HomeMy WebLinkAboutBuilding Permit #Exception - 87 GLENNCREST DRIVE 3/24/2015BUILDINGPERMIT
TOWN OF NORTH ANDOVER',:,'..:!
APPLICATION FOR PLAN'E)(AMI.NAT,40N*`.`-._,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
El Two or more family
O. -Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
D Others:
0 Demolition
0 Other
D s6ptic EI'We[I
-lain
0 Floodp 0 Wetlands
VvOtersh-ed),I)istrict
11 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED: `
Identification - Please Type or Print Clearly'
OWNER: Name: , Phone:
Address: I
Contractor Name: Ph -one:
Add res�s-
Supervisor's Construction Licemse:
at&.
Home Improvement License: iP5
x mite
ARCH ITECT/EN GI NEER —,Phone:
Address: Reg-,
FEE SCHEDULE: BULDING PERMIT. MOO PER $1000.00 OF THETOTAL ESTWATEO,60STBASED ON $125.00 PER S.F.
Total Project Cost: $
FEE-.$,.�..
Check No.: Receipj.N6i.-�`."
NOTE: Persons contracting with unregistered':.conttactors-do,yiothave'�,acces,�-to the guarantyfund
-0 -,q
,f -� 01VOWrle
W
Location B-1
No -T?:;, 3 - 1 65
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Check #
28585
Building Inspector
U
1E
Plans Su�rnitted
Plans Waived El Certified Plot Plan El Stamped Plans El
FTW��PF--OF SEWERAGE DISPOSAL
Public Sewer El
Tanning/Massage/Body Art E]
Swimming Pools
Well El
Tobacco Sales E]
Food Packaging/Sales E)
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature.
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: -Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Dimension
Number of Stories: Total square feet of floor area, based on -,Ext&i 6'r� 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.$100-$l 000 fine
NOTES and DATA — (For department use
I
0 Notified for pickup Call Email
Date Time Contact Name
Building Department
The foil -owing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
u Building Permit Application
ci 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
NC:)TE: 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/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)
u Building Permit Application
u Certified Proposed Plot Plan
a Photo of H. 1. C. And C. S. L. Licenses
o Workers Comp Affidavit
u Two Sets of. Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
u Mass check Energy Compliance Report
E] Engineering Affidavits for Engineered products'
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
][n 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
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Cons(: a
er
Services Group
50 Washington St. Suite 3000
Westborough, MA 01581
CONTRACTOR WORK ORDER
Printed: 3/13/2015
Work Order Id: S75774P80602C273
-Co0q7----1' io n
Customer/Site Details
Weatherization Incentive
Location
Building Efficiencies LLC
Donna M King
Email:
donnamking@comcast.net
18 Tanguay Ave
87 Glencrest Dr
Phone(Eve):
Phone(Day):
978-794-1579
617-543-2278
Nashua, NH 03063
North Andover, MA 01845-1314
Site ID:
S00002175774
Total Installed Measures
$1,306.51
Weatherization Incentive
Location
Description
Quantity
Unit $
Total $
Exterior Door Weather Stripping
4
$27.59
$110.36
Door Sweep
4
$23.18
$92.72
Living Space
Perform Air Sealing at Estimated 62.5 CFM50
10
$84.32
$843.20
Living Space
Attic Stair Cover Thermal Barrier with carpentry
1
$260.23
$260.23
Living Space
Insulate Vinyl Sided Wall With 4" Dense Pack
1,302
$2.41
$3,137.82
Attic
Propavent 2' or 4'
4
$3.83
$15.32
Living Space
Dense Pack 10" Cellulose In Overhang
50
$4.58
$229.00
Living Space
Attic Floor Open Blow Cellulose 6"
1,232
$1.47
$1,811.04
Living Space
Insulate Interior Buffered Wall With 4" Dense P
195
$2.31
$450.45
Living Space
Insulate Rim Joist with 6.25" Fiberglass Batting
28
$2.40
$67.20
Damming
152
$2.19
$332.88
Living Space
Insulate Buffer Wall From Interior With 4" Dens
224
$2.31
$517.44
Attic
Vent bath fan to roof flapper
2
$129.21
$258.42
Installed Measures Total $8,126.08
Road Blocks
Type Status Notes
Asbestos UNKNOWN
Payments
Incentive Payments
Customer Share
Air Sealing Incentive
$1,306.51
Weatherization Incentive
$2,000.00
Total Incentive Payments
$3,306.51
Total Customer Share $4,819.57
Less Deposit Of $1,606.52
Customer Share Balance (Due Contractor) $3,213.05
Conservation Services Group - 50 Washington Street Suite 3000 - Westborough, MA 01581 - (508) 836-9500
(SG CONTRACT FOR
ConserVation PRODUCTS I SERVICE WORK
Services Group This service is brought to you through support from your local utility
This Agreement is made by and among
and
Donna M King Conservation Services Group (CSG)
87 Glencrest Dr Attn. RCS
North Andover, MA 0 1845-1314 50 Washington'Streelt, Suite 3000
Site ID: S00002175774 Westborough, MA 01581
Project ID: POOOOO 180602 Reg. No. 173484
Customer rD: COOOOO 185832 Federal ID No. 222457170
Contract ID: 20150113WORK (Mail completed corib-act to address abovje)
1. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be performed the following work on these *Premises' in a professional mariner and in accordance with the terms of
this Contract, including the attached recommendations�work order describing the work in detail (the 'Work") which am incorporated herein by reference:
Description
Attic Floor Open Blow Cellulose 6"
Quantity
1,232
Location
Llving_�Pace
$1,811.04
Propavent Z or 4�
4
Attic
$15.32
Vent bath Mn to roof Hap r
2
Attic
$258.42
Insulate Vinyl Sided Wall With 4' Dense Pack Cellulose
Insulate Wall From Interior With 4- Dense Pack Cellulose
1,302
224
Living Space
Living Space
$3,137.82
$517.44
Insulate Interior Suffered wan With 4" Dense Pack Cellulose
195
Living Space
$450.45
Dense Pack IOCellutose In Civerha
so
Living Space
$229.00
Insulate Rim Joist with 6.2
28
Living S ce
$67.20
Damming
152
N/A
$332.88
Sub Total:
Utility Incentive Share
Customer Contribution
$6.819.57
$2,000.00
$4,819.57
For office use only
Printed: 2/1612015 Page I of 2
11. PAYMENT
Customer agrees to pay Contractor for the Work, the Customer Share of the Contract Price -is follows- Payment #1: s-1606.52 as a Deposit
payable to CSG upon signing the Contract (not to exceed 1/3 of the total retail costs). Mail check & contract to CSG, Attn: RCS, 60 Washington SL, Ste.
3000, Westborough, MA01581. Rnal Payment- S as the final payment for the Work shall be payable to the Independent Installation
Contractor ("IIC") upon satisfactory completion of the Work. Customer understands that helshe will not be required to pay the Utility Incentive Sham ofthe
Contract price in the amount of$ 2000.00 Changes to individual line iternsartizi/or previous incentives may increase or decrease the size of the Utility Incentive
Share.
Ill. DISPUTE RESOLUTION
I'he IIC and Customer hereby mutually ag" in adva= that in the everit that the HC has a dispute concerning this ConlrSiCt, the HC may siibrrdt such dispute to a private arbitration
service which has been approved by the Office of Comimer Affairs and l3usiness Regulation and Custoiner "I be irwluired to submit to such arbitration as provided in M.G.L c 142A.
You may cancel*this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
2> businpseay following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE Y BLANK SPACES.
'04" &-- ";w
Donna M KkV (Feb 16. j7015) Feb 16, 2015 Want program to assign contractor DMK
Customer Signature Date Indicate your selected 11C here, ir applicabfc- (OR) Initial here if you want
the Program to assign a
AfaqA eaufuu 2/16/1S Mark Couture 212 Participating Contractor
CSG Signature Date Name of CSG Representative (Printed)
TERMS AND CONDMONS AFPEAR ON a REVERSE. 3/14
(NG
ConserVation
Services Group
CONTRACT FOR
PRODUCTS I SERVICE WORK
FThis Agreement is made by and among
Donna M King
87 Glencrest Dr
North Andover, MA 0 1845-1314
Site ID: S00002175774
Project U): POOOOO 180602
Customer I D: COOOOO 185832
Contract ID: 20150113ASEAL
This service is brought to you through support from your local utility
and
Conservation Services Group (CSG'
Attru RCS
60 Washington Street, Suite 3000
Westborough, MA 01581
Reg. No. 173484
Federal ID No. 222457170
(Mail completed contract to address above)
1. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be perfonined the following work on these"Premises" in a professional manner and in accordance with the terms of
this Contract, including the attached recommendationstwork order describing the work in d" (the 'Work") which are incorporated herein by relerence:
Description
Quantity
Location
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour
10
Livin- Space
$843.20
Attic Stair Cover Thermal Barrier with ca!pen
I
Living_�pace
S260.23
Door Sweep
4
N/A
$92.72
Exterior Door Weather Stri 21�tng
4
NIA
$110.36
Sub Total:
$1,306.51
Utility Incentive Share
$1,306.51
Customer Contribution
$0.00
A[oil $'on
IN
For office use only
Printed- 211612015 Page 2 of 2
II. PAYMENT
Customeragmes to pay Contractor for the Work, the Customer Sham of the Contract Price as follows: Payment4l: $ 0*00 as a Deposit
payable to CSO upon signing the Contract (net to exceed W of the total retudl costs). Mail check & contract to CSG, Attn: RCS. 50 Washington St., Ste.
3000, Westborough, KA01581. Rnal Payment- $ ()-(M as the final payment for the Work shall be payable to the Independent Installation
Contractor ("[IV') upon satisfactory completion of the WorlL Customer understands tliat hrJshe will not be required to pay the Utility Incentive Share of the
Contract price in Lheamountof 5 1306.51 Changes to individual line Items and/or previous incentives may increase or decrease the size of the Utility Incentive
Sham
Ill. DISPUTE RESOLUTION
The OC and Customer hereby mutually -vee in advance that in the emit that the 11C has a dispute concerning this Contract, the 9C nrky submit such dispute to a private arbitrudw
service which has been apliroved by ihe Office of Consumer Affhas and Business Regulation anrl CustomershaIll be required to submit to such arbitration as provided in NLG.L c 142A.
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business d following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE A BLANK SPACES.
". /V �,f DMX
Feb 16, 2015Want program to assign contractor
M%..% - (OR) Initial hem if you want
'nerSignatum' Date Indicate your selected TIC here, if applicable the Prograrn to assign a
AtaxA ea"fuze 2/16/15 Mark Couture 212 Participating Contnctor
tSG Signature Date Name or CSG Representative (Printed)
TERMS AND CONDIrrZONS APPEAR ON THE REVERSE- 3114
4 k
mass save*
&WV,P dmmb -M eff6—o
PERMIT AUTHORIZATION FORM
o twat t"
0
PARTICIPATING
COWRACrOR
IMINEENNF-
Donna M King owner of the property located at:
lOwner's Name, printed)
87 Glencrest Dr
(Property Street Address)
N. Andover
(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.
1. Donna rA KIM (Feb 16. 9DI
Owner's Signature
Feb 16, 2015
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:
I—
Contractor
n ( e- ac 9 -�
Date
For Office U.Se only
32011
'WeW 21-E 7-----
The Commonwealth of Massachusew
Department ofIndustrkdAccidents
Offlce of Investigations
I Congress Street, Suite 100
Boston., MA 02114-2017
IF wwwmassgov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
V%_§- V _21A
Name (BusinessIOrganizadon4ndividual): 101-5
Addms: L/ / 1-?tYC-,- L),& -� /4� via,
0A IYP 0,404Y Phone #:
9"C[6�5
AN Y03AM employer? Check the appropriate box:
1. 201 -am a employer with 10 __
4. [3 1 am a general contnictor and I
a loym (M and/or pan -time).
have hired the sub-contnictors
listed on the attached sheet.
2.[3mp
1 am a sole proprietor or partner-
ship and have no employees
These sub -contractors have
employees no have workers'
working for me in any capacity.
(No workers' comp. insurance
comp. insurance.;
S. We an a corporation and its
required.]
3. [11 am a homeowner doing all work
officers have exercised their
myself. [No workas' comp.
right of exemption per MOL
insurance required.] t
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insivance required-]
Type of project (required):
6. [:]New construction
7. C] Remodeling
8, 0 Demolition
9. Building addition
10. Electrical repairs or addition
I I.[] Plumbing repairs or addition
12.[:] Roof repairs
13. [a Other- 0 �'Py
that chegla bm #1 must also fill out the section below shinving their wOrkffs' MmPemtiOn policy infwmation such.
who submit this affidsvit
t Ym"WPw1inewon, indicow dwy am domg a work and thm him outside contractors must subnut a new affidavit indicath*
sCmusam that chwk this box nsust attached an additional shed shomnS the name of the sub-cOnusdm and state whether Or not those enddes have
employm If the Mocounc= have employcM they mug provide their woltets' camp. policy number.
Jam ot employer dia &providing workers'Compensadon insurancefor my employee& Below is thepolicyandjob ske
1Xf*rX"*6X-
Insun=c Company N=9:__ 8 C_ A T-rl-5
C
Policy # or Self -ins. Lic. #: &-.,) , Q 4V Yl ExpirationDate: 7 -
Job Site AddMs: 1517 ",PYCAU 7-10 1� city/state/zip
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Faihire to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
no up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fin
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 fbr insurance coventge verification.
" 1 6
I do hereby Md& Oe-dury that the informadon provided above is owe and correct
T 74� Date:_3—,�
PhonaM
um ox4K Do not write in this area, to be completed by city or town Offidal
City or Town:
Permit/License #,
Issuing Authority (circle one):
1. Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector
6. Other
Contad Person: Phone#:
BUILD1
Clientill: 58837 F LIABILITY INSURANCE
CERTIFICATE 0 ... DER
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CERTIFICATIE DOES NOT AFFIRMATIVI , A CONTRACT SIETWEEN THE ISSUIN
A.M OF NSURANcF- DOES NOT CONSTITUTE
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Prww Square
P.O. Sol 23100
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INSURED Building Ef"OnCles LLC
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Nashua. NIH 03063
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STANDING ANY REG kANCE AFFORDED By THE POLICIES Y PAID CLAIMS.
INDICATED- NOTW'TH (PERTAIN, THE INSUI ,Ave SEEN REDUCED LIMITS
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LOCATIONS I Val-ROL"
Warilen; Comp Information
pmpristompartniers/Execlutive officers/Mgmbefs Excluded: Jonathan
7OD7LY wiuRy (Pw Per—)
BODILY INJURY (per 80"'
pitopERTY OAMAGE 13
E.L. DISEASE - EA EIA LOYFE $500 OC
— , AAA At
Inoluded gums - NIH & MA named as additional Insured as it pertains to the work being done during
coo, Nominal Grid, and NSTAR and
do policy period. N 9L ON f 99 CANCE"
SCPJBBD POUCIES
SHOuL.9) ANY oF THE A004E 0 CE WILL, Be DELI%
T14E EXPIRATION DATE THEREOF. NOTI
ConserVations BOrvic" Group ACCORDANCE WITH THE POLICY PROVISIONS'
So WashingWn SftvM ItEpRESEwATIVE
wesoorough, MA 01581 AUTKOVaEO
&.2010 ACORD CORpOpATION, All right
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