet fadamnahm
1
5123.00
ATTIC FLAT:Pravide kbor and mawds to b mn a 6"layer cf R,21 Class 1 Cadtadm added to(106!0 sgame kat of open att{c
SPOOL
s1.mis
KNEEWALLS:PWA&Tabor and awls to kmW r FSK faced semi-rigid m atags board irhsrrladon to(220)sgasee kat of
MOD
AMC ACCESS:Psaridahim mhdmumWsuim*fttbelsaekof(ga kbat*vftrd&Tba mbnsd.w att
pedmaea:
$moo
ATTIC ACOS:Pwvida tabor and nmm&b is h—d—dhe bask ofdw attic door wild r rigid Tttanuor board sad ad the door's
edge with b`e`l`ks adr keicaga.
573.91
VENTIt.AUON-.Provide idw and m*d&is WSW vaWbdm chanes in(26)rafter bays to mhofm air Saar.
MOD
WCIsNTM RISE Eat wID apply an epplimbk.elf8ft ioamives m tMia oonnea. Y=wnl only be b91ed the Met smouzL
Ceermty.ftcGV'&measares.Cls!=Gas offin saiaamiveof 7596`aei a ehteeed s2,o0o per Year.and as hmaaiva
of IWA fir`the Air Soft maaatmos up to toe Am 5680 asst an add dmd 5340 ifsauiep arab by the mtdkw.
FOR A Llbil'l'ED TR*M Cohobb0as wnl also out am $100 iaoeat v towards tic wcmitaihdoa work owlbted to this
peoplilt.This speetal Surmoer laoadva is avah7abie to hameowna�who bave had their Catmabla(las borne ea W at O betltmJ*
31.2016 A sipaed proposal flu moo oards to be shed by Aug o 8.1016 ad wait mast be oahmpteted by Septasmbos
RISE Enowerfug No else
A divWaa of 711lduh Egpn tag MA Coatradw ltagestratloa!to 1�eer8
RISE.: Ad&vwChy.MA W
°Q"M1NGCONTRACT
all-M� FAX iPli-123.1134
Page 2
PROGRAM sa a, otaweearsaoras�a
CMA-w
NEW
Megan Wainer (978)258.788S 07/11=6 423706 00004
Ismarlow Now WMENT--
29 Anne Road 29 Anne Road
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
30,2016.
Fac the satiety veld beach ofyow hoaae 1 bWw air quit we wt71 be orsdae- a wowe door diagnostic ofthe arsildMe as Bow in
yow hoax both beface the work is beim,orad rAer the wamberhadw work is We will W o ooadna a fall sof
dw comb sdf%7 ofyomr heating system sad wale 1199M.This has avelve afS90 aad is stao am to yoa.The m=fmm
sRawable inarlive tiHr aU bscht�tg air seaiiag,is E3,2t0
The Permit will be sc=ed by rho inwda N roc,at no adMaud cost it Is the batmownut req sibft to dose vet dt's
im*by t hY at the aimpletion ofthts work.
MOD
Tafel: $3.869.78
Program buwntive: $3.082.34
Customer Tafel: $867AS
waAellMMMIDRtorlmt BE -eotl4LEMMaaCCINMc@WMABaYE =ts.QaeMfeavaaR
*"Five Hundred Ftity-Seven S 46HOO Oogars $WAS
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m�+r�m° f°�ouam" i�m+�owc
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OWNER AUTHORIZATION FORM
i, :Q!aa vl Wa e e e-'
(QMWS Name)
oww of the property bcoWd at
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ftp" ) __.
Xr . -kAtOauew, 14%q ,
Pop" )
hemby a ftrims
(Submtaator}
an auhcrimed NA=nh ctor for RISE Engem,to act on my behalf to obtain a biMrig
permit aced to perform wank on my pmp".
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ACORO CERTIFICATE OF LIABILITY INSURANCE DA tpnvoomYr)
oer12no16
7H18 CER11flCATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLAER.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: H the arURoate holder le an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVBD,i ub)ea to
the terms and cendtdons of the policy,artaln policies may require an endorsement.A statement on this certificate does not confer rights to the
cortlBcats holder In lieu of such endorse_me s.
DU
PROcw Kai n Do—
MARTIN
o hMARTIN J.CLAYTON INSURANCE AGENCY INC 413 53e o6oa
RIl5414er h de n. In
1849 NORTHAMPTON ST.,RTE 5 m ao e N
HOLYOKE MA 01041 IN ACADIA INS CO NAM e
0
INSURED INe o:
GAUTHIER INSULATION INC i
RD
PO BOX 344
IPSWICH MA 01838
COVERAGESCEIMPIR
ATE NUMBER 75793 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.
Tna a«euRArice LRErs
c orrrRcltl oeNeRAI LNaR1TY
FACHOCCIJIVIV411 It
CLAIMeMME�OCCUR ~��-
MHD ixJ+�arse WHenl l
NIA PERSONAL t ADV I"PrY IS
OENL AOORSQATE PPS
APPLIES PeR: OEN[RAL AOORSOATe S
POLICY a JECT F1 LOC PR MPIOF A00 !
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AVTONOBULWIILIT' S
�ANYAUTOI` am INJURY(Ar person) S
AU103
WE waU N!D NIA, QOOILY INJURY IF."d.0 t
XNItDAUTOa AUTO. _^ t
1
UAIaRa1.LALW CUR MCHOCCURRENC11
aRCE0.t LIAa M—A.4•MADE N/A AGGREGATEt
AND MPLCOMPENiArUT
AND WPIOYtM'WW1.RY VIM x
A pµpFFFY°ICEwuE�Neaa a e> LuoeoiEu
WA WA WA MAARP300327 10/3012015 1O/3072016LeA XA CIDENT ! 600000
(Yeedetory MNHI ,I.OK 5•EA eMPLDYE 600000
N Women
EASfi•POLICY OMIT 600 000
N/A
014CRVTION Of 0PBRAT14M I LOCA77083 IV/N4I.19(ACORD 401,Addk*ft lt"m a SeMWN,mry ee Maned Rmenfpeu h m"Imd)
WOrkore'Compenaetlon benefits will be paid to Massachusea employees only.Pursuant to Endorsement WC 20 03 06 S.no authorization Is given to pay
claims for bandte to amplDyese In States Other then Massachusetts If the insured hires,or has hired those employees outside of Massachusetts.
This certificets of Insurance%Kowa the policy In fora on the data that this 000cala was Issued(unless the expiration dote On the above policy precedes the
IMue lots of tNe anifleata of insurance). The etatut M rids covempe an be monitored dally by aecesaing the Proal of Coverage-Coverage Verification i
&Ntrah coot at www.maga.gwrtwdtworkers.compensetiorAnvestlgctbnd.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1200 Osgood Street
AUTHONWREPAMNTATNE
North Andover MA 01845 `e='"" (. C
Dankt M.Crq�Jey,CPCU,Vice PreSldent-Residual Market-WCRISMA
01988.2014 ACORD CORPORATION,All rights reserved.
ACORD 25(2014101) The^CORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
rc
� (?wee of Itrttestigatinns
I Congress Street,Suite 100
Aq
Boston,,WA 02114-2017
www.mass.l;orldia
«=orkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibi1
Name($usinc54+OrL-anit:ttit)n`indic iduall:
Address: 00 13 o x 114
CitVIState!Zip: W i t $ Phontr
Are you an employer"Check the appropriate box: Type of project(required):
s. am a generacontractor and I
1.2 l am a employer ta'tth�_ � t l '
6.
cropfoyccs(full and or part-time).* have hired the sub-contactors [� tie« construction
t.[ 1am a +tate proprietor or partner- listed on the attached shut. Remodeling
These 4-ub-contractors ha,.e
ship and have no cmplo�'er:� S. C]Demolition
Ytrl ing tete rex in my ra.1'arit}'. emplo�et�and have workers'
\• i
9. 0 Building addition
(No worker,;*comp_insurance camp.insurance.-
requircxl.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
. 1 am a homeowner doing all work o iccrs ha`+e exerri�d there 1[.C)Plumbing repairs or additions
myself. (tit)workers' romp. right orexemption per MGL 12,113 Roof repairs
insurance required.] r c. 152,�1(4).and tite ha%e no 13.0 tither
employees. (No worlers'
comp. inscu-an.c-e required.]
':4nF aggttc3n:that:hccws tKm=t most a o Fill out aw txcu n br"shcutrg Kett wotkers'compcnsstttxt Whet'tstb mtlon.
Homco nm who submit this a€WA%it tndtcaxir-Thr are--doing alt AXWk and tt•en a new of emit mdirstiny wrh.
°Ctlrtimnors that check-tats box r.ur a..achce;m ask:ttttt^at shmi aht3utt.L the natrtr Ut t s s tbg tstt scans sttd st to%ite:her or tin rh,6C c-nstttcs h.3Nc
c.ttgtoym. tf the rmz,prx Icer thee, uvt rt, evn:F.pubc,.nwnlcr.
1 um an employer that is providing xworkcrs'compensation insurance for mt`empkvres. Below is the policy andjob site
information.
Insurance Company Name: a. It'') f o_r,, it t U;zC —
Policy=or Self-itis, Lic, P% MA
PS f Q_ t�td�r 2,� Expiration Date:1 r0�_1_3 CA�'`14 ,^
Job Site Address: 2– �( I yo t City Statc,Zip: 'V"�y,\ W v of 016'
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 elf MGL c. 152 can lead to the imposition of criminal penalties o`a
fine up to 51.544.00 and,'or one-year imprison-rent, as well as ci%it penalties in the form o`a S'I0P)FORK ORDER and a line
of up to$250.00 a day against the.violator. He advise l that a cups of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coFeravu 4erttication.
I do hereby certify under the pains and penalties ref perjury that the information provided above is true and correct.
4 11:1 r,,aturc: - Com``"'`- Date_ oI 11 �0
Phone:f:41 3 SU• T1 18 3
Official use only. Do not write in this area,to be completed by city or tower official.
City or Town: Permitll.icense x
Issuing Authorit}.(circle one i:
i.Board of IlEcalth 2.Building Department 3.C.:ityffoun Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: �._ Phone X:
b Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement aictor Registration
Registration: 173410
Type: Individual
Expiration: 10/1/2018 Tr# 291320
KURT GAUTHIER W
KURT GAUTHIER r
119 COUNTY ROAD ��w
IPSWICH, MA 01938 {7 �
Update Address and return card.Mark reason for change.
Address Renewal ® Employment Lost Card
scn1 is 20M-06/11
Office of Consumer Affairs&Business RegulationRegistration valid for individual use only before the
HOME IMPROyEMENT CONTRACTOR expiration date. If found return to:
a Registrati 73410 Type: Office of Consumer Affairs and Business Regulation
Expirati nM:2= 8 Individual
10 Park Plaza-Suite 5170
r Boston,MA 02116
KURT GAUTHIER r
KURT GAUTHIER
119 COUNTY ROAD4 .c" /a-- ( `
M4
h44ssachusetts-Department at Public Safety
Board of Budding Regulations and Standards
!111KIrui tion%UlU r�sior til"c
License;CSSL-102682
KURT IR GAUTHt9R
P.0.8ox 344 q
iryswicb MA 019jt "-
r a =
Expiration
Comnrasiorrer 08/2812017