HomeMy WebLinkAboutBuilding Permit # 3/1/2016 NoRry
BUILDING PERMIT 0.1 %AO
TOWN OF NORTH ANDOVER 0� -J3APPLICATION FOR PLAN EXAMINATION A
Permit No#:
Date ReceivednORRTEDePPp`
Date Issued: 3 �SSgcHuSE�
IMPORTANT: Applicant must complete all items on this page
l
� Pnnt 100 Year Structure yes 'no
MAP
PARCEL �� ; ZONING DfSTRICT Histonc District ye 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 it Others:
❑ Demolition ❑ Other .1
Septic 1/Vell ;❑ Floodplain, (JWetlands V1/atershed District
0Water/Se�nier•� ': ,�; .
DESCRIPTION OF WORK TO BE PERFORMED:
)'0&J X70
1/ f n-ri lgTI`® tit
Identification - Please Type or Print Clearly
OWNER: Name: e 0) ogle Phone
Address: d 13 11 57
Contractor Marne l~� ,a
L ;Phone. ' / 7G
Supervisor's Constructron License
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: $ )-;F oo,o c) FEE: $
Check No.: 111-521 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
NORTpf
2Town of
. : : Andover
....,_ 'yam•
®
`AKE ver, Mass, A
COCNICNEWICK 1'
RATED IPa`yr(�
�S
U BOARD OF HEALTH
Food/Kitchen
PER Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
LD
............... ...... .. ... ................. ... ..... ....................
..........................S"'I
..
... . ` ... ........... Foundation
has permission to erect.......................... buildings on ... ....... .1... ......
® ... Rough
to be occupied as ...................... ........,ji .`....... .........�......�.�► �A. . ... chimney
provided that the person accepting this permall 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
J
VIOLATION of the Zoning or Building Regulatirens Voids this Permit. Rough
Final
PERMITI ®NTS ELECTRICAL INSPECTOR
LES CTI ARTS Rough
Service
............. ........e.�..... . ..: ..................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Buildinz 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.
I Federal ID#
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thiclsch Engineering CT Contractor Registration No
60 Shawmut Unit 02,Canton,MA 02021 ®NTR A CT
339-502-6335 FAX 339-502-6345
E PROGRAM Page 1
THIS CONTRACT
KA
CMA-HCS ENGINEERANDWECUST ER FOBETWEEN
WORKAS
ENGINEERING OESCRISFO OELOW
CUSTOMER PHONE OATE CUENT0 14ORKOROER
Heather Doyle (978)270-7839 09/17/2015 418255 4000
SERVICE STREET 01WNG STREET
213 High Street 213 High Street
-- --- - -- 2 2 20 -
SERVICE CITY,STATE,ZJP 01WNG Crll',STATE,LP , y I 1
North Andover,MA 01845 North Andover,MA 01845 t
JOB DESCRIPTION .
BARRIER:A Blower Door Test will not be conducted at your home,due to the presence of asbestos.
$0.00
BARRIER:The following contract is not valid unless accompanied by the Pre-Weatherization Barrier Incentive form,signed by
your licensed electrician.Work will not proceed with this work until we receive a copy orate form.
$0.00
BARRIER:We have identified a moisture issue in your home that needs to be addressed.Homeowner is responsible for correcting this
moisture concern,prior to the installation orany weatherization work.B.DRY SYSTEM GOING IN OCT.3RD.SHOULD SOLVE
PROBLEM
$0.00
AIR SEALING:Provide labor and materials to seal areas ofyour home against wasteful,excess air leakage. This wvork will be
performed in concert with the use ofspecial tools and diagnostic tests to assure that your home will be left with a healthful level of
air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary
areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generdly
addressed.) This will require(8)working hours.A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual
number of cfm is not guaranteed.
At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure the solely of the indoor air quality.
$680.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass balls to(120)square feet for damming
purposes.
$246.00
ATTIC FLAT:Provide labor and materials to install an 8"layer of R-28 Class I Cellulose added to(696)square feet oropen attic
spacc.I COULD NOT ACCESS OVER REAR I ST.FL.BUMPOUT ASSUMMED SAME AS MAIN ATTIC.
$953.52
ATTIC ACCESS:Provide Iabor and materials to insulate the back of(I)attic hatch with 2"rigid Thermar board.Weatherstrip the
perimeter.
t $60.00
ATTIC ACCESS:Provide labor and materials to make(1)temporary access to an attic area. 'rhe opening will be closed with a
permanent roof vent
$92.42 r
VENTILATION:Provide labor and materials to install(3)8"diameter roof vents)to increase ventilation in attic areas. llme vent
can be supplied in(circle color)black,brown,gray or mill finish.
$256.50
VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roormounled Mapper vent to exhaust
existing bathroom Fan(s).
$118.75
VENTILATION:Provide labor and materials to install ventilation chutes in(56)rafter bays to maintain air flow.
$112.00
Federal t0 9
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thietsch Engineering CT Contractor Registration No
�u
60 Shawalut Unit 02,Canton,NIA 02021 ^®w'�b �.p.
b 339-502.6335 FAX 339-502-6345 CONTRAV ISH 1
SPage 2
PROGRAM CONTRACTTHIS
RISE
CMA-HES ENGINEERING AND THE CUST MER FORED INTO UR WORK AS
ENGINEERING DESCRIBED BELOW
CUSTOMER PHONE DATE CUENTR WORKORDER
Heather Doyle (978)270-7839 09/17/2015 418255 00003
SERVICE STREET BILLING STREET
213 High Street 213 High Street
SERVICE CITY,STATE,LP BILLING CITY,STATE,LP
North Andover, MAO 1845 North Andover,MA 01845
JOB DESCRIPTION
VENTILATION:Provide labor and materials to install(6) 6"X 16"rectangular aluminum soffit vents to increase ventilation in
attic areas. Specify color:White or Gray.
$150.00
BASEMENT CEILING:Provide labor and materials to install(86)linear feet of R-19 unlaced fiberglass insulation to the perimeter
orthe basement ceiling at the house sill.
$150.50
i
Total: $2,819.69
Program Incentive: $2,284.77
Customer Total: $534.92
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Five Hundred Thirty-Four&92/100 Dollars $534.92
A
UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMITAMOUNT DUE IN FULL IN7XREST OF HL WILL DE CHARGED MONTHLY ON ANY
FTER RT
UNPAID VALANCE A30 DAYS.SEE REVERSE FOR IMPOAM INFORMATION ON GUARANTEES,RIGHTS OF RECISIO,ICHEDULING,AND CONTRACTOR REGISTRATION. _
— NOT SIGN THIS CONTRACT IF THERE ARE -t Y BLANK SPACES z
AUTHOZWGUATURE-RISE En cerin Cr MER CCEPTANCE
NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDmONS ARE
30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DOTHE WORK
AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE
OWNER AUTHORIZATION FORM
�,__ f��4�`he►r Qo yl�`
(Owner's Name)
owner of the properiy at
( ►n )
. (Pmparly Address)
hereby m orke
( nbacbx)
an autiwdmd wboontrsctor for RISE Enghteeft,to act on my beth to obtain a buMq
permd mid to perform work on my
own ftnahue
Date
{'t� SEP 2 2 2015
The Commanweakh of jVassachmsetis
Departmew qjr1ndzistrja1,4cc&en!s
I Congress Sir_-e4 suite 100
Boston,M4_ 02114-2017
Workers'
g&v1dza
Workers'Compensation Insurance Affidavit:]Builders/Contr-actors/EleciLricians/i>lujnbers-
Applicant Information
NaM e; (13usincssIOi-ganizatioafludividull): /,A i�ij 5 ei It— !A
(7;4 4"!6, :Z�
Address: Cf
City/State./Zip
Phone-#--
ase you nn employer?Chc�:the apprvprbte be= Type ofprojet(,,q4reQ_-
1. FINew construction
I am a employer with /Q {full nodfor part-time)_-
7-
20 1 am a sole proprietor or PW1U=Vhi0 and have no employees working for me in 8- Ranodea.
any capacity-(No workers'camp.insurance -quired-I
301 h...,doirig.11wort,myself[No workers'comp_inSU%zncc,.q,&cd.]t 9- DanolitioD
F-1
4_0 I am a bomcovnux-and will he hi,�g con-h-Actom to conduct all work on may props t 10 Building addition_ twill L--..)
CUSUM 033t 811 cone actors Cither have WorkCM'C0MP=153f!Gn inStIfaDCt or are sole 11-E]Electrical repairs or additions
proprietors With no cmpjoyccsr-1 Plumbing repairs or additions
12-1
5-01 am a general acmancLor and I have bired d=SUb-contra"OrS h9cd on the attached ShcCL 13-E]Roof repairs
These sub-contractors have mvloyacs and have workers'comp-insuran=_r
6-0 We am a coxporat;on and its offic, 14.F-1 Other
.,,bavc mmci5cd tb--jr right of` p,,,\,IGL r-
152,§1(4),add we have no cmplD_yc.=-,[No workers'camp_insurance rcpirt&j
-P-y applicant that cbCCkS box#1 must also bit OW thesection lJc10W showing fficir workers'co-p-satin.polity infotmatioo
t Homeowners who submit this affidavit idicating they arc doing all work and then hire outside contractors must submit z deco ntfida,dt indicating--b-
lCoausctors that cL=k this box must attached=a zdditknml sled showing the nada orthcsu b au state_ca TxMrs a ndwb t1ber Or not tbo5c,cuti""have
C:Mp1qYccs,. If the sub-contractors have=Vjoyccs�,they must provide their workers,comp.policy numbar-
I air an employer thaf 1'S:.providing Worke7S'Comper,'Sadon inSUrancefor My employees. Below is thepo&y andjob site
rnformadon. - 7
[assurance Company Name:
0C,
Policy# or Self-ins-Lic- Expiration Date:_ 6241t'l
fob Site Address: I 'Z1 9 r Q to CitylStatd7_ip
Attach a COPY Of therkers'compensation poticy dedaratiou page(shoving the poNcy number e ad e3zp1jrzdon date).
Failure to secure coverage asrequired ander MGL c- 152,§25A iSacriminal violation punishable byafine,p to-SI500-00
indfor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of LIP to 5250.00 a
iay against the violator-A copy of this statement may be forwarded to the Office of Investigations ofth,DIA for in--n-
-overage verification.
do h-0by CW-dfy wader the pains and 17enald=qFfuej5Fuiy that the informaffon proyMed awye is true and eorrgct
Date:
"hont;
Ojffci'al use oirly. Do not write in this area,to be completed by ciky or town OfficLaL
City or Townt PertnitjLkenSefi
Issuing Authority(circle one):
L Board ofHealth 2 Building DF-pnrment 3-Ciq/Toym Clerk 4-)Electrical IDSPe-d6r 5.Plumbing I-Wect"
6-Other
Contact Person: pbone#:
POLABEA-01 JONEI
LL
DATE(MMDDYYYY)
2CERTIFICATELIABILITY INSURANCE 1/6/ 016
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 - —
11 Saunders Street A/c No Fact_(978)688-7000 —_ _ _(ac_NoL_(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 956 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.
TYPE I I LIMITS
INSR i iADOL SUER; POLICY EFF POLICY EXP '
LTR I .INSD I WVD I POLICY NUMBER MMIDD ! MMIDD
A I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
)C ( NN58691 03124/2015:03/24/2016 j PREM SES Ea accu AMAGE TO RtzN I o ncel S 50,000
CLAIMS MADE OCCUR 3
j i I
;MED EXP(Any one person) S 5 000
--
____ PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. i GENERAL AGGREGATE l
)C I POLICY PRO- - i S 2,000,000
JECT LOC PRODUCTS-COMP/0P AGG S 1,000,000
i - —
OTHER: i S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i S 1,000,000
.._ j accident
B _ ANY AUTO X2100926 01/04/2016 t 0110412017! BODILY INJURY(Per person) S
!
ALL OWNED SCHEDULED ; BODILY INJURY(Per accident)'$
AUTOS AUTOSI _
HIRED AUTOS - )C I NON-OWNED PROPERTY DAMAGE :S
.AUTOS ),(Peraccidena _
— — I $
... _ —
I
UMBRELLA LIAR !)C`OCCUR EACH OCCURRENCE $ 11000,000
A EXCESS LIAR AN019284 03/24/2015 03/24/2016 — __ :SAIMS-dADE
DED RETENTION 5
WORKERS COMPENSATION PER OTH- '
.ANDEMPLOYERS'LIABILITY Y/N i ;__ STATUTE ER _ -
ANYPROPRIETORIPARTNERIEXECUTIVEDIN/Ai i E-L EACH ACCIDENT is _
OFFICER/MEMBER EXCLUDED?
!(Mandatory in NH) I ; j E.LDISEASE-EAEMPLOYEE
S
If yes,describe under --
DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT 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
Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
g g ACCORDANCE WITH THE POLICY PROVISIONS.
195 Francis Ave
Cranston,RI 02910
AUTHORIZED REPRESENTATIVE
_Y r
!l ia0o•nAn Arlr%Ort^/ nnf1MATrdf%@1 A11-"t-
...............�.!
IW2016 Preview:Certificates of Insurance
3 DATE Iri!xonzyYYYJ
CERTIFICATE OF LIABILITY INSURANCE
011041ZO16
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRD41ATIVELY 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
Ute 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 COUP ACr
HAIAE:
PHONE AS
Automatic Data Processing Insurance Agency,Inc- E.0: I Vc.Nn;
I Adp Boulevard ADDRESS:
Roseland,NJ 07068 IISURERIS)AFFORDIMIG COVERAGE NAIC7
INSURER A: NorGUARD Insurance Company ' 31470
INSURED
INSURER e:
POLAR BEAR INSULATION CO INC
INSURER C:
PO BOX 988
Andover,MA 01810 INSURER D:
INSURER E:
INSURER F-
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY TH:T THE POLICIES OF ItJSJRAirCE LISTED BELO'l.HAVE.nEEN ISSUED TO THE INSURED NALILD A.5QvE FOR THE FOL-CY PERIOD
INDICATED Ido i A`ITHSTAP-JOING ANY REOU:REi.:Et1T.T`oRL:OR CONDMON OF ANY CONTRACT OR OTHER DOCULIENT YiITH RESPECT TO%VHICH THIS
CERT!FICATE LIAY BE ISSUED OR L:.+Y FERTA.(d.THE TISURANCE AFFORDED BY THE FOL=CIES DESCRIBED HEREIN:S SUBJECT TO ALL THE TERLIS.
EXCLUSIO;JS AND COND)TiOP•:S OF SUCH POLIC•!ES ULI)TS SH017N WAY HAVE SEEN REDUCED BY PAID CLASP'S
INSR TYPE OF DL— POLICY F P LICY 1' i Llf.IiTS
LTR It 1 POLICY NUMBER (1�L4'DD.YYYY) 1f61•�O YYYYj
COLIMERCIALGRIERAL LIABILITY t:.cr- clhtdtLCt
L:.L'.LLI•:Ut LU: I+i;ELlr�"�It.*.�rc•_r:-•: _ '
VEIN
tSEr:L i:Gr11iEG%•I't LILIr I dl7'LItS PEI:. I GEKtH:.L AGC,h ti^.I t
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AUTOf.:OHILE LWBILITY LI'O.ED SILCLI LI.II 1 -
al' _
Al =:.1�1•; i fiLL'•IL'=If:JIli::i4"p,r-'�tt:
::LFE:VL U
.H_I I;'s AL:I CS _
1.1,C11-111
I rIF:tU AL I::_= PAu ki 13
ft 13
UM:.aRELLALUfe -L1. =ALI- ::tiI%MILL-!:
EXCESS LIA9 I CLAIMS.Lc.Dt Aul-HH>:.I t '.
OIL` ' RL-i EIaIP�65
11ORKERS COMPENSATION X W.1' I'
AUD EM..PLOYERS'LIABILITY I SI AILIE N:
Y.N 1.000,000
):':IT:_I;I;I�II'i:'I':.Fi11.E1-:c:itLlTl':E V 1 D�I� 1 011011-7017 t` t:.t;h:•1'L1L'•tl.i �`-
A :FFtdLRr ISH{ • LC•G, 1111A R P 1 772258 01101,12016 '
(Lmntlalory fin❑H) tL.ulst.Ist-ta trJPu^•tE 1,000,000 '..
ILcS:_Inrilci:cF crtr.:.ncl.s n__:: I � �t.L.ulSEast r-�.u��ur.u) - 1,000,000
DESCRIPTION OF OPERATIONS i LOCATIONS,VEHICLES 1ACOR0 101.Addib.-I Rema.kl Seh Walle.n1.J be attached it mausp—,Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
TheilsclT Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS-
195 Frances Ave
Cranston,RI 02910 AUTHORVED REPRESEI1TATn'E
Ac 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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