HomeMy WebLinkAboutBuilding Permit #719 - 20 Redgate Lane 6/22/2009Permit NO:
Date Issued:
LOCAT
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
PROPERTY OWNER
MAP NO: PARCEL: IO
e- ,Ggiq 7
Print
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PROPOSED USE
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DISTRICT: /�'3 Historic District yes
Machine Shop Village yes zop
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
ew Building
a family
or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic,—zLe.I.11
Floodplain Wetlands
Watershed District
Wat Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name:_s ,��� r �,�����/� T Phone:
Address: 1&,5- 5, D 1 �/
CONTRACTOR Name: %1 G r- C -- Phone: �' �- (�"qe'y
Address:T Aelc
Supervisor's Construction License:Exp. Date: / 'U
Home Improvement License: Exp. 'Date:
ARCHITECT/ENGINEER/Yd ��� C�,hnP // Phone: ZZ,4— s`�o _ 333
Address: 2 Z,o/- S� �� (,��� y�4 Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: FEE: $ `7 4e!5�
Check No.: Receipt No.: 1165'
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
acto
Signature of Agent/Owner Cr 5igriature of contrr
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 FgLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS All
CONSERVATION
Reviewed on
Sianature
ec-l 5/�)0 ,
F,2),1226 i/��
COMMENTS�L(
HEALTH
N
COMMENTS
Reviewed on
Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature D-g;F60ay Permit
DPW Town Engineer: Signature:
Located 384 Qpgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes g `'
Located at 124 Main Street_ f
Fire Department signature/date fes'
COMMENTS
Dimension
Number of Stories: 04-- 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
Li Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o 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
o Building Permit Application .
❑ Certified Surveyed Plot Plan\t i
o Workers Comp Affidavit
L3 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)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location
No. 719" Date ? d
NORTH
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Nus
Building/Frame Permit Fee
$
�d
Foundation Permit Fee
$
/00
Other Permit Fee
$
Cf U
TOTAL
$
Check # // 4 S/
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22�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 N'aashhTWn Street
Boston, MA 02111
c ' www_mass.gov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Eiectricians/Plambers
mficant Tnfnrmoiinn
• � i ■ Lltt LC"(rJ(
Name (Business/Organizafion/Endividta!);
Address:_
Citystate/Zig:
Phone #: C— -- "e
Are you an employer? Check the appropriate box:
1. ❑ It am a employer with 4. ❑ I am a genera( contractor and I
Type of Project (required):
employees (full and/or part-time).*
2I am.a:sole Proprietor or partner-
have ihfired the sub -contractors
listed on the attached sheet $
6. Z New construction
7.!❑` Remodeling
ship and have no employees
working for me in any capacity,
These sub -contractors have
workers' comp. insurance.
8. [] Demolition
�Tio workers comp. insurance
P
5. ❑ We are a corporation and its
9- ❑ Building addition
required.]
3. ❑ I am a homeowner doing
officers have exercised their
10.❑ Electrical repairs or additions
an work
myself[No'v'o�� ' comp,
right of exemption per MGL
c. 152, § 1(4), and we have no
11.0 Plumbing repairs or additions
�N ].
.employees. [No workers
repairs
12.[] RooOther
comp. insurance required_]
I3.[].Othtr
`AnY aPPlieamn that checks bcd * I must also fill out the section below showing their workers' compensation
t homeowners who submit this affidavit indicating they am during an work and than hire outside contactors
-- ;Corttmctorc that
policy in
most
check this box must attached an y submit anew affidavit indicating such
addrtirnml shashowier. the name df&e and their worhets' ser F 'F"lic, irinrmatian
I carr ort employer that is prnmding.workerscompe
' zsadon lasurance or
information. f mY employeaL Below is the policy andjok site
Insurance Company Name:
_
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/StateJZip:
Failure to
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date}
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 free
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 u der the rad penalties of erjrny t*at the information provided above is true acrd correct
Si nitre: -- Date: — �- � j Q y
Phone#: �.� �— �drf g r
7�1s!�uilng
usedty. Do not write in this area, to be compl d �, J' or town o iia[
n: Permit/License #
ority (circle one):
L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
6.Other
11 Contact Person• Phone #:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp 3oyers to provide workers' compensation for their employees.
Pursuant to this statute, an enrptoyee 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 mom
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 apartme= and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair wdrk m 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 ito construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence -of compliance with the insurance' coverage required."
Additionally, MOL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract far 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 -contractors) name(s), addresses) acid 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 requiredz to carry workers' compensation insurance. lfan 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'
oompensation policy, please call the Department at the numberlisted below. Self-insured comoanim should enter their
self insurance"license number on the•appropfiate 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 sura 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
policyinformation (if necessary) and under ".lob 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 futum 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 fbr 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 Iavesti rations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4904 6Kt 406 or 1-8.77-MASSAFE
Fax # 617-727-774
Revised 5-26-05 www.mem.gov/dia
J06/22./2009 09:02 FAR 19766833147
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CERTIFICATE aF LIABILITY tNSUR NG S A INATTER
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DATE THEREOF. THIS "UNG INSURER WILL ENDEAVOR 70 MAIL _
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NOTICE TOTOCERTIFWATEHOIAERNAMED TO7HELEPT.BUTFAIWRET0��5S09
IMP05E NO 08LIC+AT OR LIABILITY OF ANY KIND UPON YHE I!$URER, ITS AGENTS OR
ATT14: GERR'Y H/�B REPRESENTATIVES.
WJYxAING CC iISSIONHR AUTNORIMD REPO
1600 OS600D STREET
01845
NORTH ANDOVER, 2g+ ®1g6a,009 ACORD CORPORATION. Atl r{ghts reser4e�
ACORD 25 (2009101) The ACORO na1TH► and logo are reglsWmdRlarks of ACORD
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IN
REScheck Software Version 4.2.2
Compliance Certificate
Project Title: redgate
Energy Code:
Location:
Construction Type:
Conditioned Floor Area:
Glazing Area Percentage:
Heating Degree Days:
Climate Zone:
Construction Site:
20 redgate lane
north andover, MA 01845
2006 IECC
North Andover, Massachusetts
Single Family
2937 ft2
17%
6322
5
Owner/Agent:
whispemg pines realty trust
82 belmont street
north andover, MA 01845
978 609 6481
kc_realty @verizon.net
.
Compliance: 2.7% Better Than Code Maximum UA: 521 Your UA: 507
Designer/Contractor:
richard keller
keller contracting
4 fosters pond road
andover, MA 01810
978 475 7273
Wall 1: Wood Frame, 16" o.c.
1680
19.0
0.0
101
Wall 2: Wood Frame, 16" o.c.
1512
19.0
0.0
59
Window 1: Vinyl Frame:Double Pane with Low -E
527
0.280
148
SHGC: 0.43
Ceiling 1: Flat Ceiling or Scissor Truss
1469
30.0
0.0
51
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
1469
19.0
0.0
69
Basement Wall 1: Insulated Concrete Forms
1444
14.0
79
Wall height: 8.0'
Depth below grade: 7.0'
Insulation depth: 8.0'
Furnace 1: Forced Hot Air 90 AFUE
Furnace 2: Forced Hot Air 80 AFUE
Air Conditioner 1: Electric Central Air 13 SEER
Air Conditioner 2: Electric Central Air 13 SEER
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 2006 IECC requirements in
REScheck Version 4.2.2 and to comply with the mandatory requirements listed in the RES eck Inspection Checklist..._
k let //t,� , j d fj
Name - Title Sign ure Date
O W AJ 0
IL aw
Project Title: redgate Report date: 06/18/09
Data filename: C:\Program Files\Check\REScheck\20 redgate.rck Page 1 of 3
Massachusetts - Department of Public Sjet,.� .
Board of Building Regndations and Standards
Construction Supervisor License
License: Cs 42845
Restricted to: 00 re
RICHARD G KELLER
4 FOSTERS POND RD
ANDOVER, MA 01810 I
Expiration: 8/21/2010
( u1)till �mrr Tr#: 1941
JAMES A. O'DAY, P.E.
SHEET NO.
OF
CALCULATED BY DATE
CHECKED BY DATE
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1 Amlaole from jVEs�
�/ Inc. Groton. MRSSL 01450
JOB
JAMES A. O'DAY, P.E.
SHEET NO. � OF
CALCULATED 8Y ,!_1 L?_ DATE
CHECKED BY
SCALE
DATE
FORM 204-1 Available fromA2 93I fna.. Groton, Mass. 01450
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