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HomeMy WebLinkAboutBuilding Permit #799-2017 - 40 MEADOWVIEW ROAD 2/23/2017J BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 2r} Permit No#: �! ' v _ I Date Received -del / 7 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION LA b '( ( V ` CW �40- t Print PROPERTY OWNER LLJ V �(L 0 YVo // Print 100 Year Structure yes no MAP / PARCEL:_ ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Nz- Resid al Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial Iel Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �__r`_ ❑Septic El Well El Floodplain 'Wetlands , ❑ Watershed: District 0 Water/Sewer OWNER: Name: Address: Contractor Name: Email eauJVAl i -Addres . iso We 3' ESCRIPTIUN Ir vli'UKt I V bt rr-mrumivir-u. t K GI t tification - Please Type or Print Clearly i; I, n I & r nV-1 0 Ph hone: t Supervisor's Construction License: W.1 -SID Z— Exp. Date: I Home Improvement License: I 1,:3 I O Date: k Q I k ARCHITECT/ENGINEER Phone: Address: Reg. No. , ZZ,gq FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �� ci � FEE: $ Check No.: Receipt No.: 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 ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dumpster on Site ❑ Swimming Pools ❑ Food Packaging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature. 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: Conservation Decision: Comments Comme Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osqood Street a:,.�:=_—. �6:eg•• _ ..�. .. ..„1r yes �F� at 1%24 Main Street ".4? N �_a e partment signature.. 'tat.+ ��� _.`�",+`,.y f•—y�"'x'"-'�. � � s y 'Y`1"'�F "�"..�"`�, iJOM�EI". T,[iS r� R ': a` `,�;4.�.� �dl fL..}�� 4t�1t''S � 1YAJ kc.t f� § •_ { r`. � �' lY N � . +;f3 .. 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 ®ANGER ZONE LITERATURE: yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine of 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 Building Permit Application i6 Certified Surveyed Plot Plan 16 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 OTE: 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 I ECC Energy code Engineering Affidavits for Engineered products 10TE: 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 4o 0 -P,� J 6 �,,, r, -1 M - No.�� Check # L J,062 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ O x Q U. O0. oui m � uv� \ O O LL E ) Q N N p V W z z m c O 7 O LL E t U N U- O U W z 0 zV m D d S O W LL O U W z J W to p w U N — C LL OC O w H z � UA p w C I..L z W Q W o LL 41 m Z U1 N + cu E N 41 0M O � v o Z W :�Q L a 1:m°' z _ C : ® ♦:`„-� z C U m < E COV 0L o� U)4 � � O m y U ® w Cl) �; W � so� 0 �H � - y :a CoQ c i<z. s w 0 -,�.�� �w tm > o c W J U.a L- ~ 0.z CL CL � CD 0 O y V O C = O Q (n O H Ouj:E m O ti •� � � m c O O ' r O W (, . L a C-) C o� !n d > ;� c ---� N a o O 1=- t 4- CL000 > ti w f, v O 9 E O o a z- C o A� a W Q y �Emm aI.- ca v co O � Q O Y� :3 M ca v J �CL O =z O CL V U) c U) 0 11 RISE Enginewing RISEA &Adw ofThkhch gnegawft 60 Shawmnt, C oa, SNA OMI 339.5024:197 �-�.»'...y-,1.�...._. i FAX33P4014115 PROGRAM Z t» s CMA HES CUSTOM Paw % Sf'13SSben Iacono + (97$2294 40 Meadowview Road an40 Meaduwvk%v Road errl.sr map u North Andover, MA 01 ice: i Feft RI r Rein No8,86 9ACOUb;aCtorRqft0WwftjftM CT ConbaftReafthation No IM20 CONTRACT pup I Tlpa T a Ealr� of tp aE7� p{gE 1��e��A0A11ORiTAa DATE Cum@ w O 1IWW15 405553 00004 snAms CM.D Wap North Andover, MA 01$45 JOB DESCRIPTION O -Pmpwd foram t'eat's WC8dWdZWW pfojecL Pdm and>g iWoCnfiM"panmtWj 00 BASEMENT C£RM. Provide labor and vasn b to install (44) limens feet of R-19 bmf wed fibughn fns to ft pauaeoer of the basentm odl'mg at the hoose sill. $77.00 GARAGE CflLB�[Cx Pcavide ia6orattd to ww r R-14 dmaebypaded pass i C I (720) sgme fed of garage Ceiling located below a hand Amuck by drilling ImkS m tk oa"biiog Som below Elates driffed wig be phW& flings be spadded and � bn a rd0vely S� contig �. Fmish s aft ad toxh-tip will be the e�om may, 51,332.00 RLSE wM 8p* alt bte,eligthle isoeatives tatldsaa t. YosTv& ou3ybebiiEsd t 11ars Cmtadty fhr mom' Col+aabia o� 75% • aorto exceed $2,� percdwAwM ad as bnopativeof 1009E ftdm Air Scaling mans UP to the fiat 5680 and an additions! SW ifsa&p wcjUsdW by thaaoditor. For the sa$t end health ofyow homes mdmakgaa q, no will be coadactiogablow door aosticoftheavailobkw flow your home bodk bdw the wait is began, and aft the w walk is compif, We win abso N Watt a fid toftite combustion safety of your beating system and water heater. This has avatm of$90 and is atao cost to you. ToteldWablawcagoftatiog incentive is Ski 10. 590.00 TateL. $1AW.08 FroBmm hweMive. $1,146.75 Cutremw Totalk $362.25 VVE AMM HERMTO FURIM tis-COMUM WACC01UW=VMeatnoveta .rptMMSUMof "'Three Hwldted Fifty Two & 269Q0 DoRmis $352.25 anmi Am/IaPROIra aria El w8T0 @AQa�amr�JgTAgalrro INw9LaliH�rOFISVIu6Ef ND"Mararan a aoou►to aaa vmasarmtaa errua paTicacr bra awns a000nwo mnecoT vam DOMFGMTMCOMRACTO TMMAREAMBLAWSPAM ROTA:mcoxmwrwwwvm4•RA=,Sy0l:ww,, V91. l DATEOFMMO ATM --57" _3 30 YTOUSA DIMI MOVA OMMMUM 10�aNIDOORaMIaARE o� sATa,rrDsaAemAmRraecET>TEo;.�+aREAvn�soTODDT�wo►a< 12SP PAVNEWvealaEeWASOUr" IDA$OVE I OWNER AUTHORIZATION FORM SP�o-d��tN l fl ct name owner of the property Located at hereby authorize �0 (Property Address) P, �(46ACIV�, (fUSSY3) (Property Address) S '%-cr- 1N)j� , Ivt-, an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date The Commonwealth of Massachusetts Department of Industrial Accidents F Offw of Investigations I Congress Street, Suite 100 4 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers &MAH&ant I&IMI ion�•r _ Please Print; gibly Name (Business/organizadon&&vidual): `q W YK% c6^ JaJ 4. 6n j \V4...• - Address: ?- 0 130X -344 Ci /S 04Wi U\ C"1 A 0 t4i 3 6 Phone #: 11 i• 3LU .1\1 6 3 Are you an employerf Check the appropriate box: Type of project (required): 1. M am a employer with 4. ® I am a general contractor and I 6. New construction employees (full and/or part-time).* 2. ® I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. Remodeling ship and have no employees These sub -contractors have g, ® Demolition workingfor me in an act y capacity. employees and have workers' comp, insurance. t 9, C1 Building addition [No workers' comp. insurance required.] 5. [, We are a corporation and its 10.® Electrical repairs or additions 3.[31 am a homeowner doing all work officers have exercised their 11.® Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs insurance required.) t c. 152, §1(4), and we have no 13.[3 Other employees. [No workers' coma. insurance reauired.l *Any applieantthat checks box #1 must also fill out the section below showing their workers° compeasadon policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue 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, f ob site information. Insurance Company Name: Nn,a.. i tk ri�v 111C,1J U , Policy # or Self -ins. Lic. #: NA, N K IL 7° 3 4 0 3 V+ Expiration Date: 10 30 }� Job Site Address: "i 0 P14— M-A—b t�4 1m c4i City/State/Zip: N,\-oAyyn f" o��uF 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. Y do hereby cen fy under the pains and penalties of perjury that the iq ormation provided above is true and correct. Phone # q a • 'I �' V Qricial 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 Penn: Phone #: AC01RLIF CERTIFICATE OF LIABILITY INSURANCE `� DATE(MMIDD/YYYY) 10/18/2016 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: It the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. It 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). PRODUCERCONTACT- MARTIN J. CLAYTON INSURANCE AGENCY INC ONT CT NAME:Me Munroe NAME:.. PHONE (413) 536-0804 a No: RS: mmunroe@mjclayton.com ADDIES 1649 NORTHAMPTON ST., RTE 5 HOLYOKE MA 01041 INSURERS AFFORDING COVERAGE NAIC # INSURER A : ACADIA INS CO 31325 INSURED GAUTHIER INSULATION INC INSURER 6: INSURER C: INSURER D; PO BOX 344 INSURER E; IPSWICH MA 01938 1 INSURER F. COVERAGES CERTIFICATE NUMBER: 94521 RFVIRInN N!IURRD. 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. fNSR TR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF (MM/nonlym POLICY EXP (MMOONM LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ A A T T-0- PREMISES Ea occurrence $ _. MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'LAGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT 7 LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acciderd BODILY INJURY (Per person) $ ANY AUTO AUTOSCHEDULED OWNEDALL AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB_H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE N/A AGGREGATE $ DED RETENTION $_ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVEE.L.Fr4CHACCIDENT OFFICERIMEMBEREXCLUDED? WA (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below WA WA MAARP300327 10/30/2016 10/30/2017 X STATUTE EH R $ 500,000 E.L. DISEASE - EA EMPLOYEE s 500,000 I E.L. DISEASE - POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space 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/twd/workers-compensation/investigations/. 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 MA 01845 Daniel M. Crovv)by, CPCU, Vice President — Residual Market — WCRIBMA ©1988-2014 ACORD ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD All rights reserved. ACOR0 CERTIFICATE OF LIABILITY INSURANCE 16...E DATE(MMOW" 8/12/2016 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. 1649 Northampton Street F. 0. BOR 989 Holyoke MA 01041-0989 NAME: C Nancy Usher PHHCONo Extt (413)536-0804 AM Not. (413)534-7874 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Nationwide Mutual -Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURER C : P.O. BOR 344 INSURER D: INSURER E: _ DAMO RENTED 50 PREMMISES SEs occumanaa_]$ 50,000 IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1663001850 120VICInKI w IaeDCD. 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. ILTRNSRTYPE OF INSURANCE A DL UBR WVnPOLICY NUAABER POLICY EFF POLICY EXP LIMITS A R COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR I EACH OCCURRENCE $ 1,000,000 DAMO RENTED 50 PREMMISES SEs occumanaa_]$ 50,000 I MED EXP (Any one person) $ 5,000 GL43487F 7/6/2016 7/6/2017 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: R POLICY u PRO- JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2.000,000 $ OTHER: I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1.000, 000 B EXCESS LIAR CLAIMS -MADE AGGREGATE $ 1,000,000 DED RETENTION $ EBU028251970 10/18/2016 10/18/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA PER T - STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) I yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below "UN OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Town of North Andover 1200 Osgood Street North Andover, MA 01845 TION 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 Sullivan/MEG O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD FTFPrdF6§tbd with pdfFactory trial version www,pdffactoa..com a ii o� OC OD W W—MC) :F��j 0< =Z 0U ��v3 aoc0,CO) �YTa