HomeMy WebLinkAboutBuilding Permit #516-2017 - 380 SUMMER STREET 11/15/2016LJ BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: S%(-" _ O / % Date Received It -Ir- o'?D t
Date Issued: ( I ^ / S- _ o�La I (o
IMPORTANT: Applicant must complete all items on this page
LOCATION 3 gD S-�d1�M�r S
Print
PROPERTY OWNER Ct_Mu SL&1,\S\
Print 10o Year Structure yes o
.MAP Q PARCEL: Q �� ZONING DISTRICT: Historic District yes no
Machine Shop Village. yes. no
TYPE OF IMPROVEMENT
PROPOSED USE
ResigLential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
ff"Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
r ff Septic ❑ 1Nelf
❑`Floodplain, pW
'etlands
❑ V1/atershed®strict
,. a❑ Wates/Sewer
_
.
a
DESCRIPTION OF WO K TO BE PERF MED:
•-e • A11rn M I Y -R, (A, I kitz� f v\4, �,.. k Ir" 11,I rl 41�
\\ Identification - Please Type or Print Clearly
OWNER: Name:y (st m< S SLd ��J� Phone: ��; i • 31 to . (9
Address: 3G 0 SvMiMCr Sir- -
Contractor Name:.
AddressJ P-0i3aL 31%-1
Supervisor's Construction License:
Home ,Improvement License:
ARCHITECT/ENGINEER
Exp. 'Date:
` 7
Exp: Date:
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: $ 3 FJ�- , kg !�- FEE: $ q7
Check No.: --3 o 3 7 Receipt No.: ? /19. D
NOTE: Persons contracting with unregistered contractors do not have access to the g�anty 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 PSE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature.
CONSERVATION Reviewed on Signature
1
COMMENTS
HEALTH
z
COrWENTS
- Reviewed
Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
of Ir
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 bumpster on site yes no
Located at 124 Mairi Street �,� : *''
Fire Department si-g `Slurs/date'�'� `Z+".af�t� •t� ;'"'
Mi
�,� d $ .� � a •... �'f^+`,�+ `#'4t"�;:x;�; +r�.h�i'�Y`4 �ti.r kms& �� ,t f'. >� �•'-a a.,,p� �y3 �,.
}. •a 1 C•� i'•., F L � k3'w °5", .,�''� A" 7 T.ay
:jr
oil rflft=�
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 ease)
El Notified for pickup Call Email
Date Time Contact Name
Doc.Building 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
:4, Building Permit Application
4. 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
TE: 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
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
Doe: Building Permit Revised 2014
Location 97b S U ell
No. sl (O - 9 61-:2 ,y_ Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
31190 C/ Building Inspector,
6
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RISE
60 Shawmut Road, Unit 2 1 Canton, MA 02021 1339-502-6335
ENGINEERING www.RISEengineering.com
OWNER AUTHORIZATION FORM
(Owners Name)
owner of the property located at:
�! (Property Address) _
(Property Address)
hereby authorize. �
( ubcontractor)
an authorized subcontractor for RISE Engineering. to act or my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
Ther Permit will be secured by the insulation contractor, at no additioi;al cost. It is the homeowner's
responsibility to close out this permit by contacting their inunicipality at the completion of this work.
Owner's Signature` -� ----. -
Date
5.2016
Fod}iral 10 6 05.0405628
RiSE, Engineering RI Contractor RogletIVIUM No 6186
120479
MA Contractor Roglelr"on No
C7 Contractor Rtfglstratlon No
r�
���
■ �GtJlStta»mut Road. A's nlnn,.1., CONTRACT
ENGIPIEERtNG'
(401) 784-3700 FAX (4e1) 784-3710
Page 1
PROGRAM
711tl GOMRACT Da ENTERED INTO 8ETIYEEN WSE
CMA -IBES ENDU/EEsuka AND "* CUSTOMER FOR WORrr AS
DUCRMED OCiOW
CUSTOMER PHONE DATE CUEWa WORK ORDER
James Scalisi (781)316-6787 09119/2016 438767
35002
SEIWICE DTRttT Dai. STREET
380 Summer Street 380 Summer Street
SERVICE CITY.STATE. ZIP MUN0 C1rY.OTATE.ZIP
North Andover. MA 01845 North Andover, MA 01845
.108 DESCRIPTION
I IAZARD 13ARRiRR- Rte hate identified that there arc rvcc%sid lights preicnt in your home mnllcs% the rccc-.scd light; arc certified
as IC -rated tlnsulation Contact Rated) uc /sill create a 3" clearanec .pace around the fissure by ming fiberglass blanket insulauon is
a damming material. no insulation Lyall he installed acro:, the topand closed cavihcs which contain recessed light. yyill not be
uuulalcd.
S(Oao
AiR SEALING: pros Ide fabnr and materials til seal areas of your home a-L'auist wastetul. c\el'.% air feakagl I his %%oak %%dI he
performed in concert with the use otspeciaf [lulls and diagnostic tests to assure that y,mur ln.mc will he felt %sita a healthful Ic%cl of
air exchange Arid indoor air quality Milictials to he used to scat your humc cart include caulks. foam. and other pri,ducis Primars
areas for scaling include air Icakagc to attics. bascnicuts. alfachcd varagcs and other unheated areas t%%it:dnw. are not ecncralh
addressed.) This tell require (81 worklne hours. A reduction in Cubic sic/ Per minute (cI mI ofair infiltration will tt-cur. but the
actual nunihcrofetm is not guuramcc&
At the compaction orthe wcathcrvauon fwd.. ami at no additional coo to the homeottner. ;I final blower d,utr andiur combustion
sa}iay analyxis will he conducted by the sub -contractor to ensure time safely of the indtax air qualu%
5680.00
AIR SEALING: Provide ichor and materials to seal :rex of your honle aganbt %%astc'}nl, c\CCS\ air leakage t fu, wart ulA tin,
perfbrined In concert with the mt.c of.sliccial tools and diagnostic tests to assure that )surr humc will he telt will a healthful level of
air C\chanle and indotir air quality. Materials to be used to Seat stout home can include caulks. loani. and Other pri ducts. Primary
ares lir scaling include air icakape to attics, ba.enicim'. rttuchcd garares and other unheated arca, tuindows airc not generally
attdrLssed.) 'Ibis wli rcqurc (3) workin,_ hnurs A reduction in cubic tett per minute iclIli) of air iolilit auonwill occur. but the
actual numhcr of clan r: non guaranteed.
At the cornpiction o!'the wcatheriiation work. and al no additional cost to the homcomicr. a final blomvcr thou aroXor conihusu(vt
safety analysis will he conducted by thesuh-contracitir tocnsurethc s.nety ofthc indoor atrquald).
S25:.0u
Rt?MOVE RAILING OVI:R FI ib. PULL Di M"N STAIRS 014 t)RIII.I( III t't $NS'i t Rt' I AN I i:Fl:.t' I IVV 1-11P.RMAIX IMI l
SoJin
DAMMING: Prrn ide labor and Materials lot Install a 1'" layer orl(-3S un}heed fthrr_lass hats. to (lnut squats list tier damming
purposes.
5205.00
A171C FTXF: Provide lahor and materials to install a 7' layer of R-25 Class 1 t'cliuh,u added i., t 1 tk,ul square sect of opYst ::111:
space.
S1.378.0(1
XITIC FLAT: Prot ids labor and materials to ittsall a 7- later ol'R-25 C lass 1 C'ellulosc added to 0101 square feast of open attic
Npacc.
S5_'0.(s)
< ' _b SEP 2 0 2016
now
Federal ID a 064MO"29 No alae
Rag
��= RI Contractor
RiSF Fngineering MA Contractor Reglstr1l"On No 1211879
NO
CT Contractor Rpghl"tlon
RISE60 ('anion. NIA CONT I^CT
Sha%mut Bead.
ENGINEERING
(401) 7x4-3700 FAX (401)'+84-3710 Page 2
l/jt(X;RA41 THIS CONTRACT ISENTERED INTO tETMENRISE
CMA-1lES ENGutEER7N0AN0THECUSTOMERFORWORKAS
pESCRteED BELOW
CLIENT F WORK ORDER
DATE
PHONE
CUSTOMER 09!19(2016 438767
(781)316-6787
3 5002
James Scalisi
WLu?M STREET
SERVICE STREET
380 Summer Street
380 Summer Street
CrELINO CITY. STATE, ZIP
SERVICE C7TY.STATE.ZIP ;worth Andover, MA 01845
North Andover.;VIA 01845
.JOB DESC:RIPT1ON
fall the attic awes folding stair. -
the opening within the attic. This tvili allele thrt ancrs integral ++cnttrcr-
:YtTIC' ACCESS' Provide labor and materials aI i -Tall i t) easily novel. In+Mating is will
small flat surface of pI%ood n i8 he crested annutd
-tripprng to MAnct 31T leakage-
1'10v10e luhor and matcriah to install {?) insui:ucd exhaust h<.+c to existing h:nhrrxtm fanlsl
51U(t t1U
Vtii+1Tlt-ATIOti:
FSI: flaccd semi-ngld libcrgla" + board insulation to t i 2�t +4uarc feet
COMMU bC:V.i.S: Provide labor and materials w Install'_"
of common Nall arca.
$427,00
file eligible nlra+ures' Cutulmbir Gas uStcrs 75"o eligible
_c"". VIVA to svecdt51- ittutt rSTct `atcrullu M hill an tiiu3l°tiOi,f !Ott orimir.
the Air Scaling mc;"Ic up a) the tint 5690 and an additional S34t1 if sat DIP arc Justif icJ b} the auditor.
ic
air
elo
in +aur I one bthe afety athlt+LiilrL the wurf }intngun. and afterattic +F �tbcriiati, nlit� Ill be ndufwt ii mtplcl �rlfYa{>u clmducr a firlF bla >sm Ant
of the combustion saftK) of wur heating s} stem and hater heater Thi; ha+ a t atuc f SSU and is at no cost uV %41U, final
allowable weallicri/ In incentive is 53.11 n, S9Qttlt
Total: $3,892.65
Program Incentive: $3,025.00
Customer Total: $867.65
WE AGREE HEREBY TO FURNISH SERVICES • COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATImiS" FOR THE SUM OF
$867.65
—Eight Hundred Sixty -Seven 8.651100 Dollars
UPON FINAL INSPECTION ANDAPPROVAL BYRISE ENGINCEM" CUSTOMER AGREESTORTC37 Px'W„T t»�'H L'SHTSCHC CFNOVA000 TRACTO REG'STY TI ANY
UNPAID BALANCE AFTER 30 DAYS. SFE REVFRSE FOR MID TAN NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANKDSPACESRACTGa aecLarRATIOn.
x Z
r� '-."f.US10NFR ACCEPTANCE !.
AUTHORIZED SIONATURE •RISE ErWnnV p
PATE QF ACCEPTANCE E% r
NO T S CONTRACT MAY BE VATHDRAWK BY US IF NOT EXECUrED WITHIN _
ACCEPTANCE OF CONTRACT -THE AD OVE PRICESj•6 YOU
TO
WORK
_ SATISFACTORY To US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED
✓ �/ DAYS. AS SPFCtFIED, PAYMENT VALL BE MADE AR GUNNED ABOVE
.�L.i.
1% L ,1
The Commonwealth of Massachusetts
Department of Industrial Accidents
O, ke of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
""- www mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �Cj (�A,yhti A_R er\ 1 `V`.,
Address: �f - 0 BOX "3 4 q
iv: r 01WUN rl 1A 0 M 3 6 Phone #:
Are you an employer? Check the appropriate box:
1. EfI am a employer with (_
4. ® I am a general contractor and 1
employees (full and/or part-time).*
have hired the sub -contractors
2.0 I am 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
required.]
comp. insurance.1
5. ® We are a corporation and its
3. ® 1 am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
insurance required.] t
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comms. insurance reauired.l
Type of project (required):
6. ® New construction
7. ® Remodeling
8. ® Demolition
9. ® Building addition
10.® Electrical repairs or additions
11.1] Plumbing repairs or additions
12. ® Roof repairs
13. ® Other
*Any applicant that checks box #I 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 sub -contractors and state whether or not those entities have
employees. If the sub -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 Name: Na% b (J_ 1 n,SQ fGA'\ Q_,
Policy # or Self -ins. Lic. 0 0 3 Expiration Date: 10 30 1 2Q i
Job Site Address: 3 SO s`)1'VVY— City/State/Zip: ArL&AV(f fit big V
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 under the pains and penalties of perjury that the information provided above is true and correct.
SienatureLC16 `r � Date: I \A IS -11V
Phone#: gfi(a - 3s�0' 3`(.ES3
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 S. Plumbing Inspector
6. Other
Contact Person
Phone #•
ACC>R ® CERTIFICATE OF LIABILITY INSURANCE
�/.
DATE Oil
10i1 8 812016
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
MARTIN J. CLAYTON INSURANCE AGENCY INC
CONTACT
NAME: Meg Munroe
acc°Hro Ext: (413) 536-0804 NC No:
E-MAIL ton.coml
mmunroe m ca
ADDRESS: @ ) y
INSURERS AFFORDING COVERAGE NAIL#
1649 NORTHAMPTON ST., RTE 5
HOLYOKE MA 01041
INSURER A: ACADIA INS CO 31325
INSURED
INSURER B:
INSURERC:
GAUTHIER INSULATION INC
INSURER D:
INSURER E:
PO BOX 344
1 INSURER F:
e��VLNnwl w111w11D CO.
IPSWICH MA 01938
----"-
COVERAGES L r -m I Irm m I C 19V IYR -n. -;i I ---------
OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES
THIS
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED. NOTWITHSTANDING ANY
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRADDL
SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE POLICY NUMBER MM/DD/YY MM/DD/YYYY
LIMITS
LTR
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
DAMAGE T RENTED
PREMISES Ea occurrence $
CLAIMS -MADE E OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
N/A
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO-
❑ D LOC
PRODUCTS - COMP/OPAGG $
$
POLICY JECT
OTHER:
COMBINED SINGLE LIMIT $
AUTOMOBILE LIABILITY
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED N/A
BODILY INJURY (Per accident) $
PROPERTYDAMAGE
Per accident $
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE N/A AGGREGATE $
DED RETENTION $H -
WORKERS WORKERS COMPENSATION /� STATUTE ERH
AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ 500,000
A
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? WA WA WA MAARP300327 10/30/2016 10/30/2017 E.L.DISEASE-EA EMPLOYEE $ 5001000
(Mandatory in NH)
If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
N/A
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more. pace is required)
Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
CERTIFICA It: MULUr-K
TOWN OF NORTH ANDOVER
1200 OSGOOD STREET
NORTH ANDOVER
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
L L'
MA 01845 Daniel M- Crqey, CPCU, Vice President — Residual Market — WCRIBMA
-- -n Ad%^Mn f-/112Df%0AT1f%M All rinhtc rAQPrVPd
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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