HomeMy WebLinkAboutBuilding Permit #520-14 - 35 MARIAN DRIVE 1/6/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
7 i Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION -
M _0 (6
_nNt
A 4 V Prin
PROPERTYOWNER
Structure___ yes no
in
MAP -',NO': PARCELIJ ZONING DISTRICT
-Historic District yes ino
Mbchi,n'e. S116' Village ve$ no.
Shop
TYPE OF IMPROVEMENT.
PROPOSED USE
Resi5ential
Non- Residential
0 New Building
Vbne family
11 Addition
El Two or more family
11 Industrial
El Alteration
No. of units:
11 Commercial
0 Others:
11 Repair, replacement
El Assessory Bldg
El Demolition
11 Other
❑ mic, -11"
e
-0 in _-Wetlphd
0 Watershet jstficV
t&/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Nc aa1 and OD r mwz�-A"e
Identification Please Type or Print Clearly)
OWNER: Name: /-il i )SCJ() f<au
V ,
Address:,35 man an f \re -
CONTRACTOR Naffi'6:,
() (-+Vi Andutw-
q-7P
(aq
Addreq�.. (Die 5
Supervisor Go -n struction License_
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_ y-
Home I ffiWovement" Udeme:
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.
.I -
Total Project Cost: $ 7,20-(121 FEE: $
Check No.: b b Receipt No.:
Persons contracting with unregistered contractors do not have access to Pe 91 uaowpnd
gr aturei.oT.,co-n1rc
ri,
Plans Submitted '-i Plans Waived El Certified Plot Plan 11 Stamped Plans
r—
Building Department
`rhe fol!,iwing'is`=a-list of the required forms to be filled out for -the appropriate:permit to .be obtained.
Roofivg, 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
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
❑ 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apo -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bubding Permit Revised 2012
Plans Submitted ❑ *.Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
WE_OF.SEWERAGE DiSP_OSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
FoodPackaging/Sales ❑
Private (septic tank, etc.- ❑ ..
.-Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
:DATE REJECTED DATE.APPR.OVED
PLANNING &DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on _ Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
R
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Conservation Decision:
Comments
Comm
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;., Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT = Temp Durn S f on site .yes no
Located'at.124,Mair,.Street
r- a ,
Fire Departmen sigiiaturdldate
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.$10041000.:fine
NOTES and DATA — (For de
® Notified for pickup - Date
Doc.Building Permit Revised 2010
ent use
( av'n"A
Location t t
No. 15 d ^ Date
Check #
271 15 9
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee ;$
Other Permit Fee $
TOTAL r$
Building Inspector
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Conser atlon
Services Group
CONTRACT FOR nationalgrid
PRODUCTS / SERVICE WORK HERE WITH YOU. HERE FOR YOU.
This service is brought to you through support from your local utility
This Agreement is made by and among
� 911,3
Allison Ray OCT q G 1 201q
J
35 Marian Dr
Notch Andover, MA 01845-6003
Project iD: P00000124762 Contract ID: 20130309_ASEAL
Site ID: 500002120768
mitt
Conservation Services Group (CSG)
Attn: RCS
50 Washington Street, Suite 3000
Westborough, MA 01581
Reg. No. 173484
Federal ID No. 222457170
(A1ail completed contract to address above)
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be perfumed the following work on these "Premises" in a professional manner and in accordance with the terms of
this Contract, including the attached reconunendationstwork order describing the work in detail (Ute "Work") which are incorporated herein by reference:
Description
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour
Attic Stair Cover Thermal Barrier with carpentry
Quantity Location
8 Living Space
$616.00
1 Hallway
$237.65
Sub Total:
$853.65
Energy Efficiency Incentive
$853.65
Net Sales Tax After Incentive
$0.00
Total
$0.00
Printed: 319/2013 Page 1 of 2
II. PAYMENT
Customer agrees to pay Contractor for the Work, the Customer Share of the Contract: Price as follows: Payment #1: $ as a Deposit payable
to CSG upon signing the Contract (not to exceed 1/3 of the total retail costs or actual costs oft orders, whichever is greater). Mail check & contract to CSG,
Attn: RCS, 50lVaslwngtot St., Ste. 3000, Westborough, AU 01581. Mimi PaynnenC $ � as the final palmlent for the Work shall be due and
payable to the Independent Installation Contractor ("IIC") upon sa' fn to{y completion of the Work. Customer understands that he/she will not be required
to pay the utility Incentive Share of the Contract price ha the amount of $ -65- . The Utility Incentive Share is dependent upon the package ptuchased and/or
prior incentive utilization. Charges to individual lune items and/or precious incentives may increase or decrease the size of the Utility Incentive Starr.
III. DISPUTE RESOLUTION
The IIC Bund Customer hereby mutually agile in advance that in the event that the IIC has a dispute concendng this Conti -act, the IIC may submit such &9)ute to a private arbitration
service which has been approved by We Office
-ooff Coo>_sumer Affairs and Business Regulation and Oistonaer shall be r�>gtwtxt to submit to such arbitration as proOded in ALG.t. c Id2A.
r ���pat'.�
Custoer:' L' I Contractor: cL�-CV7�,
rt�
You may cancel this agreement if it has been signed by a party there to at a place other than an address of the seller,
which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch
by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the
signing of this agreement. DO NOT SIGN TH�SNTRArT IF THERE ARE ANY BLANK SPACES.
Qn l
Custonner/Agnatare ' / Date Indiiccite your selected IIC here, if applicable (OR) Initial here if you want
C xis C % c r the h-ogrann to assign a
Participating Contractor
CSG Signature Difte Name of CSG Repres ntative (Printed)
TERMS AND COND[TIONS APPEAR ON THE REVERSE. 1/13
Conser atlon
Services Group
CONTRACT FOR nationaigrid
PRODUCTS I SERVICEWORK ORK HERE WITH YOU. HERE FOR YOU.
This service is brought to you through support from your local utility
01411 completed coati
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor vpill perform or cause to be performed the following work on these "Premises" hia. professional maturer and in accordance with the terns of
this Contract, uuhtding the attached reconunendatirnts/work order desrrihing the work hu detail (tire "Work") which are Iucorpolated Itereln by reference:
Description
Attic Floor Open Blow Cellulose 6"
f)amming
Insulate Wood Shingle Sided Wall With 4" Dense Pack Cellulose
C
Install 6" Fiberglass Batting In Open ill
eiling
Install 2" Themnal Barrier Polyiso On Open Crawlspace Ceiling
Vent bath fan to roof flapper
Quantity Location
1_,036
Living Space _
$11,3138.2.4''
20
NIA
$37.00
1,808
LivIng Space
33 581 76
216.
LiNng Space .-....
$44064...
_216 _
Living Space. _ .- _ . ,.
$868.32
1....
.Attic
$118.00
Sub Total:
$6.413.96
Energy Efficiency Incentive
$2.000.00
Not Sales Tax After Incentive
$0.00
Total
$4,413.96
Printed: 3/9/2013 Page 2 of 2
II. PAYMENT Y7�. 3
Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows: Payruent #l: S as a Deposit payable
to CSG upon signing the Contract (not to exceed 1M of the total retail costs or actual costs of special orders, whichever is greater). Alan check & contract to CSG,
Amt: RCS, 50 Washington St., Ste. 3000, Westborough, ATA 01581. anal Pa}mcenh $ 'Z j 9 Cf z .(q as the final payment for the Work shall be due and
payable to the htdependent Installation Contractor ("IIC") upon satisfactory completion of the Work. Customer understands that he/she will itot be required
to pay Ilse Udilly Incentive Shareof the Contract price ht the annotunt of $ Za-?& . The Utility incentive Share is dependent. upon the Package purchased and/or
prior incentive utilization. Changes to hulividuad hue items and/or previous incent�increase or decrease the size of the Utility Incentive Share.
Ill. DISPUTE RESOLUTION
Tlrv. IIC and Cuslouter hereby mutually ng ee i» art sue that. in tine event that the IIC has a dispute concerning this Contract, the UC may submit such dispute to a private arbitration
service which hubs been approved by the office of Constuner Affairsand Business Regulation and Customer shall be r egWred to submit to such arbitration as provided in AI.G.L c 142A.
Customer: ui/ Contractor:
You may cancel this agreement K,it has been signed by a party there to at a place other than an address of the seller,
which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch
by ordinary mail posted, by elegram sent or by delivery, not later than midnight of the third business day following the
signing of this agr'ee/ en O NOT SIGN THIS CONTRACT IF T `R11E A ANY BL NK SPACES.
— --- -- .......__V _ - .- -- .—--....— -- ._ — �CM ton)
Customer Signature Da[e Indicate ,Your selected 715 fiere, it applicallle Initial here !f you want
U the Program to assign a
—1 -/iv e G l��Y�y' Participating Contmetor
CSC; SiSignature. Dine/ Name of CSG Repr ctitative (Printed)
TERMS AND CONDITIONS APPEAR ON TRE REVERSE. i/13
The Commonwealth of Massachusetts
Departtnerit of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
°'4 3V•�, www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: PCa
City/State/Zip: ML hal ts ` C�tE/Mhone.#: 3 (4- "
Are y an employer? Check the appropriate box:
1. I am a employer with.
4. E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. C I an 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 workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. Q Weare a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
e. 152, § 1(4), and we have no
employees. [No workers'
insurance required.]
Type of project (required):.
6. E3 New- construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.[] Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roofrepairs
13.[VOther 1�6'a_b6,
'Any applicant that checks bbx #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.
#Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If thtsub-contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. _
Insurance Company N
1
Policy # or Self -ins. Lic. #:_ r� Expiration Date: �4
Job Site Address: � 1 Tian I I Dotlt City/State/Zip: (j ®`�J�✓
Attaciv a copy of the workers' compensation policy declaration page"(showing the polity 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 lip 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.
Ido hereby certify under thqpains.ag4fMalties ofperjury that the information provided above is true and correcx
me #:
Official use only. Do not write in this area,
City or Town:
G/0/do)
or town official,
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 #:
CERTIFICATE OF
DATE (MMIDDIYYYY)
LIABILITY INSURANCE 12/5/2013
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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. Astatement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Farm Family North Andover Office
857 Turnpike Street Suite 133
North Andover, MA 01845
TYPE OF INSURANCE
CONTCT
NAME: Cathleen E. Rossiter
(AIExtExt: 978 208-4713 i C, No): (978) 208-4716
ADDRESS: Cathleen.Rossiter@farm-family.com
INSURER(S) AFFORDING COVERAGE NAIC0
INSURER A: Farm Family Casualty Insurance Company 13803
INSURED HRH Construction
80 Campbell Street
North Andover, MA 01845
INSURER 8:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
rnvCcecCc rGGTIGIr1GTl= NH InnRFR• 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.
INSR
LTR
TYPE OF INSURANCE
A L
ID
BR
WVD
POLICY NUMBER
POLICY -EFF
(MMIDDIYYYY)
POLICY
(MMIDDNYYY)
LIMITS
x COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
PREMISES (Ea occurrence) S 100,000
CLAIMS -MADE CI OCCUR
MED EXP (Any oneperson) S 5 00
PERSONAL&ADV INJURY $ 1 000 000
A
2001XO726
11/20/2013
11/20/2014
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE s 2,000,000
PRODUCTS - COMPIOPAGG $ 1,000,000
rEN'L
POLICY PRO-
JECT 0 LOC
$
OTHER:
AUTOMOBILE LIABILITY
Ea accident s 1,000,000
BODILY INJURY (Per person) $
IANYAUTO
BODILY INJURY (Per accident) $
ALLOVVNED SCHEDULED
A
AUTOS AUTOSNED
NON-O(Per
2001C4287 -4A
3/16/2013
3/16/2014
PROPERTY DAMAGE $
X HIRED AUTOS X AUTOS
accident)
$
UMBRELLA LIABEACH
X
OCCUR
12/14/2013
12/14/2014
OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
A
EXCESS LIAB
CLAIMS -MADE
2001E1169
DED X RETENTION $ 10 000
$
WORKERS COMPENSATION
PhHSTATUTE X ER
AND EMPLOYERS' LIABILITY YIN
2005w6827
12/7/2012
12/7/2013
E.L. EACH ACCIDENT $ 500,000
A
PROPRIETORIPARTNER/EXECUTIVE
ANY Y
OFFICERIMEMBER EXCLUDED'
N I A
12/7/2013
12/7/2014
500,000
(Mandatory in NH)
E.L. DISEASE- EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT S 500,000
Ifyes, describe under
DESCRIPTION OF OPERATIONS below
-
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached if more space is regwred)
Operations of Named Insured - Insulation and Carpentry
Officer David Hope is Excluded
TinnnTc uni rico rONCFI I GTIr1N
HRH Construction
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
80 Campbell Street
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
North Andover, MA
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
0 1988-2013 AGUKU I:UKNUKA HUN. All rlgnTs reserveu.
ACORD25 (2013/04) The ACORD name and logo are registered marks of ACORD
Massachusetts - departmentOf o
Board o" Building uoi „
s ng Regulations and Stancarci'
C un%rru
"' "n Sullen i+„r
License: CS-Gmu
go
NANDO'4MA 01945 —
Commissioner
03/0412014
Office of Co ' oatt�to�ttoeai o�'crt3aeiwactt�
nsnmer Aliairs 8e Btcrinzss Regalafion
ME 1MPROVEMEW CONTRACTOR
istration: ;101730
ir�tion: `6/29j2Q34� Private Corporaticr,
HRH CO NSTRUCTtQN•II�iC: '
Wlltiam Hope
80 CAMPBELL RD
NORTH ANDOVEP, MA 01845 —
Underseeretery
License or registration valid for individul use only
before the expiration date. 1f found return to:
Office of Consumer Affairs and Business Regulation
10 Park plaza - Suite 5170
Boston, MA 02116
r
i
1
Not valid withontsi hrre