HomeMy WebLinkAboutBuilding Permit #383-2017 - 478 WAVERLY ROAD 10/11/2016 l
A W -6t BUILDING PERMIT N°oT"'°qti
I TOWN OF NORTH ANDOVER o?
� -
APPLICATION FOR PLAN EXAMINATION i
H
Permit No#: 90/7 Date Received /0 o' w& TED
�gSSACHU`����y
Date Issued: /10
IMPORTANT: Applicant must complete all items on this page
LOCATION �_ �(g U_)aV(Dkj 1100
Print
PROPERTY OWNER Ryn,i a Ml'o 0.;'11-jo'ft, I
' Print 100 Year Structure yes no
MAP tiL PARCEL: L ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
iteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed, District
❑ Water/Sewer
DESCRIPTIONIF WORK TO BE PERFORMED:
z'
Identification- Please Type or Print Clearly
OWNER: Name: ( 0'_ h Phone:q IS- 0 Z f • X13�0
Address: i LY 1
Contractor Name: O✓f r Phone: OtIrb IS • Y6 3
Email: % ; A " aY) ) 0�0.i
Addres � d�_E fi
Supervisor's Construction License: C01—S-61- Exp. Date:
Home Improvement License: Exp. Date:
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.
Total Project Cost: $ ?-,()7,1 .14 o FEE: $ 30
Check No.: 9.9Q1`7�' Receipt No.:_...3/0 /`'
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Sianat PrP of Agent/Owner Signature
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art Swimming Pools El❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
I
HEALTH Reviewed ori Signature
f
COMMENTS
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date DrivewaV Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
-
' FIR EDEPARATMENiT Tempi®umpster onsite eyes. ..� � < no ` $
Lo'gated at1�24MainStreet, t ' I -
a � `r a
F,ire'Departmentsignatur�e/date { �� „
s ..,.,s,x-,.* .--nr K
j t
C MMENTS° - u; 4
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
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
it
LI Notified foricku Call Email
P P
Date Time Contact Name
Doc.Building Pennit Revised 2014
i II
r
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
�I
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
aPhoto 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
;6 Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
4h 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
Doc:Building Permit Revised 2014
Location 4179' by A V F pe f I-
�
No. 3f 3—a o 17 Date
f
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check.# V`r
r. f ' Building Inspector"
r 7 - r NORTH '9 I
6 . .. .c ve,
O
No. T
C+0�hh
ver, Mass, /a • 1 - 016
Ab COCI.ICKl WICK
CRATED
S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT �V RT � BUILDING INSPECTOR
has permission to erect .......................... buildings on .....!7.g...w.My!��� �b
e Foundation
Rough
to be occupied as �' ~ ... ... .......... Chimney
............. .......... 1 .........................�.................................�+
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the,Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI START Rough
L . ... Service
....... ... . . ................ Final
......... .....
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final T
No Lathing or Dry Wall o Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Federal 10#05-0405629
JUSE 1"11"ineerig-14, RI Contractor Registration No 8186
MA Contractor Registration No 120979
RISE di%isioll of,j.hiCINCII Ell"illecrill., CT Contractor Registration No 620120
60 Sh:m mill.Canton.MA 02021 CONTRACT
331)5
' "07-5-
- 197 FA 339-5024,34-3
Page I
;WF CC%TRACT iS V;TO VLfW7L%INSE
AND THE CUSTO'ER FOR V.-ClIK
if ..
PELO117
PHONE CLIENT WORK ORDER
13cil.jaiiiiii Camphell (917S)62 1-7910 1 1,2W201 5 419692 00003
SERVICE GTREETDIL(If4f;MPTEI
47S Waverk-Rw<l -17S Waveriv Road
SERVICI,CIIY,SIATE.ZIP UILU:;G
Not-Ili Aiiclover. MA (118.1.5 North Ati(lover. MA€11"145
-----------
JOB DESCRIPTiON
Ill 1ASI- 11\'r)-Proposal fill next-,car's ploiccl.Prices and pro.,%.un illccllliw,s[fill:_,Ilaralllccd
,Z0.00
\',.\I I,S hirniA and install bitmil in C hs s I Ccilillow It!111111) quare 1iet of:,hill,!-'IC and or clilphoard cxleflof the bull of the 11131%:f
COMtC 01\0IIr VM)d 1411;11t i�Litt it)dlih hk,ics info life r all"Ilcathill'u,I":11irld. I lit:hoiv,alc liml phlygvk):tfld;;I,: i"
11',1112 11;lit)less,;feel finish flail, (ouch-up pailltllw.. %%ill K:the cli'lollicir" lllwicill,: .Nill l� lfl upon completion of
11I.Malhilloli. Subsequent it,wor patiIIICIIL,is an'Ititicti ,cr%icc.RISE hlnillecrin!!"ill Icillfal \%,::filter licrillil',tel chw,71,1,0rant, Noids
%t fill an inl'rarcd scanner. AU: major%oid.,v that imly be 101fild x1ill he filkd at fill;idtlil it's 1:11 cu.v
51.931.40
RISI:Fwlincering a ill apply:111 npillicable,Cli!!illlc ificcilliv"to Illi,Contract, You trill olll\.he hilted tit;:\.cl:imoifnt. Ctfircnil%%for cli,�ibfc
Measures,Colwnbizt Gas oflei,T;",,inecmixe.rull Iklc%ct:,:d 1,21100 triccrililte of Ior life Air Scallnt_,incaN'ljlcs
up If,the Inst%"li and:III ad61111-11MI S110 i1`-1.i\i112'1 s110 JDAiiiedlY,lih!auditvi.
for life ateti and licalill ill,wtir hollic,",illdilor;w ljllali[R_%,tc%%ii]lit:coildiscilliga 1,14met dool diagrfoslic of clic 3%ailablc air lit",% Its will
home 1)(411 hdore life t"olk Is :ind nficr the Nwrk is compicic,%%c%I ill:tkfl conduct a hill 01,111":
colill'u<61,J) .')I el*\ of,\ow bczfliv�,,1.%sleyll.1113(1 cN:Jler fivalvr Hiss has a%alticol-S110:still I..!!1w voczj Itl\vIl. ljI,fI1:lIlh-
iliccilli,tc is S )(I-
S90.01)
Total: $2,021.40
Prograrn Incentive: $1,538.55
Customer Total: $482-85
VIE AGREE HEREBY TO FURNISH SERVICES-COMFLETE IN ACCORDANCE VATH ABOVE SPFCIFICATIONS.FOR THE SUM OF
"*Four Hundred Eighty-Two&851100 Dollars $482.35
UPON TORr?.*.ITA�',OU.'ii*t)tJr--ITI;tJLL.1?111:iiESI OF I'WA 1.W
UNPAID q,,I1,UCr AFTER 3a nAY.,.SEE REVERSE FOR MAPORTANT INFORM floss Of-'GUARATITEE-5,Rt:11THOF RECIS!O.N.fCHED1,11-J':G.AM)CONTRACTOR REGISIRATIOU,
DO NOT SIGN THIS CONTRACT IF THERE AR[-;7JY BLANK SPACES
, . ......
AU VEO SiG'IATURE RISE.
011.11:(If ACCEPTANCE 1_/
VP 1.
ACCUPLANCEOF GCNITIACt AftoVF�fTP.I-:S.GP/ECiF.tCATfCJFIS ALIUMMITIMS ARE
30 DAYS.
R .J)Ta no Tf(E
AS W It E C I f I S 0.PAY?"E 14 T GALL UE?.*,A 1)U A!;Of J I Ui.EIT A 9 07 F
(00-n-
OWNER AUTHORIZATION FORM
Benjamin Campbell
(Ownees Name)
owner of the property tooted at
478 Waverly Road, North Andover, MA 01845
(Property Address)
478 Waverly Road, North Andover, MA 01845
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to art on my behalf to obtain a building
pemrtit and to perform work on my property.
S Signature
Dat MOM -
,� 22015
,4ctE;Roe CERTIFICATE OF LIABILITY INSURANCEDA1a(NWDOIYY
oen2nole
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
.CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the Pollcy(les)must be endorsed. If SUBROGATION 18 WAIVED,subject to
the terms and conditions of the policy,certain polloks may require an endorsement. A statement on this certificate does not confer rights to the
Certificate holder In lieu of such enclorsome s.
Paoouua Kalil n Do sh
MARTIN J.CLAYTON INSURANCE AGENCY INC PH 413 sae oeo4
a& Ede da .00m
1840 NORTHAMPTON ST.,RTE 8 AFF E Nue s
HOLYOKE _ MA 01047 MsuaaR ; ACADIA INS CO 31328
MSURED
eft D:
GAUTHIER INSULATION INC e
Play o
PO BOX 344 R
IPSWICH MA 01938 t
COVERAGES C RTIFtCATE NUMBER 78783 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES QF INSURANCE USTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POY PERWD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WLICHICH 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.
TYPR OP ssURMCM mmNyMsERLaArte
COUM RMALOENMALLUWLITY
� EACNO URRENCE {
CLAw1S ADE E]OCCUR
Meow ono Peon
N/A PERSONAL IADVOWRY 13
6ENL AOdRewTE pLIMIT APPLIES PeR: GENERAL AGWWGATR to
Pq,ICY❑dECi O too P T,4L�f�OIAP/CP 40
t
AUtOMpaoeLMaIUTYEUMH i
ANY AUTO SOORY INJURY(Por Pe ) t
All OWNBO aCHECUCFD
AUTOa A11T�NE N/A BODILY MJURY(Pw w4sm%)e
HIRED AUTOS CAUTOS Z i
UMaptLL UuOCCUR ACN OC RRENCE t
"CUOLw CLVMS-MAZE WA AOGREw {
WORKERS COMPENSATION
AND EMPLOYtM'UASaM Y N
A ApNFPIYPRCErMACM &JOWEE 07 seri WA N!A MAARP300927 10/30/2016 tOt30/2018 El.EA ACCIDENT s 6W,000
IMPndarwy In NH! eA.DISEAs .EA EMPLOYE 800000
S yPs,w un
ESC 1.omaAsa.POLICY rr 500,000
NIA
DlaCRrATgN O/O►BaATx)Ner LOCATIONS/YENICIat(ACORO/01,AtlGWmI W,nnM OCNwuM ergo uuoMtl Rmon rPreoNrrp,nndl
Workers'Compensation benefits will be paid to Massachusetts Employees only.Pursuant to Endorsement WC 20 09 09 8,no authorization Is given to pay
Claims for benefits to employees In states other than Massachusetts if the Insured hires,or hes hired those employees outeldo of Massachusetts,
This Certificate of Insurance shows the policy In force on the date that this Certificate was issued(unless the explration date on the above policy precedoe tie
issue date of this cat e of insurance). The status of this coverage can be monitored daily by accaasing the Proof of Coverage•Coverage VerIE=n
Search tool at www.mase.gov/lwcVwO"wM-WmponlatiOMnyestigationN.
CERTIFICATE HOLDER CANCELLATION-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1200 Osgood Street
AUTHORMED RSPRESENTATIM
North AndoverI MA 01845 "'`C.'
Dan WI M.Cfq�ey,CPCU,Vice President-Residual Manuel-WCRISMA
®1088.2014 ACORD CORPORATION.All rights reserved.
ACORD 26(2014!01) The ACORD name and logo are registered marks of ACORD
The Commonwealth of 1lassachusetts
Department of Industrial Accidents
Office of/n>restigations
I Congress Street,Suite 104
r Boston,1A 02114-2017
' yttWW%mass.govIdla
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumhers
Applicant Infonanation Please Print Legibly
Address: V 013 0 x l i 4
CitY State!Zip: i 3 Phone k: 3 `'L • 34%3
Are you an cmploy-er`'Check the appropriate box: Type of,project(required.):
LK I am a employer with S 4. Q l am a general contactor and i
employees(full arnd,or pati-tithe).* have hired the sub-contractors 7. �Ren xicli construction
t, 1 am a scale proprietor or partner listed on the attached sheet. �, �Rct7actticling I
ship and have no employees `i`hesc sub-sett€teractors have g. ®Demolition
e+orking lair me in any capacity. emploi'i:es and have%vorlaers'
9. [ Building addition
[:pct%vorkms' scamp, insurance corn).itasur nce.•
rcc1 uircd. {. [ We are a corporation and its 10.0 Electrical repairs or additions
1
?. I am a homeowner doing all work officers have exercised their I I.[]Plumbing repairs or additions
Tell: �t7 wzarkern"dant right of exemption per XIGL
my [ p- l 2.[]Roof repairs
insurance required.)` c- 152,41(4),and we have no
employees_ (No workers' 13.0 tither
comp.insurance required.}
Any appliean:that checks box zo Trus also till oui the secuwr belou shcu'iIl¢their w'afka r5 cerr tsr�zr�pi litF'rash:=�erte�h.
Namcnwmcm u n suhmrit this af#idatiit n*dicati-T they are domzgall work=4 d than him oumidc cm-race-Rs mutt suhmst a new a f!ida%it indurating such.
=Cvntracturs that check tits bot must arached'an addi;ttrul 41et1 shouin�the narTr ;i:su static u'hrter err 110 t rC crtttae=hate
e mptttyi; . t,`'thc>Ur ti4cttTb>3r5 ha eml tmrss,t to nus": roF d:S}ter utr;lr s'coat -l ulict t:untt t.
I am an emplo;rer that is pros iditkq n»rkerc'compensation insurance for my employees. Below is the polish acrd job site
information,
Insurance Company 1\ame;_���`� _ ����►���.n� t �.�-?.- f
Policy t or'Self-ins, Lic. #_n.[-? Expiration Date: k 0 3 1 ti p al I�
Job Site.address:�� �v e� W1 L CimState-Zip:N�,0 0�e t"_.1�
4
Attach a copy of the workers"compensa'it on policy declaration page(showing the policy-number and expiration date).
Failure to secure coverage as required under Section 25A of NICL c. 15'can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and or one-year imprisomnent, as wc1l as civil penalties in the forth of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the%iolator. Be advised ghat a copy of this statement may be forwarded to ibe Office of
Investigations of the DIA for insurance coverage: verification.
I do hereby certify ander the pains and penalties of perjury=that the information provided above is true and correct.
ttmatare: _-. t3art*: 00 l V
Official use only. Do not write in this area,to be completed by city or tnxn nffcial.
City or Town: Permit/License�
Issuing Authority(circle one):
I.hoard of health 2.Building Department 3.C ityffown Clerk 4.Electrical Inspector 5.Plunmbing ll.nspector
6.Other
Contact Person: � Phone#:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massac setts 02116
Home Improvement t ctor Registration
Registration: 173410
Type: Individual
Expiration: 10/1/2018 Tr* 291320
KURT GAUTHIER
KURT GAUTHIER a
119 COUNTY ROAD
IPSWICH, MA 01938 "
f9 syv Update Address and return card.Mark reason for change.
SCA c5 2oM-os�ii [] Address Renewal ® Employment Lost Card
�ze�anrmiarec�o�C�/�aaaaa�ivaak$ � I '
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
s Registratio •3410 Type: Office of Consumer Affairs and.Business Regulation
Expiratl u.F`_, _ !x(18 Individual 10 Park Plaza-Suite 5170
_- Boston,MA 02116
KURT GAUTHIER
KURT GAUTHIER
119 COUNTY ROAD'.
Massachusetts -DepartnIent of Public Safety
Board of Suifding Regulations and Standards
t`c,r�Yrru�litrss�a�e.7°�r.rr �,�st€aattbr
Licensee:CStSL-lOM, 2
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