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HomeMy WebLinkAboutBuilding Permit #641-2017 - 84 BRENTWOOD CIRCLE 12/14/2016Permit NO: Date Issuec I-2�o1 BUILDING PERMIT 3a °'�.``. ;�c TOWN OF NORTH ANbOVER APPLICATION FOR PLAN EXAMINATION Date Received k ILA IV RTANT: Applicant must fi PARCEL Y ",;ZONING,DIST all items on this Flistork Machir Village ayes ;rib, r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N.One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Sepfic � ❑�1JVell Q Floodplain i C" Wetlands ¢ Watershed District * �.�❑"Water/Sewer fi > OWNER: Name: Ai Identification Please Type or Print Clearly) -7 u.SAIn _�S�mQ to Phone: !91 - &,g(e - &!moo ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED O T ED ON $125.00 PER S.F. 11I Total Project Cost: $ "t 00FEE: $ Check No.: Receipt No.: 727) i z, ?4 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund �...9 afA a ': i nature g nt/Ownerx 4 ,.1:kSignature of'contrctoG5 F BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family El Addition 0 Two or more family El Industrial 0 Alteration No. of units: 0 Commercial 0 Repair, replacement 0 Assessory Bldg El Others: 0 Demolition 0 Other 0 Septic- '11- ell OFIO6dplpin­ [1WetIaa`Kd4' 91 Watershed District . Elwat&ls e -w' er."- JA DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly' OWNER: Name: Address: Phone: Contactor Name' Ph0he- -- Address _ S- 006-rvisbr?§,. q-6`h-9tf ubtibri, L ig- 44i 6 Improvement License Home : 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. 1, Project Cost: $ FEE: $ IE Check No.: Receipt No... NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund t ge `11,0 _Lig , qj�� of A . n wher sianature of cohtracto*f' 0. CD CD 0 O O 0 N —I — r Q Q w CD `0 2) 0 0 -n m 3 3 _ � 0 Z -nm O O CD cn 3 O In CD c Z m O CD m CD = Z 6s 6s 64 G O m m Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ " Stamped Plans ❑ TypE bF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi,nming 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 Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Signature COMMENTS s t HEALTH COMMENTS Reviewed on Signature y Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Wafer & Sewer Con nec#ion/Si_qnature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -.Temp Dumpster on site yes, Located at 124 Main Street Fire Department signatureldate COMMENT Located 384 Osgood Street no -Mmension 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 21 A —F and G min.sloo-$1000 fine 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o 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 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 Cor—tract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 r O v O z 0 �h CD N 0 c0 0 c0 CD to 0 0 N S CD N O = � O _ �`DCL CD0 CD c-> rtrt�c� 3 U) v> rt CDo. O O r+ Q -- y CD O W c0D V N O —I CD 2 c� 0 m a O O co CL _n ,0 0 S rtSm CD CD -a o c c0 0(n O 0 = �(n"o z CD — aCD S CL o °—'T to 0 CL — N < CD N .� CD CD C W � '< <D SU'a0 as - CD 0 0 0 LA0 O O P g: CD U) C 3 CD y aCD - O o as - CL - no O 0 r7 OZ v T T D m -O d O 5 H N 'OZ m P1 O T d Nl G r) y T r- n � r H m 0 v Z7 C QO r C W Z M Z N m 0 -n ii S mG .a T O 7 O O W C v z Z m 0 In (D L rN+ T O Q S 3 C � O CD CD 0-0 Z: Z '0 Cram' r -m A) m ;o =r o It Cf) — � > to 0 O � z� vCD `° �� CD O m �• c to cr 0 - S -0 CD o � O )--1 ic 00 00 9 O CD fi Z .L 5.0 CD CD Z Y v l� Z CD C4 O a m O O O v O z 0 �h CD N 0 c0 0 c0 CD to 0 0 N S CD N O = � O _ �`DCL CD0 CD c-> rtrt�c� 3 U) v> rt CDo. 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PoRdalZr M aim 1=9 gar kyWdR-XCbmea I OdktloseMW to(1128)sgnmof00tofgma* OPOL IOO=NGCWrWOATTICHAUM7'OSMALL.FOUNDVF!B®MLASL S1.4GM KNEWALL&PmMftdm"WQwOWb=dbwWmtDQMqmjmd Imenvomm1welcumasSBYL[t3iiC8ilAP'Ii8ANDBAMGPK46MBMROOMVAUL-M S448A0 A1'RCACC88&t�torMolat�araada�$It►kt�aq(i) ttew�tm�at�Oad.ai@�r�d7�mezl,osat,w MbSP osa0oe bt& PeTa00000tandlarpalott:aotio0tudrd. SiISAD VSNTRAATIONahovld0tatarat�oset atoleslailt+eadtatlonatpamto(4�raR�bagstot0elaeelaatrUt♦ar. S84A0 LMMM TCmtzoPtat44elebarandt<ta0IIItoto04ait(M§ftff%ddRrt9entf@aad1Ragteasi �ttapat6�4x d1tobX9mMcdrkaa1dwb=s1L S U70 to° ,, �~1 rural to a; asaaostlx4 RISE Engineering in contractorR"IIsball0on No 18Z097a A division orl blehch Engi wring 60 Shawmut Unit 02, Conton, MA 02021®��®�RA �� 334-502.6334 FAX 339502.6345 Page 2 PROGRAM CMA -HES oeae i wtxeauaro�xrox wwaAa oA Jason Eastman (781)696-6790 11/13/2015 406774 00003 84 Brentwood Circle B4 Brentwood Circle C . A North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION RISC C•ngincering will apply all applicable, eligible incentives to This contract. You will only be billed the Net amount. Currently. for eligible measures, Columbia Gas offers 7S% incentive, not to exceed 52,000 percalcader year. and an incentive of l00% for the Air Sealing measures up to the first 5680 and an additional $340 ifsovings are Justifled by the auditor. rar the safety and health ofyour Win* indoor air quaihy, the will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun, and alter the weatherimtion work is complete. We will also conduct a Rdi assessment of the combustion safety ofyour heating system and caner heater. This has a value of S90 and is at no cost to you. Total allowable wcatherimtion incentive is 53,110. S90M Out 1. 6%r,14Vr5 04" Pt 6-7l, L - Total: $4,002.70 Program Incentive: $3,109.99 Customer Total: $892.71 WE AGREE MERMTO FURNISH SERVICES-CDMPLM tN ACCORDANCE WffH ABOVa SP=UgCA7tONH. FOR7HE S= oP ***Eight Hundred Ninety Two & 711100 Dollars $892.71 {ATF�Aro 3�DOA �uvoaaru,ou�aaA�araes.oRa�ur�°FarN�o.a" ro�eetrrnAeioaaae°°�4isravA� a Noir sioN THIS commoT IF M ARE ANY BLANK SPACES UUMTr08COMRACTNIAY MWMWAwN STUBIFNOT61NCOrioMM OATBOPACCO A M II ACCMPL4GFCOMnACT-TNBAaOVBPFJMBPECMUTIMMANat014MIUNOARa 30 DAY& BATRI FAYa�BrrVml6aKMAaO�R!®YWWdORMI000TIM ORK L A � 0 OWNER AUTHORIZATION FORM i, -i-,J aso1d kgsT Ma tf - owner of the property located at ;q -y (mp" Address) • 1���/� UP,�, �2�• �Ls14rs (llopelty hereby authorize C�1�► � s � 1�h� h an authored subcontactDr for RISE Ertgtneering, to ad on my behd to oto a buKmg permit and to perform work on my prop". — �-41 L, -t:) OwIr m lI A�L�'iSi Date . The Commonwealth of Massachusetts w Department of Industrial Accidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual): Builder Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03060 Are you an employer? Check the appropriate box: Phone #: 603-324-1984 1. ®I am a employer with 100 employees (full and/or part-time).' 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] In I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance3 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. E] Remodeling 9. ❑ Demolition 10 Q Building addition 11.0 Electrical repairs or additions 12. Q Plumbing repairs or additions 13 . ❑ Roof repairs 14.®0ther Weatherization Any applicant that checks box ii 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 -contractors and state whether or not those entities have employees. If the subcontractors 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 thepolicy and job site information. Insurance Company Name: ACE American Insurance Company Policy # or Self -ins. Lic. #: WLRC 48151553 Expiration Date: 6/30/2017 Job Site Address:6"^ Ct0CLe City/State/Zip: 4almr,AIP 0(51 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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. Phone #: 603-324-1984 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A� h® CERTIFICATE DAT101520,16YYY, OF LIABILITY INSURANCE INSD 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Central, Inc. Southfield MI Office 3000 Town Center Suite 3000 Southfield MI 48075 USA CONTACT NAME: (PAH1 No. Ext): (866) 283-7122 C. No.: (800) 363-0105 E-MAIL ADDRESS: X COMMERCIAL GENERAL LIABILITY INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Old Republic insurance Company 24147 TruTeam Builder Services Group. Inc. d/b/a Quality insulation A TopBuild Company INSURER B: ACE American insurance Company 22667 INSURER C: 110 Perimeter Rd Nashua NH 03063 USA INSURER D: INSURER E: INSURER F: 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD Exp MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MW2:Y EACH OCCURRENCE $2,000,000 CLAIMS -MADE X❑OCCUR DAMAGE ToRENTED PREMISES Ea occurrence)$2,000,000 MED EXP (Any one person) $25,000 PERSONAL BADV INJURY $2,000,000 GEN -L AGGREGATE LIMIT APPLIES PER: X POLICY 0PRI- JECT LOC GENERAL AGGREGATE $4,000,000 PRODUCTS - COMPIOPAGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MWTB 307519 06/30/2016 06/30/2017 COMBINED SINGLE LIMIT Ea accident) $5,000,000 BODILY INJURY ( Per person) X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident X HIREDAVrOS X NON -OWNED ONLY AUTOS ONLY UMBRELLA LIAB R OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED I IRETENTION' B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR I PARTNERI EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA WLRC47860180 All other States SCFC47860209 06 30 2016 06/30/2016 06/30/2017,PER 06/30/2017 OTH. STATUTE E.L. EACH ACCIDENT $1,000,000 (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below WI Only E.L. DISEASE -EA EMPLOYEE $1,000,0 . DISEASE -POLICY LIMIT E.L$1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) r - O Z w A V tir 1.' O) V �.Cnrtrwr�LC rlVLUCK CANCELLATION &% SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover AUTHORIZED REPRESENTATIVE Building Deurtment Attn: Donald Belanger 1600 Osgood street, Suite 2035 North Andover MA 01845 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD J YWowonmss (dVu4iness egu ation 10 Park Plaza - Suite 5170 Boston, Iii sachusetts 02116 Home Improvem ,contractor Registration BUILDER SERVICES GROUP, RICHARD SCHWARTZ 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 SCA 4 0 ft1 BUILDER �� mm�nu,'ru a�C/��aa.ac✓ruaellc orConsumer Affairs & Business Regulation RICHARD SCMAR 110 PERIMETER RD NASHUA, NH 03063 CONTRACTOR Type: Supplement Card Undersecretary Registration: 179141 Type: Supplement Card ,Expiration: 6/25/2018 ite Address and return card. Mark reason for change. LJ tiddress rLj" Renewal F� Employment ❑ Lost Card License or registration valid for individual 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 Not valid without signature Ilk Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-105992 Construction Supervisor Specialty Construction Supervisor Specialty Restricted to: CSSL-IC - Insulation Contractor Failure to possess a current:sditlon of. the Massachusetts Slats Building Cotte Is cause for revocation of lftls license. OPS Licensing Information visit: WWW.MASS.GOVIDPS ° RICHAR[3. SCHWARTZ 260 JIMMY ANN DRIVE< DAYTON A (BEACH FL .32114 Z7V Expiration: Co missioner 0912612018 Construction Supervisor Specialty Restricted to: CSSL-IC - Insulation Contractor Failure to possess a current:sditlon of. the Massachusetts Slats Building Cotte Is cause for revocation of lftls license. OPS Licensing Information visit: WWW.MASS.GOVIDPS