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HomeMy WebLinkAboutBuilding Permit # 2/22/2016 OORTH BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 6PermitNo4.) Date Received 0 rep �� �cwus Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 12 Print .......... PROPERTY OWNER Print 100 Year Structure yes no I MAP PARCEL: ZONING DISTRICT: Historic District ye - no rl Machine Shop Village yee no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential F-1 New Building One family D Addition [I Two or more family 11 Industrial ;gAIteration No. of units: 11 Commercial 0 Repair, replacement 11 Assessory Bldg El Others: 11 Demolition [I Other zg�, W e a U1, as I OWN J"ON/W UN, YOWN/W DESCRIPTION OF WORK TO BE PERFORMED. E, Identification- P k�ase Type or Print Clearly OWNER: Name: Phone: 75 1 - 57- Address: -z" (4-'J, Phone: Contractor Name- E 4,L� A; Email: 4 JV-r,,,41 -) Al Address: Eft Supervisor's Construction License: Exp. Date: 61 Home Improvement License:J2Exp. Date:=4=/ 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. C Total Project Cost: $ Lo FEE: Check No.: 0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the kuarantyfund r. ,- of rnntrr ter0-,��7- @ tAORTH Town of2 ;, Andover ® ^�! h ver-, ass, 49,?0�61 q COCKIC1tl WICK x rA0 RATE® U BOARD OF HEALTH PE RI T tLD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ........... .... ..... ............................................................�........................... has permission to erect .......................... buildings on .. ......................................... . .............................. Foundation ® 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 PERMITOT ELECTRICAL INSPECTOR UNLESS I STARTS Rough Service ........... ..... ... .... ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do of Remove Fitel No Lathingor Be® Wall o Done FIRE DEPARTMENT Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. i U_ffa Fedora)IDU 05-0405625 R1 Contractor Registration NO 8186 NIA Contractor Registration No 120979 R 6 E A dit'isiffll of ThidsCh Engincurinp F N'G 1 1\1 FT R I N G' 60 X!iw.-vinu, ("Rott,;o, f'20219-50 'ONTRACT 33ML3 ­ ,l5__ ---j FAX P290 PROGRAM CM A-I I ES ENGINEERING AND THE CU510,MEN FOR WORK AS OE CRIOIID DELOVI CUillumul PROBE DATE: CLICTITO V1,01"lit 0110F.11 Ocall calur (781)307-01104 01/0712016 427433 00004 ,IS SFRVICk 1550 Sul(nn Strut 1550 Salem Sued SEAVIIX North Andover, MA 0 RjlNardi Andover,IVIA 01845 1 J, rf JOB DESCRIPTION I'l IANE'l WO-)'I­Oposill I'M llcXk YcOl's LNeDtficrizationi Project.llrice5 and piogram incentives not guaranteed. (RAWLSPACE:Protide labor and materials to install(288)square feet of It-19 unraced fiberglass insulation to 1110 crawlspace Ceiling to he in coom"t with the,suhnorlyllid cumplutely filling tiivjolst cavity to be nus),Lou,ji,cjOls,boti,D11s. install I" polyisticyantirme foam board insulation. Scat lilt scams%yiIII FSK(ape. RISE linginecring will apply lilt applicable,aligible incentives to this Gonlrttcl. You will only be billed dIV,Net amount. Currently, CUT cligitllc Incasurvi,Columbia G:Li otrers 75%inrxntivc,not to exceed 52,000 per calendar year,and an incentive of 100%for the Air Sealing nmisures up to the first 5080 and,it additional 53,10 if savings are justified by the oadilor. for the safety and Imalill oryour ilume's indoor du quality,LvI.:trill be conductill":1 blower door difliloo-We of the nvailatilt;air flow in your home ImIli before Ilio\tiuk is bv;po,and after the kyeailterization work L%cOniplctc.We hill also conduct a lilt[rssessmcnl of the combustion Safety Of your ImItillpSyStel(I and water healer,This has a value of and is at tin cost In you. 'I'Ditil allowable ,vea(licrimlion incentive is 53.1 10, S00,00 Total: Program Incentive: $921.60 CustomerToial: $277,20 WE AGREE I BE R MY TO BURNISH SERVICES-COM PLETF IN ACCORDANCE V,11 It ABOVE SPECIFIGAI IONS.FOR THE sUTA OF "'Two Hundred Seventy-Seven RL 201100 Dollars $277.20 UPON,HUAI,11,1511CCI Io it ?,GINEERING.CUSTOMER AGREES TO ROln AMOURI DUE IN FWLI_1.4 IVRWIT OF 1-4 WILL BE CHAROUD MWITHLY OR MY UUNIF)LIN-AICEAFIIJ Ej I, II,.,PUjn!y(T 114FORtw-lioi1 Oil(WARANTELIB.1416117:1 DO NOT SIGN71-11S CONTRACT IF THERE AR)4 JY BLANK SPACES AIIfUtlHiN, (-/,�,-_Rr.1 rE, U01 E:TICS ccliMAC F I.-AY BE V10 HDIIAV(II IWts IF NOT VXFCUT,0 YfI Till!; OAT.';'IF ACCEPMOME ACCLPIM:CE Of CONTRAI;f-TTI''-AOOVE AUD CCNI)DION,ARE 30IAI lia"At.1 CRY in Lis ADO..Fili IIERMY Acccpnio_YOU Ann mintolvro 10 00 THE WORK DAM AS PAYMC?n Wll�t�UE MADE AS OUTI-MED AAUVE_ 434", The Commonwealth of Massachusetts Prirrt For Department of Industrial Accidents Office of Investigations 3 ` 1 Congress Street, Suite 100 �o Boston, MA 02114®2017 e www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatioti/Irrdividttal): guilders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 Phone #:603-324-1974 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 100 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp, insurance comp. insurance.' ❑ e are a corp required.] 5. Woration and its 10.❑ Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner•doing all work 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no Weatherization employees. [No workers' 13.❑✓ Other camp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire 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 thepolicy and job site in forrmation. Insurance Company Name: ACE American Insurance Company Policy# or Self-ins, Uc. #:WLRC 48151553 Expiration Date: 6/30/2016 Job Site Address: " City/State/Zip: , e" Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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 Investigations of the DIA for-insurance coverage verification. I da hereby cert/f under the eahis and enalties of perjury that the information provided above is true and correct. Signature: ~' Date: Phone#:603-324-1974 Of ricial use only. Do not write in this area, to be completed by city or town official. City or Town: 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#: D/YYYY DATE061241/2015 ) CERTIFICATE OF LIABILITY INSURANCE 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 w certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 'p NAME: Aon Risk Services Central, Inc. PHONE (866) 283-7122 FAx (800) 363-0105 a Southfield MI office (AJC.No.Ext): (A C.No.): 3000 Town Center E-MAIL o Suite 3000 ADDRESS: _ Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Old Republic Insurance Company 24147 TopBuild Corp. INSURER B: ACE American Insurance Company 22667 260 Jimmy Ann Drive Daytona Beach FL 32114 USA INSURER C: ACE Fire Underwriters Insurance Co. 20702 INSURER D: INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER:570058348882 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. Limits shown are as requested LICY EFF POLICYEXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDOlYYYY MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY304834 EACH OCCURRENCE S2,000,000 CLAIMS-MADE X OCCUR DAMAGE O RENTED $2,000,000 PREMISES Ea occurrence MED EXP(Any one person) $25,000 '.. PERSONAL&ADV INJURY $2,000,000 '.. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S4,000,000 X POLICY ❑PEO- F—]LOCPRODUCTS-COMPIOP AGG $4,000,000 0 ul 0 OTHER: r A AUTOMOBILE LIABILITY MWTB 304835 06/30/2015 06/30/2016 COMBINED SINGLE LIMIT $5,000,000 ul Ea accident X ANY AUTO BODILY INJURY(Per person) 0 ALL OWNED SCHEDULED BODILY INJURY(Per accident) d AUTOS AUTOS NON OWNED PROPERTY DAMAGE (a X HIREDAUTOS X AUTOS Peraccident) t.. i= d) UMBRELLA LIASHOCCUR EACH OCCURRENCE U EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND WLRC48151553 06/30/2015 06/30/2016 X I STATUTE EOR H- EMPLOYERS'LIABILITY YIN All Other States ANY PROPRIETDR I PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000 C OFFICEWMEMBER EXCLUDED, NIA SCFC48IS190 06/30/2015 06/30/2016 (Mandatory in NH) WI Only E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000— T I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 7y� Evidence of Coverage J" J.r r- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. c„a Builder services Group, Inc. AUTHORIZED REPRESENTATIVE A TopBuild Company 260 Jimmy Ann Drive Daytona Beach FL 32114 USA ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD yy � t= C� ce of Consurner Ava— sand Business Regula tion .:,�_.. ` 1 Park Plaza - Suite 170 Boston; Massachusetts 02116 Horne I111provernent Contractor Registration Registration:: 179141 Type: Supplement Card Expiration 6.'2512016 BUILDER SERVICES GROUP, INC. RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 03063 ('ridate Address:and return card.Mark reason for change. Addres,, Ren""al Entnloymert Lost Pard Of,ice of Consumer Affairs b Business Regulation License or registratian valid for individul usL t>nh before the expiration dR!t:. If found return to: g:7-F_ 140ME IMPROVEMENT COt�TRfiCTOR Oiztcc of C:onsuntcr A;iairs and Business ttegularc�n R2gsstratiar.: 17 14 i Type it) '4r<#'l:azs tivate 5170 - -x irarjon_ Si[5/2G10 Supplement -afd f?oston,MA 021 H) ALDER SERVICES GROUP,INC. HARD SCHWARTZ 0 jItviivtY ANN DRIVE .YTONA BEACH L 3211, t'ndrr>ccrttzr. dot vaii:w ithout sign21ure CSSL-105992 RICHMM S(,I-IWAR*I'Z 193 HUNTRESS SMEIET Manchester NH (13102 09/26/2016 Restricted To CSSL-K.- In,,k)lM'M Contractor Failure to pcjsses, `rent edition of thc�Massachusetts Statp.Building Cot jjtjse for revocation of nw-,license