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HomeMy WebLinkAboutBuilding Permit # 4/19/2016 0O R Ty p�'11490 '6 ��NO BUILDING PERMIT TOWN OF NORTH ANDOVER ° t APPLICATION FOR PLAN EXAMINATION i Permit NO: Lw. Date Received '7 pbk'Ay. SSA C WUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page / r � // fM1. / �r,;,, rr i//rr / / Ii / /�, 1 � r, -, ✓%/���„, o�i i %r 'rir� i%, G 1 ;r111(l//�"r��i �% fi%� �",,���,0,1���� y�/�;�r% Vii: �r,,,,r ,,,,,,„��„,r,,,: „r!/ii<�i//�i i,✓,��//,,, ,,,,,, o��//ai�i/i°,.,����%f�r//ii„�i,;, ,v,�✓/"., rr i� ,r L, � ,,// v�?f TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Fs'bne family Addition Cl Two or more family ! 1 Industrial d�Alteration No. of units: [,l Commercial Repair, replacement 11 Assessory Bldg [7 Others: L) Demolition u Other / ,..%, ../ (A 1..... 11 7(.. )��'�w l Identification Please Type or Print Clearly) OWNER: Name: �.. �.. tw � ." Phone: Address: � ,� �. l, j ” T. / r / r,/ i��,.,r,✓�� / r r , D„ ��/fir / � ////i��/ ii „t ��� Y,�;, ✓�/�%��f 0/�7/ 1//,� �r/�,r;/ r/�r , ,, / r / 'an �/ ARCHITECT/ENGINEER pu Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ -FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with uni-egzstered contr-actors do not have access to the guaranty,fund igo e dfAi O.W ler �' , � `;, Sfr"oture of comet �- . NORTH Andover Town of _ T � ® �� — a' h- , ver, Mass, �.� COC NIC Nl WICK V A�RATE� �P�,�'�y BOARD OF HEALTH S U Food/Kitchen IT T Septic System gg ®® \� BUILDING INSPECTOR PERM ord�s w�•k .... THIS CERTIFIES THAT ............:.. . Foundation q Q. 7. . .... .................... Rough ...... buildings on .. ""' .... .. ......... . has permission to erect ...................` •••• Chimney i r . A ........................ ... ....................... ...................... to be occupied as .... • ••••• I• '•••••'••"""" p application Final s of the term provided that the person accepting this permit shall in everyrespect By-Laws e relating t rm othe Inspection,Alteration and PLUMBING INSPECTOR on file in this offBuildnn Buildingsthe provisions of the inthe Town of North Andover. Construction of g Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ELECTRICAL INSPECTOR PERMIT EXPIRES 16 MONTHS Rough UNLESS CONSTRUCTIO RTS Service . ,',','- ....... ..................... Final BUILDING INSPECTOR GAS INSPECTOR Rough ®ccuancy Permit Required to ®ccupv Building espy Final Display in a Conspicuous Place on the Premises — Do Not Remove FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Burner Until Inspected and Approved by the Building Inspector. Street No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lipwiv."lass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Co-op Power Address: 15A West Street City/State/Zip: West Hatfield, MA 01088 Phone#: (413)772-8898 Are you an employer?Check the appropriate box: Type of project(required): 1.2 1 am a employer with__-20 4. El I am a general contractor and 1 6. F-1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.El I am a sole proprietor or partner- listed on the attached sheet. t 7. F] Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions required.] officers have exercised their 3.R I am a homeowner doing all work right of exemption per MGL I LR Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.E] Roof repairs insurance required.] employees. [No workers' 13.[R Other comp. insurance required.] *Any applicant that checks box#1 11flUst also till out the section below showing their workers'compensation policy information. 9 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors Mast submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ant an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:__HDI Gerling America Insurance Company Policy#orSelf-ins. Lie. g: EWGCCO00187715 Expiration Date: 11/08/2016 < Job Site Address:- t) (:1rtCity/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine Lip 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 tip 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. l do hereby c e airs and penalties of pepur that the information provided above is true and correct. SignaIt Date: �h Official use only. Do not write in this area,to be completed by city or towntownofficial.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 RISEGo Sj'awmut Road,Wt 2 1 Canion.MA 02021 j330602-6335 E F,c vrwNq.RISEenqinn0TIn9.C*m OWNER AUTHORIZATION FORM o"iner loceted P.". -ertvderess ---------- Fd 106 obtaln q *or RISE or. RI � RI5>::�:tlgincrting twit _ _... � Rt� ..ditWop ar'tbictafi T:�inatfvd cT Cadr6Bar EMGMdNG b0 au wut vwt Oz.<'m nor MA CONTRACT iad117Ai3'r00 FAX(d011711td^Id Face j PRO09AM p C�#iWtES atenaaevrew rswa �� sanroan+s ' 43034b Melis4aGdwartl< (7$1)249-9416 oJl2f3(tiG reum i11W stkv"s+r,u* 889 Johnsson 5lrttt 889 Johmon Street muwu arr,x+.tcss evsse inv,rist s's. North Andover.MA 0181. Noah Andover.MA 01945 JOB DESCRIPTION AM$VAIR((i:Mrc id<latwrxd IIu�er'.+F+wsest aem ui)vef}ime mea ful,cY%ori,tom.rko xiat»8tto perWtxmd In tveccA moist,tM tec arspttiaf 14-katd daemsskeR(b psave tbl s hontc sb—WW�4tro a#n visd itdoot ale 4.Ay,mmer bpm mh.00.d w sed yowq ma tn2lode tmo�. omu.a:e smi Orazaoy mYiss fvtsiYinL•)«'deair keVq wwie,bahnaall 0trtie6_ aW o�e'on3tat arm iw oncmv.lfad t+c xtwi vddj�d.)Ttur wiSSr�t(u(1)udtdelq Mm�x.nttdogWrint�k� fcG R7v+bxifttc&nl afair iafiM:wnu \wo 'Lr pt<(ssis dtt,+yvars+tt<d nrtb At thea>.rp�twn oitac u-d--twe usl:.:�vl x m additav+ai ma ta dq htxna xo r.a fasd bhnrcr svr Ju!yx iatiun sadc(Y t+s tritl lx am=odd by iRr wibttv,s..tt wwvn'de 0tW OYlhe cda<ne r}>' SO— yp},{�(}gK}?A S}i()Z7A IR�tA1.1.A f)iX)P 1`7R}TIi(:l.'AAWt-SPM'f TI1.AT Titi:C(wMWf0ft cA\1h5UlAT8 �.W OAI�AJG'Pso'tWz Fahr,orad tt aatnl+w imm)i a IY 1a)>7 ofR=38 d fiber trYti w i tJ)ai,n+c C�to dstiratb>4( $24.70 A"f'f1C RAT:?reside i�xx aaI rmia`ssls m imta5 a»"h}a rdA•ta('hus I lcltdava ddd w Rory.,bi'ee fxt c,ropea 5ti: VENrilA7R1N:trt+ride kfiw n+d macxiakw Mumd(2)brtui dcxfiwstiwuweatix\>Knicam,fri\) ctro VF�'7'dAYON:hmfde labor std nxaia,\in i.YVd1 va»tAia)At<Ivrrn w(tee)rsnabays w raairaaU,aft i'nn+. SSl.W p(riinntt w RM%F.h1F:h'T('F'RJwi:pM e IObM cad n aarmatt in)nsml!(!1)Anes fat of R-19 unfaccd filux-,lass in,alaf.+a w dK aftkclt ails a:the b:w'\e siu St'y.'.3 CRntV1St'ACIi:P:axiik Ltiwr sed ir.W iks w i,,ttt11195)sq-v fxt b<A•14 unkad fik�'r>_1a<Y in:id;viv-,o,stx:ran talc e<Uinp.W b<ul<rnune whh th<sabr*w area mn plct iy fdPA@ the ida trrrttY w tr?imp,.sieb iF.<jorat ltialan..T7 eot�)I' Ipty'rse>�ipvyt<fo5++h6wd mcela±imt%asl a!F Dams uhll FSK 1w. 47 cn.7: ALt,{OVAL'Asrnm( (45),,Kiat;fi'Ct of bait st}tc k>stMiw tcom dx patttayxe vc+ S;t:/< ids w inaulau:ll)ba<kbf the eawisfrx<�us qfd\?'rit'id Tixnvn bwd,orad scat t`w IRAWLS t dte rnid�rtiib.aesll,crst iIbw t Y WOO g tit>i apNy all appfiCbiG tltglbk tibYtniYQS w thF(tonuaa YW u51t qtly 0.M1itnn ih`.Nat amwo f Ctvcmdy. RISE Fasd4ie�ln Calirmbia Gas orTtio75Y.intvti(ivc,riot tq tsexd 5:.000 t»cakbth, t•and M in:<ren5 of tlltl:i fred for the ifrdi.#16lo.tn wd>eArsl 56b0 and mr add'ntM»1 S3a0it+sNr>as ar<jaulby tht xwiwr. nk�irig memvaet vp htdsh of}mor 1»w,'s indxv ori;qual)0'.ua xiif be caad�tb4".a bwwcr dar.dm�n'wi:ni Ux ava:lnb6o ak itnc in For da saCaY✓�. atvk is nxnpMc.lk'e uiU also conduct a foil ass<saittiv of wtv rn n.Mh befixe limo a.xk is won.a+d nAc(du o(xhairallnd Ii15E F.tl�i»eeria� w ftvwr?tl�Wo uA GonufNar oro RI A disisien uY1 hirlr b fugi ttatec Cr 6a�tmeta No Wwdiow 60 Sha -f 3'-it 9:.1'anta ,MA CONTRACT (401)794.3700 FA\1401)U"710 Page 2 PRWR:AU CAIA4IES Tr A,*"d t�isra uro� � aeseexatrtater twtoano nr� vert crvr. wumc watn MelissaF.dwarils (781)249-9316 02/1203016 .430446 00002 s4.+w4 M". curve anurr 889 Johnson Street 889 Johnson stre.-t ae+nXr atr,atATcra aM.u.a att.rT+va. North Andover.MA 01935 North Andover.MA 01835 JOB DESCRIPTION the ttimheWlou 3fftdYnflwu lt=iag assttat and n'attrlrsei.Thi i bw a.atic d5S0 anal r,at r orsa to ws 1-0W a3lwu 1 exhn ton n"WIV is S3.t 10. 590.00 i Total: 52,20.95 Program incentive: 51,705.90 Customer Total: $544.05 vJE AO/t"11MMY TO M)PL nSrWAM-GOav IUMAGCORDAWA MTHAaove SFLCMATOM F0a TN8MA'0F I j -*Five Hundr*d Forty-Four&061100 Dollars $644,05 v�innr�'`tauaw��veva."..�"+tea`ratwu'r'�c,r`iveaian«1"'ma1�"stw"�.vea�ma'ea%`"i�Mi."so i,:rz.�oarr�ict°,max"�ur�raTe°'r.� 00,NOT=W THIS Cd11RACT W-OOM ARE ANY eLANX80ACAS •Unl0uaa0tlWWt�%t.MCf 1✓1.^� MTOWA1.Ctaiivcr vaff-Tw tbl/fY.4.Wvesw�Muamc ev l2,[!SrLYCWtCa rnva wil.N r+tY�isx>: .'' `.�i(� 1. 7 7� .czt+nuxa a+t¢vrwcr-az aatve ras.atevra �Hm caa,nx,.ac anus, rJIr4I.tCYWHta4'aA%allA MiRtBYJCCarita.KYtARS�UMk010'tabC YNilmvl lt!NPeYMA.Y1Tttafl t#L tl Y+UL b OYf yl1YU ri W y i1,�..�}14�✓« amu✓ I LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC11/12/2015 HOLDER. THIS BELOW. CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED ATBY E 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 James J. Dowd & Sons Ins NAME: Debbie MacNeal PHONE FAX 14 Bobala Road A/c No Ext: - - A/c No: AD Holyoke MA 01040 X'699 ss: dmacneal@dowd.com PRODUCER CUSTOMER ID#:COOP INSURED INSURER(S)AFFORDING COVERAGE NAIC# Co-op Power, Inc. INSURER A:HDI-Gerling America Insurance Compa 15A West Street INSURERB:Torus National Insurance Company 25496 West Hatfield MA 01088 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:254565888 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 SUER LTR TYPE OF INSURANCE IN D POLICY NUMBER �MM � MM/DD� LIMITS A GENERAL LIABILITYEGGCC000187715 015 11/8/2016 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY D AGE-l6RENt ED CLAIMS-MADE D. PREMISES Ea occurrence $100,000 OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY LOC PRODUCTS-COMP/OP AGG $2,000,000 iL. $ X PRO- A AUTOMOBILE LIABILITY EAGCC000187715 11/8/2015 11/8/2016 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS j BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ i (Per accident) X NON-OWNED AUTOS $ Comprehensiv B X UMBRELLA LIAB OCCUR 70354Q150ALI 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADEI -11 AGGREGATE $1,000,000 DEDUCTIBLE i $ X RETENTION $10,000 - -- A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N EVIGCC000187715 11/8/2015 11/8/2016 WC STATU- OTH- T RY LIM ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) Ityes,describe under E.L.DISEASE-EA EMPLOYE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Certificate Holder, Eversource, and National Grid are Additional Insureds on a primary and non-contributory basis per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED CLEAResult IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Contractor Services Dept. 50 Washington St. AUTHORIZED REPRESENTATIVE Westborough MA 01581 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD � s g Office of C�;or�SUrner �ffairt� ``�rrrcl Business 1�f �sr�lation 10 Park Plaza ... SI-lite 5170 Boston, Massachusetts 02116 1 forne Improvement Conti-actor Registration Registration; 165217 Type: supplement Card E�xpiratJan 1/21/201{3 CO-OP POWER, INC. 1 EAI-.{ DANIELS 15A WEST ST WEST HATFIELD, MA '01088 I plate address and return card. stark reason for chaohe. Address 1ienew4 ll Employrnerrf Hast Gird -014-1CC Orf ofiSnlll(, AffalrS&Bnslne�s Regulation license or reuistralion Valid for individul use only_ HL�ME IMPROVEMENTCONTRACTOR before the exlairatiou date. If foundrr.turn to: Office of t.onsumer affairs and Business fieunlation registration: 165217 Type= 10 I':rrh d'laz.r- quite 5170 Expiration: 1/21/2018 Suppletnent Card Boston.NI N 02116 CO-OC-PC)WER, INC. LEAH DANIr-l_S 15A WE:S7 S WEST HF , IELD, MA 01088 t ndcrsc+crctar} �� Not valid without signature t� afi f CS-097409 LEAH M DANIELS 12 MARCELLA ST ROXBURY MA 02119 05`18?2017