HomeMy WebLinkAboutBuilding Permit #484 - 99 OGUNQUIT ROAD 1/20/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: ' Date Received
Date Issued:
IM ORTANT: Applicant must complete all items on this page
LOCATION LNER
CSCuY (I al� Tt,��lIJ Print
PROPERTY 1' 1k3 re. -e.- K-)
Print
MAP NO: a PARCEL: ZONING DISTRICT: (Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Building
One family;
-ffew
dition
wo or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Seti Well
Floodplain Wetlands
Watershed District
Wate Sewer
L-�nd�r
F0 VAq,WG -1'(oI/
or Print Clearly)
ax-Cbm
hC)�I�e�
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ARCHITECT/ENGINEER 1,°�( omg('� tt- �� rl , �° Phone:�'1��( J5;
Address: �G�d Il') �3�, C�c � ( �{� - MO Reg. No. 6� 7Wos
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST SED ON $125.00 PER S.F.
Total Project Cost: $ 7�� �D� FEE:.$
Check No.: `i Receipt No.:
NOTE: Persons contr cting with unregistered contractors do not have access to the gu an and
Signature of Agent/Owner Signature of contractor
T-
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE 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
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
tr COMMENTS
Reviewed on U
Reviewed on
te a.,,. ;1- -P -a V--v--r- � ` Z, A s -3//,7// u
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Commen
Water &Sewer Connection/Sig nat M D veway Permit
DPW Town Engineer: Signature: <f--�
.11� 11 PX4
41 Located 384 Osgood Street
FIRE DEPARTMENT - Temp Du Aster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
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 Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
❑ Floor/Crossection/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)
Building Permit Application
w 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
o Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: 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: Doc.Building Permit Revised 2008
7 aG
Locatlo''n///�_
No. �� Date 4�v
M�RTM TOWN OF NORTH ANDOVER
f �,y
41
3? o • OL
Certificate of Occupancy $
'T Mus E< Building/Frame Permit Fee $
Foundation Permit Fee $ /dd
Other Permit Fee $
( ` TOTAL $
Check # �jrr
r � Irl
22/
Building Inspector
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CERTIFICATE OF LIABILITY INSURANCEI DATE(MMIDPIYYYY)
11/16/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
M.P. Roberts Insurance ,Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATIr
1060 Osgood Street HOLDEQ. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
ALTER .1'HE COVERAGE AFFORDED BY THE POLICIES BELOW.
North Andover, MA 01845
INSURER:* AFFORDING COVERAGE NAIC 0
INSURED _...... .......
1NSURER_n 1 Z,OYD' S LONDON _
PETER BRE�,N OXC,A,vp,TING INC INSURER O: ;}fIZ.GRTM,.,INSVRANC)~-,
A/0 TRAVIS & TIM CONSTRUCTION
770 BOXFORD STREET INSURER C: LACE USA
D: L ....___
INSURER —..,
NORTH OVER, MA 01845 INSURER E: --- ---
COVERAGES
THE POLICIES OF INSURANCE LI$TEb MLOW HAVE BEEN ISSUED TO THE INSURED NAMEO.ABOVE FOR THE POLICY PERIOD INDICATEQ, NOTWITHSTANDING
ANY REQUIREMENT, 'TERM OR CONDITION OF ANY CONTRACT OF? OTHER DOCUMENT 111TH RESPECT TO WHICH THIS CERTIFICATE NAY BE ISSUEDIOR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE$CRI5F_p HEREIN IS SUBJECT TO AU. THE T FRMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L. 1M,5. POLICY NUMBER POUCY EFt cnji POLICY FJ(PIRATION LIMITS
GENERAL LIABILITY
EAC
N OCCURRENCE0'00
A coMMERCIALr3£NFRALLIABILITY LGL0816724 2/19/(49 2/19/10 ------ CLAW MADE MADE Ex:1 Occun
GEN'LAGGREGATE LIMIT APPLIES PER
POLICY P 0" LOC
AUroMOBILP UAFJ I,ITY
B ANYAUTO
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�{ SCHROULED AUTOS
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GARAGE LIABILITY
ANY A LITO
SSS I UMEIRELLA LIABILITY
OCCUR CLAIMS MADE,
DEDUCTIBLE
MED EXP (Ally corn pt,— � 9
PERSONAL &ADVIN.IURY
GENERAL AGGREGATE A
PRODUCTS - COMPIOP AGC S
COMB INED SINGLE LIMIT
P0000001007123 11/22AC 3 11/22/09 (Eeecclderd)
BODILY INJURY
(Per Paf:on)
BODILY INJURY
(Per atxitlehl)
AND EMPLOYERS' LIABILITY
C OFMCANY ERPIrMI3REXCLUDEoa�'Urn� Y� C45868134 11/13/0, 11/13/10
Imencraronr In NMI
OTHER
0E99RIPTION OFOPERATIONS / LOCATIONS I VENCLES 1EXCLUSIONS ADDED BY ENDORSF.IIMENT/ SPECIAL PR6
POWN OF NORTH ANnOVPR IS LzsTED AS AN .ADDITION.AL INSTJREp
P-978-689-$740
TOWN OF NORTH ,ANDOVER
OSGOOD STREET
NORTH ANDOVER, MA 01845
X;0RD 25 (2009/01)
The AC
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PROPERTYDAMAGE B
(P er eccltlent)
AUTO ONLY -EA ACCIDENT S
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SHOULD ANY bFT WE AMOVE bESCRIBED P OLICIUS ER C A NCELLH D BEFORE THE EXPIRATION
DATE THER60, THE 18SUNG INSURER WILL ENDEAVOR TO MAIL 10 DAYS WMI TtN
NOTICE TO Till! CERTIFICATE HOLDER NAMED TO THE LZrT, BUT FAILURE TO DO SO SWALI.
IMPOSE NO LIMLIGATION OR LIABILITY OF ANY KIND UPON TN6 INSURER, ITS AGENTS OR
O 198$.,2(109 ACO
name and logo are reglsrered marks Of ACORD
reserved,
Energy Code:
Location:
Construction Type:
Conditioned Floor Area:
Glazing Area Percentage:
Heating Degree Days:
Climate Zone:
Construction Site:
Lot 28 - Ogunquit Rd.
North Andover, MA
REScheck Software Version 4.3.0
Compliance Certificate
2007 IECC
North Andover, Massachusetts
Single Family
3848 ft2
19%
6322
5
Owner/Agent:
Designer/Contractor:
'Fm``"'3'1
Comp �ance,PassesontUA4;trade off;
Compliance:
cemng i: mat cemng or Scissor Truss
1924 38.0
0.0 58
Wall 1: Wood Frame, 16" o.c.
3434 19.0
0.0 165
Window 1: Vinyl Frame:Double Pane with Low -E
601
0.350 210
SHGC: 0.70
Door 1: Solid
20
0.350 7
Door 2: Glass
60
0.350 21
SHGC: 0.70
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
1924 30.0
0.0 63
Compliance Statement. The proposed building design described here is consistent with the building plans, specifications, and other
calculations submitted with the permit application. The proposed building has been designed to meet the 2007 IECC requirements in
REScheck Version 4.3.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist.
Name - Title Signature Date
Project Title: Report date: 01/07/10
Data filename: Untitled.rck Page 1 of 3
Ceilings:
REScheck Software Version 4.3.0
Inspection Checklist
❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-38.0 cavity insulation
Comments:
Above -Grade Walls:
❑ Wall 1: Wood Frame, 16" o.c., R-19.0 cavity insulation
Comments:
Windows:
❑ Window 1: Vinyl Frame:Double Pane with Low -E, U -factor: 0.350
For windows without labeled U -factors, describe features:
#Panes Frame Type Thermal Break? Yes No
Comments:
Note: Up to 15 sq.ft. of glazed fenestration per dwelling is exempt from U -factor and SHGC requirements.
Doors:
❑ Door 1: Solid, U -factor: 0.350
Comments:
❑ Door 2: Glass, U -factor: 0.350
Comments:
Floors:
❑ Floor 1: All -Wood Joist(Truss:Over Unconditioned Space, R-30.0 cavity insulation
Comments:
Floor insulation is installed in permanent contact with the underside of the subfloor decking.
Air Leakage:
❑ Joints, attic access openings, and all other such openings in the building envelope that are sources of air leakage are sealed.
❑ Recessed lights in the building thermal envelope are 1) type IC rated and ASTM E283 labeled and 2) sealed with a gasket or caulk
between the housing and the interior wall or ceiling covering.
❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated (without insulation compression or
damage) to at least the level of insulation on the surrounding surfaces. Where loose fill insulation exists, a baffle or retainer is installed
to maintain insulation application.
❑ Wood -burning fireplaces have gasketed doors and outdoor combustion air.
Sunrooms:
❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U -factor of 0.50 and the maximum
skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope
requirements.
Vapor Retarder:
❑ A minimum of Class II (1.0 perm) vapor retarder is installed on the interior side of above -grade framed walls or it has been determined
that moisture or its freezing will not damage the materials.
Exceptions:
Class III (10 perm or less) vapor retarder is permitted for vented cladding over OSB, plywood, fiberboard, gypsum, or for sheathing
over 2x4 framing having insulation of R-5 or better, or for sheathing over 2x6 framing having insulation of R-7.5 or better.
Materials Identification and Installation:
❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions.
❑ Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value.
Project Title: Report date: 01/07/10
Data filename: Untitled.rck Page 2 of 3
Materials and equipment are identified so that compliance can be determined.
Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided.
Insulation R -values and glazing U -factors are dearly marked on the building plans or specifications.
Duct Insulation:
Ll Supply ducts in attics are insulated to a minimum of R-8. All other ducts in unconditioned spaces or outside the building envelope are
insulated to at least R-6.
Duct Construction:
F1 Air handlers, filter boxes, and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and
mechanically fastened.
All joints, seams, and connections are made substantially airtight with tapes, gasketing, mastics (adhesives) or other approved closure
systems. Tapes and mastics are rated UL 181A or UL 181 B.
Building framing cavities are not used as supply ducts.
Automatic or gravity dampers are installed on all outdoor air intakes and exhausts.
Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International
Mechanical Code.
Temperature Controls:
L1 Thermostats exist for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or
cooling input to each zone or floor is provided.
Heating and Cooling Equipment Sizing:
Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code.
For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2006 IECC Commercial
Building Mechanical and/or Service Water Heating (Sections 503 and 504).
Circulating Service Hot Water Systems:
L] Circulating service hot water pipes are insulated to R-2.
Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the
system is not in use.
Certificate:
El A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window
U -factors; type and efficiency of space -conditioning and water heating equipment. The certificate does not cover or obstruct the visibility
of the circuit directory label, service disconnect label or other required labels.
NOTES TO FIELD: (Building Department Use Only)
Project Title: Report date: 01/07/10
Data filename: Untitled.rck Page 3 of 3
Wall 19.00
Floor I Foundation 30.00
Ductwork (unconditioned spaces):
Comments:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: V _ () o
City/State/Zip:A/a f �ni) ,%Itr MA (3M S'
Phone #:-.'1 7 S - q E-7 -- Gt.( � L4
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. E3I am a general contractor and I
employees (full and/or part-time).*
2.
have hired the sub -contractors
e I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' Comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. [V New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
u1e seCuon oei01V snowmg fhb 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.
*Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
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 certify` under the pains and pew ties o5PIriury that the information provided above is true and correct
Phone #:
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investibations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass..gov/dia