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 $
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10/01/2015 08:06 5083303403 WESTBOROUGH
DocuSign Envelope ID: 2B733082-E2D5-4E67-AD74-197F9F 11 FF2B
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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
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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
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DESCRIPTION • :..:':.,�; •'.
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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