HomeMy WebLinkAboutBuilding Permit # 10/20/2015 O� NORTH
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BUILDING PERMIT �? y�::,c �0
TOWN OF NORTH ANDOVER ° ti �
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
�9SSACHU`��4�y I
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER' `,iq- f rj&= M 'V
Print
MAP NO: PARCEL:`'' ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no F
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
0-New Building AOne family
❑Addition ❑ Two or more family ❑ Industrial
,KAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Q Septic' 01Nell � Floodplain ❑Wetlands ❑ U1/atershedDstrict
'C]UVater/Seriuef
QS OPG &-cvU ZAIT t LE DAM,�, lM
W LNll ' vie _. .8 Am f L)E �
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Identification Please Type or Print Clearly)
OWNER: Name: ' 11aw &byc-ea&L Phone: Q' _ '7-7-5 Oy
Address:
CONTRACTOR NameJii //Y _Phone: - =ter 777
/Address:
Supervisorrs Construction License: Exp. Date:
Ct7 '� i b
Home"lewrovementLicense: Exp. Date: `
IUP
ARCHITECT/ENGINEER Phone:
Address: Reg. No. F
C
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ [C-61 , Lit FEE: $
Check No.: i 12Z Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/OwnerJb6� � 4 ign ture of contractor
t4OR'TH
own
of _ t_ E _ I' Andover
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7,9ls�
it BOARD OF HEALTH
ijERMIT T Food/Kitchen
Septic System
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THIS CERTIFIES THAT ! �� �`� ���......,�''� N BUILDING INSPECTOR
has permission to erect ....... buildings on /C �c%� !/ Foundation
�� Rough
to be occupied as /G�/../l%rc,/C:F.7 y' ............................................................. 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
IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTION STARTS Rough
.'............ Service
.......
,�_........... Final
BUILDING INSPECTOR
GAS INSPECTOR
ccupaneV Permit Required t® Occupy Buildinor 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-lD18-46EA-9BAF-7E86E94F436F
GCONTRACT 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,NIA 01581
Project ID:P00050043915 Reg. No. 173484
Customer ID:000050038345 . Federal ID No.222457170
Contract ID:20150619 WORK (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 terms of
this Contract,including the attached reconmiendationshvork order describing the work in detail(the"Work")-,vlrich 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 $387.87
For office use only Printed:7/1/2015 Page 2 of 2
II. PAYMENT 29 00
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1: as a Deposit
payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CSG,Attn:RCS,50 Washington St.,Ste.
3000,Westborough,MA 01581.Final Payment:$ 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$_1163.61 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 it the event that the HC has a dispute concerning this Contract,the HC 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 Al.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
Docus' ed b
slp�ss �y'�ollowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THER ANY BLANK SPACES.
�b l�Lbv<t VIMAIn 7/2/2015
Custom r r ua ure Date hrdicate your selected IIC here,if applicable (OR) Initia sere if you want
Mike Varney 7/1/15 Mike Varney the Program to assign a
CSG Signature Date Name of CSG Representative(Printed) Participating Contractor
TER3IS AND CONDITIONS APPEAR ON THE REVERSE. 3/1=1
RCS PLANVIEW DIAGRAM
Customer: q 606arr, /1QV�/' w' Home Phone: ( )-
Address: �g K 4o4mJ R), _ Work Phone: ( )-
Town: - - 1�x1T# �fis�0�/ _ _ - Cell Phone: ( 77Z 775— - ON,
Any limitations for access by large truck? No -ell Yes If yes,describe:
Any specific directions or landmarks? No I/ Yes A If yes.describe:
Site ID: sdc*;t7v 3-7110 Energy Specialist: r�t'� t rAe ' �Reviewed by:
0 of 044k W Fr.PPS
-(pJ fin. ��r ���
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For Office Use Only
Bushes Ladder Neighbor Proximity Pocket Doors Insert Radiators Fences)
Existing Conditions X=Access ❑=Vents Note Inside 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
Q=Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For.Access
22.99=39.1/i:5
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
wlvw.mass.gov/dia
Workers' Compensation Insurance Af>l davit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Ln y 11(`Ui/ m ()�-
Address:
City/State/Zip: - Phone#: -Z _q_1 _)b
Are you an employer?Check the appropriate box:
4I am a general contractor and I Type of project(required):
.
I am a employer with — g 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees Titbse sub-contractors have g, Demolition
working for me in any capacity. employees and have workers'
insurance. 9• Building addition
[No workers comp.comp, insurance p•
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 117JV_k )0_11_
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 afn an employer that is providing workers'compensation Insurancefor n:y employees. Below is the policy and job site
information.
Insurance Company Name: ���1)(, ( ,e f iii' It1._)G(r4/?GL c
Policy#or Self-ins.Lic.#: �� 12`-/x) Expiration Date: S
Job Site Address:11 Gl HC,(,t,i U y-a(t`Li� City/State/Zip:
Attach a copy of the worizersr 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/terebv certiJv tinder fire paints acrd penalties of perjury that the Jnformatlon provided above i true and correct
Sinature: _.... __ ... .__.._._._.__..._._ .. ......_.___... _.__._......._...... ...... Date: iU s
77
Phone#: _7 61 ` "!��`4 —619
Official rise only. Do not►prite In this area,to be completed by city or tome 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#:
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NCCI Co. No, Atlantic Charter Insurance Company VDAC
:29211
1• INSURED: Policy Number: WCV01124501
Environmental Abatement, Inc. Prior Policy Number: WCV01124500
1200 Bennington Street Producer:
East Boston, MA 02128 Federal ID Number:275382735 DeSanctis 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 policy applies to the Workers Compensation Law of the states '
here: MA (IstE
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 is subject to verification and change by audit.
Classifications Code Premium Basis Total Rate Per Estimated
No, Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$550 $6,721
Interim Adjustment: Annually
Servicing Office: Total Estimated Premium $8,351
25 New Chardon Street Surcharge(s) 458
Boston,MA 02114-4721
Total Premium and Surcharge(s) $8,809
Issue Date 12/16/2014 Countersigned By1.C' (I
2 .Com; 21
Copyright 1987 National Council on Compensation Insurance
Form:9(
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 177555
Type: Corporation
_ Expiration: 1/2/2016 Tr# 247688
ENVIROMENTAL ABATEMENT, INC:.
GEORGE WATTENDORF III
1200 BENNINGTON ST
EAST BOSTON, MA 02128
Update Address and return card.Mark reason for change.
SCA1 :5 20M-05/11 0 Address E] Renewal ❑ Employment f-I Lost Card
an 1onruea,&/ba�b- �llau e(
\ Office of Consumer Affairs&Business ReguJJlation((c/ !J
License or registration valid for individul use only
fiOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
_registration: 177555 Type: Office of Consumer Affairs and Business Regulation
Expiration:.:.112/2016, Corporation 10 Park.Plaza-Suite 5170
Boston,MA 02116
ENVIROMENTAL ABATEMENT;INC.
GEORGE WATTENDORF CII':i•:
1200.BENNINGTON ST;•.. `°, ' g ���� f �,__ —
_EAST BOSTON,MA 0212$' Undersecretary �vNot valid without signature . .
.0
1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor = }
License: CS-090209
GEORGE V WATYENDORF
14 Millett Lane. � e o��� .�•-
Swampscott MA 151907;j '°
91,41 Expiration
03/16/2016
Commissioner +�
J