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Home My WebLink AboutBuilding Permit #688-2017 - 705 MIDDLETON STREET 1/4/2017BUILDING PERMIT ej, Lr TOWN OF NORTH ANDOVER -APPLICATION FOR PLAN EXAMINATION Permit No#: n g6I / Date Received j Date Issued: IMPORTANT: Applicant must complete all items on this LOCATION %a m It t`0 N qt .Print PROP%TY OWNER LLQ 0YOS cls Print 100 Year Structure MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Village yes yes /L8U .6�6ryQ H TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition ❑ Two or more family [I Industrial ❑ Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑ Assessory Bldg A Others: /k'n'ow ❑ Demolition ❑ Other -t�s� D Septic []Well ❑Floodplain ❑ Wetlands 11 Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Pie P4 - %/,t VI -It s Atr i c �h f e/rT H 7.0 Q- `�A 021>.6 9:hf o h DA W Identification - Please Type or Print Clearly OWNER: Name: Le o L a No vA a Phone: t)/- 361A Address: 7a s_ 0 %?) r). AN Al r C Contractor Name: ?rTz i l ,r ra v\_r Phone' Email: Address: J- 57- cDta:S rd w /I, o 3eF4_S Supervisor's Construction License: /06 e/7 Exp. Date: Home Improvement License )D1- i�- G Exp Date: r 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: $ /3 �U d d FEE: $ J Check No.: %,�? 7b Receipt No.: 144 NOTE: Persons contracting kith,#nregi (eyed contractors do not have access tto)thy guaranty fund 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 ,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 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 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 Doe: Building Permit Revised 2014 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 -'U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes x Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street T,FIRE DEPARTMENT , +� D rffi �':n site?�y i yes Tem tero � „i l;Located at124 MainStreet s �+ 2 �Fir�e Department�signature/dater- t k., � k•� i ++ -� t = 3 "+ fir .. 3 fi� �� q 1 ,, r 'e s`�-!i "376 + Y" ,qy..- _....�- ��.r� — r..�, �' + i .may .. ,r r ::t• s �} .+3 °� %s+ � + 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 Z®NE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Pennit Revised 2014 Im— Location No. Date Check # 31 401 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ��` Building Inspector _v C � N n a 0 CD � 0 CL 2) �o 0 v �. MQ o C�= CD O �o oo m CLO U). � v 0 CO) z CD 0 O CD 0 9 v z z ca 0 z ''2 ^ mA V/ C o O 1 o0 0- =� _ —DI � `°• L0 CD n O 00 r.L C.) � ;� z o• =r =r., O o O .•o. 0 m W CD N rt Cl) N C•cOp� <D 2 0 (D (Q• y Q O '�°':O O O CO's W S�0 CD ,!o AL -1 0 O 7• o <(a: o0� CD :A -� O o o -9 a o D Q. 0� < Q- O v, CU)CD. - U) CDN ' C r in Q% N 0 0 �• 0 c A 0 e•t � CD: rt 10 y �D � N o °, RrN CD m "o O n' 2) o Q : N O (D r L07 rD �'�' Z C T mz D m z T x S Z Ln O T ID N fD fD .Z7 OCO S m mc D r m T x m S V Z G1 m T n 7 ro x UQ 3 T 7 Q lu j C M CA M m N f'f N N 3 T Q S � W ° O m O �P x 4c 3 This agreement is made by and among: Leo Lopiano i R 705 Middleton Rd North Andover, MA 01845-6341 Site ID: S00050267105 Project ID: rD: 05030 268 HoMeWok Customer ID: 000050268885 Contract ID: 20161203 WORK ripI fir` iI 68 Cummings Park Dr., Woburn MA 01801 Office: (781) 305-3319 Ext. 120 Contracts can be sent to: inboxhomeworksenergy.com Description Quantity Location Propavent Z or 4V 36 Attic Attic Floor Open_ Blow Cellulose T' 554 Living Space_ Vent bath fan to roof flapper _ 1 _ Attic _ Damming A 100 NIA Sub Total: Utility Incentive Share Customer Contribution 6 $137,88 $847.62 _ $129.21_ _$219.00_ _ $1;333.71 $1.000.28 $333.43 Pana 9 of 9 HomeWorks Energy agrees to perform the above described work, furnishing the material and labor for the listed total price. Payment of the customer contribution is expected upon completion of the work, Customer Signature: ? Date: J-2/3 Cell Phone # (used forscheduling purposes only): Contractor Signature: Date: I'D LIMITED TIME OFFER: The prices and incentives offered in this contract are subject to change in accordance with the sponsoring utility Mass Save Home Energy Services Program offers. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl POLAR BEA N Name (Business/Organization/Individual): PO BOX 958 ANDOVER, MA 01810 Address: Phone #: Are you an employer? Check the appropriate box: 1. N I am a employer with 4. ❑ I am a general contractor and I _(!!5p_ employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are 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 c. 152, § 1(4), and we have no employees. [No workers' coma. insurance repuired.l F1- CTb-s/JPs_ Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. F-1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #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. tContractors 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: V A K,- Z'n S v f G W ro 61 M Q4 N% — Policy # or Self -ins. Lic. #: C7W C y 03 (i/ Expiration Date: at 0 Job Site Address: 7,05— .__ r`. -f d City/State/Zip: ►'� , ,�,.d0 J t i , 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 thLpains, andpenalties ofperjury that the information provided above is true and correct. Date: Phone #: qPF^ L%6;> >r.3b Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: 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 #: 1/3/2017 Insurance Services ACORV CERTIFICATE OF LIABILITY INSURANCE 01/0TE 3/ 017 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 endomement(s). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. FAX PHONE Ext): Arc Noy ADDRESS: 1 Adp Boulevard Roseland, NJ 07068 INSURER(S) AFFORDING COVERAGE NAIC S PREMISES Ea occurrence $ INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC PO BOX 958 INSURER C: INSURER 0: Andover, MA 01810 INSURER E: AUTOMOBILEUABILITY INSURER F: COVERAGES CERTIFICATE NUMBER: 599370 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 AUUL INSD 5Ut%K WVD POLICY NUMBER POLICY EFF MWDD POLICY EXP MIDI! LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE EIOOCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ MED EXP (Anyone person) $ PERSONAL & ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: POLICY ❑JET LOC OTHER: GENERAL AGGREGATE $ PRODUCTS -COMPiOPAGG $ $ AUTOMOBILEUABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS D HIRED AUTOS AUTOS Eaaoddent $ BODILY INJURY (Per person) $ BODILY INJURY (Per aodderd) $ Per accident $ UMBRELLALIABOCCUR EXCESS UAB CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERT LIABILITY OFFICCEE MBEREXCLUUDED?ECUTIVE YIN (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N POWC840361 01/01/2017 01/01/2018 �(PER STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYE $ 11000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached Nmorespace Is required) Contractor License: CSL 106017 HIC 102726 NGR I Irl{IN l C f7VLYCR LA19 V CLLA I I%JM Town of North Andover 120 Main st North Andover, MA 01845 ACO RD 25 (2014/01) 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 The ACORD name and logo are registered marks of ACORD https:lladpia.adp.coml[SExtemal/app/index.html?clientid=20373MrequestFrom=run#/home 1/1 '`;O R0® CERTIFICATE OF LIABILITY INSURANCE DA ioM� 0 6Y) 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 endorsemen s . PRODUCER CONTACT Linda danowicz NAME: BOg PHONE(603)382-4600 FAX NO: (603)382-2034 Insurance Solutions Corporation EIIL..Iindab@isc-insurajice.com 60 Westville Rd INSURERS AFFORDING COVERAGE NAIC a# INSURER A.Mestern World Plaistow NR 03865 INSURED INSURER B Nautilus Insurance Group INSURER C: Polar Rear Insulation Company Inc PO Box 958 INSURER D: INSURER E: UPP8274967 Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBERCL1632326134 RFVISInm mnuRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDING 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 INSURANCEADDLSUBFI POLICY NUMBER POLICY EFF M Y POLICY EXP YY LIMIT'S A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE To RENTED 100,000 PREMISES Ea occurrence $ MED EXP (Any oneperson) $ 5,000 UPP8274967 3/24/2016 3/24/2017 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: RO- POLICY ECT r LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) P i ( t) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accide $ $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 B EXCESS LIAR CLAIMS MADE DED RETENTIONS $ AN026107 3/24/2016 3/24/2017 WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y/W ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? El N/A STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Town of North Andover 1600 Osgood St, Ste 2032 North Andover, MA 01845 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 th Maglia/SJAf�jC--- @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025r7m4nn w r Office0 E IUE - Affairs and BilsinessRic gopliation - 5170 Boston, Massachusetts 02116 Home Improvement C-6atractor Registration Regisft ion: 102726 Type: DBA Expiration: 71=18 Tru 419291 POLAR BEAR [NsuL4TiON CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 - - SCA 1 0 20td-W11 J1c `r�nnr�a�a»roea/lfi af'C%l�lnt:;a�nsctl� OIDee of Consumer Affairs & Business Regatation - HOME IMPROVEMENT CONTRACTOR Registration: 102726 Type: Expiration: -712/2018 DBA POLAR BEAR INSULATtON Vincent LeBlanc 51 SO. CANAL ST -NA :��,�_�«,, LAWRENCE, MA 01841 .Undersecretary Update Address and return card. Mark reason for chaugm F] Address C] Renewal [] Employment Q Lost Card I.ieense or registra#on varid for individual we only before the expiration data If found return to.- Office o:Office of Consumer Affairs and Business itegakition 10 Park Plaza - Sift 5170 Boston, MA 82116 Riot valid without signature Massachusetts = Department o` Public Batty Board o; Building Regulations and Standards Clinstractior, Super; Nor Specialty 'se: CSSL406017 :' = PETER A LEBLANFC 2 EASTPINE STREET a . Plaistow NII 03811.5 R - =xp►ration Commissioner 04/28/2018