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HomeMy WebLinkAboutBuilding Permit #619 - Exception 3/26/2007Permit NO: / Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received '3 — 66 TYPE OF IMPROVEMENT of. Residential TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic L11 e 1 ; . I F1 iodpla r " .I Wetlands © tershe istrict . F DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: lXoo nsGaczn �2- t-/.0 I Phone: AdrirPcc- ARCHITECT/ENGINEER %`>Phone:69x� ?® Address: No. "'511)q 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: $ % S3 Check No.: D P/ 2 Receipt No.:,� o o G 6 NOTE: Persons contracting with unregistered contractors do not have access to e guar ty fu Signature of Agent/Owner �F C ��+� ��1 Signature of contractor r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ PLANNINP & DEVE 2 , COM ENTS / o CONSERVATION COMMENTS HEALTH COMMENTS THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM LOPMENT ❑ DATE REJECTED DATE APPROVED P/ -ue- r'4- 0 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ 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 ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments 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 Doc.Building Permit Revised 2007 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 u/ Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses d Copy of Contract Lrl 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 ❑ 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 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 2.2007 Locaxion le - No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 7, C -?Z Check # z — 2 0 U' 6 0" e5l� Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):�_,.I% Address:% �1 rlrP.✓�_�y�r� 7�3 3 City/State/Zip: - A -pp � mA (9)g� Phone #: A7§� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10 JK Electrical repairs or additions 11. [1 Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other 5n " 6I t� *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 him 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �1-{�� �,t,z t ,y Policy # or Self -ins. Lic. #: Expiration Date: -- Job Site Address: City/State/Zip: k. 4,40A ,,d91)'�Q 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 Investi¢ations of the DIA for insurance covers-ze verification. I do hereby center th3,1)a1ns3 pd pePtes of perjury that the information provided above is true and correct use onty. Do not write in this area, City or Town: or town of}iclaL 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 #: Are you an employer? Check the appropriate box: 1. g I am a employer with -� 4. ❑ 1 am a general contractor and I 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 comp. insurance.# required.] 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10 JK Electrical repairs or additions 11. [1 Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other 5n " 6I t� *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 him 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �1-{�� �,t,z t ,y Policy # or Self -ins. Lic. #: Expiration Date: -- Job Site Address: City/State/Zip: k. 4,40A ,,d91)'�Q 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 Investi¢ations of the DIA for insurance covers-ze verification. I do hereby center th3,1)a1ns3 pd pePtes of perjury that the information provided above is true and correct use onty. Do not write in this area, City or Town: or town of}iclaL 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 burn 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fax # 617--727,;.7749-- Revised 1?=727-7749--Revised 11-22-06 www.mass.gov/dia INFORMATION PAGE NEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: TWIN CITY FIRE INSURANCE COMPANY HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115 NCCI Company Number: 14974 Company Code: 7 CV 0 0 a POLICY NUMBER: 108 WEC RH7835 in en Previous Policy Number: NEW — CD HOUSING CODE: SB a 1. Named Insured and Mailing Address: NEXGEN ENERGY SOLUTIONS, LLC CD (No., Street, Town, State, Zip Code) N O Ln 857 TURNPIKE STREET SUITE 233 M FEIN Number: 204782764 NORTH ANDOVER, MA 01845 State Identification Number(s): The Named Insured is: LIMITED LIABILITY COMPANY Business of Named Insured: SOLAR ENERGY INSTALLATION & RE Other workplaces not shown above: 857 TURNPIKE STREET SUIT NORTH ANDOVER MA 01845 2. Policy Period: From 08/10/06 To 08/10/07 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: R C LAFOND INSURANCE AGENCY INC 396 ANDOVER STREET NORTH ANDOVER, MA 01845 Producer's Code: 088474 Issuing Office: THE HARTFORD 4401 MIDDLE SETTLEMENT RD. NEW HARTFORD NY 13413 (800) 962-6170 Total Estimated Annual Premium: $3,786 Deposit Premium: Policy Minimum Premium: $500 MA Audit Period: ANNUAL Installmente : The policy is not binding unless countersigned by our auth rep�sentati44� Countersigned by Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 08/25/06 ORIGINAL THE HARTFORD suffix LARS RENEWAL 00 Page 1 (Continued on next page) Policy Expiration Date: 08/10/07 j ,. Zimfims Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the meted here: MA ' foyers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee Other States insurance: Part Three of the policy applies to the states, if any , listed here: ij, STATES EXCEPT ND, OH, WA, WV, WY, AND cSTATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. Tbis policy includes these endorsements and schedule: 00 01 13 WC 20 03 03B WC 00 04 14 WC 20 03 01 WC 20 03 02 iX 20 04 01 WC 20 04 03 WC 20 04 05 WC 20 06 01 & The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating u All information required below is subject to verification and change by audit. Premium Basis cations Total Estimated Rates Per Estimated d2assifiNumber and Annual $100 of Annual iption Remuneration Remuneration Premium r B.S 49,800 6.72 3,347 ,SWC METAL WORK - SHOP AND OUTSIDE NOC - DRIVERS -TCTAL ESTIMATED ANNUAL STANDARD PREMIUM 3,347 .9WENSE CONSTANT (0900) 284 _--7-':, iMSSACHUSETTS DIA ASSESSMENT 4.192 PERCENT 140 FOREIGN TERRORISM (9740) 49,800 .030 15 *10TAL ESTIMATED ANNUAL PREMIUM 3,786 Total Estimated Annual Premium: $3,786 Deposit Premium: Policy Minimum Premium: $500 MA Interstate/intrastate Identification Number: NAICS: Labor Contractors Policy Number: SIC: 1711 UIN: NO. OF EMP: 000001 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 08/25/06 Policy Expiration Date: 08/10/07 UTT BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 093806 Birthdate: 12/19/1976 Expires: 12/19/2009 Tr. no: 93806 Restricted: 00 DANIEL P LEARY 49 COURT ST N ANDOVER, MA 01845 �/ Commissioner CA m m m m YI m m — m n CD am y CD C36 O C2• C d C a� y �CD C d CD CDCL o C x O CD CDoat O CD COW a C CP �. yCD� �O y O I co CD � r °x � CO) v O .0 CD "d SZ x O CD O C CD PL 0 ,v r cn n O cn O (n cn 4 �� � r °x tom-' �� �� a "d :1 x a W tv O� n r H C7 O H 0 c t 1600 OSGOOD STREET, LLC SUPPLIER AGREEMENT AGREEMENT made this day of "Supplier" NexGen Energy Solutions, LLC 857 Turnpike St., Suite 233 North Andover, MA 01845 Attn: Dan Leary Tel: (978) 688-2700 Fax: (978) 416-2525 2007 by and between: and "Owner" 1600 Osgood Street, LLC c/o Ozzy Properties, Inc. 3 Dundee Park, Andover, MA 01810 Attn: Orit Goldstein Tel: (978) 475-4569 Fax: (978)475-4638 Owner hereby engages and retains Supplier to perform, and Supplier agrees to perform, the services and/or provide the equipment and materials identified herein for the property known as and located at 1600 Osgood Street, North Andover, Massachusetts 01845 (the "Property") in accordance with the Schedules described below and the Contract Documents, as defined below; for the period of one (1) year from the signing date. The Contract Documents consist of this Supplier Agreement, the 1600 Osgood Street, LLC, Supplier Terms and Conditions attached hereto and all Contract Documents as defined therein. The following Schedules are attached hereto and incorporated herein: Schedule A - Scope of Work Schedule B - Payment Terms Schedule C - 1600 Osgood Street, LLC Supplier Terms and Conditions Schedule D - Insurance Appendix Supplier shall execute the Scope of Work ("Scope of Work") as defined and identified on Schedule A attached hereto and incorporated herein in accordance with the Contract Documents. Executed as a sealed instrument this 01-f . day of 200--j- SUPPLIER: NEXGEN ENERGY SOLUTIONS, LLC By: Name: OWNER: 1600 OSGOOD STREET, LLC By: Name: oi?- T Cxo LDSTi1a0 Title: 7 SCHEDULE A SCOPE OF WORK NexGen Energy Solutions, LLC (NexGen) of North Andover, MA will integrate a 103,360 kWDC (STC) photovoltaic (PV) array at the south, upper roof of Building 30, 1600 Osgood Street, North Andover, MA for the client, 1600 Osgood Street, LLC. NexGen will provide turnkey project management, installation, and commissioning for the array to include, but not limited to, the following tasks: 1. Design Oversight Note: Designs will be completed and stamped by a contracted licensed PE. 2. Grid Interconnection Submittal 3. Town Permitting Submittal 4. Site Preparation Oversight Note: Site preparation will be completed by In House labor. 5. Materials Selection and Ordering 6. Material Delivery Coordination, Inspection, and Staging 7. Module Racking Installation and Attachment 8. Electrical Installation Management Note: AC wiring will be completed by In -House Labor. DC wiring will be completed by a NexGen electrician simultaneously and at separate cost to the array assembly. 9. Massachusetts Technology Collaborative (MTC) Reporting Submittals (3 Deliverables) 10. Commissioning Management Note: Commissioning must be completed by an independent contractor per MTC requirements. NexGen intends to execute this Scope of Work according to the following Timeline: NexGen intends to execute this Scoue of Work to the following Architectural Desi System Description. NexGen will integrate a 103,360 kW DC (STC) PV system on the southern, upper roof of Building 30. The system consists of 608 Evergreen ES -170 PV modules, configured in to 38 parallel strings. The modules will be mounted on a non -penetrating PowerLight PowerTilt racking system according to applicable building code requirements. The strings will feed DC current into a Solectria PV190 Grid -Tied Inverter, located in the adjacent Penthouse main electrical closet, providing distributed generation to BLDG 30's main power feed per all applicable National Electric Codes (NEC), local Inspector requirements, and Utility Company requirements. Example System: SCHEDULE B PAYMENT TERMS This contract will be executed with the intent of the agreement on August 15, 2006 (Performance Agreement and Commitment, Leary and Goldstein) on a Cost Basis. NexGen will provide the above work, except where noted, for the sum of $31,000. Payments will be made on satisfactory completion of the prescribed work according to the following schedule: 33% due on Submission of the Task Order to MTC (approximately January 10, 2007) 33% due when construction begins (approximately January 29, 2007) 33% due when construction is complete (approximately March 10, 2007) The remaining project costs will be invoiced on a Cost Basis, with no mark-up from NexGen according to the following estimated budget: Note: This budget format is required for MTC reporting. All project costs to be invoiced by NexGen on a Cost Basis as provided above, including, but not limited to, all costs for any of NexGen's suppliers, subcontractors and vendors, and all other reimbursable costs must first be approved (via email) by 1600 Osgood Street, LLC prior to NexGen incurring such costs. If NexGen has failed to obtain 1600 Osgood Street, LLC',s prior approval for any project costs invoiced by NexGen, 1600 Osgood Street, LLC shall not be obligated to pay for such costs. Working/Expected Budget I. Direct Labor (Direct Labor and Overhead can not exceed 5% of total budget) J name/title hours Irate1hr Total Cost Project management Maintenance and Facilities Total Direct Labor 28,500.00 II. Subcontractors/Consultants j name/title hours Irate1hr Total Cost DC Racking Installation-NexGen 35 5 $ 15,000.00 DC Wiring Installation-NexGen 1201 7 $ 7,000.00 DC Component Installation-NexGen 121 7 $ 3,000.00 Electrical Labor- In House 16 7 $ 6,000.00 Engineering (Structural)- In House 5 12 $ 4,000.00 Engineering (Electrical) -In House 8 12 $ 1,250.00 Management -Reporting, Permits, interconnection-Nex6en 7 6,00101.00 Logistics and Leased Equipment-NexGen $ 500.00 Commissioning -Subcontracted $ 2,000.00 Total Subcontractors/Consultants 5 54,750.00 III. Direct Materials (Not Applicable for Feasibility and Design Grants) Item Total Cost Electrical AC Components $ 2,000.00 Panels, Inverters, Mounting (Per invoice 1014) $ 520,800.00 Monitoring $ 1,889.00 Misc $ 10,000.00 Total Direct Materials $ 534,689.00 IV. Travel Total Cost $ - V. Other Direct Costs (list by type) Total Cost Permits -Zoning $ - Permits -Electrical, 2% of Electrical Cost $ 1,800.00 Permits -Building, 1% of Cost Basis $ 4,800.00 Interconnection Appilication $ 300.00 Total Other Direct Costs $ 6,900.00 VI. General & Administrative Expense/Overhead Rate (% of DL only): Total Cost $ 28,500.00 10.00°/ $ 2,850.00 Cost Summary I. Direct Labor (Direct Labor and Overhead can not exceed 5% of total budget) ,500.00 11. u con ra ors onsu an s III. Direct Materials (Not Applicable for Feasibility and Design Grants) ,689.00 IV. Travel r$48 - V. Other Direct Costs (list by type) 6,900.00 VI. General & Administrative Expense/Overhead 2,850.00 Total Project Cos,689.00 Total MTC Grant Reque,250.00 Total Cost Sha$ 139,439.00 Cost Share as a Percentage of Project Cos 22% Direct Labor and Overhead as a Percentage of Project Cos 5% MTC Grant Request as a Percentage of Project Cos 78% / e(!� a er; _. ! . � ❑ . i ) ) ) , t i -\ |\[ ! ! § m .( ! $ :GH-). \ �@3 @; ;) � ) � ) @!� |� ea } ILI § ] d c � / e(!� a er; _. ! \ |&2 t i |\[ ! ! § m \ ! $