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HomeMy WebLinkAboutBuilding Permit #498-16 - 99 HAY MEADOW ROAD 5/1/2018 ,, G i/Ae D /df/91/.f � 0RTH q BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION - Permit NO: / �d Date Received AcHU �J Date Issued: EAPORTANT: Applicant must complete all items on this age LOCATION l C7 HA MffW_,u W ez� Print PROPERTY OWNER ]� �}" f dfQB� ` Mc7V P✓t/I7 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P(One family ❑Addition ❑Two or more family 0 Industrial )KAlteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer Col Z sr- _7 Cca buL-b E O -�\i Rio i L /,, p,,I ( D,� a p p J J(e Q �71 U CSU��S V l�/ V d Z .i7 11H ��ID �E F:a,6PA2F0` �Km) L,8re e fl-T-n C3 Identification Please Type or Print Clearly) OWNER: Name: )Y64 /l&Vmenz Phone: 0M - 1"S 6y1�j Address: qq Mqy ;b CONTRACTOR Name: �(UI(,()NWCMM U f'fSf(V7_ Phone: k j 7-2--7_�_-:517 7D Address: 1�0 ;6NNI Nn1D1\l slyt6i Supervisor's Construction License: Exp. Date: 3/1(0/1 to Home Improvement License: Exp. Date: e j-11 5�� �1'2-/1 tp ARCHITECT/ENGINEER �/f 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. /l Total Project Cost: $ 1S� o �� FEE: $_ � Check No.: i C;q.f, Receipt No.: --Q NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner &�)Mignqture of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE OF SEVMRAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Ste" "'tngPools ❑ Well ❑ Tobacco Sales ❑ )Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes P! nning Board Decision: Comments Conservation Decision: Comments ''Water&Sewer Connection/8►" nature� ®ate Driveway Permit 11PW Town Engineer: Signature: Located 384 Osgood Street FIRE<®EPAR;TMF:-NT - TOM-1p. ©umpster an sit :y e es_. . . no._. '(ocafed at V4,Main.Street _ Fir&Departs n s gnatiar /cla�� CC)MMENTS - Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I I i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL.Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA-- (For department use) El Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 OTE: 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 ®TE: 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 Location �' / �� c IOU., --z No. ��1� Date r r . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ J P Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# A F wilding Inspector r1 IAORTy . - _ . w: 1 s_E :. .c . . ve. . No. T - �o h ver, Mass, /o 1_�2 o CO[NICN!WICK 1' sj'ATED P'Pp`,�'(y U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect ........ buildings on f®cam Foundation Rough to be occupied as .......... Ui`j.............................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ....... Service ...................... I.NG INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. DocuSign Envelope ID:F661242C-1D18-46EA-9BAF-7E86E94F436F CONTRACT FOR Conner ation PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among Barbara Moverman and 99 Hay Meadow Rd Conservation Services Group (CSG) North Andover,MA 01845-1405 Attn:RCS 50 Washington Street, Suite 3000 Site ID:500050037990 Westborough,MA 01581 Project ID: P00050043915 Reg. No. 173484 Customer ID:C00050038345 Contract ID:20150619 WORK Federal ID No. 222457170 (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the ternis of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location Propavent 2'or 4' 36 Attic $137.88 Vent bath fan to roof flapper 2 Attic $258.42 Damming 58 N/A $127.02 Attic Floor Open Blow Cellulose 7" 672 Living Space $1,028.16 Sub Total: $1,551.48 Utility Incentive Share $1,163.61 Customer Contribution $387.87 For office use only Printed:7/1/2015 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:s-1 29.00 as a Deposit payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check R contract to CSG,Attn:ACS,50 Washington St.,Ste. 3000,Westborough,MA 01581.Rnal Payment:$_258.87 as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisf—^....--letion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$_1 163.6 1 _Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The HC and Customer hereby mutually agree in advance that in the event that the DC has a dispute concerning this Conuact,the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required 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 slr��`ssi e'yb� '�oIlowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THER ANY BLANK SPACES. �Olo 010 alA, 7/2/2015 Custom r e "' Date Indicate Your selected IiC here,if applicable (OR) Mt] sere if you want Mike Varney 7/1/15 Mike Varney the Program to assign a CSG Signature Date Name of CSG Representative(Printed)ntec) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. 3/14 RCS PLANVIEW DIAGRAM Customer: Home Phone: Address: 7 tA i f N)mj R), Work Phone: ( )- 7rAnyTown:_-_ _- - - jAr-4-k �11s� - Cell Phone: ( 27Z )- 775— Any limitations for access by large truck? No Z Yes If yes,describe: Any specific directions or landmarks? No ✓ Yes If yes,describe: Site ID: Sao,gip;-71 0 Energy Specialist: -Jt',�►o Vt(Al11P Reviewed by: III` . rl, V ,�,QS�ftf•{� � t 4k i jia o�W ly' Aj 1.__r ev L W i d,tf ya For Office Use Only Bushes Ladder Neighbor Proximity Pocket Doors insert Radiators Fence(s) Existing Conditions X=Access ❑=Vents Note.lnside Square R=Roof S=Soffit G=Gable RV=Ridge Vent CS=Continuous Soffit COE=Continuous Drip Edge T=Triangle Install O=New Access Note in Circle C=Ceiling W=Wall S=Sheathing Temp Unless Noted Otherwise ©=Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For.Access zzfl9-19-1/ts The Commonwealth of Massachusetts Department of Industrial Accidents 9' - Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 ivivmmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E,n V 11'Dr) 1aWn�c��in Address:. City/State/Zip: Phone#: -Z�I3 — _7C) Are you an employer?Check the appropriate box: Type of project(required): I am a employer with . 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I ani a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp,insurance.$ required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself.*[No workers' comp, right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' Other 1121 l�� l`7 comp. insurance required.] *Any applicant that checks box#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 sub-contractors have employees,they must provide their workers'comp.policy number. I attt mt employer that is providing workers'co»tpensatlon hrsrrrance for my etttployees. Below Is the policy and job site Information. Insurance Company Name: (�t�"I� �j C,t/�.�ta,,K� Policy#or Self-ins.Lic.#: V\"o 112`-/_CU) Expiration Date: S Job Site Address: City/State/Zip: ,(,(G�� Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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 certiry under the pains and penalties of perjury that the information provided above true and correct. Sinature:` - _.... _._ _._ _.. -._.-............. .. ......_....._...._. _............_... ...... Date: ,� S Phone#: I �1 q D-1 ,"BCS Official use only. Do not ipr/le lit this area,to be completed by city or town official. Cit or Town: Permit/Lice nse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector• 6.Other Contact Person: Phone#: �. O ; KERS-,. ;. ,: . :_ .• ;.: _ - - - - - _ ,AND: '•E Q Y• L I - AB - IL I R S UIZ:A• - -- n . C E. [o wc_oo::aa~off...._.. Atlantic Charter Insurance Company n Y V DACNCCCo. No.:29211 I. INSURED: Policy Number: WCV01124501 Environmental Abatement, Inc. Prior Policy Number: WCV01124500 1200 Bennington Street Producer: East Boston, MA 02128 Federal ID Number:275382735 Inc. tis Insurance Agency, Risk ID Number: 100 Unicorn Park Drive Business Type: Corporation Woburn,MA 01801 Other Named Insured: SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Work Places: 2. POLICY PERIOD: The Policy Period Is From: 12/19/2014 To 12/19/2015 12:01 A.M.Standard Time 3. COVERAGES: at The Insured Mailing Address A. Workers Compensation Insurance: Part One of the here;"NIA policy applies to the Workers Compensation Law of the states liste B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of our liability,under Part Two are: Bodily injury by Accident $ 500,000 Bodily Injury by Disease $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit C. Other States Insured:Part Three of the policy applies to the states,if any, listed here: each employee COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B' D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications Rates& Rating Plans.All information required below low rs subec ftov erif l rcafion and change by audit. Classifications Code Premium Basis Total Rate Per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium i i See WC 00 00 01 Minimum Premium: Deposit Premium: $550 $6,721 Interim Adjustment: Annually Servicing Office: Total Estimated Premium 25 New Chardon Street Surcharge(s) $8,351 Boston,MA 02114-4721 458 Total Premium and Surcharge(s) $8,809 Issue Date 12/16/2014 Countersigned Copyright 1987 National Council on Compensation Insurance Form;7( (71 Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 177555 ::..:.:.:.... Type: Corporation Expiration: 1/2/2016 Tr## 247688 ENVIROMENTAL ABATEMENT, INC: GEORGE WATTENDORF III 1200 BENNINGTON ST . EAST BOSTON, MA 02128 Update Address and return card.Mark reason for change. SCA t 20M•05/11 E] Address E] Renewal n Employment Lost Card (92eaneoi�a�revet�ll/c o/�C'/�i�CIJJCIC�r�e((J \ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only —140ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 177555 Type: Office of Consumer Affairs and Business Regulation xpiration:...11212016: Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 ENVIROMENTAL ABATEMENT•INC. GEORGE WATTENDORF 1111:`:-.'-.: 1200.13ENNINGTON ST.`.:.. ;? g _EAST BOSTON,MA 0212$ Undersecretary Not valid without signature 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards j Construction Supervisor License: CS-090209 i S�ml GEORGE V WATYENDORF ��,. i 14 Millett Lane. a !? Swampscott MA b1907<<Ci U Expiration 954, 03/16/2016 Commissioner