HomeMy WebLinkAboutBuilding Permit # 2/3/2016 NORTH
BUILDING PERMIT o��zLeo '6q�O
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _
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,
&�X Permit No#: �7` Date Received �9R'0rgreo
j 1 �SSRCHRsw�
Date Issued: I
IMPORTANT: Applicant must complete all items on this page
LOCATION /d pr?- 5�-011 Si
Print
PROPERTY OWNER / �%� 5-5e7 "
Print 100 Year Structure yesCn
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
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 9 Others:
❑ Demolition ❑ Other .�rn�u/�iioy
e t e I '. ���F ood lal: ®�Wetlands sr ershed'®jst ic'��� Y
DESCRIPTION OF WORK TO BE PERFORMED:
Trr'G A- cJr�rit�T�'d�
Identification- Please Type or Print Clearly
OWNER: Name: lq�,�3Gi► ,145"S,7A Phone: l91/�
Address: ld p ke5",.07— i
Contractor Name: Pe/r-F /YAgAe Phone: V'o
Email:
Address: 2 17 /g;6,W ✓ �I,�!
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ //da- ® ® FEE: $ �
4 �
Check No.: Receipt No.: �
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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NORTH
Town Of '_ '' Andover
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�0 LAI E h �V�, ��A7, 0-A 02 1 1 lipQL
coc.ac"IWICK �1
ll BOARD OF HEALTH
D_PERIqT
Food/Kitchen
L Septic System
•
THIS CERTIFIES THAT 1 �,,,; ,,,, BUILDING INSPECTOR
............... . .. .l�.. .................. ... .....
.. .. Foundation
has permission to erect .......................... buildings on .. ...... ........... .I� .Cr.R. .......... . .............
A% Rough
tobe 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
PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR
UNLESSCONSTRUCTIOIL
Rough
Service
...................... ................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Requiredto Occupy Building 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.
Nov. 13. 2015 2:20PM No, 0495P, 2
Fetterol in 0 06-W6620
RISE Eagiueering RI Contractor Itegistration No 8 106
MA Contractor Registration No 120070
A division of'fbiC)Scb EO9i0tCfiu8
ENGINEERING'
60 Showarot Unit 112,Conlon,MA 02021 CONTRACT
339 9p2 6335 FAX 339-502-6345
Pago
PROGRAM
Inn CONTRACT 18 ENTEREO 0410 DEME04 0106
CMA-tulis enGtNeRNING AM TIQ CUMMER FOR WORK M
OESCMKO BELDW
CUSTOMER w-75 P140NE WE- CUENTO INUM MEN
Abigail AsSani r" (978)869.1942 10/27/2015 416447 00002
SERVICESTREETGUING Sheer
108 Prescott Street LV4 109 Prescott Street
SERVICE CITY,BTAIr:,ZJP Oft UNC CNV,9TATE.ZIP
North Andover,MA 0184 North Andover,MA 01845
JOB DESCRPTION
AUDITOR'S NOTES HOUSE BELOW BUILDW AYR FLOW STANDARD
BLOWER DOOR-1061 @ CFM50
BLD.STANDARD=1343 @ CPM50
AT 70% -940 @CFM50
CUSTOMER MUST INSTALL BATHROOM VENT FAN To MAKE Alit FLOW STANDARD.
LOOK AT EFLORO WISPER FAN. CONTACT ME WHEN INSTALLED.
$0.00
AUDITOR'S NOTES HOUSE BELOW B(UMfffL AIR FLOW STANDARD
BLOWER DOOR=1061 @ CFM50
BLD.STANDARD--1343 @ CPM50
AT 70% -940 @CFMSO
CUSTOMER MUST INSTALL BAT11ROOM,VENT FAN TO MAKE AIR FLOW STANDARD.
LOOK AT EFJ.ORG WISPER PAN, CONTACT ME WHEN INSTALLED.
$0.00
DAMMING:P;;vFz labor and 11 a 12"layer of R-38 unfaced fiberglass baits to(48)square fed for damming
purposes.
$98.40
ATT1C FLAT:Provide labor and materials to install 0 4"layer of 12-14 Class 1 Cellulose added to(916)square fed of open attic
space.
$922.08
VENTILATION.-Provide labor and materials to install ventilation chutes in(26)rafter buys to Maintain air Slaw.
$52.00
RISE Engineering will apply all applicable,eligible incentives to this contract You will only be billed the Net amount. Currently.
for eligible measures,Colombia Gas offers 75%incentive,not to excecd$2,000 per calendar year,and an incentive of 100%for the
Air Sealing measures up to the first$680 and an additional$340 ifsavirip are justified by the auditor.
For the safety and health cifyour home's indoor air quality,we will be conducting a bloWtr door diagnostic of die available air flow in
your home both before the work is began,and after the wcathorizAtion work it complete,We will also conduct a full assessment of
the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you, Total allowable
weadierization incentive is$3,110.
$90.00
Nov. 13. 2015 2:20PM No. 0495 P. 3
Federal to s 0544MM
WSE Engineering R.1 Ea+boe"Reglst 80w No Gies
MA Conwwr ReQbtratbn No 420079
RISE : AdiVW0S0fTUbch XD&aT;"
ENGINEERING 66ShxwmvttU■;t1MCr9toe,MA0= CONTRACT
339-502-6335 FAX 339-592.6345
Pago 2
PROGRAM
TlAS taNrRACT w&ItE115o OTo eEtwmt RISE
CMA-HFSEO TWcwToMroaWMM
OESMGEWW
CU"V&*R PNOBE DME IXxwil VOWORM
Abigail Assam (978)869-1942 107/2015 416447 00002
80WE STREET ORL M6 STM -
108 Prescott Street 108 Prescott Street
SWOM 0MOFAMMP OWN arv.STAT ZP
North Andover,MA 01845 Notch Andover,MA 01845
JOB DESCIMION
Total: $1,162.48
Program Incentive: $694.36
Customer Total: $268.12
We AGMNRYTopjRt 6Nte1ViCF.i-CoNPLMN#=OFID+rCEVM"AWKSPWWATWWrMINESUMOF
*-Two Hundred ShdyZight&12MQ0 Dollars $268.12
�e�"�uwr"�.s���OnA��'oaveA�se es�oaTOiwur�t�, a�esa� �+wa�aa�owtRi�eTea�TwY►T�iow�
SKM THIS CONTRACT IF THE E ARE ANY BUM SPACES `
wine oncmYPAt7MAY ONWITMORRGMISYUSIFNOTOMCUM THIN OATSOFACCFYTARM �"� •'�� ��
AOOEP►MfCEOFOONTR -TwABMPRXMSPEMFiOAMWANOCONDMOARE
AUTWORMDTOOOTNEWOM
30SATIOFACIORYToua ANOARS NQEOYAOL -YOU ARE
DAYS. Ad SPEE1wieD.DAYN6IF gyJ.OBMAOa M OIRUNEO ABOYa
Nov. 13. 2015 2:20PM No. 0495 P. 4
- I
OWNER AUTHORIZATION FORM
2kfggs ) l9 .Qsgn
ownerafthe p apiw4 toed at
(may Adab=)
iCl �1 odariwa _ oc�k
an m Atwimd mAmw o*r for RISE Erekwa ire,to act on nV baW to oUnin a blMrog
permit and to Wm work on my property.
Ownbes s
Dam
The Commonivealth of jVassachasetts
Department o`��aclastrialAecidersLr
I Congress Street,Suite 100
Boston,)kL4- 02_1_74-2017
www.mass govIdia
1NVorkers'Compensation Insurance Affidavit:Bui'Iders/Gonirsclors/Eiectrieians/Plumbers-
a€����L�ID��l a Tie PEl�lt�il3''���•�tJ�®Reuel_ _
Am brant IInform2tion Please Primib
Name (Business/Grgan=zation/lndividua)): �r, j�` ;;1 �`r j"
Address:
City/StatPJZap: 1 �— ;' ` • /u Phone 4:
Ast gots na c mploycr?Ox-ck the npproprlate boa: - Type orproject(required):
1. I But a employe•with ,plo =(full nod/Or part-tmx)_' 7- `New constructiorl
2�I am a sole proprietor or pa trurshtp and have no enpIoyeeS working for me in 8_ RC3nOde1lllg
any—p2City_[Ivo workers'Oomp.insffaaa raNired-1 9_ 0 Demolition
3-0 I am a homcowncr doing nil wort my�-_l!_[NO workers'comp-insurance r+cqu rcd-]t
10 rl Building addition.
4_0I am a homcowner and will be hiring conhactors to conduct all work on my property_I will
I 1_0 Electrical reps or additions
insure that all contractors athz have workers'COmpensaaion insurance or etc soli
proprietors with no employes 12_n Plumbing repay or additions
5 I am a gcncral contractor and 3 bavc birtd the sub-contrzttors listed on the attached shecL 13_rlRoof repairs
These sob-contractors have cnptoye_s and have workers'CUMp_ius m Mr
6_L_1 We arc a corporation and its officers have exercised thcirri t ofcx en } �Othlx
,gorygh spa per MGL�
152,§I(4)�and we have no amployws [No workers'COMP_rastua]=tcgttitu ]
-Any applicant that cheeks box#I must also fill ora thesccdon below sbowing theirworlcem-coition policy information
t Homeowners wbo submit this affidavit indicating they arc doing all work and Baca hire outside contractors trust submit a new ntSdavit indicating sucb-
tConanctors that check this box mast attached an additional shed showing the nose of thcsub-Onuacznrs and ante wbabcr or not ibose cntitias have
employees- If the sub-Contractors have employ.they Musa Provide their workers'comp.policy Durnbc_
i aur an employer that is providing barkers'compensation insurance for fi y employees. Below is the policy andJob sate
F-formadon.
Laswartce Company Name:
Policy#or Self-ins-Lic.#: }y vJG 7��='=; J Expiration Date: J%%='//�J/7
Job Site Address: C(7 �i (�t SCO/�/ City/State/zip: n- Yj N o/d✓'e t�
Attach a copy of the workers"compensation policy declaration page(showing the jwlicp number and ezpprntion date).
Failure to secure coverage as required under MGL c. 152,§25P_is a criminal violation punishable by a fine up to$1,500_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$25O-Go a
lay against the violator_A copy of this statement may be forwarded to the Office of investigations ofthe DLA for iztsZtrance
:overage vcsification_
t do hereby certify under the pains candpen dues of pe'jury thatthe information provided above is true and eorrect
iit?nature l c t= �-�' ,i= '_ Date:
'hone#- 12-2 -7 v f i r
Ojrwial use only. Do not write sn this area,to be completed!ry dry or Powys o Izc�
City oY"LI'own_ - Permit/License# -
issuing Authority(circle one):
I_Board of Health 2. Building Dep2rtweut 3-CRy/Town Clerk 4_(Electrical IInspector 5-- Plumbing)InspeCtor
6_Other
Contact Person: phone#:
114/2016 Preview:Certificates of Insurance
p DATE(LVdfDDYYYY)
CERTIFICATE OF LIABILITY INSURANCE 01/0412016
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 15 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).
PRODUCER WNIACi
I'MIE:
PHONE
Automatic Data Processing Insurance Agency,Inc. IaiC.tto.EXnr In+c.Ito)
t•n�aL
1 Adp Boulevard ADDRESS:
Roseland,NJ 07068 IRSURER(5)AFFORDING COVERAGE NAICd
msURERA: NorGUARD Insurance Company 31470
INSURED INSURER B:
POLAR BEAR INSULATION CO INC INSURER.C.
PO BOX 958
Andover,MA 01810 INSURER 0:
INSURER E:
IIISURER F i -
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF ItISURAiJCE LISTED BELO7.HAVE BEEN ISSUED TO THE INSURED NALIED ABOVE FOR THE POLE.CY PERIOD
INDICATED.NOTI.VITHSTANDING ANY REOUREiSEF1T.TERMOR CONMMOI-I OF ANY CONTRACT OR OTHER DOCUMEnT V.-TH RESPECT TO':YHiCH THIS
CERTIFICATE LIAY BE ISSUED OR t AV PERTAiFI.THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIJ iS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND COND)TOFJS OF SUCH POLICIES LIMITS SHOL'PJ t.!AY HAVE BEEN REDUCED BY PAID CLAa.'S
INSRMURF POLICY EXP 1 LUMITS
LTR TYPE OF INSURANCE INSD YlVD POLICY HUMBER irdt.FOD,YYYY) trdLUDD:YYYY)
COMMERCIAL GENERAL LIABILITY E OF UC:;W.HEi.CE
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U6:BRELLALNB +LI< LACI-
EXCESS LIAR CLAq.1S IJ:.L•E 1Cn1.E" i E
DED I:EIENIKJ1.S i
VIORKERS COMPENSATION "
ANDEMPLOYERS'LIABILITY YItII ( ' - 1,000,000
1 Ii 1 w 1 1 1 I.0 ErEEcc
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1,000,000
LcS-I:11'1141.!•F CI•tlii,I ICI:5 U:�we EL U1n_ :.E-1-.U�1 ULIII
1,000,000
i
DESCRIPUON OF OPERATIONS i LOCATIONS t VEHICLES IACORO lnl.Additional Remarks SOndul,m/be alucF.ed if n--pace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave
Cranston,RI 02910 AUTHOftLED REPRESEtITATtVE
ACD 1988-2014 ACORO CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
POLABEA-01 JONEILL
CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/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(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).
PRODUCER CONTACT
Durso&Jankowski Insurance Agency PHONE 97 FAX
11 Saunders Street A/c,No.F�tl:( 8)_688-7000 (ac,No)_(978)688-7001
_ _ —
North Andover,MA 01845 E-MAIL
ADDRESS:
----INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Nautilus Insurance Co. 17370
INSURED INSURER B:Safety Insurance Company 33618
Polar Bear Insulation Co.Inc. INSURER C
Peter Leblanc&Steven Leblanc
P O Box 958 INSURER D: _
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.
INSR ADDL SUBRj (POLICY EFF POLICY EXP LIMITS
LTR INSD WVD i POLICY NUMBER MM/DD MM/DD I
TYPE OF INSURANCE
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
'DAMAGE TOARENTED 1. -
CLAIMS MADE '�OCCUR { NN538691 { 03/24/2015 03/24/2016 PREMISES(Ea occurrence) $ 501000
MED EXP(Any oneperson) $ 5,000
-- -- {
PERSONAL&ADV INJURY $ 1,000,000
--- --— —
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
POLICY ]PRI-
AGGREGATE
E0 LOC PRODUCTS-COMP/OP AGG ;$ 1,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
{-A { Ea accident �_ _
- -_ -
B { ANY AUTO 2100926 01/04/2016 i 01/04/2017 BODILY INJURY(Per person) I$
ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $
_ AUTOS AUTOS I
--
X HIRED AUTOS !i X NON-OWNED ; PROPERTY DAMAGE $
AUTOS I I ._(PeraccidenN _ i
is
UMBRELLA LIAB X
OCCUR EACH OCCURRENCE $ 1,000,000
A 11_EXCESSLIABCLAIMSav1ADEl ANO19284 03/24/2015 i 03/24/2016 !AGGREGATE_ $
DED ( RETENTION$
i $
WORKERS COMPENSATION PER DTH-
AND EMPLOYERS'LIABILITY I { _STATUTE �_ 1 ER
Y/N E.L.EACH ACCIDENT $
ANY PROPRIETORIPARTNER/EXECUTIVE { j _
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) I � 1-DISEASE-EA EMPLOY_EF11$ _
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT{$
I {
i
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 Thieisch Engineering
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thieisch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 9 ACCORDANCE WITH THE POLICY PROVISIONS.
195 Francis Ave
Cranston,RI 02910
AUTHORIZED REPRESENTATIVE
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