HomeMy WebLinkAboutBuilding Permit # 2/3/2016 BUILDING PERMIT t%o DT,
TOWN OF NORTH ANDOVER �� h�,•`• ^•46
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received �RA�RgTEoWPQ¢yR5
�SSaCHUSEc
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION /3� OA4n PSC Ge, A ?—
Print
PROPERTY OWNER ��� 0ecg,J'o
Print 100 Year Structure yes no
MAP NO_ PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village ye no
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 ,�h S v/moi r�®0
* s, �«
e c IIif-
1136I`oo am q s ® 1Na ergs ed$®' t c k
elf,eel ,.
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: rg-9 h t D eea !'v Phone:
Address: 13 f Vl/ lem P.'c 14W?e- 17 ,n /0 ver
Contractor Name: P r rc it f rg C Phone: 9 >-
Email:
Address: 57- /`5T0w
Supervisor's Construction License: l® C, 0 Exp. Date:
Home Improvement License: 10) 2A G Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.: !i'i��
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
AM tkORTH
Town of
Andover
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COC MICNEWICK y�•
�ds R^TEO r.Pa�,�S
V BOARD OF HEALTH
E R Food/Kitchen
Septic System
L U
THIS CERTIFIES THAT ,,, �, BUILDING INSPECTOR
.............. ... ..... .... . .......... .. ...... ......... .......................................
.. 1
...,..... Foundation
has permission to erect .... buildings on J
® Rough
to be occupied as ........... .. . ..... . . ................... -, ........ ........................ Chimney
provided that the person accepting this permits 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMITI ES IN 6 MO THS
ELECTRICAL INSPECTOR
Aff RoughLES CONSTRUCTIO RT Service
.................. ...... ...........
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Fedora ID It 05-0405629
RISE Eiigineering RI CZractor Registration No 8186
PAA Contractor Registration lie 120979
RISE A division ol"11liel'sch Engineering
ENGINEERING 60 Sbawinul Unit 42,(.'anion,MA 02021 CONTRACT
339-502-6335 FAN 339-502-6315
Page I
PROGRAM
711111 CONTRACT 13 V4rFRXO of TO BETWEER RISE
CMA-IIES ElIGINEER1110 AND THE CUSTOMER FOR WORK AS
OESCRIBED 0ELOW
CUSTOMER PHONE (WE CLIVIT 9 WORK ORDER
Frank Decaro (978)725-2577 12/09/2015 4419439 00003
SERVICE STREET BUJUG STREET
139 Olympic Latie 139 Olympic Lane
SERVICC CHY,3TATE,7.IP BILLING CoY—%TATE,ZIP
North Andover,MA 01845 North Andover,(VIA 014045
JOB DESCRIPTION
PI IASH ONE-Proposal for this calendar year,
AIR SEALING:Provide labor and materials to seal areas ofyour home against wasteful,excess air leakage. Tlns work will be
performed in concert with the rise of special look;and diagnostic tests I()assure that your home will be left with it healthful level of
air exchange and indoor air quality.Materials to he used toseal your home carr include caulks,foams and other products. Primary
areas 1'1)r scaling i irel fill e aur leakage to allies,base filet]is,attached enrages find other unhealed areas(windows are not generally
addressed) This will rcrillite(8)�vorkinf,hoors.A reduction in cubic 1'ect per minute(clin)ref air infiltration Will OCCUr,bill tile actual
number of arm is not guaranteed.
At file completion of the weallicrizatioll work,and at 110 additional cost to file hoincowner,a final blower door and/or combustion
solely analysis will be conducted by the sub-contractor to enSLIfe(lie SOtely0fthe indoor air quality,
$680.00
AIR SEALING ADDER: (2)working hours.
S170.00
DAMMING:Provide labor and materials to install:1 12"layer of"R-38 milliced fiberglass birds to(80)squire beet lor damaging
purposes,
ATFIC FLAT:Provide labor ami materials to mss all;16"layer ol'R-211 Class I Cellulose added to(948)square lect of open attic
space.
S1.068.48
STORAGE HARRIER:Homeowner is responsible R)r file removal of the stored doors blocking tire installation ol'weatheri/ation
work in life attic. Removal must occur prior to the scheduled work start.
SOMO
ATHC ACCESS:Provide labor and flialcrials In insiall(1) easily moved,insulating cover lor lac attic access fielding stair. Asinall
flat surface orplywood will be created around the opening within the attic, This Will allow the cover's integral weather-stripping to
restrict air Icakage.
$237.05
VENTILATION:Provide labor and materials to install ventilation chutes in(102)rarer hays it)maintain air flow.
5204.00
RIS 1:1 iog'illccri ng will apply all applicable,eligible incentives to this contract. You will only be billed the Nei amount, Currently,
for eligible measures,Columbie Gas offers 7513G,incentive,not it)exceed$2,000 per calendar),car,and an incentive of 10014,for the
Air Scathe measures tip to the first 5680 and an additional$340 ifsaving-s arejuslified by the auditor,
For the safety find heafth of your home's indoor;fit-quality,we will be conducting a blower door diagnostic of the available air)low in
your home beth belbre the work is begun,and tiller file weatherizatioll work is Complete.\Vv will,rise conduct 11 Full assessment of
the combustion solely oryour bearing system and\%,;nor heater,'Mis has it value ol'S90 and is at no cost to you. Total allowable
weallierivatioo incentive is$3,110.
$90.00
Federal 10#05-0405629
RISri. Engineering RI Contractor Registration No 8 186
MA Contractor Reg IstratIon No'120979
RISE k division or'rweiscii E'vigincering
ENGINEERING 61)Shawnint Unit 42,Canton.INIA 02021 CONTRACT
339-502-6335 FAX 339-502-6345
Page 2
PROGRAM
THIS CONTRACT IS EMERED V470 BETWEEN 1413E
C INI A-I I].�"S EN 0 VIE E FUND AND T I I E CUSTOMER FOR WORK AS
DESCRIBED UELOVI
CUSIOLIER PHONE DATE CLIENT 0 WORK ORDER
Crank Decaro (978)725-2577 12/09/2015 419439 00003
SERVICE STREET BILLING STREET
139 01yinpic Lane 139 01yBipic Lane
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,2111
North Andover,MA 01845 North Andover, MA 01845
JOB DESCRIPTION
Total: $2,614.13
Program Incentive: $2,105.60
Customer Total: $508.53
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
'Five Hundred Eight&53/100 Dollars $508.53
7
PO I FNdAL,Xf15PECTION0 D APPROVAL I 41SE ERGP�E RING.CUSTOMER AORCES 70 RrJUT AMOUNT DUE IN FULL.INTEREST OF IN WILL HE CHARGED MONTHLY OR ANY
r
nPMOU RCCAFIC D"Y f PHSEFORIPAP RTA"TllFIFIOGUARANTEES,RIGHTS OF REC15ION,SCHEOUUJIGAND CONTRACTOR REGISTRATION.
DD NO SIGN THIS CONTRACT IF THERE ARE ANY 13L��ES;
US—
�VIU rozy SIONAT�11K� RISE E.Ukwe.161.) C
,A,
NO7E:THIS CONTRACT&I Yl.,YVHJRAk'iII13YUSIFNOTrXECUTFOV4ItHirI DATE OFACCEPTANCE 2-111/
ACCEPTANCE OF CONTRACT-THE ABOV17 PRICES,SPECIFICATIONS AND CONDITIONS ARE
30 DAYS, SATISFACTORY TO US ADD ARE REREGY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WOIIK
AS SPECIFIED.PAY1004t POLL 06 MADE AS OUTWIED ABOVE
OWNER AUTHORIZATION
(Owner's Name)
owner of the property located at
(Property Address)
l..f o
(Property A dress)
hereby authorize C°�°� e e,
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
I
i
Owner's nature
Date
s
C
The Commonwealth of Mossaeh vsEm
Department®J�ndustrzalAcc&ents
1 Congress Streeg,quite.100
Boston,.-02114-2017
www_mas&gov/rdar
Workers'Compensatiou InsuranceAffidavit_laua'iders/Oonumciors/Elec-nicinns/glumbers-
3®ll��B.,LID�a&i37FdE PEl`LIv1s�N�•�iJ���l��l_ _
Aiinolicant Information Please Pring b
Nafne (Businessioromizatiowindividual)= li }` i`•=' G' ?r"
ti's 1,
Address_
City/StatelZ=p: Phone#:Are you nu employer?Cbectt the approprlase boa: Type offproyea(,,�ujred)=
1. I sm a carployc with �� —PW--PW—(full and/or part-time)-- 7- F71 New eonsrru ion
'i
20 I am a soic proprietor or parinc,_,bip and bave no employes working for roe in 8- 0 Re modeling
any��[No workers'comp.ire nce required_]
o workers' insurance g- Demolition
3-01 am a homeowner doing all work mys`It[N °rp- roquired]t
10 0 Building addition.
4_0I am a homeowner and will be hiring contractors to conduct all work on my property_ I will
enure that all contractors either have workers'campcosation i—or arc soli 11-�Electrical repairs Or additions
proprietors with no employers- 12-F1 Plumbing rept or additions
5.0 I am a gc cral contractor and I bave bffed thw sub-eootr c ors listed on the attached shut ]3 }Zppf repairs
Tbcse sub-rona=ors have:4IIployces and havewnfkcr5 vtr
Comp.inanct aII5
6-n We arc a corporation and its officers have exercised rhcirright ofc—ption per MGL c- 14_F[Otht r
15:2,§1(4�and we have no employees-[No workas comp-iast a roquircd-]
`Any applicant that chola box#I must also 611 out thesxtion below showing their workers-COMpensation policy
information-Homeowners wbo submit this affidavit indicating tiny arc doing 211 work and then hire outside contractors must submit a new affidavit fodicating sucb-
tCootractors that cbcck this box mustarteeh stn additional sbca showing ncc name of-tbcsub-connaclnrs and sate wbabc or not those mtmcs bavc
employees_ If the sub-contrngors have employes,they must provide their workers'comp.policy number_
i am,an employer that is providing porkers'comi,ensation insaarance for my employees Be#ow is the policy andlob.site
iraf`ormataola. t
Insurance Company Name: 0 L `�G ✓7�G
Policy#or Self ins-Lic__ 0( _ J Expiration Date: e'21 f 1%�2
lob Site Address: 139 -0l oyd c l q✓►4 __City/State/zip: – A h4 p
4,ttach a copy of the vdorkens'cotnpeMsation policy declaration page(sbowing the palitq number and e_1pirati0n date).
Failure to secure coverage as required under MGL c. 152,§25A 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$250.00 a
Jay against the violator_A copy of this statement may be forwarded to the Office of investigations ofthe DIA for;Itst—n—
:overage verification.
t do h—eby certa•fy mender thepains candpenalnes of PerjVuly *at&c informa9on provided above zs true Lmd correct
>ienature: c '-,; batt:
'hone
®fficial arse 011,0: Do loot write iia thIS area,Eo be completed lsy city or to o0reraL
City or Town: Permit/License#
Issuing Authority(circle one):
1_Board of Health 2.Building Department 3.City/Town Clerk 4_Electrical 1nsglert16ur S:Plumbing Inspector"
b-Other
Contact Person: Phone#:
1/1/2016 Preview:Certificates of Insurance
CERTIFICATE OF LIABILITY INS1.1RANCE DAT011110412041ZO1'6
1 6
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)mustbe 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 CON?ACT
HAAIE:
Automatic Data Processing Insurance Agency,Inc. PHONE.Exu- t.ilc.No)
t•HAIL
1 Adp Boulevard ADDRESS:
Roseland,NJ 07068 IRSURER(S)AFFORDING COVERAGE MAIC 9
msuRERA. NorGUARD Insurance Company I 31470
INSURED INSURER B:
POLAR BEAR INSULATION CO INC INSURER C: I
PO BOX 958
Andover,MA 01810 INSURER O:
INSURER E:
INSURER F: -
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF It ISURANCE LISTED BELOI.N HAVE BEEN ISSUED TO THE INSURED NANIED ABOVE FOR THE POLE.CY PERIOD
INDICATED.NOTS'!ITHSTANDING ANY REOUiRELIENT-TERM OR CONDIT?Ohl OF ANY CONTRACT OR OTHER DOCUMENT F?STH RESPECT TO':,`HiCH THIS
CEP.TIFICATE LIAY BE ISSUED OR? AY PFRTAR-I.THE INSUPANCE AFFORDED BY THE POL'CiES DESCRIBED HEREN iS SUBJECT TO ALL THE TERLIS.
EXCLUSIONS AMID CONDIT;OA:S OF SUCH POLICIES L?L)ITS SHOWN L'AY HAVE BEEN REDUCED BY PWD CLAIMS
NSR LI tF POLICY FJ(P I LC.71T5
LTR TYPE OF INSURANCE INED PND POLICY NUMBER (t.IA'DD:YYYYi (L7LU•OD:YYYYi
COMMERCIAL GENERAL LIABILITY I E.:Ct CCI.I:NEhCE
:T NEULA.""",
CL:ILIS-t.l•;DL ❑ (:LI. IHIELII;it tc,ac-cr_r;
Ulr:LAC-CRFU;IEDLIII A11'1-IEJ I'Lk. %tt:EF2.L;.GLlibC.AlE
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PCLIC`❑Jti;l �L:)L: I'I:r,l?::MI5 ':CL71'.CP qG�
AUTOV.OBILE LIABILITY I .tL•SII:LLt Llt.11 l
rt1
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EXCESS LIAR CL;dLISi-li.C•t I SCGIitG%JE
OLD HL-lttz!IU._ I I (,
WORKERS COIAPENSATION
AND ELIPLOYERS'LIABILITY >L'JLIE Lli
Y;N 1.000.000
N li Ila Ir I l I I1. i L Ltr.t rv—t ?A N POWC772258 01,01,2015 01101;201,' LLE%.l.l- lL1ltI-.i (� _
A rl LI t in UH L 'LLL L :: I 1,000,000
(ti ntlalory in UH) tl D15L x t,tI:IYU:'tt >
L III Nr,l r F LI li;.l1�!'S I t.L DISI L-r:u:='L1IJN
1,000,000
DESCRIPTION OF OPERATIONS?LOCATIONS/VEHICLES tACORO 101.Additional Rematks Schedule.may be alml ed if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE 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 AUTHORLEO REPRESDITATIVE
I
ACD 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
POLABEA-01 JONEI
LL
FDACERTIFICATE OF
LIABILITY INSURANCE 1/612016
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).
PRODUCER CONTACT
NAME.
Durso&Jankowski Insurance Agency PHONE 978 688-7000 FAX Z( )
11 Saunders Street Nc N, o ( _)_ _ �(A/C,No): 978 688-7001
North Andover,MA 01845 E-MAIL
ADDRESS:
i
INSURER(S)AFFORDING COVERAGE— NAICS _
_INSURER A:Nautilus Insurance Co. 117370
INSURED INSURER B:Safety Insurance Company_ _IL33618 _
Polar Bear Insulation Co.Inc. INSURER
Peter Leblanc&Steven Leblanc INSURER 0:
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.
!NSRI ADDL SUER; POLICY EFF POLICY EXP
LTR I TYPE OF INSURANCE INSD WVD! POLICY NUMBER MM/DD MM/DD J LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE OCCUR NN538691 03/24/2015 03/24/2016 pREMI$ES Eaowurrence) 5 50,000
j MED EXP(Any one person) 5 5,000
- —
PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER I I I
GENERAL AGGREGATE 1$ 2,000 000
I PRO- I i PRODUCTS-COMP/OP AGG $ 1,000,000
1C I POLICY i JECT LOC _ _
-- '; OTHER_ .._
!AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT S 1,000,000
Ea accident
B ANY AOTO I '2100926 ` 01/04/2016 101/04/2017 j�DILY INJURY(Per person) i$
ALL OWNED j SCHEDULED BODILY INJURY(Per accident)'$
AUTOS _. AUTOS I PROPERTY DAMAGE
NON-OWNED ! $
HIRED AUTOS X .AUTOS , i (Per accident
UMBRELLA LIAB 1 IOCCUR EACH OCCURRENCE j S 1,000,000
j
A EXCESS L.IAB ` AN019284 03/24/2015 03/24/2016 AGGREGATE
CLAIMS-MADE] I
DEDi RETENTION$ ! I PER :0TH- $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY + L—1-STATUTE ER !
{ Y/N{ f EL EACHA_CCIDENT !$
ANY PROPRIETOR/PARTNERIEXECUTIVE I _
;OFFICER/MEIABEREXCLUDED? N/Ai
!(Mandatory in NH) i j i E.L.DISEASE-EA EMPLOYEES
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 S
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
ThielSCh 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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