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HomeMy WebLinkAboutBuilding Permit #666-2016 - 30 AMBERVILLE ROAD 11/30/2015&'q/Ver- D /b - 3 - is Permit NO:WVAF' Date Issued: 0 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this rft LOCATION 1t�3Qr'd►.� iZ Print PROPERTY OWNER C- ar 105 642is a -r) Print MAP MAP NO: 1 PARCEL:�_ZONING DISTRICT: Historic District yes(Qn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 4K One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commerctial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic t1 Well C i Floodplain 11 Wetlands ❑ Watershed District ❑ Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: GA.V- (DS�c �,,i�// a.� Phone: ,3 Address: o /-'tithe.,-Vil�.z N� IZJ � AI�d6Ve !Y/h1 CONTRACTOR Name: 60MID Phone: Address;5?- b f- J&A'I'; Supervisor's Construction License: 67 Z --V6 Exp. Date: Home Improvement License: iZV-/ZJA& Exp. Date: ARCHITECT/ENGINEER Phone:_ Address: Reg. No FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ .3; FEE: $ Check No.:"'5(0--it Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION' — Pnnt 'a\ PROPOSED USE A 4q \O �.d CRATED y OH 1. PROPERTY OWNER Print 100 Year Stfucture yes no MAP PARCEL-.- __ ZONING DISTRICT: _ Historic District yes no 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: El ❑ Other -Demolition El Septic ❑ Well ❑ Floodplai"n ❑ Wetlands [IWatershed' District . 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: AridrPss ARCHITECT/ENGINEER Address: Phone - Reg. No. FEE SCHEDULE: BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/nwrier, Signature of contractor _ . Location ✓" `� +�y � ` � �Pj' No. �/�Date ll�•��.� Check #�, 2748 TOWN OF NORTH ANDOVER. Certificate of Occupancy $ Building/Frame Permit Fee $ "t? `- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ l vs--� Building Inspector 0 Plans Submitted it , ' Plans Waived ❑ Certified Plot Plan ❑ r 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 COMMENTS Reviewed On Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes • Planning Board Decision: Conservation Decision: Comm Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street AFIRE �DOEM OttMENT - Tem0udDumpst0r 01 site IL_©cated:at 1141mi stieet� ''Fire Deparfinent signature/date. __ __,� ___ __ _ 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 NV I tJ ana UA 1 A — (-or aeoartment use ❑ Notified for pickup Call Email f Date Time Contact Name Doc.Building Pcnnit Revised 2014 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 o 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 Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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) 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) Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 ❑ 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 submitted with the building application Doc: Building Permit Revised 2014 < 0 0 U) Mu CA < CD -CL 0 CD 0 CD m N _0 0 0 CL 0 O O v► Q; FD- to i7 C rt o o c m `< m W C' to O N - CD CD = • ca- CL Q U) O 1 p c� CD WCODCD cz CD Cl) Zo CD o-0 ;z z� T. -.*' QO M C/� m m n cQ• U' C7 �. a- :O ti Om sC=D- =� nZ < CL c U2 CD C c0 _— $00 cn < v�� Q <y� o CL�• C N CLC ch N as z CD W _ _ �-1� o �� �� 03 Do cnZ CD ri �"� 0 i rt O CL Ov �co)• = o �• O b cn o CQ CD v `°CD o rt r : t U) WCD z 0a 0 CP O G)rt 7 CD v_ < n CD o :� O � � CL N 3 �p CD rr (f,W - N �+ o c 3 •n m IV v -ZI T S. 2 W o .� S D InA N I T �' N N < N ,O o QUO S m m T N w o W S C m p T R7 n ? 3 7 Z7 O Oti S T c o =3 C Z m m 0 N v "'�. f) 3 T o G. rD W D p T 2 rA rA 10 0 :r Conner atlon Services Group 50 Washington St. Suite 3000 Westborough, MA 01581 CONTRACTOR WORK ORDER Printed: 11/11/2015 WorkOrderld: S14170P30061C332 Contractor Information Customer/Site Details Weatherization Incentive $2,000.00 ESE Carlos Guzman Email: CGUZMANMD@GMAIL.COM Total $ $694.02 Phone (Eve): 718-551-2173 52 Fitzgerald Dr 30 Amberville Rd Phone (Day): 718-551-2173 Jaffrey, NH 03452 North Andover, MA 01845-3375 Site ID: S00050114170 Installed Measures Total $3,740.30 WorkOrder Notes Payments Incentive Payments Air Sealing Incentive Total Installed Measures Weatherization Incentive $2,000.00 Location Description Quantity Unit $ Total $ $694.02 Door Sweep 4 $23.18 $92.72 Exterior Door Weather Stripping 4 $27.59 $110.36 Living Space Perform Air Sealing at Estimated 62.5 CFM50 10 $84.32 $843.20 Damming 134 $2.19 $293.46 Living Space Attic Floor Open Blow Cellulose 7" 924 $1.53 $1,413.72 Living Space Hatch: Thermal Barrier Polyiso 2 inch (Attic) 1 $41.71 $41.71 Attic Propavent 2' or 4' 71 $3.83 $271.93 Living Space Attic Floor Open Blow Cellulose 7" 440 $1.53 $673.20 Installed Measures Total $3,740.30 WorkOrder Notes Payments Incentive Payments Air Sealing Incentive $1,046.28 Weatherization Incentive $2,000.00 Total Incentive Payments $3,046.28 Customer Share Total Customer Share $694.02 Less Deposit Of $231.34 Customer Share Balance (Due Contractor) $462.68 Conservation Services Group - 50 Washington Street Suite 3000 - Westborough, MA 01581 - (508) 836-9500 DocuSign Envelope ID: 5FD306CC-23FC-4101-B8C9-4C6D92A01E13 muss cave 5 wutgs through onergy efficlency PERMIT AUTHORIZATION FORM Carlos Guzman (Owner's Name, printed) 30 Amberville Rd (Property Street Address) 6 PAIR"PICIPATI NG COIR "KZZ:=� , owner of the property located at: North Andover (city) 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. DocuSigned by: x44 09130, oWn l @F1874FE... 10/30/2015 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: SZ 0 Participating Contractor Rev. 12132011 / lllelkr Date For Office Use Only RCS PLANVIEW DIAGRAM Customer: C OV',Sh %0(V% Home Phone. -719 -SS` -QA-73 /� Address: 3o / ,% er vt a Work Phone: Town: NO 1-V% - A hcA cjj e-4-- Cell Phone: - Any l(mltatloas for access by large truck? No Yes if yes. describe: Any specific directions or landmarks? No ^ Yes If yes. describe: Site ID; EQ j 1 I+t •7C) Energy Specialist:�tN �'1 U1-�� x-33 '� Reviewed by: A tJa•ti.,..,. h -- 131- X pr -of O►Vev%v - 71 A ir' Sec k I'" dour S N CA),\, 5 o o , o o d 9E C) ® o cR)/ I ao1. ag ERV 1 a I l O o �' o _ 000 O 8 1l a rd o� For Office Use Only Bushes Ladder _ Neighbor Proximity Pocket.Doors Insert. Radiators Fence(s) Existing Conditions X = Access Q = vents Note Inside Square R= Roof S = Soffit G = Gable RV = Ridge Vent CS = Continuous Soffit CDE = Continuous Drip Edge T = Triangle Install O = New Access Note in Circle C = Ceiling W = Wall S = Sheathing Temp Unless Noted Otherwise Q = Vents Note in Triangle R = 8" Roof S = Soffit G = Gable M = 12" Mushroom For Access 2200-10-1/15 The Cotrtnronwealth of Massachusetts Department of Industrial Accidents i� 1 Congress Street, Satite 100 Boston, MA 02114-2017 f ivits.rw. ntass.gov/ditr 1 milkers' (2ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. 1`0 f. E hiLF;il Wli'II 7'l4l I'EilM1tl`f"1'I �G At' 1'FiOItI E'1 . Applicant Information Please Print Legibly Name (liustnessl(rr anirzufott'Indtwidunl): ESE INC Address- 52 Fitzgerald Dr Clty/state/zlp: Jaffrey, NH 03452 Phone g- 603-532-6346 Are You an emplorler? Check the appropriair ho%: I ❑✓ I am it a ntpluw er %k fill 5 _`employees (Full and/or part-time) ? I atn it axle propncior m partnership and have noemptovices working fix me in arw copacitx INo %%orkers' conip insurance a'eyuired I i ® 1 am if homeo%%ner doing all wyork nth.Nell' [No workers- comp insurance requured 1 z I ant a homeowner anti will he hiring contractors to conduct all )Durk on ntw propen% I v%til ensure that all contractors enl',cr have workers' compensation utsurance or :tie sale propr,ctors yvitlt it,, entlwlovccs I atn a gencratcontnictoi wid I hawe lorcd the stili-:anuacturs listed on the attached sheet 17use sub -contractors have eniplowres and have workerscomp insurance U ® NN'c ;tie a corpiation and its ol'iicers have exercised )hen' right ul exemption per ,N161 - c 152, � Iiat. and we have no cmplovecs 1114o "orkers' camp insurance required I Type of project Ireyuired) 7 Neyw Cortstt' ICtloll 8 � Rrmtulehn ti � L)enu?liuon 1(i ❑ Building, addition I 1 F-1 Electrical r'epanrs or addition, 12 ❑ I'Iutnhut1i rep-rs oi- : dJtCtitns I ; Roof I– pan's I 1 DUthcr Insulation^_- :Anv applicant that checks bux f:I nntst also fill out the section bekm showing their wNo6ctS cumprnaauon puhcw ,ntormauon I knttcuwiers who submit this trl'itdavtt indicating Chet aredump all work and then Ivry outside cuntrarnxi roust >uhnvt ., neww :d'tiJ.rw n md,r:wng such :C:oniniciors that check this box must attached an aJditional sheet showing the mine til tale soh-c«ntractar. and state whether or not those entwe, hnr e employee:. I ['the sub -contractors have enplovcC.N. they must pruvtale Own )%orkers' comp pal ley number t am an enrplayer t/ntt is prat=idilrg rvurkerti'' COlr7pelrJ'(rQE/rr tlLS'tlrttlrCe jrOr Irtr' t'rrrplorets. Beloit, is the polity and juh site ltt�t7rinallOtt. lnsurancC Company Nance National Liability & Fire Insurance Company Policy 4 01- Self -ills 1.Ic it V9WC629429 l:xptratxm I?atC 3/8/2016 Job Site Address. � (/mit Villi —Ct1N %5l tiei!_t!7 / _ _ � _ / � � Attach a copy of the workers' compensation poked declaration page (showing the Frolic) number and expiration Elate 1. Failure to secure covcrangc as requn-ed cinder MGL c 152. §25A is a cruntnal vinlatton pLill lshahle 11\.'a fine till to b 1., 100 fill and/oi- one -,.-car iniprisonmeni. as vNell its civil penahies fit tine fonts 01 "1 ST(A) W(WK ()RDI- R and a fine of Lill tit Y_Sli fui a &N' against the. violator A copy ofthis stateinient may he tiir%\arded tet the: Office of lnvcstr atntn; of the DIA iitr imurctncc covcraue verlficatfon ! du hereby rc=rtrfF, to r the petit art r/ tr res' ofper un that the r'nfonitation,pro aided abov' is tri a an it correct. Ctonaturrp Utlte /( 1 kr 603-532-6346 Officiol use only. Do not write is this area. to he completed ht- city or town afficital. City or Town: Permit/License 9 Issuing Authority (circle ane): 1. Board offlealth 2. Building Department 3. Cityfl'uwn Clerk .t. Electrical lnspectnr ti. Plumhini Inspector b. Other Contact Person: Phone +#: -1 -10 A� v CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/23/ao15 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(les) 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 FIAI/Cross Insurance 1100 Elm Street Manchester NH 03101 CONTNAMEACTKaren Shaughnessy (60 /C No: (603)645-4331 A/C No xt: 3) 669-3218 (AA ADDRESS:kshaughnessy@crossagency.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA West American Ins Co 44393 INSURED Ese Inc 52 Fitzgerald Dr Jaffrey NH 03452 INSURERB:Ohio SecurityIns Co 24082 INSURERC:Ohio Casualt Insurance Company 24074 INSURER D National Liabilit & Fire Ins Co 20052 INSURER E: INSURER F: 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. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFFPOLICY MM/DD/YYYY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 A CLAIMS -MADE a OCCUR MED EXP (Any one person) $ 15,000 BKW55684497 7/31/2015 7/31/2016 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2, 000,000 X POLICY ❑ PRO LOC JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BAS55684497 7/31/2015 7/31/2016 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 C EXCESS LIAB CLAIMS -MADE DED I X I RETENTION$ 10,000 $ USO55684497 7/31/2015 7/31/2016 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N❑ (Mandatory in NH) N/A V9WC629429 (3a.) NH & MA All officers included 3/8/2015 3/8/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500f000 E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GERTIFIGA I E HULUCK laMl\VCLLA r IVIS Town of North Andover, MA 1600 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Laura Perrin/JSC �r- V -I WOO-LU'14 AV%JF%9J ray . cacr rcu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INSO25 nOtdrnl Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super4icor License: CS -072316 CALEB AHO 482 JARMANY H�i.L ''it SHARON NH 03458 two Expiration Commissioner 1211912015 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 161406 _ Type: Individual Expiration: 10/20/2016 CALEB AHO I CALEB AHO 482 JARMANY HILL RD. ° = SHARON, NH 03458, SCA 1 Ci 2OM-05111 Office of Consumer Affairs & Business Regulation 4iOME IMPROVEMENT CONTRACTOR Eegistration: 161406 Type. xpiration: 10/2612016 Individual CALEB AHO CALEB AHO 482 JARMANY HILL RD. g SHARON, NH 03458 Undersecretary Tr# 258803 Update Address and return card. Mark reason for change. Address _- Renewal Employment " Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza -Suite 5170 Boston, MA 02116 Not valid without signature