HomeMy WebLinkAboutMiscellaneous - 33 Baldwin StreetLocation_,r—
o. Date
NORT1y
TOWN OF NORTH ANDOVER
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9
Certificate of Occupancy
$
Building/Frame Permit Fee
CNUS
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # (� 1
23807 "'building Inspector
TOWN OF NORTH ANDOVER
q APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:a::4
IlVIP RTANT: Applicant must complete all items on this page
LOCATION'
r. Print
-print J U
MAP NO: - 13 PARCEL: b1- ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
XTwo or more family
❑ Industrial
❑ Alteration
-No. of units:'
❑ Commercial
,Repair, replacement
❑ Assessory Bldg
❑. Others:
❑ Demolition
❑ Oth�eTr-�
3CiM'�S'4"1£ Al
0 5 ptic ❑Well -L:^..
f -�--. SF x^cF Y $ ��S
y3 -4 i... SY •1Z�"v'• Z• X aT' = ��F
y� D Floodplam'D�Wetlands-'�
.yl. 1 Y ^ t'"•'
�- R., i.L �-+' i tC.'Ei y�--i .
Lxpatersh_ ed"District
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DESCRIPTION
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: 1 Phone: ��1 ' Vis'I`
Address:
CONTRACTOR Name: - �x t � -\a, Phone: t Q 11 Z ) -`\ V
Address:
Supervisor's Construction License: ' l�` �`) Q—Exp. Date: �� ► I 1 z
Home Improvement License: �loU`h Exp. Date:.
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT.• $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: FEE: $ �`I 0
Check No.: (� �3 Receipt No.: a�T3d
NOTA Personfl'cgontracting with uffregistered contractors 46 not h#p access to the guaranty fund
A
Ignature of en Ow er
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ .
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageBody Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales El
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 Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date _ Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site.. yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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Low -Income Multifamily Retrofit Program
9/26/10
Administered by LEAN
North
Andover - DRAFT
Overall Work Order
For Program Approval Only
North Andover HA
Job 10-123-0
Multiple
NORTH. ANDOVER 01845
Joanne Crawford
(978)862-3432
Section
Measure Installed
Unit Price
Price
Attic
"Unfloored
R-20 open/unrestricted Cellulose 11700
$1.23
$14,391.00
Sub Total 11700
$14,391.00
Wall
'All Walls
Clapbd/wood/vinyl R-13 18720
$1.70
$31,824.00
Sub Total 18720
$31,824.00
Floor
Floor Insulation
Basement Overhead -R30 11700
$1.73
$20,241.00
Sub Total 11700
$20,241.00
Infiltration
Airsealing w two-part foam 26
$75.00
$1,950.00
Sub Total 26
$1,950.00
Distribution
Duct insulation R-5 520
$2.95
$1,534.00
Sub Total 520
$1,534.00
Grand Total
$69,940.00/ bU11in
* Attic & Wall insulation savings estimates are based on audit limited access evaluation of'need. initial vendor walkthrough will
determine the ability to install these
measures and estimates will be updated at that time.
`� .
J-1
1(
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
vj
www.mass.gov/dig
Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): r�L
0
Address:
City/State/Zip: rf�'k Phone.#: Un-
*Any applicant that checks box #1 must also RE out the section below showing their workers' compensation policy information.
t Homeownerswho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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:__ w�-� \���i�u� �i �Yl�t�cun� N)
Policy # or Self -ins. Lic. #: 1U_, MyacIc)\G� Expiration Date:
Job Site Address:-n� �(��L����l� 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
finetup 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 penalties of erj that the information provided above is true and correct
Signature: Date:
Phone #: an • 13 . 1 �
Official use only. Do not write in th a ea, lb be completed by city or town official
City or Town.
Permit/License #
Lssuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical I.ngpector 5. Plumbing Inspector
6. Other
II
ContactPerson: Phone #:
Are you an employer? Check the appropriate box:
1. I am a with �O
4. ❑ I am a general contractor and I
.employer
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a •sole proprietor or partner-
listed on the•attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'_._
[No workers' comp, insurance
required.]
comp, insurance.# '
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp,
right of exemption per MGL
insurance required.] t
c, 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also RE out the section below showing their workers' compensation policy information.
t Homeownerswho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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:__ w�-� \���i�u� �i �Yl�t�cun� N)
Policy # or Self -ins. Lic. #: 1U_, MyacIc)\G� Expiration Date:
Job Site Address:-n� �(��L����l� 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
finetup 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 penalties of erj that the information provided above is true and correct
Signature: Date:
Phone #: an • 13 . 1 �
Official use only. Do not write in th a ea, lb be completed by city or town official
City or Town.
Permit/License #
Lssuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical I.ngpector 5. Plumbing Inspector
6. Other
II
ContactPerson: Phone #:
ACORD CERTIFICATE OF LIABILITY INSURANCE
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
T"'
041232010YYI)
04/23!2010
PRODUCER (800)225-1865
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Fred C. Church, Inc.
41 Wellman Street
Lowell, MAO] 851
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
LIMITS
800-225-1865
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A.- Citation Insurance Company
Advantage Weatherization, Inc.
Two Adams Place, Suite ] 00
Quincy, MA 02169 -
INSURER B: National Union Fire Insurance Company of Pittsburgh
Selective Insurance Company
INSURER C: P Y of America
INSURER D:
}( COMMERCIALGENERAL LIABILITY
CLAIMS MADE OCCUR
INSURER E:
r t vi=1c1.TN=y
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
T
ADD'L
E O SU C
POLICY NUMBER
POLICYEFFECTIVE
D
POLICY EXPIRATION
D E D
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
}( COMMERCIALGENERAL LIABILITY
CLAIMS MADE OCCUR
DAMAGE f0 R ED
P EMtSES Ea occurence S 100,000
MED EXP (Anyone person) S 10,000
C
S1928883
4/2/2010
4/2/2011
PERSONAL 8 ADV INJURY 1,000,000
GENERAL AGGREGATE S 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 3,000,000
-
PRO LOC
POLICY JECT
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
BODILY INJURY S
(Per person)
A
X
X
X
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
BBNT98
4/2/2010
4/2/2011
BODILY INJURY
(Per eccident) S
PROPERTYDAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLALIABIUTY
_R] OCCUR - E1CLAIMSMADE
EACH OCCURRENCE S 15,000,000 .
AGGREGATE $ 15,000,000
B
BE1223010
6/20/2010
6(20/2071
$
S
DEDUCTIBLE
X RETENTION $10,000
S
WORKERS COMPENSATION AND
X WC STIMrr FR
B
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE
WC001290194
620/2010
6/20/2011
E_L.EACH ACCIDENT S 1,000,000
E.L. DISEASE- EA EMPLO $ 1,000,000
OFFICERIMEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMB S 1,000,000
OTHER
DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate is Issued as evidence of coverage.
uv n -wry r c nvLVGR �.AIVI.CLW I IVnI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LWBIL TY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
'kL,UKU LD (ZUU1/uta) Client# '17Arl Msr# 2010 GL,Auto,WC,Umb Cort# ACORD CORPORATION 1988
9
{
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.$10041000 fine
----I MA'rn lG.,r AcknnrtmAnf user
Doc:.Buildiug 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. An C.S.L. Licenses
❑ Copy of .Contract
❑ Floor Plan Or Proposed Interior Work
❑ EngineeringAffidavits avlts 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/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
❑ 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
dOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
hist be submitted with the building application
Doc: Doc.Building permit Revised 2008mi