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HomeMy WebLinkAboutBuilding Permit #493-2016 - 89 MOODY STREET 10/19/2015AlAeO 11-2 /s tiorarN BUILDING PERMIT TOWN OF NORTH ANDOVER 0- APPLICATION FOR PLAN EXAMINATION * ,- l / ' !/ �I � O'P ntwcN y. Date Received � gogq,rED PpA` �c Permit Nod: �Ssgcwus�c Date Issued: I �� LWORTANT: Applicant must complete all items on this page M 0 0� LOCATION 1 /1 Print PROPERTY OWNER / ��O � Dr' S� Print 100 Year Structure yes (io MAP PARCEL: ZONING DISTRICT: -Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE N Residential OWNER: Name: ( -o l I Address: Looay S� ' Se6t��w o� - Please Type or Print Clearly �sl,�ll one: �96 00 M �► r Contractor Name: Phone: 'Dog Email: D 00 , �I ��et' ..CIO Address �D6 'Sod► Si' -� o3lfla. Supervisor's Construction License: Ws�o 6 03s- Exp. Date: S } i Home Improvement License: 19;1.1 '(cls Exp. Date: 14- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. T®tal Project Cost: $ � , (� �-J . �� FEE: $ Check No.: / 0 . Receipt No.: ZO�Z- NOTE: Persons contracting with unregistered contractors d not have access to the guaranty fund Residential on- ❑ New Building One family ❑Industrial ❑ Addition E] Two or more family ❑Commercial Iteration No. of units: El Repair, replacement ❑Others: ElAssessory Bldg ❑ Demolition V t`T O epfic; I -a Ngill� ❑ Other ��FI®` p ri od 1 in tWeflantls �❑ IWatersh_ etl ®fstru � �� � .. µ :U Watef/Sew >� DESCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: ( -o l I Address: Looay S� ' Se6t��w o� - Please Type or Print Clearly �sl,�ll one: �96 00 M �► r Contractor Name: Phone: 'Dog Email: D 00 , �I ��et' ..CIO Address �D6 'Sod► Si' -� o3lfla. Supervisor's Construction License: Ws�o 6 03s- Exp. Date: S } i Home Improvement License: 19;1.1 '(cls Exp. Date: 14- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. T®tal Project Cost: $ � , (� �-J . �� FEE: $ Check No.: / 0 . Receipt No.: ZO�Z- NOTE: Persons contracting with unregistered contractors d not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinning Pools ❑ Well ❑ Tobacco Sales El Food Packaging/Sales El (septic lank, eta ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE DISE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS .HEALTH ►i ."'COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comm Water & Sewer Conneetton/signature . Driveway Permit DPW Town Engineer: Signature: FIRE DEPAR�TNiNY _ Located 384 Osgood Street ated at�124� r, ,Ternp;DumpSfer on site :yes Lo r °Main;Street FireIDepartineri signature/cia t t, t ; COMMENTS�.. � 4 f. b �. , Dimension Number of Stories: I Total square feet of floor area, based on Exterior dimensions Total land area, sq. ft.: ELECTRIGAL : Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 966 section 21—A —F and G min.$100-$1000 fine Doc.Building Pervnit Revised 2014 l0 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 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 TOTE: 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 IECC Energy code Engineering Affidavits for Engineered products IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit Ire 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 No. Date'V �c( Check # IDL, TOWN OF NORTH ANDOVER Certificate of Occupancy $ w` Building/Frame Permit Fee $� Foundation Permit Fee $ •� Other Permit Fee $ TOTAL $ t Building Inspector C 5 CA � . Z CD O Cr 0 CL > co -0 O O p C C a' sv CD O W W CL O 5' O tQ CD N N O 0 r_ CD CDa U)' N 7 � O CCD O CD 0 "ft. Er o x O N_ CD N C c m � n CD o 0 CLC.) z o =-o �_ v, O N CD T rte. O O C m N W m U)cD 2 Q. O CD �• O O r0+ co CL N Q O W C CD C � o < CO CD �c0� d - h 0 CD 0. c -J 0 �� Q <Q Q 2. N Q. < y O >:V. vs T : Q/ CD y O r N N tD •� * Q y •�� o su C-7 N 3 O (rD o N N r -r z O W O - m D m zl T m T7 O � S O G T v N fD C � � � r, r m A r N m 00 ;a C �C C W H ° p :0 T 7 of A S 7 � y O T C Q �. W C O z O � m O ;a V1 O n Ln N N 3 T O Q \ S N W � O _ m 2 ID C.) N o O - = D CD -0 O O O O CL N 3 O (rD o N N r -r z O W O - m D m zl T m T7 O � S N H A O T v N fD C � xT O oo S r, r m A r N m 00 ;a v x O S C W H ° p :0 T 7 of A S 7 � .Z7 O S T C Q �. W C O z O � m O ;a V1 O n Ln N N 3 T O Q \ S N W � O _ m 2 4 ba w rA rA 1 -qw 10/01/2015 08:06 5083303403 WESTBOROUGH DocuSign Envelope ID: 2B733082-E2D5-4E67-AD74-197F9F 11 FF2B k1b COQ conservation p d � Cr � 1 SC'rvlces Group `,S l &*&IN ' j/r C -F WORK N This service; is brought to you throe gh PAGE 04 DESCRIPTION Or vuo Contractor wil RK TO BE PERFORMS flits Cnntr I perform or Mine to he perfnelned the fol act, lnclud{ng the 1VIC!"d owing work on tRe "i'temises" in a pmfcac{.onal manner and in arcenlance with tRe to Rcommendatinn5/woriz artier describing file wnrle in dekti! (the "T4'orlc j which Ora {nrorporated herein rnrs oI' byrefer -nr Descriptlpn Qmm ty L.ocatl.. Sub Total: 882.77 UtlBty Inceritive Share 38?6,87 C ustawr Contribution 3820,87 $0.00 Flow 11 W. Fel' ofi'lea u9e Only Printed: 80012075 Page 2 of 2 PAYMENT -�- AstomGr agree4 to pry rnntrnctor ror the Work, (.lir•.. Customer shoe of the Contract: Price as rollown' Payment #1.; 3 as a. Deposit ►gable to CSG upon ;40 119 the Cont met (nnt to exceed Viff. the total re.{-xjil costs). !Miall check Rz contract to CSG, Atm: RCS, 50 Washington St., Ste. )00' WeathMAoroagh, M015RI. enol Poymenr. 4_ —4c=:i _ is the final prt,ymcnt for the Work ahnil be payable. to the Independent Tristillation antr AGtnr ("lfC") upon raadsflr co ctior+ of the Work. Customer understkinds that he/she will not be rnquired to pay Ill,* Utility Incentive Share. of the 7ntract price #n the arriotint of 4e. C�ianges to Individual line it<_msand/or previous incRnfivcs m?y incmase nr deen�se the s17c of the TJtility Incentive care. I. DISPUTE RESOLUTION 1e iiG and C»stomex herei=n rn.�rinally rgrM! in mimic.p. Brat in the event that the ITC linea a d imi concerning this CnmTacl, the 110 mtiy Sl�bmit Stich rliapiiLe 1'n a private puhihatiofl �rvicc which Ilns igen apnmved by the dyrtne of C.r,ncnnner Atfalrs and BiWnew ReRnlation And Cnatonier shall be rmlired to mihmit to st?ch whits nton ns prr.,vlrlecl in Y.G.T. c 142A. ou may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided ou notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third 5j,0"�ollowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 10/16/2015 e Dare Indieditc your eiccted ITC here, Ir appii-II)e (nR) 1n1i3a1 hare. l.ryou want the hriProgram tc ntric a �-.—� Part{r.;pating Contractor :SG Signatu Date Name of CSG Kepr'esu taiive (Frinted) TERMS ANDCowuMONlSAPPEAR ON'.t':>R y14 10/01/2015 $:49AM (GMT-04:00) 10/01/2015 08:06 5083303403 WESTBOROUGH DocuSign Envelope ID: 20733082-E2D5-4E67-AD74-197F9F11FF2B (Ar - Conser c Ian PRODUCTS C't�;l TRACT' poR Services GroupS/�#/,/�'�0�1�/ rya PAGE 03 ,rn,' _ _ _ 1s service is brought to you through Su ri6d a* ,I" ra . ,..- •: �:� pPort from you j••��_ - SCii - `.Sr 9•r' T"V` . �tadow lam. tl ; S; y/y� V , ,qVY/ p V�"W :.•" r buil' ,PO'b0 5 r.i arz` t 1`, 1; 1i•I W• a�obA �.j DESCRIPTION • :..:':.,�; •'. b aF;1, GRIP,,:... .. :. •.., ,.; ....: �,.._, ,.,,..,..., :��:�'.. : TION OF WO .':.: '.,., :..,:.• ...:. •: ,. ,;',:`: '': dtcrairt�irltilitr t Qontrartor RK TO BE PERFORMED b'.'ttrJtit ' U'ti0;ej:' Will perform or emx5p to h this Contract, including t h attar a petfo med endat he foltowilig work on these bed PFComm e/work order describin wmises" in a. pmfeaclon tt manner and in accordance with the I.Prms of R e OPk in det8il(the-Wo rk• which are incorpprs11-d herein Icy refs"nce: 0scrfption Quantity Locamm Sub Totai;l $6 utility lnawd" share $1,38268 Customer ConMbutlon SMO.90 1 1 Far offic® use only Printed: W301MIS Page 7 of 2 . PAYMENT uatnme.r agree., to pay Contrnetvr for the Work, the Gnatomer Shari of the Conu,'trcl. Priee :a-, follows; FRyment #1: S �, L 6 3 1AS a Ueposii; nyable to CSG upon signing the Contract (not toP P I•i of total retail Costs). Mail Check & contract to CSC., Attru RCS, 50 WmiOngton St.. Ste. 000, Wment Westborough, MA 01581. Final Pay $ 51 as the final payment for the Wnrk shn11 he. payable to the Independent installation ontractnr ("TIC") upon satisfactory ccoom`pletion of the Iklorlc Customer undemwids thRt hFJshp will not he rNnired to pay II)c Utility Incentive ShAre of I,he ontract price In the amount of o Z" (5 }. ChmgPh to imlMdual line items and/or prnvinnP inr.Pnrives mny incrr,,1go or dr..etease VIC Sire of the Utaliiv Incentive Mir- I. DISPUTE RESOLUTION he TTC crud Ctrmxrmnr hnrriby mnhla]ly .".. in ,td =rn that in the event that the TTG has a ftpnte cnnceming this Contrart, the 1TO may anhmit .Rlr.11 diApntn to a privntd arhitx rlinn :tvice wI&Ii has been approved by lbe Olrrcc or. Congtlmer Affair, mid $Ir onens Repilation and 0Latnmer Alrall hr rMiired M qiihmit to mu h ,whitntion as rmvlded in M.G.L. c 142A. ou may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided ou notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third rt. ,A,following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 10/16/2015 Vista . tt9to ss re _ Date ThdTicatQ y rid selected 11(: here, irapplieaable (OR) Int -t.: lhere if you wont,el" /!.. the Program to aAaign a SG Signatya ° ^ 1� Name of (:SG l;Pp�P9e tiv (Printed) Participating Contractor 'rERNISAND CA�x"MOI"A>rTrwt ON TUI 10/01/2015 8:49AM (GMT -04:00)1" DocuSign Envelope ID: 2B733082-E2D5-4E67-AD74-197F9F11FF2B arks say s -orgy. fancy PERMIT AUTHORIZATION FORM Beth Driscoll , owner of the property located at: (Owner's Name, printed) 89 Moody St 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. DocuSigned by: vyisca Owners ignature 10/16/2015 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: Participating Contractor Rev. 12132011 Date D�10 01 For office. Use only A� CERTIFICATE OF LIABILITY INSURANCE DATE 66/i2o�' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS THE ISSUING NSURER(S), AUTHO POLICIES IINIURANCE DOES ATIVELY NOT CONSTINTUTE EXTEND ONTRACT BETWEEN COVERAGE R12ED BELOW. THIS CATE R 11FICATE NOT AFFIRMATIVELY 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. A statement on this Certificate does not confer rights to the certificate holder in lieu of such endorsement(s). Slawsby Insurance Agency 3 Mound Ct, Suite B JADWM13R GONPRODUCER E Sarah, Lauersen NE (800) 258-1776 �: (603)429-1843 -MAIL. slauersen@minutemangroug.com S AFFORDING COVERAGE NA{CitMerrimack PO Box 1.807INSURER Mutual NH 03054-1807URERA-Liber-t INSURED INSURER.B: INSURERC: Mill City Energy LLC INSURER 0: PO BOX 6411 INSURER E: rGENLGGREGATE INSURER F: oalnCinaF NI IiaRCD• Manchester NH 03108-6411 --- -- - COVERAGES IvtFCi li'IVAIC nuanocrc.� 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. NSR LTR TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR SUOR POLICY NUMBER POLICY EFF M POLICY EXP M LIMITS EACH OCCURRENCE S P EMISES Ea ocaar�_ $ MED EXP (Any one person) E PERSONAL & ADV INJURY S rGENLGGREGATE GENERAL AGGREGATELICY LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ PRO_LOC JECTS HER: AUTOMOBILE LIABILITY Ea accXMB'N L I $ BODILY INJURY (Per person) b ANY AUTO ALL OWNED SCHEDULED AUTOS NON-0WNED HIRED AUTOS AUTOS BODILY INJURY {Peraccident) S PROPERTY DAMAGE $ r accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE s TH DED RETENTION $ WORKERS COMPENSATION TE R ACCIDENT $500 000 A AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTNE Ya OFFICERIMEMIER,EXCWDED? N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA HC531S341202-025 7/25!2015 7/25/2016 7E.L.DISEASE-EAEMPLO S 500 000 SE - POLICY LIMIT S 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional RenmrM Schedule, may be attached V more apace is required) lip SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE Herod/SARAH i 1 Oc 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (2otool) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF. 600 Washington Street Boston, MA 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationlindividual): Mill City Energy, LLC Address: P.O. Box 6411 uty/state/GIp: Manchester, NH 03108 Mone 4: tw�sat-ryes Are au an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 6 4. [] I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2.0 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. Demolition workingfor me in an capacity. Y p tY- employees and have workers' 9. ®Building addition [No workers' comp. insurance comp. insurance 5. F1 We are a corporation and its 10.0 .Electrical repairs or additions required.] 3111 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] 1 c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box 9 t must also fill out the section below showing their workers' compensation policy information. # Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. EContractors 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 the policy and job site information - Insurance Company Name: Liberty Mutual Insurance Policy 4 or Self -ins. Lic.14: �n��WC6 '/5-31S-391202-025 Expiration Date: 7/251201 Job Site Address: gq ` _ j% S4 . City/State/Zip:AL Ali°yv', �� S 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 S 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 cerlt; jy un#ee le,#rs and penalties of perjury that -the information provided above is true and correct" 4WWat use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfUcense i# Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M I-- Massachusetts Department of Public Safety Vjj Board of Building Regulations and Standards License: CSSL-106035 Construction Supervisor Specialty MICHAEL JOY 106 JOSEPH STREET,—,,, MANCHESTER NH 03102. Expiration: Commissioner 0810712018 �fr. �lntnraJrvlrn�/� a/"C✓��rt„t+rfr<aelll Office of Consumer Affairs & Busi6ess Regulation OME IMPROVEMENT CONTRACTOR egistration: 182792 Type: xpiration 7/27/2017 LLC MILL CITY ENERGY LLC: MICHAEL JOY 106 JOSEPH STREET�� MANCHESTER, NH 03102 Undersecretary 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 02115 N vat Ithout si Lure