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HomeMy WebLinkAboutBuilding Permit #474-2017 - 340 WOOD LANE 11/4/2016BUILDING PERMIT X� 1 l(p TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION Permit No#: 147 4 - a017 Date Received J ! — 4 -'>-O I C® Date Issued: 1 t + 4 - ?�,Dr 6 IMPORTANT: Applicant must complete all items on this page LOCATION 2 1—O Wo&J Lean e- not PROPERTY OWNER1 V 1����n yz nl- h Print 100 Year Structure yes no MAP PARCEL: i PARCEL:_ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 9�-Qne family ❑ Addition El Two or more family El Industrial '!.Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition❑ Other v .m 0 Septic d Well ❑ floodplain 0 Wetlands El Watershed, District 0 Water/Sewer OWNER: Name: Address: Contractor N Address: DESUKIP I IUN Ur VVUKM, 1,U tsc rr_mryminE:v. Identification - Plea ype,or Print Clearly �. (Ar -e- e -n h -e Phone: �7 - Supervisor's Construction License: —Exp. Date: Home Improvement License: �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: $ —FEE: $ 13 Check No.: l �L F % Receipt No.: .3113 S' - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS T" HEALTH Reviewed on Signature _c COMMENTS 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 ROD- "f ,,FIRED ,� a rMENT T.Pm©ump�steron�sltA e,' lyes, _ m ►,Located�at �124tMainfStreet `" ` ` "� """'""�'�"'�"���`" Ftri4g)" fflu ent sig:natureeLdate, 'COMMENT�S 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 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 NO I tb and IJAIA — (tor department use ❑ Notified for pickup Call Emai Date Time Contact Name Doc.Buildin,; Permit 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 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 TE: 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) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products E: 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 TOTE: 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 Location 3Y0 No. Y7 ` 9 01 -2 Date /! Ll— ;01(.0 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check #Yl 135 ! �� Z"' Building Inspector s r oc i 3 0 H 04 0 krl un J 2 LL D Q mO t u +' \ O LL £ ate. N N U O_ Ln 0 N Z Z 0 J m C Op� z 'O 7 LL L = T C U LL p v LU LA ? Z m J d L cr LL O u LU 4A Z u w 1- W ui L O d' U - (n LL ac OLU u LLI d Z Q L O U, LL z F- Q a W W w LL i m Z - W LA +� 0 4J Y O y C 0 O O O J a ca �a sy C. L � lid. •: C 0 0 �� E� � N J >dip_ 0 L ate.=CD> �' c � t U a MM o 0 as z CL O .y C 3 r c 0 CL 0�+s' 0 y c cc 0 .y IM F- O 0 ' c Q i = 0 0 f~ i0. U) 0 .v m W 0 -0-,. O O LL 12 D R N C 'a � 0 N = — Lu .E .� L V Q 0-0 a) N 0 .0 � C 2 m o o C 0 F- t Q. 0 U oc z Cfl z Cl) a W W CL I 07 s w z W O z CL O U) ^� c �_ W Q •(1) m m CL t O � o �+ �0 0 m O Q a CL � a O •r.L O O Z d O V tU tQ � Q O V\: /,,. R1SE Enoeering atotg80 AdlvhdoaofThidich Bashmertag tilACatib rti arbpttMo17A9re RISE' E3 DIMWIT 69 8 ihdt 02, data- mA em, CONTRACT Man.( 3S FAX3"402-" � xxmarnaaerrseaeotmreersaaasa "ucnuraurtw* llum oaaMtrmRoche -`�� (918"2070 01/212016 416115 00004 semen sasear tsuaxo tmrmr 340 Wood i ane' ,t 1 340 Wood ime saweea errr tnarRstr Mason* arr.s"Ma v North Andover, MA 01 North Andover, MA 01845 (F [i j7f JOB DESCPJMON PHASETWO-Rapmaifat yso t primwdprogmmiaptivcaGot gamremoed BARRtBR ABfowaDoorTeawfUmbecoa&z*xlatymbome,daetothe of 50A0 BARRIER: We bevndiwovmW v&u agpatsm be s amid / miMdew-lfbe la yo& hens. This is balq bmu& m yatt m h ns n pmo §mg omadidm m dma hwhi w rad alt waft wakptanaa3 for your booms. yaw is yasa�theseooad mtd t m pmnecal. $0.00 WAt2.3: FuroLh amsd iattaU blown in t�era 1 t3etbdore to (1ti64j txptano fox ofsbiogte andJor cispboatd taaaI�weUs The baa of 914UPPeteCaMefYoutwoWdftiscdt*&Mhchmbftdm=UdwWhWgbddbd The halos are dm phmgged and the wood sid6tgistdmtalladuslsgstsiafesaattbl6atrhaat#sY pai�ag,Racaded.wRibothnamstoma"s ity. iavdchgwni oaatr ttps mgwmEot l cion. ttragnmt to yow psymeat, as aadded swilm ROE Englwft wmM ro- yubm weedw peretitato check fiatanyvoids whb an hs8amed sumer. Any v" tbat maybe Amad will be filled at month wd oat. $3.078.40 BAS NP DOM pmovfde lsborm d ttmte dWs to brAme ft back *(the besesnmt+door tmdh* to am bu idmad with r rigid bawd that meets the mcdam R.316.SA and 31" mphemeAw of buf Roods. Sad an edge ead reams wnh PSK tape. $72.22 R6B Eagi4eaiog wmT!apply eI apptfcabfe, eUgibte taeaRivas m thin caazrart. Xao will only be bitted the tier am mt. Curawly, fa aEglbtn u , t lien alias 7596 inaeative, mrt mexceed 52,000 per eakmdaryam, and an h:oeative of t009b fardw AirSaftnmom up to ft&df680sodsuadeiandS340ifaevingaweJaaiitr 4,%* =4W. ftrdwsAdyand heattbofyowbonrata fedoa air gtmtiiy, wewill be oondnahng it blowadow diegm *oc of theavam&bl*Wr flaw En yaw lea= been tufom the wodk is begin, nod aiTar dsa wI S, Wolkiscanviewwowillabacaudi,ct a ful assem mu of the 000>bnsoims sa&tyedyamrbmaiagsystem ami wager hsata This lens a vahte ofW and fs at as c mk to yao. Tatsl aftm6le i cadwois53,110. s90A0 RISE Eugloceriog A "too OrThitloch Faglattriag 60 sbawmyt Valt 02, Cancan. MA 02021 331140243M FAX 139.5OUUS RISE Maureen Roche Wroca eTQaaT 340 Wood Lane Worth Andover, MA 01945 Poftw (Do r4 0MV4tw Rfaftbatm W* MACOMB" we a coftmew no CONTRACT Pop 2 PROGRAM CMA -HES nrlIATOIPaaMeaaU Mew oars emwo wauaMata (978)979-2070 06/0212015 416115 00OD4 340 Wood Lae =Loa CRT,6TlTE Lf NOfth Andover, MA 01845 JOB DIZSCRIMON Total: $3,240.02 Program humn"Ve! $2,0119." Customer Teftf- $1,150-63 WE souse MSMVTO nftM SERVOM -CD #PLMMAtC*R*A#MVMAWA VWX400M FM TKaWtS *"One Thaumind One Hundred Fft & 631100 Dollars LV"Fmk Dwalmum"POW& aye= 30 VOL AwrAMOMMOTM NO A7'7—.'314-& 10 39vd 66E5Z89816 IPG:El 9t0Z/8Z/T6 The Commonwealth of 1"assucrtu3c "' Department of Industria! Accidents — Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El Please Print Leg bl' Name (Business/Organization/Individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 L] Are you an employer. Check the ark, r 4. b jam a general contractor and 1 I. ✓❑ I am a employer with 100 employees (full and/or part-time). 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself_ [No workers' comp. insurance required.] t Phone #:603603-3 have }tired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their right of exemption per, MGL c_ 152. § 1(4), and we have no employees. [No workers' comp. insurance required] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other Weatherization `Any applicant that checks box -91 must also lilt out the section below showing their workers compensation policy information. Homeowners check this boa must attached avit an additional doing sheet showing he name of -the sub -cont acto s and must state whether or not those'entitiies havech. Contractors thatp. policy employees. If the sub -contractors have employees. they must provide their workers com oli number. g tion insurance for my employees. Below is the policy and job site ( am an employer that isproviding workers' compensa information_ Insurance Company Name: ACE American Insurance Company Expiration Date: 6/30/201' WLRC 48151553 Policy # or Self -ins. Lic. 9: City/State/Zip: / � • !'? a�e� �'/7'L/ / � �O tJ Job Site Address: —I� age ( Attach a copy of the workers' compensation policy declaration pshowing the policy number and expiration date). Failure to secure coverage as required under ecnas5A of well as�c vilGL c. 152 can lead to the imposition of criminal penalties in the form of a STOP WORK ORDER and a fine fine up to $1,500.00 and/or one-year imprisonment, of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o Investigations of the DIA for insurance coverage verification. 1 do lzerebV certify under the pains and penalties ofperjury that the information provided above is true and correct. i 1 603-324-1974 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License N. Issuing Authority (circle one): City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 1. Board of Health 2. Building Department 3. 6. Other Phone #- Contact Person: CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDM'YY) a6/,4/zD,6 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS THIS CERTIFICATE IS ISSUED AS 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- i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). DAMAGE TO RENI ED $2,000,000 PREMISES Ea occurrence CONTACT NAME: PRODUCER Aon Risk Services central, Inc. PHON (866) 283-7122 FAX (800) 363-0105 (AIC. No. Ext): (AIC -No.): Southfield MI office E-MAIL ADDRESS: 3000 Town Center Suite 3000 Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURER Old Republic Insurance Company 24147 INSURED TrUTeam Builder Services Group, Inc. INSURER 8: ACE American Insurance Company 122667 INSURER C: Lloyd's Syndicate No!, 1969 AA1120106 -- d/b/a Quality Insulation A TopBuild Company 110 Perimeter Rd INSURER O: Nashua NH 03063 USA INSURER E: INSURER F: GENEP.AL AGGREGATE $4,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO ❑ LOC JECT oC\/ICI!'9 AI ILII IIURI-D- L;UVtIKAkUCJ \.rC ill-_ — ____ .. .--. 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. Limits shown are as requested TNSRLTR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X❑ OCCUR INSD SUBRIUMBER WVD POLICY N Mk2Y 1 —POLICY EFF IMMIDDIYYy'Y 1 POLICY EXP MM/OO/YYYY i LIMITS EACH OCCURRENCE $2,000,000 DAMAGE TO RENI ED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) S25,000 /l Nashua NH03063 USA PERSONAL 8 ADV INJURY $2,000,000 GENEP.AL AGGREGATE $4,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO ❑ LOC JECT PRODWCTS- COMPIOP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MwTB 307519 06/30/2016 06/30/2017 COMBINED SINGLE LIMIT S5,0001000 Ea accident BODILY INJURY ( Per person) X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per acodent) PROPERTY DAMAGE X HIRED AUTOS X NON -OWNED ONLY AUTOS ONLY Peradodent I cx UMBRELLA UAB X OCCUR TH1600027 SIR applies per policy terns 06/30/2016 & conditions 06/30/2017 EACH OCCURRENCE $2,00D,000 AGGREGATE 52,000,000 EXCESSLIAB' CLAIMS -MADE I DED X RETENTION B B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR I PARTNER /EXECUTIVE � OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA TT WLRC47860180 All other States SCPC47860209 WI only 06/30/2016 06/30/201606/30/2017 1 06/30/2017 1i )( I PR STATUTE ERH E. L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE S1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached if more space is required) Evidence of Insurance. rANCFI 1 ATinN vY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder Services Group, Inc. AUTHORIZED REPRESENTATIVE dba Quality Insulation A TopSUild Company /l Nashua NH03063 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD j m m v N O O Z R V d U C)tflce of onsumer s (R&OZss�egti 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne Improvers&_'ontractor Registration Registration: 179141 n. 0,%^jam Type: Supplement Card t' BUILDER 1, Expwatlon. 6!25!2018 SERVIC=S GROUP, 3N RICHARD SCHWARTZ 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 SCA9 G 20U-WlZ fJlu C v�nnurruue¢:1� o C�J%�iurc�iii4elL We of Consumcr Affairs & Business Regulation E IMPROVWNTT CONTRACTOR ReglstratEoat _=_ fai;; Type: 'I-8; Supplement Card BUILDER SERVICE! RICHARD SChWAR 110 PERIME7ER RD NASHUA, NH 03063 to mares Boa return Cara. marts reason for change. U � ddress ❑ Renewal ❑ Employment ❑ Lost Card License or registration valid for individual use only before the expiration date. If found return to: Office of Cousumer Affairs and Business Regulation 10 Park Plaza -Suite 5170 Boston, MA 02116 929 Undersecretary Not valid without signature VIA, Massachusetts Department of Public Safety = Board of Building Regulations and Standards License: CSSL-105992 Construction Supervisor Specialty JUCNARDSC+IW'ARTZ 260 JIMMY ANN DRIVE`, p DAYTON A BEACH FL� 32114 ; Expiration: Gofnmissioner 09�262018 Construction Supervisor Specialty Restricted to: CSSL-IC - Insulation Contractor Faiturs.to possess a currant edition,of.the Massachusetts State BuilMing Code Is cause for revocation of [his license. DPS Licensing information visit: WWW.MASS.GOVlDPS