HomeMy WebLinkAboutBuilding Permit # 2/10/2016 BUILDING PERMIT %AORTH
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
PermitNo#: Date Received
RATED Pr
C7
�SSg
Date Issued: CHUS
liV*ORTANT: Applicant must complete all items on this page
LOCATION 57-
Print
PROPERTY OWNER 0qmNe 74y' ('0 q 0
Print 100 Year Structure yes no
MAP 7 PARCEL: ZONING DISTRICT: Historic District yes no
0
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building 1:1 One family
El Addition El Two or more family El Industrial
El Alteration No. of units: El Commercial
11 Repair, replacement El Assessory Bldg 3, Others:
El Demolition 0 Other -7-M 5 V I
IN Og
g
ORNp
DESCRIPTION OF WORK TO BE PERFORMED:
x,rr(-1'10F W, ft rksd"L>100 d r hs-e P,*e, k-
Identification- Please Type or Print Clearly
OWNER: Name: bei ni-a Tr-Ccen Phone:
Address:
Contractor Name: pt;rr Irgle'Y" L Phone: 2&36
Email:
Address: j- e4 5 7 7-
Supervisor's Construction License: /&&0/ 7 Exp. Date:
Home Improvement License: 16 —Exp. Date:_ 2&�16
ARCHITECT/ENGINEER Phone:
Address: 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: $ 3 '.5-b 0,O'D FEE: $, �Ja I
Check No.: -774, Receipt No.:_ Q7�9 7
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
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NORToy ", over' irown ot Anuoq
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U BOARD OF HEALTH
Food/Kitchen
Septic System
0
THIS CERTIFIES THAT L!1
NOW] BUILDING INSPECTOR
. ... .. . ... ... ....
Foundation
has permission to erect .......................... buildings on ............. ............ .. ....... ...... . .....
Rough
to be occupied as .... .. . .... .. . . ..... .. ............ ! . ....!' ....................................... 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
EXPIRESPERMIT IN OTHS ELECTRICAL INSPECTOR
UNLESS TI S ARTS Rough
Service
........................................ ........'� Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises - Do Not Remove FirWl
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
7-1 4�f-_ d
Federal IO#
RISE Engineering RI Contmetur Registration No
MA Contractor RegistreNon No
A division of Thietsch Engineering CT contractor Registration No
60 Sbawmut Unit 92,Canton,MA OMI CONTRACT
339-502-6335 FAX 339-502.045
Page 1
R I S EPROGRAM
_ THIS CONTRACT is ENTERED INTO 8>:,YNRJ:N ROE
CMA-HES EN NGANDrM=rWXRFORWORxASM
ENGINEERING ��i �L ---- - DEaCRMEDBELOW
CUSTOMER PHONE DATE CLIENTS WORIORBER
Daniel Tiernan (978)828-2641 07/10/2015 400396 00005
SERVICE a"U r ` - 6aaaNG STREET _ —•-
12 Stonington Street 12 Stonington Street
EEW=CITY.STATE,IIP ` BWJNGCLTY,STATQIIP --
North Andover,MA r%I 2A1, North Andover,MA 01845
JOB DESCRIPTION
WALLS:Provide labor and materials to install blown in Class Cellulose to(1672)square feet of asbestos-sided exterior walls. Touch-
up painting,if needed,will be the customces responsibility. Invoicing will occur upon completion of installation. Subsequent to your
payment,as an added service,RISE Engineering will return when weather permits to check for any voids with an infiared scanner.
Any major voids that may be found will be filled at no additional cost.
$3,344.00
BASEMENT CEU ING:Provide labor and materials to install(78)linear fat of R-19 unfaced fiberglass insulation to the perimeter
of the basement ceiling at the house sill.
$136.50
RISE Engineering will apply all applicable,eligible incentives to this contract- You will only be billed the Net amount. Currently.
for eligible measures,Columbia Gas offers 751/6 incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the
Air Sealing measures up to the fust$680 and an additional$340 if savings are justified by the auditor.
For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is begun,and after the weatheriiation work is complete.We will also conduct a full assessment of
the combustion safety of your heating system and water heater.This has a value of S90 and is at no cost to you.Total allowable
weatherization incentive is 53,110.
$90.00
Total: $3,570.50
Program Incentive: $2,089.99
Customer Total: $1,480.51
WE AGREE HEREBY ro FURNISH SEWCES-COMPLETE IN ACCORDANCE Wrr"ABOVE SPEC WATTONS.FOR THE SUM OF
***One Thousand Four Hundred Eighty&511100 Dollars $1,480.51
UPON FINAL(NEPECTIOa AND APPROVALOY RISE ENBO EERmcL CDSTOMEa AGREES TO REMRAIOUNT DDE N FULL INTEREST OF t%WALL BE CHARGED MONTHLY ON ANY
UNPAID BALANCE AVV 30 BAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANT91M IUGHTG OPI'" ON.SCHEIR —AND CONTRACTOR REAISTPATICIL
DO NOT SIGN Tt{IS CONTRACT IF THERE AR
81tNNA -RISEEnQ4noeaAa —'�._ - —- ------ aONER AeeeaTAN �"'--
NOTE:THIS CONTRACT MAY BEYMMRAWN OPUS IF NOT EXECUTED WITHIN OATEOF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONOTRONS ARE
8ATLSFAeTORY TO UB AND ARE HEREIIYACCEP'MYOU ARBAUTHORD:ED TO DO TREWORA
30 DAYS. AS 8PECfftED.PAYMFJITW4L BE MADaAS OUttINEDAnnIm
i
OWNER AUTHORIZATION FORMA
r
owner of the property located at J U t 1 3 2015
CS'!`c7vl � CJ7`
(P )
(Po0erty Addr�m)
hereby authorize
(Subcorrtrador)
an authorized sutrooatrador for RISE Ergineeft,to ad on my behalf to obtain a building
permit and to perform warts on my property.
Owm s Signature
Date
The Common-wealth of Massachusew
Depaa aerat o��ndustr al. ec&en1s
I Congress Street Suite_700
BoStorc,MA- 02_1_74-2017
www m as&govIdia
Workers'Compensation Insurance Affidavit_Builders/Contractors/]Elecuiciaus/Plumbers-
TO BE n PLED VAi-H Tb- PER mi- nNG AUS b-IOIITl-
Ago&carat IImforaraatio® �lesse I nt
Name (Busincss(OrpnizatiomIndividual)- o /,A t 1 i5-,-.i tr^
Address: - _ Cr' 1�Y`' c
City/State/Zip: f ;:. ; , L:.�� �— :i�.i"— 1;%1 Prone-4--
A—
:Arc yo®n-n—player?Cbcci:a]r appropi Intc bos: Hype 0irproyeet(irequireo,
I.r0 I am a cmploycr with i_ �cmpkrf s(fill)nnNcT part-time)_- 7_ New construction
2.01 am a sole proprietor or partnership and have no®ployccs working for me in 8. Remodeling
—Y t24-ny-(No workcs'comp_inszssunce required-1 E_s
301 am n ham. rr doing nll worlr myself:Caro workers'comp_insmat�
ncc cd.l t 9- D molltion
4-F]I am a boracowncr and will be hiring conhactors to conduct all work on my property- I will ;0 Building addition
cosurc that all contractors other have workers'eompeosation insurance or art sole I I-E]Electrical repairs or additions
proprietors with no cmploye¢ 12-ID Plumbing repairs or additions
5 1 am a gmaal conaactor and I have bald ilia subconazaors listed on the attached shccL
I3- Roof repairs
Tlrese sub-eontiactors have employers and haveworkers'catap_insraanec.r
6_E]We arc a corporation and its o¢'iws jyavc ecuiitsed tl>;it right ofcxctnppoo p�-1v7GL e
I4.00thcr
_ 152,§I(4�and we have no®ploy.(Ido workem'comp-insurance rrquirc&I
'Any applicant that chcchs box YI must also Gil ora the Action below Showing their workers'compensation policy informnlion
t Homeowners who submit this affidavit indicting they arc doing Al work and then hire outside contractors must submt a new affidavit iodicating sucb-
tCoounaors that check this box must artwjh d ser sdditional shot sbowing the nitre orthe sub-contractors and start wbctbrr or nor tbose entiti-have
employers. If the su contractors have employees,they must provide their workcm*comp-policy number_
a ata an employer that is provzdFng Markers'compensation insurance for,pry employees. Blow is the poiicy andlob site
r�t�`omrratlovz.
/ 9
Insurance Company Name: 1 G
Policy#or Self-ins-Lic_#. !J�vJG 7/rn.:_, J Expiration Date: c,%%_
Job Site Address:_ 7-0 v\ City/state/Lip:- �, I' /ldOt�I'-
Attach 3 Copy of the workers'compensation policy declaration page(sbvsviatg the policy nutnbec tad eNpIN716013 dote).
Failure to secure coverage as require}under MGL c- 152,§25A is a criminal violation punishable by a fine up to S1500-00
md/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
lay against the violator_A copy of this statement may be forwarded to the Mice of investigations of the DIA for irtstusnce
:overage vcsification.
t do hereby certitefy ml der t/ae paints andpenaldzes ofPglarY dratthe informadortprovided ahwe is true olid eorreet
; Mature: ��c l c,`' � �, {:1
Date-
'hone#: Gr a'. `� 2-2 ,_7�f
ORL-i'al use only. Do not?yule in this area,to be completed by city or toWR 0-67 a2
City or Town: Per-mit/Lkense#
Issuing Authority(circle one)-
I-Board of Health 2 Building Department 3-CRyflovrn Clerk 4-Electrical Inspector S.Numbing IInspeetor
6-Other
CoAtact Person: ?'bone#:
® p� @ �/ p� ® �® p� POLABEA-01 JONEILL
CERTIFICATE E LIABILITY INSURANCE DATE(MM/DD/YYYY)
1/6/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
CONTACT
PRODUCER NAME:
Durso&Jankowski Insurance Agency PHONE 978 688-7000 ac No:(978)688-7001
11 Saunders Street A/c N,_ o_Ext k___ ---
11
_- — -- -- -
North Andover, MA 01845 ADD less:
- --- -T
INSURER(S)AFFORDINGCOVERAGE I NAICR
INSURER A:Nautilus Insurance Co. 17370
INSURED INSURER B-Safety Insurance Company _ 33618
Polar Bear Insulation Co.Inc. INSURER C:
Peter Leblanc&Steven Leblanc INSURER D:
P O Box 958 —
Andover,MA 01810 INSURER-E,
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
- ADDLUBR_ POLICY EFF POLICY EXP "
ITR TYPE OF INSURANCE INSD WVD I POLICY NUMBER MM/DD MM/DD 1 LIMITS
T EACH OCCURRENCE 1,000,000
' MMERCIAL GENERAL LIABILITY
DAmAG€TORENTED-. __--- -I --- --...-
11
Q I X CO CLAIMS-MADE �OCCUR NN538691 -3/24/2015 j 03/24/2016 PREMISES(Ea occurrence) $ 50,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000000
GEN'L AGGREGATE LIMIT APPLIES PER: (GENERAL AGGREGATE $ 2,000,000
PRO- (( PRODUCTS-COMP/OPAGG $ 1,000,000
X POLICY f JECT LOC
OTHER: — -----�$
LEa
INED SINGLE LIMIT $ 1,000,000
AUTOMOBILE LIABILITY ( cident —B 21-0926 Y INJURY(Per person) I$
ANY AUTO _ -
01/04/2016 0104
ALL OWNED X I SCHEDULED $
AAUTOS UTOS BODILY INJURY(Per accident) $
NON-OWNED PROPERNbAMAGE
HIRED AUTOS AUTOS i$
UMBRELLA LIAB X i OCCUR j i EACH OCCURRENCE $ 1,000,000
-- —— --
A EXCESS LIAB CLAIMS-MADE I �AN019284 03/24/2015 03/24/2016 AGGREGATE $
DED I RETENTION$ AER OTH-
WORKERSCOMPENSATION I STATUTE I�_ER_ _
AND EMPLOYERS'LIABILITY
--
Y/N i E.L EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE ---- -- - -
OFFICER/MEMBER EXCLUDEN/A
D?
(Mandatory In NH) E-L-DISEASE-EA EMPLOYEE $ _
If yes,describe under E -DISEASE-POLICY LIMIT 1$
DESCRIPTION OF OPERATIONS below
I I
I i �
f I
I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Insulation Work-Mineral
Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf
by the above insured is Thielsch Engineering
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS.
195 Francis Ave
Cranston,RI 02910 AUTHORIZED REPRESENTATIVE
L���l
rn�000 on�n AI�AOr1 l�fIO0A0ATIAAI All.:..r.E�....-.........+
1/4/2016 Preview:Certificates of Insurance
F0ATE1(rl?.vDl)--yyyY)
-CERTIFICATE OF LIABILITY INSURANCE' roalzole
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED.subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
coNrncr
PRODUCER t1A!.tE:
PHONE Ax
Automatic Data Processing Insurance Agency,Inc. la c.Ho.E.H' (VC,not
t•rna1L
I Adp Boulevard ADDRESS: _
Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE HAICV
INSURERA: NorGUARD Insurance Company 31470
INSURED INSURERS:
POLAR BEAR INSULATION CO INC INSURER C:
PO BOX 958
INSURER D:
Andover,MA 01810
ISURER E:
INSURER F: - I.
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES Or'IIISURAtICE LISTED BELO'1d HAVE BEEN ISSUED TO THE INSURED Nr,RIED ABOVE FOR THE POLICY PERIOD
INDICATED.NOT:';ITHSTANDING ANY REOU;REL'.El-T,TERL!OR CONDITION OF ANY CONTRACT OR!OTHER DOCUMENT VJ'ITH RESPECT TO VdHICH THIS
CERTIFICATE MAY BE ISSUED OR L'AY PFRTAi1-1.THE iNSURANCE AFFORDED 13Y THE POUCIES DESCRIBED HEREIN iS SUBJECT TO ALL THE T ERLIS.
EXCLUSIONS AND COND)TiOI IS OF SUCH POLICIES LINITS SHOIi'N L'AY HAVE BEEN REDUCED BY PAID CLt adS
INSR POLICY F POLICY EXPr
L4.11TS
LTR TYPE OF INSURANCE INSD VIVO POLICY NUMBER (+dIYODIYYYY) (1,11.1-DWYYYYj
CO�iLiERCIAL GENERAL LIABILITY I E.CE°3'1::1-I.HELCt
CLAIMS LI:Sit ❑;`r,LI, PHELIIStS 1c` _ _ _
LIED b.P Lir.;_n_;,_�;or•:
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i`ii(;1::•tel;-:_t.tl'.::I::.U:. >
ca.l r.eDSR:LLtu:.ul
AUTCN4OsILE LIABILITY
6CUIL'�IGJ!li't a_P-'rant '.
.:LI C:'.t,cU SCPcL'YLED tiCUIC''IF)I,li`.IPL�[3]:f_aJ; � ',..
%JI�;i .1!'I(:S 1'I:L-1•thl'�L'•.:i.l•llt '
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EXCESS LIAR ;;L„!l.15 LtAL•t -
DEC, I;El Ela 1:11.5
VlORRERS COMPENSATION Y !*-t 1~
ANDEMPLOYERS•LVelL1TY :AQI-AC Eli
Y;N 1.000,000
;.t *'H:cPlatul:Pn1a14,E:.ECLu'E I v 1l,+ra� T: POt:'C772258 01:01:20:5 01101120/7 tL t:.cE:.caCthl
A R E+;LE+.16EI:Ei:LLL•tt f I I 11000,000
(tdandatory in NH) �1 E L L'IS&Y6E b-r ELII'LC''tt i
it- �.;;:n:m. 11000,000
IL'cS'Clill'fIC'I:+'F L:PEIi::11 CI:S•v:-�:: E-L.DL E;,_t-1-:'U�'UI.111
DESCRIPTION OF OPERATIONS i LOCATIONS f VEHICLES ACORD 101.Additional R-1,5 Sch.dole.m be aWCF.ed if moresPace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Theiisch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave
Cranston,R102910 AUTHORLED REPRESENTATIVE
i
A^1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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Office of C
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10 Park-Plaza �02116B,asto% s = timan
a�a Ci»_-t�tax R ans � �� -
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VOL&R BEAR INSULA--TION Co-
Vincent LeBlanc
p.o.BOX 958
ANDOVER, MA Oig10 - �- `_ 'Up,aateA�dres�9ndLR;tMM� �,i ]�Lost0ird
1 Address v Renewal
ops.cat u �pq.Gtot2as
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