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Building Permit #681-14 - 80 LOST POND LANE 4/3/2014
4 Permit NO: Date I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page n LOCATION Print PROPERTY OWNER 1� Print 100 Year Old Structure yes no MAP NO: 1 _ PARCELLZI1 _ ZONING DISTRICT: Historic District yel no Machine Shop Village yei I no TYPE OF IMPROVEMENT. PROPOSED USE Resi ntial Non- Residential ❑ New Building leOrne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Others: ❑ Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer ur_0%.,Rir 1 JUN Ur Wumn I U tit F'tKFURMED: Identification Please Type or Print Clearly) OWNER: Name: ,t,ip Phone - Address: Losc- (&Uo LR,\ CONTRACTOR Name:4 Phone: alb -:2,14 -=;_q .2 Address: Supervisor's Construction License: Exp. Date: 3i., Home Improvement License: Date: Com' 29 - 2sz 1 ARCH ITECT/ENGINEER _ ( I 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: $ FEE: $_" Check No.: Receipt No.: 21�4 NOTE: Persons contractiQ with unregistered contractors do not have access to the gu fund Signature of Agent/Ownecgnature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ r` Plans Submitted ❑ -.Plans Waived -0 Certified Plot Plan ❑ Stamped Plans ❑ TI'PE -OF: SEWERAGF, DiS-P_OSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swi nmmg 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 .....-.DATE REJECTED DATE.APPR-OVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: : Gomments Z Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;-, Engineer: Signature: Located 384 Osgood Street FIRE DEPARTM °NT - Temp Dumps, ter on site yes no -Located-at 124 Mair Street. Fire Departmei f signatu'r'e/date"` COMMENTS L 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.$100-$1000.fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 F Building Department , The fol:`swing is a -list of the requlred.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 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 cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-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.Bui"ding permit Revised 2012 Location Kb t -A �✓�� s U - No. W" Date 1 Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $L— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building .l6spector 3 0 N a, V[ M W O O O O E2 .Q CL a� cua w o y V Q L � tm o � a o V N caca V L m a .r t t E o m oz CLCD MA O o tmn 3 c>0 QCLd CD CA CO) CL cn m W O -01- o O N W U Q Cf) w N -0 04- f- .$ CL 0 0 W O E O O N CL L W t d V ca CL V .CL N r_ V ca _m CL U) w ca jo 00 L C L- 0 CL � Q .F.. Cc ca J •0 O d Z N J 2 LL D Q m L N _0 O LL Em acu U ? O_ cu Ln O LLI Vf Z Z z 0 J O + 7 LL 7 K E U (O LL O N Z Z m � J d j Q: _ co LLd' 0 v1 ? Q U U W W t :3 U L Ln O LL Ouj F- U a Z y Q L :300 K LL z LU F - a W O W I1 E m O Z a) N v0 N v O v Y o In O O O O E2 .Q CL a� cua w o y V Q L � tm o � a o V N caca V L m a .r t t E o m oz CLCD MA O o tmn 3 c>0 QCLd CD CA CO) CL cn m W O -01- o O N W U Q Cf) w N -0 04- f- .$ CL 0 0 W O E O O N CL L W t d V ca CL V .CL N r_ V ca _m CL U) w ca jo 00 L C L- 0 CL � Q .F.. Cc ca J •0 O d Z N d _ = CERTIFICATE OF LIABILITY INSURANCE 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 NAME Cathleen E. Rossiter Farm FamilyNorth Andover Office PHONE (ac. No. Ex : 978 208-4713 bac, No 857 Turnpike Street Suite 133 AODREss. Cathleen. Rossiter@farm-fa North Andover, MA 01845 INSURER(S) AFFORDING COVERAGE Farm Fa=ly Casualty Insurance Company INSURER A. INSURED HRH Construction INSURER B 80 Campbell Street INSURER C North Andover, MA 01845 INSURER D: INSURER E INSURER F DATE(MM/DD/YYYY) 12/5/2013 (978)208-4716 ily.com NAI.. COVERAGES CERTIFICATE NUMBER: 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, enAV uevF nFFM RFnuCPn RY PAID CLAIMS. (NSR LTR TYPE OF INSURANCE x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR 05—L INSO R WVD POLICY NUMBER (MM/DDrYy'YY) (MM/DD/YYYY) LIMITS EACH OCCURRENCE S 1 000'..000 PREMISES (Ea ocwrrence) $ 100 ,000 MED EXP (Any oneperson) Sj ,000 PERSONAL &ADV INJURY $ 1,000,000 A 2001X0726 11/20/2013 11/20/2014 GENERAL AGGREGATE S 2 , 000 , OOC' GEN'L AGGREGATE LIMIT APPLIES PER: �[ POLICY J PE4 CT CI LOC PRODUCTS -COMP/OP AGG $ ], 000,00C OTHER: AUTOMOBILE LIABILITY SINGLE LIMIT $ 1 000, OR Ea acaden1 BODILY INJURY (Per person) $ AAUTOS IANYAUTO ALLOWNED SCHEDULED AUTOS X HIRED AUTOS X AUTOS WNEO 200104287-4A 3/16/2013 3/16/2014 BODILY INJURY (Per accident) $ PR PERTY DAMAGE (Per accident) $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 2001E1169 12/14/2013 12/14/2014 EACH OCCURRENCE S 1,000,00( AGGREGATE $ 1,000,00( _ $ DED I X I RETENTION S 10 0 0 0 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED (Mandatory in NH) Ifyes,desenbeunder DESCRIPTION OF OPERATIONS below NIA 2005w6827 12/7/2012 12/7/2013 12/7/2013 12/7/2014 I STATUTE I X ER 500,00( EL. EACH ACCIDENT S / E L. DISEASE- EA EMPLOYEE $ 500,00( EL. DISEASE -POLICY LIMIT S 500,0011 DESCRIPTION OF OPERATIONS ILOCATIONS /VEHICLES (ACORD 101. Additional Remarks Schedule maybe attachedlf more space Is required) Operations of Named Insured - Insulation and Carpentry Officer David Hope is Excluded CERTIFICATE HOLDER GANGtLLA I IUN 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, NA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2013 ACORD CORPORATION. All rights reserved. ACORD25 (2013/04) The ACORD name and logo are registered marks of ACORD HFH VWarn Hop 80 CAMPS NORTH Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super%i+or License: CS -057754 WILLIAM D HOP% 80 CAMPBELL RD N ANDOVER Mk 0184 Expiration Commissioner 03/04/2016 0mce of Co �Po�scmao�xoc�rrl o�'C acisu3em nsnmerAtfaim & Bus,nessRegnlation ME IMPROVEMENT CONTRACI.tegishaflomOR :101730 irai"ron:�.6l29I2Q�4 P _ Type.- date Corporatictn STRUGn NC - e'= EU M ANDOVER. MA 01845 Undersemfarg License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 r I i Net valid without si store The Connnottivealth of Massachusetts Department of Industrial Accidents = Office of Investigations - 600 Washington Street Boston, MA 02111 '4 >V•y. www.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Db _V16L Wk 6) &Phone.#: Are y an employer? Check the appropriate box: 1. I am a employer with 3 4. E] I am a general contractor and I employees (full and/or part-time).*. have hired the sub -contractors 2. 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.$ 5. Q 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' comp. ms,,, nce required.] -Type of project (required):. 6. ❑ New. construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0,Roof 1-3.2Othez '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 sub{ontractors and state whether or not those entities have employees. If thcsub-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:_ Policy # or Self -ins. Lie. M �S 1n 6b � Expiration Date: — — Job Site Address: ab lel �I'OUM City/State/Zip: M , 6)mxk_ SQA, 6)8qS Attaeft 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 iip 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 Investiz-ations of the DIA for insurance coveraee verification. Ido hereby certify under thgpains"agpA#alties ofperjury that the information provided above is true and correct: use only. Do not write in this area, ib 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/ToNvn CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: �i t s :'Yi I^IIS. mass savePARTWATI PERMIT AUTHORIZATION FORM uaNr CONTRACMR I, Gary Lafpnd , owner of the property located at: (Owner's Name, printed) 80 Lost Pondk*1NL" North Andover (Property Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. ."A'. <3 *" Owner's Signatu Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Rev.12132011 Date DfJQ For Office Use Only I . (%G Conser ation Services Group CONTRACT FOR PRODUCTS / SERVICE WORK This Agreement is made by and among Gary Lafond 80 Lost Pond Ln North Andover, MA 01845-1466 Site ID: 500002205411 Project ID: P00000210570 Customer ID: C00000215475 Contract ID: 20140131 WORK This service is brought to you through support from your local utility and (� Conservation Services Group (CSG) Attn: RCS 60 Washington street, Suite 3000 Westborough, MA 01681 Reg. No. 178484 Federal ID No. 222467170 (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these "Premises' in a professional manner and in accordance with the terms of this Contract; including the attached recommendations/work order describing the work in detail (the 'Work*) which are incorporated herein by reference: Description Quantity Location Attic Floor Open Blow Cellulose 5" v _ 6.50 , _ Living. Space _ _ _._ $632.00 Vent bath fen to soffit exhaust 2 Attic _ _ _ _ _ _ _$230.00 Damming _ _ 49 N/A _ _ $98.00 _ - - - — _ Sub Total: ! $1,160.00 Utility Incentive Share $870.00 Customer Contribution $290.00 MAR 12 1201 4 C For office use only Printed: 3/5/2014 Page 1 of 2 II. PAYMENT C} f Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price as follows: Payment #1: $ / • psT as a Deposit payable to CSG upon signing the Contract (not to exceed 1/3 of the total retail costs or, actualfTf ccLtt��I11 orders, whichever is greater). Mall check & contract to CSG, Attn: ECS, 50 Washington St., Ste. 8000, Westborough, MA 01581. FInai Paymet: $ 3 - as the final pnymer:t for the Work shaU be due and payable to the Independent Installation Contractor ("IIC") upon dory completion of the Work Customer understands that he/she will not be required to M the Utility Incentive Share of the Contract price in the amount of $ . The Utility Incentive Share is dependent upon the package purchased and/or prior incentive utilization. Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Shares III. DISPUTE RESOLUTION The ITC and Customer hereby mutually agree in advance that in the event that the DC has a dispute eorx=rdng this Contract; tIAUC may submit such dispute to a private arbitration service whichX7�0� bytheWit Affairs and Business Regulation and Customer Eto such arbitration aspnndded htb1.GL c 14M Customer. Contractor.You may cancelas been signed by a party ther;tola�tia'place`b r than an address of the seller, which maybe his main office or a branch. thereof, provided you notify the seller in w ing 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 sign' of this re ment. DO OT SIGN THI CONTRACT IF THERE RE ANY BLANK SPACES. g t� d3 o,e tV4' Con Sg,c m Inc . S e Date -indicalie your jelected IICere, if applicable (OR) Initial here if you want 5 ' l e-'4 J J) CC L k\ the Program to assign a Date Name of CSG Representative ted) Participating Contractor TERM AND CONDITIONS APPEAR ON TSE REVERSE. 1/13 (%GCONTRACTFOR Conser atlon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Conservation Services Group (CSG) Gary LafondAttn: Pond Ln `- RCS 80 Lost 50 Washington Street, Suite 5000 North Andover, MA 01845-1466 Westborough, MA 01581 Site ED: S00002205411 Reg. No. 178484 Project ED: P00000210570 Federal ID No. 222467170 Customer ID: C00000215475 (Mail completed contract to address above) Contract ID; ;20140131 ASEAL I. DESCRIPTION OF WORK TO BE PERFORMED Contractor willperform or cause to be performed the following work on these 'Premises" in a professional manner and in accordance with the urns of this Contract, including the attached recommendations/work order describing the work in detail (the "Work") which are incorporated herein by reference: Description Quantity Location Attic Stair Cover Thermal Barrier with carpentry ._ _ 1 _ .. _Living Spave ,$237485 Perform Air Sealing at Estimated 62.5 CFM50 Per Hour_ ` . _ _ _8 _ Living Space _ _ _ _ _ _ $616.00 _ Door Sweep _ _ 2 N/A _$42.34 Exterior Door Weather Stripping _ _ _ _ _ ^ _2_ N/A _ _ _ _ _ _ $60.40 Sub Total: $946.39 Utility Incentive Shan $946.39 Customer Contribution $0.00 OFf MR. For office use only Printed: 3/512014 Page 2 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 of special orders, whichever is greater). Mail check & contract to CSG, Attn RCS, 50 Washington St., Ste. 8000, Westborough, AZA 0168L Final Payment $ as the final payment for the Work shall be due and payable to the Independent Installation Contractor ("IIC") upon act%7 completion of the Work. Customer understands that he/she will not be required to pay the Utility incentive Share of the Contract price in the amount of $. me Utility Incentive Share is dependent upon the package purchased and/or prior incentive utilization. Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. 111. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Con the IIC may subunit such dispute to sprivate arbitration service which has approved by of Canayiner AWs and 13usrress Regulation and Customer to such arbitration as provided in MG.L c 142A. Customer. t/�(�Contractor. You may cancel t s ag a if it has been signed by a party there tO at a place o er 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 sig 90 f a ee ent. O NOT SIGN THI C NTCTARE AE A BLANK SPACES. a CC?Ol M 5 ruc ier7 tic. Gus m S' fe D lith yowl selected II here, if applicable (OR) Initial here 1f you want �assign orpating rogram Con Date Name of CSG Representative (Printed) TERM AND CONDMONS APPEAR, ON THE RIMPAE. 1/18