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HomeMy WebLinkAboutBuilding Permit #673-2017 - 96 MILLPOND 12/28/2016BUILDING PERMIT Iy� AAJ4� W TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION', Permit No#: Date Received TYPE OF IMPROVEMENT PROPOSEDUSE Residential Non- Residential 0 New Building )(One family 0 Addition El Two or more family 0 Industrial 0 Alteration No. of units: 0 Commercial XRepair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other ❑Septic �Weff; Floodplain E! ModdpJl­.` E) Wetldhi-, 9 vv*6e rs,f� d 'kri6 aler t 0 V V /-S. br., DESGKIP I IUN Ul- WUMh, I U Or- rr-MrUM1v1r-LJ GttY ,n6LW4415 Xlppw (AstclAhori in U / U 1 alts mSIIAII V"14,hcq du" ih rfiGf- hKAf Identification - Please Type or Print Clearly' OWNER: Name: KvrjAc4-b CArvvr Phone: Al 273 -72 FT_ Address: CL6 Kill Vor-A 1s)or*i­ Pndpvtg' i KA 01M --e- Phone,. - Cbrit rab-tof,'Na'rn Mt, 10" Address. -,.P0 'lox -L-4-R, ma4CkU5ft-4-_-_W: 03 10T.- Supervisbr`,§ Construction eDate: 1 27 2017. , . ..Home: Improvement- "License:......._- -- ARCHITECT/ENGINEER Phone: Addres Reg. No. I— r FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. __,Total Project Cost: $ $5,01, bt, FEE: $ 0 Check No.: . 2- a- S Receipt No._-, S NOTE: Persons contracting with unregistered contractors do not have: access to the guaraylyyfung en_tl_b . fi e r` Signature of contractor.,� Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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/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 (COTE:: 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 JO`S'E: 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 Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑ •TYPB-OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ 'P THE FOLLOWING SECTIONS FOR OFFICEbSE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Sianature COMMENTS HEALTH. Reviewed on Signature `- COMMENTS 'r .'Zoning Board, of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board.Decision: Comments=: Conservation Decision.- Comments Water & Sewer Connection/Signature & Date - Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fibre Department signature/date COMM; lkT iimension 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 lies No � DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 Location of (_r1 � j t. � FO/ J No. n -;LO/'7 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # Fj k -/Building Inspector o = - O O 2 y < CD -0 y CD � CD -9 m Vl• O 0 n C) B ;a z o �;�� iD-• �7 C a% �'0 0 r+ CL o' m I"- ft =4 S cn (DD W �j O N O —1 N =. CD 'a O 2 0 a.fuy y C) CL a t/i n O �• O .-F Da CD CD n Z � A C. __. CD � O CL F)' m M N• .� co cr �n rt CL �0=.n OX=CD-a No =4 ZNv _ N �D O� 0 CD CD 0 Mas < r -L* CCn Q 1 r - co Cr a1 r � _� CD ---I CD `c w =r O� � � m CD o O z �' U) CD 0 �O W a Z p CD Q _ o N b Vi o CD p CD N O 00 N CD Z 0U) `° o 0. O G) > D `D D -0 CD C n rt ;� pau o ;a = = CL V) N co T M T VI Z7 T m T B - C 5. O O O O �' 3 O O (D O O dam' D) < D) N 3 Q ao m m * Z s (D (D Q n L 0 O rt rf O 3 r (D (D r m C w G7 rl C v o N co n z z Z v D G) M y r O LA M M m m D z p = 0 0 0 O 6 J O 0 c 41, RISE Eatgiaeeft Alcollb r pasta Seca lto star CTcoeeaeser �itef ttaq RISE. ere ah.wtaat l:o,a, c.nton, M�► e2o:I CONTRACT :13%502-M _ =-V"X ➢-102-fiw t �`N P 1 PROGRAM ----� CNL**—=OWN —MMIUM 4 L C3 /Iter OAtt c{mlit welet01el6t MtaeditttQatver # � (978)273.7187 t iII312(i16 44'18&9 239Q1 s clam, ' , _ j snug ease. 96MMPond c�. 96MMPmtd asnvser orM,alrt4� �� �� k c_b � snarsnonrsarrs,m North Andover, MA 01$6' `, North Andover, MA 01845 JOB DESCRIMON AIR SEAL * Provide kWt%kd a 'ter seel'W m of your home agab a aastetW. tacoassir This work wilt be performed In ooatxrt vdth them of special tootsmddiapostic tats to amtre that yoty home VM be left wBh a hmitwd level of sir c whow and bAw ak quMy. MrdalNs to be raedto sed your home can bdude cardlar, foams and oMer peodoets. Primary am Por seating Leib* air leakage to attk4 besemw% attadtod gt mm and other mhmwarcm (wiadots ere not wily adhessad) This adD negairo (2) wMag hours A raWioa in aft feet per minae(ft) of air bion wUl oomr, bat the mud amber ofcfm is not pare mad. At the completion of the utaba ration work, cad at no adti juW cart to the homoowmur. a ihtel btov" door wWor oombation aetbty analysis WD be conducted by the obvontreetor to a►ada the safety of the indoor air quality. $170.00 KNERWALL S.OPE: Provide laboraed maurials to iattaga 9• layer of R -3o 66mMm batt$ to (78) sgrme fast of rales ope amabehinda imseaelE. NOTE, THIS ISTHE,E SLOPE OF THE MACANIM ROOM WHICH 1S IN THE 3EER FLOOR LOFT. $157.S6 KNE13WALL SLOPE. Provide labor and materials to instep r FSK ftedsemkisd tibaglem board baimbn to (78) 91we feet of knormll tafter arse. NOTE. THIS 18THEE SLOPE OF THE MACAMCAL ROOM WHICH 19 IN THE 31MRFLOOR LOFT. $273.00 REMOVAL: Remove (78) square feet of batt style iasdation from the kmeciaeil area. NOTE: THIS IS THEE SLOPE OF THE MACAMCAL ROOM WHICH 19 IN THE 3EER FLOOR LOFT. $58.50 VEN'T'ILATION: Provide labor and materials to into ventitadon chides is (18) rafter hays to malwalo air ilow, NOTE. THIS ISTHEE SLOPE OF THE MACAFIICAL ROOM WHICH ISIN THE 3BER FLOORLOFT. 536.00 COMMON WALL& Provide labor and mataiats to insta0 blown in Chas t Whim to (40) square feet of4' common van thm* an interior surface *M and plug method. Phm *3 be epadeled sed loft in 8 fekdvely smooth oudtim. Fhft sending and touchup primbtgrpaimirrg WU be the cmtomces mpm db0it . Homeam- hasteoeivod a copy of the EPA's Re ovate light La d&h h fermmtoa 03ds =Mbhb*tbo potcmw d* of the lad harmd acp sure Dom the atwtberiration wmk to be Performa& Your Opetwe isyoarectaoraedamumt ofnocipt and aVventat to pr.... STAIR WELL TOOARA(W. $74.00 R= Enghuoertng vM apply aU sOPI dig is b=tim to thin amtf= L You wiU only be bidod the Na amoau. Carnoy, for oUBibte macaws, Coh®bie Gnoflbrs 7S%b mtive, rent to a= d 5,2,000 per ealenft year, wdan ftomive of 1 00%for the Air Seating mcaanes up to the fent Sao and an additional 5340 if savhzgsare juetifred try the auditor. For the safety sad health of your homds indoor air quit. vm wW be condactinga Now door diaB mfc of the ava0eble air Row W 6bawwaf 110 Cwdw, UAA WM PAX3 Mtaed$b CNM SOM owm 96M®Paad ormammmo North Andovat;MA O1MS W)VA =7 11/i5/m 40699 =02 "Maaer 96MMPbod a m a kfumm NoethAudovat:MA 01645 JOB D -moi wma w�aoaw�aysvvgra soe�, aaoaaerraot ooeta �raata amnaoo�oet a ltd? 1 aadv wbWi r.Thh;blk iavdw4ofMudbataoaorttoym Tod TiaP=k VM baMO dby Gro badam GUMBOMat= aMttonl GEL It btbo bo=wmwtspa-Aft to doaaoat tbb pmk by ooat wftdtadr aR r at d w oom hdm of ttda=& amiftaaraaomarae>oaearaaranasva aaami 30 aoa RISE608haYrreat load, Well 21 caebn, NA 020211 399-=4= ENGINEERING' www.Rl8Ea WnswkQ.=n OWNER AUTHORIZATION FORM i, owner of the Property located at: Mdressj hereby auft tie an authorised sumer for RISE Englnseft, to act on my behalf to obtain a burg pem& and to perform work on my property. This form Is only valid with a signet! contract, The Commonwealth of Massachusetts Department of Industrial Accidents 3 I Congress Street, Suite 100 Boston, MA 02114-2017 www ass govIdia Workers' Compensation Insurance Affidavit: GeneralBusioesses. TO BE FILED WITH THE'PERIVIrI'TINC AUTHORITY. Applicant Information Please Print Legibly Business/Organiution Name: Mill City Energy Address: PO Box 6411 Uty/State/`Lip: iviancnesier, tyn us tva 1' Are you an employer? Check the appropriate box I . M I am a employer with 12 employees (full and/ or part-time).* 2. C3 I am a sole proprietor or partnership and have, no employees working for mein any capacity. [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption ,per c. 152, +31(4), and we have no employees. [No workers' comp. insurance requiredl* 4. rl We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.j hone #:603-391-7923 Business Type (required): 5. Q Retail 6. n Restaurant/Bar/Eating Establishment. 7. Office and/or Sales (incl. real estate, auto, etc.) $. ® Non-profit 9. Entertainment 10.0 Manufacturing I I.[] Health Care 12' Other W UkVdAi2k` o`n *Any applicant that checks box fit must also fill out the section below showing their workers' compensationpolicy information. ** 9f the. corporate officers have exempted themselves, but the corporation hn other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers I compensation insurance for my employees. Belmv is tite policy iitfornration. Insurance Company Name, Clark Insurance Insurer's Address: One Sundial Avenue Suite 302N City/State/Zip: Manchester, NH 03102 Policy # or Self -ins. Lic. #MIWC791896 Expiration Date:4/2912017 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 $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 cerizfy, u ins and penalties of perjury that lire information provided above is trite and correct Signature: Phone #: 603-396.7520 f Official use only. Do not write in this area, to be completed by eity or tmvn official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office S. Other Contact Person: :Phone MILLCITY-1 AGOULD '44cOR15- k. � CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/19/2016 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 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 License # AGR8150 Clark Insurance One Sundial Ave Suite 302NIA/C,Na Manchester, NH 03102 CONTACT NAME: PHONE FAX Ext): (603) 622-2855 AIC No): (603) 622-2854 -MAILADDRESS: agould@rlarkinsurance.com E-MAIL-ADDRESS:g INSURER(S) AFFORDING COVERAGE NAIC # 04/29/2016 INSURER A:Arbella Mutual Insurance Co 17000 EACH OCCURRENCE $ 1,000,000 INSURED INSURERS: AmGuard Ins Co 43290 MITI City Energy 106 Joseph St PO Box 6411 INSURER C: INSURER 0: INSURER E: Manchester, NH 03102 INSURER F: A 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INS WVD POLICY NUMBER POLICYEFF MMIDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 8500065735 04/29/2016 04/29/2017 EACH OCCURRENCE $ 1,000,000 TOtER€FcTE6 300,000 PREMISES Ea occurrence $ � MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT F—] LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS 1020050919 04/2912016 04/29/2017 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS UAB X OCCUR CLAIMS -MADE 4600065736 04/29/2016 04/29/2017 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000, DEC) I X I RETENTION $ 10,000 $ B WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A MIWC791896 04/29/2016 04/2912017 OTH- X STATUTE ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEd $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached U more apace is required) CERTIFICATE HOLDER coNr_FI I ATInN ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ivjasbaunubutis veparttnent or ruouc safety Board of Building Regulations and Standards License? CS -110041 Construction Supervisor MICHAEL JOY 106 JOSEPH STREET MANCHESTER NH 03102 —^R CA__ Expiration: Commissioner 08/0712019 +o. r67/'- I.YiIMY1}fxPfltYCl1FI✓+� +r :^T rK+RiRinddawf OftictofCoaxumcrAffairs Rini .essRegulation 0MlIE 0VIP1 VENA NT CONTRACTOR �,,,, • }listration` 182791 Type: xpiration: f2TiZ0f LLC Ph!LL 1T�" ENERGY�44.C. MICHAEL JOS' 106 JOSEPH STREET MANCHESTER, NH 03102 t srdet�rnfary Construction Supervisor Restricted to. Unrestricted - Buildings of any use -group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Bu ldirg Code is cause for revocation of this license. DPS Licensing infonnation.visit: WWW.MASS_l3OVfDpS Umnse or registration valid for indh ldul use only before the expiration darn tf:found return to: 0frtce of Consumer Affairs and Business Regulations 10, Park flava -Suite 5170 Boston, MA 62116 . tVvn tb"t s` ttre