HomeMy WebLinkAboutBuilding Permit #483-11 - 323 CHESTNUT STREET 12/14/2010Permit NO• � f
Issue
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicani must complete all items on this
LOCATION -S�2-3 "
-
Print
MAP NO: S PARCEL: S �— ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
- DESCRIP'IIUN Uk W UK & 1 U tsr rr-tcr vtcuvML:
Out
Identification Please Type or Print Clearly)
OWNER: Name:
CONTRACTOR Name: H -kA 1-&c_ Phone: qM 3�4 IZL-25
Address: � b �zsi hR �t UW
Supervisor's Construction License: S� Exp. Date:
Home Improvement License: 1 3 Exp. Date:2-57 201
ARCHITECT/ENGINEER_ Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED cosrBAsED ON $125.00 PER S.F.
Total Project dost: $L�]�
�'%FEE: $
Check No.: p'�n� 7 ' Receipt No.: �1
NOTE: Persons contracting with unregistered contractors do not have access to the gu r "fund
Location —;Z3
No. Y60 Date !-Id
Check #
23779
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee. $
Other Permit Fee
TOTAL
8uitding inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassagelBody 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
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
r
® Notified for pickup - Date
Doc_.Building Permit Revised 2008
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
o 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 Permit
Addition Or Decks
o 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 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
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
g0TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
lust be submitted with the building application
Doe: Doc.Building permit Revised 2008mi
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Conservation Services Group
SHAUN CALLAGY
323 CHESTNUT ST
NORTH ANDOVER MA 01845 5309
SitelD: S10003981951
CERTIFICATE OF COMPLETION
Phone(eve): (978)688-9863
Phone (day): (603) 860-1868
E -Mail:
Contract ID: S10003981961 -3282010C Sub -contractor Work Order #: HRH_2010120B
Location Description Quantity Installed
KWL Polyisocyanurate 2" 290
AFL Attic Floor 9" Fiberglass Batting 93
AFL Open Attic 6" Cellulose 988
PLEASE NOTE: The Inspection of the house is for the purpose of finding
out whether the Contractor completed the work.
CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR
ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY
COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO
SAFETY.
It was the Contractor's sole responsibilty to assure that the measures
were installed property and safely. In addition, this Post -Installation
Inspection does not replace inspections by licensed inspectors where
required by state or local law. It is the duty of the Customer to obtain
such required inspections.
CUSTOMER AUTHORIZATION OF CERTIFIED WORK
I confirm that the measures listed above have been completed to my
satisfaction. I have received a copy of the Certificate of Completion and
hereby authorize the release of any final payments to the Contractor. I
understand that this Authorization of Completed Work does not in any
manner void any warranties provided to me by the Contractor.
inspector's Signature Customers's Signature
Date Date
Conservation Services Group - 40 Washington Street - Westborough, MA 01581 - 800-480-7472
CONTRACTOR WORK ORDER
Conservation Services Group
Contractor Information l Customer/Site Details
Dave Hope SHAUN CALLAGY
HRH 323 CHESTNUT ST
57 Chase St
Methuen, MA 01844 NORTH ANDOVER MA 01845 5309 ()
Appointment Details
Completion Deadline:
Location Description Quantity
Work Order: HRH 20101208
KWL Polyisocyanurate 2"
AFL Attic Floor 9" Fiberglass Batting
AFL Open Attic 6" Cellulose
Road Blocks
Printed: 12/8/2010
Phone (eve): (978)688-9863
Phone (day): (603)860-1868
Site ID: S10003981951
Unit $ Total $ Notes/Revisions
290 2.75999
800.3999
93 1.58000
146.9400
988 1.16999
1155.959
Total for Work Order HRH 20101208:
$2,103.30
Grand Total:
$2,103.30;
Conservation Services Group - 40 Washington Street - Westborough, MA 01581 - 800-480-7472
MassSAVE Planview Diagram
Customer - Home Phone (j?j)IA - 3
Address -3?-3 Work Phone ( ) -
Town �"" �enn.` Cell Phone (o6o3) �I'O - 114)?
Any limitations for access by large truck? NO / YES If yes, describe
Any specific directions or landmarks? NO YES If yes, describe
Energy Specialist who spec'ed job: 4AI.904itf.01Cell Phone # 403 Ur .*7wz
File reviewed by Office # 508-836-9500 ext Cell #
NOTES t t hd• a�,(, i3�'
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Existing Conditions — X = Access O = Vents Note inside square: R = roof, S = soffit, G = gable,
RV = ridge vent, CS = continuous soffit, CDE = continuous drip edge, T = turbine
Install -- O = New Access: Note in circle: C = ceiling, W = wall, S = sheathing Temp unless noted otherwise
A = Vents Note in triangle: R = 8" roof, S = soffit, G = gable, M = 12" mushroom, ST = 12" Stack (flat roof)
The Commonwealth of Massachusetts
f Department of Industrial Accidents
Office of Investigations
ECra ;
•l;.?v 600 Washington Street
; a 1. t Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/lndividual):
Address: 5ff C S its
City/State/Zip: �4IP5MLffAl Wk Phone #:
Areyou an employer? Check the appropriate box:
Type of project (required):
1. CJ I am a employer with 2.
4. ❑ I am a general contractor and I
6. ❑ Newconstruction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor orpartner-
have hired the sub -contractors
listed on the attached sheet. t
❑Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
9• ❑ Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10. ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152,§ (4 1 , and we have no
)
12.❑ Roof repairs
insurance required.] u
q ]
employees. [No workers'
13. Other CJ)1i116Ci&Et'lCLA
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. _ _
Insurance Company Name: t1(. y_/�1 441
Policy 4 or Self -ins. Lie. #: 2 m5 sk 11,S 2- Expiration Date:
Job Site Address: 323 �` 1fY*SrKLL.JTT "M City/State/Zip:4.60 6XAL Mk 01845
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
Investigations of the DIA for insurance *coverage verification.
I do hereby certify unn er=p#dpenalties of perjury that the information provided abbove is,�t'rue aan�d eo�ieci
A.i� Date: d � 1_'�7 oCu31
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and. who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or.on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you Have any. questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple-permit/license applications in -any given year, need only submit one affidavit indicating current
Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-87�TMASSAFB
Revised 5-26-05 Fax # 617-727,7749
www.mass.gov/dia
'-` Jlussuchusctts - Delru-1ntent of Public Safeth
Board of Buiitlina f
Rc'ulations and Standards
Construction Supervisor License
License: CS 57754
Restricted to: 00
WILLIAM D HOPE
57 CHASE ST
METHUEN, MA 01844
t'.+nunissiuncr
Expiration: 314/2012
Tref: 18748
Officeof�o>m rc iness egu a ion License or registration valid for individul use only
k!WRCIN
HOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
Registration: :,101730 Type: Office of Consumer Affairs and Business Regulation
9/20
_ = Expiration: �/i12 private Corporation
10 Park Plaza - Suite 5170
Boston, MA 02116
STRUCTIN'JAC
William Hope"\ `t _" ?r1
57 CHASE STREETf�"
METHUEN, MA 01844;::
Undersecretary Not valid without signat e
t
l
ACORD. CERTIFICATE OF LIABILITY INSURANCE
°A7E(IANIID°'"YY"'
PRODUCER
Emond &Associates
857 Turnpike Street
Ste. 133
North Andover, MA 01845
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Farm Family Casualty Insurance
INSURER B:
INSURER C
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
ADUL
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
ARNTED
COMMERCIAL GENERAL LIABILITY
DAMAGE
PREMI ETOEaEoccurence $ 50,000
LAIMS MADE 17 OCCUR
H
MED EXP (Any one person) $ 5,000
PERSONAL &ADV INJURY $
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
PRO
POLICY LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
BODILY INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person) $
BODILY INJURY
$
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE
$ 0
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTOONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR FICLAIMS MADE
AGGREGATE $
$
$
DEDUCTIBLE
$
RETENTION $
WC SMUT OTH-
WORKERS COMPENSATION AND
EMPLOYERS LIABILITY
$ S
E.L. EACH ACCIDENT OO,DOO
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE - EA EMPLOYEd $ 500,000
OFFICER/MEMBER EXCLUDED?
2005W6827
12/07/2010
12/07/2011
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT I $ 500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Operations by named Insured.
CFRTIFICATF HOLDFR CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENTATIVE i