HomeMy WebLinkAboutPermits Permit # 2/3/2016 fi
BUILDING PERMIT °&No oT 6�wo
TOWN OF NORTH ANDOVER �� h `'`. = .,6
APPLICATION FOR PLAN EXAMINATION o
Permit Nod: Date Received
Q�RAreo
�SSAC HUS��
Date Issued: ll
IMPORTANT: Applicant must complete all items on this page
LOCATION D fir.
Print
PROPERTY OWNER t o c vl S An;T In
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes (Jno
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 k Others:
❑ Demolition ❑ Other Tr\5v1�3'���
e« 7ell WORUNJ-ands ® IIU�jatersf
� a ,
mate f fewer
DESCRIPTION OF WORK TO BE PERFORMED:
�� r!' ��/i`✓`9 k-n-e2 u/oi// T71,-,S U JA i-%014
Identification- Please Type or Print Clearly
Y
OWNER: Name: Ica r{v�, 5 ^,\,17-L, Phone:
Address: )-o 7"hr r'd S i /l• ��►�®��/�
Contractor Name: Pei :° C l C 1� e Phone:
Email:
Address: C�- eqTr ,\o e 57— P Tq /-ao W., �- �. ® � §-_d 3—
Supervisor's Construction License: /060 / G Exp. Date: t/
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B BED ON$925.00 PER S.F.
Total Project Cost: $ 3 ,®0 -a o FEE: $ e
Check No.: Receipt No.: �� t
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
�
'Town of ' � NORTH q
E. ... �.
Andover
® �� p►
�o L.K. h ver, ilss, 9L AP
,y 4
COCMICNEW.CK
7,9 A04nreo �` �(�
S U BOARD OF HEALTH
ER IT L 'U
Food/Kitchen
Septic System
Nmr
CERTIFIES THAT . BUILDING INSPECTOR
THISC .........f4r*.0........... . ...............................................................................
Foundation
has permission to erect .. .................... buildings on ........... .R ........ ........................ .. . ... .,. .
Rough
tobe occupied as ......... ... .. .... ....................... �.. ... .. . . . .......................... Chimney
provided that the person accepting this perm hall 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 IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCT194ST TS Rough
Service
... ......... .................... ..
..... .
BUILDING. INSPECTOR. Final
GAS INSPECTOR
Occupancy Permit Required t® Occupy BuRough
Display in a Conspicuous Place on the Premises — Do Not Remove Fin,Dl
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
Dec 10 1509:14a Iloyd smith 9786557582 p.2
federal coaosoaosszs
RISEEllt it0eering RiContracbarReglstrddtm Rales
lila contras Reg$atratlon No IUM
Adivision ofTlddseb Engineering CTcoxt aeterRe$Tshadon tto020420
60 Sbawtouk Canton,MA 9Z= CONTRACT
3WS02-5197 FAX339-502-dM
It l S E PROGRAM
Page ,
ENCiNEER1NC rtascoHcBacrat3ttt�trtioEestrE�rh
CMA ilES �� 'nra+woxene
CUSTOM AMnaE QaTC CIJ6rTI WCAMORCUR
Karen Smith (9-19)853-765S 07123/2015 409M 00003
Gomm XTFAWr etWae Sit1W
20 Third Street 20 Third Street
Sow=0Ty.eTATF MP GMLM CT;MnLz P
North Andover,MA 01845 North Andover,MA 01845
JOB DnCREMON
P�IASE o}VE-Proposal farthis caleadaryaw..
(� $0.00
AIR SFALWG:Provide labor and materials to scat areas ofyow home against wasteiLl,excess air ledmga 'ibis wade will ba perrocared in
concert with the use of special tools and dielgnostic tests to assure that your home grill be left with a haddiful level ofeir exAange and indoor
air quality.Materiels to be used to seal your home can include cmitlts,the and other products. Primary areas for sealing indudc air feat-age
to attics,basements,attached garages and other untested meas(windows are not generally addressed)This will require(8)work tg Mum
A reduction in cubic feet per minute(!dim)of air infiltration will occur,but the amat number of etin is nal guaranteed
At the eatnpietion ofttte weathatadoa work,and at no additional cost to the bw=wner,a final NO=door andlor combustion safety
analysis wilt be conducted by ft sub•emitractar to ensum the safety of the indoor air quality.
$680.00
AIR SEAIM40 ADDER: (4)vmfi tS horns.
$340.00
? KNE EWALLS:Pcovida labor and materials to install R-J 3 taced fiberglass to(184)squaw fat of lmccwall. Then iusta112•rigid board
insulation.Seal all seams with FSI:tape.
$671.60 "
KNEEWALI S:Pmvide tabor and materials to insmll 2" FSK raced semirigid fiberglass bond Insulation to(144)square fat:of lmcewali
area.
$504.00
XNEEWALL FLOOR:PlovW kWand materials to instaU a 6"layer of dense padDed R 22 Class I Celhdose octal to(656)sgoam fleet of
knaewall flaor.
$1,167.68
AT1IC ACCESS:Pmvide labor and materials to institute the back ofthe attic door with 2"rigid Thermax board and seat the door's edge with
• ttartb�tsRiippingt0restrictair lealrags.
$147.82
VENTrt_A77ON:Provide labor and materials to install ventilation chutes in(57)ratter bzrs to aminmin air How.
$114.00
RiSE Engineeringwill apply all applicable,eligible incentives to this twtmad You willonly be billed the Wel tm mmL Ctuaeetly,far eligible
measurs,Columbia Gas offers 7S%incentive,not to wwwd$2,000 per calendar year,and ea incen•^�af. r� a �/�� in your
0. . measures
up to dw first 5680 and an addhimW$340 ifsavings are Sustiftcd by the auditor. �V
For the soft and health ofyour homers in door air quality,we will be conducting c to aver b r
home both before the work is begun,and a8er the weetheriaa t an track is 18150 asnduct a full
combustion safbtq of your heating system and water heater.This has a value of no can to you. Total allow izefien
incentive isS3,110. DEC 1 0 2015
590.00
Dec 10 15 09:1 ba wya smim 9 t86bb Ib8? p.3
RISE Engineering M conaaacwrRee°SOewmew"Dales
Iiia C0nh8GWrRe8tstratkM No 120916
Adlvb1=otThtdschEogiueeriog t:rCanvu arRegWAftnIloG=iae
W 3b&vmmr.CantM19AOMI CONTRACT339 71SI97 FAX 339-542.63 5
R1 S E Page 2
PROGRAM
ENGINEERING CMA-HES T°6cwsaws+Faeinoax�
oanaR�eeaeoow
custn�
ROOM orae awn VIMMOROW
Kasen Smith (978)853-7655 071231015 409588 00001
OEM=aTSU= GUAM WWMr
20 Third Street 20 Third Street
asivroe my.STATmnp sumo C".OT mar
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIMON
Total: $3,715.10
Program Incentive: $2,72382
Customer Totat Mw
WEACRPENURMrToRMNMSERVICES.COAUIL McNACCORDANCEVATHABOVESPCCFCATNWLMATHESUM(W
""Nine Hundred Ninety-One 8 27/1x0 Dollars $801.27
Up"A"AL AADA9PRWMLerR=w=Ww=CU&=xw"=isratmarrueaw►autwaaa.wtersaroex►wnsesa�wer�owamarae�air
UNPM AElH=M%TLWEREVMMFMVDDWAWSLCMMT10 CWWARANIFPS.RI MOPMEMOIi.W�OJW.AIOCONiQ�C76SR 7D�L
` 00NOT MON TrUS CONTMWrW Til£RE AMANY GLAWSPACES
I jl
im•aseeao�.�a eusTe�caeesv*aw:c
MWMnaacaMfVLrFUWUZwrtAU%UUM ft01P"oroczcu=a" UMCFACCEPAMM
oFC9ATPAGf-TXE�BO�ePRICE6.RPBCQ7CATImi4At000tmaiDlDA7�
30 VAV LtTiNAC7011YT046AM0Al8H E91fA tEdY6t1A08A1Ifl10AQ[L T000�lsWORIt
AsSPFOMPAVWWFA LWIMOEA&0UMFnAMM
Dec 21 15 12:02p Iloyd smith 9786557582 p.2
OWNER AUTHORIZATION FORM
Karen Smith
(Owner's Name)
owner of the property located at
20 Third Street, North Andover, MA 01845
(Property Address)
20 Third Street, North Andover, MA 01845
(Property Address)
hereby authorize N 16 ,r Re A --
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.
ner's Signature
Date -
The Cori monwecal&ofjWassachaaseM
UTDepartmenY of ndustriaIACCLdenfs
I Congress Ser ee4,Suite 100
Boston,M4-02II4-2011
W W-Mass gov1dJa
—
Workers'Compensation InsuranceAfiidavit:lguilder-JContmctordEfectriciaffis/plumbers-
3®��:�AD,i✓D�� PE132�f1T>T11V�AU�'3�®l�a's�l_ _
ADDlicant IInffornaaFrorr Pieasel nF tb '
NaMe (BusinesslOr-pnizatiou/individual): (�DIIS i 1 d� ; �'� 1 I/iS u; ! i t'pi
Address:
City/State/Zip: �:• , L..�` #— i'�;� 1.1% Phone#: `= `-.5 ,—
Arc you an employer?Oxch file apprupdnte'ho>: Type of project(required)'
1. I am a employer with- employees(full and/os part-tam)-' 7- New construction
2❑I am a sole proprietor or panocrship sad have no employers working for rue in 8. RernodCling
any cal—ity.(No workers'comp.in=-an r r=4nutd]
n���,� instuanxx 9_ �DernoIition
3�1 am a homeowner doing all work myse1L[i l rnp- rtgtnred.]t
10�i Building addition
4-❑1 am a homeovincr and will he hiring coot-actors to conduct all work on my property- 1 will
ensure:that alI contractors tither have workers'compensation insurance or era soli �1 i Electrical repairs or additions
proprietors with no ampioyc s 12. Plumbing repairs or additions
5C I am a gerrerai contractor and I have hired tl=sub-connectors luted on th`attached shxL 13_ {��f
These sub-contractors have employers and haveworkas'comp.inv,ran�t L_l
repairs
6.n We arc a corporation and its o$rccm have exercised their tight of ccemptien per MGL c- 14.F-1 0thtr
. 152,§1(4)�nod we have no employers[No workers'camp.iuSlUa Dw rzgttire&]
`Any applicant that chcrhs box 41 mast also fill out thescction below showing thcirworlcus-conVensation policy information_
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside coutractnrs mtra submit a=w af$davit indicating such.
tCooaactors that ch¢k this box mist attached w additmnal sheer showing the nam,of tbesub-coanacmrs and start whetbc or not tbose entities have
employees- If the sub-contractors have employrcS they must provide their workers'comp.policy number-
1 are are employer that is provtdjng Workers'cots peMatzon inswrance for My erreplo}rses- BdOw is the policy andjob site
[-formation-
Insurance Company Name: 0 `�G ✓,1G�
Policy#or Self-ins-Lic-#: Expiration Date-
Job Site Address: �0 'Tto; r t o 5'/ City/stat&zip: j-) lq
Attach 2 copy of the vvorrkers'compensation policy declaration page(showing the}.witty number and e4pirntion 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
1nd/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKORDER and a fine of up to$250.00 a
lay against the violator_A copy of this statement may he forwarded to the Office of investigations ofthe DIA for insurance
:overage verification-
do hereby certafy mnder tlaepal'as and pen dues ofperjsaay that flee infornwi on provided above is true and corm
?itnature: i c ' Y,-�y ..', Date:
'hone# G'7 — j4.1
fr
®ffzcical use only. Do not 1S?Ste iter thgs area,to be completed by slay or toxnr o�tiaL
City or Town_ IDermit/)[,iceuse#
Issuing Authority(circle one):
I_Board of Realth 2 Building Dep2rtstlent 3.City/Town Clerk 4.lElectdcsl I11SpeCtGT S:Plumbing Inspector
6-Other
COnt3cf Person: Pl1oIIe#:
1/4/2016 Preview:Certificates of Insurance
•�� °
CERT IFICATE OF LIABILITY INSURANCE DATEIt•1l.71OD1YVY)
�. 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 CONFACr
NAME:
Automatic Data Processing Insurance Agency,Inc- lac Bio.Ext)- lac.not
t•r AIL
1 Adp Boulevard ADDRESS:
Roseland,NJ 07068 IRSURER(S(AFFORDING COVERAGE NAIC7
INSURER A: NorGUARD Insurance Company I 31470
INSURED INSURER e:
POLAR BEAR INSULATION CO INC INSURER.C. I
PO BOX 958
Andover,MA 01810 INSURER D:
RISURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: 420703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF HISURANCE LISTED BELO'A'HAVE BEEN ISSUED TO THE INSURED NALIED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REOUiRE(dENT.TERL'OR COND':PON OF ANY CONTRACT OR OTHER DOCUMENT vl'TH RESPECT TO vVWCH THIS
CERTtF;CATE(.;AY BE ISSUED OR LIAY PERTAY-I.THE iNSURANCE AFFORDED BY THE POL'CIES DES'CR!BED HEREIN iS SUBJECT TO ALL THE TERMS. _
EXCLUSIONS AND CONDIT;OP!S OF SUCH POLICIES LIMITS SHOWN L'AY HAVE BEEN REDUCED BY PWD CLA!!dS
INSR LILY i- POLICY P i
LTR TYPE OFINSURANCE IVSD PND POLICY DU!:1BER ((.1RFOD.YYYY) It.L'.1•on:YYYYj L1:7175
COMMERCIAL GENERAL LIABILITY
CLAILIS I.1-*LVk F]r LCLh I I+tGI�tS�I_.ErrC._
OtI.L i.LO1:EiJA E LI1.111 AFFLIESPEH, r+El:tr.L AC-ChtCAIt
I'IiL:
I'�LIC��JELI �LOL'. i'RCCi•�iS-=CLII°.Cp•:GG -
AUTOM,OSILE LIABILITY UZA.l'It.t SII.LLt 0t.11I
ALL L.W.LC° "L,-L%LLED
%.L ICS AL'1 CS bLUILd11 JI-10 Ir•��:a:a7�rJi
1 .L'-'.1L• 1.1:t1'tl�l''L'.:LhlLt
I-
UM.BR'cLLALIAB L.1, LA.C17CCCL'1-?aT:Lt
EXCESS LIAB CL..!l.15t.1:.C•t
WORKERS COM.PENSATION X I't c I r r
AND EM.IPLOYERS*LIABILITY STAILIE tit
v r N 1,000,000
A
;4.Y ctf,LEMW,EAIiN it ALU uusE rYY N(A N ,POWIC772258 X 01/011201& 01/01:2017 E L E•'+CH:.caDEr.1 I>
°R�tL-.`.'i.UH)6r:CLL L
(tlandalar)m NH) L--1 t L.UL"'cASt t%.tP.u'Lr`'tt 5 1,000,000 '.
::vs:rt:.e::r:=.. - 1,000,000
L-_':_I:11'NCI:r_1-CI:1:I:.l ICt.S b::�._ E-L.UI_EnSE-i'::0::'OI.111
DESCRIPnOtl OF OPERATIONS;LOCATIONS;VEHICLES(ACORD 101.Additi.-I Rem:rki Szh.Wuta,-I be I..hcd it n _.P.cc is rcquircd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE 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 AUTHORVED REPRESENTATIVE
I
A(:1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
POLABEA-01 JONEI
LL
DAT (MMDD/YYYY)CERTIFICAryF LIABILITY INSURANCE 01E1!6/26
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 -- --- FAX
688-7000 (a/c No: 978
11 Saunders Street A/a N. o.��:(9.78)._ 1--)688-7001
North Andover,MA 01845 E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Nautilus Insurance Co. 117370
INSURED INSURER 8: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.
INSR' ADDL SUBR; POLICY
EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD! POLICY NUMBER MM/DD I MM/DD ! LIMITS
Q X COMMERCIAL GENERAL LIABILlCYi EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE (� OCCUR NN538691 03/24/2015 03/24!2016
DAMAGE TO RENTED
_- PREMISES(Ea occurrence) $ 50 000
MED EXP(Any one person) 5 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE 2,000,000
�GEN'L AGGREGATE LIMIT APPLIES PER: � i 15 _
X_POLICY f JE Q j LOC (( ) PRODUCTS-COMP/OP AGG
$
OTHER= — i -- - --
AUTOMOBILE LIABILITY �BO.ILYEJ'U
MINSINGLE LIMIT $ 1,000,000
__ . cid -B ANY AUTO -'2100926 01!04/2016 01/04/2017RY(Perperson)- i$
ALL OWNED �SCHEDULED
AUTOS X AUTOS , BODILY INJURY(Per accident)!$
— -- -
X ' NON-OWNED ! PROPERTY DAMAGE •$
HIRED AUTOS AUTOS i i(Peracciden�
$
UMBRELLA LIAB )( i_ ! EACH OCCURRENCE $ 1,000,000
— -- _
EXCESS LIAB
A DED RETENTION$ CVdMS-MADE] AN019284 03/24/2015;03/24/2016 AGGREGATE
_ OCCUR
I �$
WORKERS COMPENSATION i PER OTRH-
AND EMPLOYERS'LIABILITY ' i �_I STATUTE iE
IANY PROPRIETORIPARTNERIEXECUTIVE Y/N I I - ! E.L EACH ACCIDENT ;$
OFFICER/MEMBER EXCLUDED. N/A —— -- -
j(Mandatory in NH) ( f i E.L DISEASE-EA EMPLOYEE$
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT 1 5
; i 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 Thielsch Engineering
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, CE WILL BE DELIVERED IN
Thielsch Engineering Columbia Gas ACCORDANCE WITH THEOCY PROVISIONS.
195 Francis Ave
Cranston,RI 02910
AUTHORIZED REPRESENTATIVE-
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ANDOVER, MA Up�Add,� edpi
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