HomeMy WebLinkAboutBuilding Permit # 4/16/2016 00nrn
0
BUILDING PERMIT
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINAT * -
Permit NO. J �' ��" �.�� �-.)� � �7 Date Received i.
Date Issued:
VS US
IM ORTANT: A licant must complete all items on this page
140ATt' l � ,
lltrlt n
Maclt�n Sh� 'Vill rt+
TYPE OF IMPROVEMENT PROPOSED USE
Reside,tial Non- Residential
New Building k,- ne family
Addition ❑ Two or more family Industrial
COlteration No. of units: a Commercial
Repair, replacement Cl Assessory Bldg ❑ Others:
Demolition ❑ Other
I it, C1 WeM1 U Flo
cctlrri`" D Wetlands Wnt+ rhd Dtriit
Ir
Identification Please Type or Print Clearly)
OWNER: Name: �, . W Phone: "k" ,' A ,:KK
Address:
OOIRATI Nate, Phore: ey.
A40 µ
41,
l er or' 00 rt ctlon Lice e Exp. date:
eIlrlit ' Cxpte:
ARCHITECT/ENGINEER I . Phone:
6
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: $ � � "� FEE: $ �.
Check No.: �... � �� .... Receipt No.: L
NOTE: Persons contracting with unregistered contr-actors do not have access to the guaranty fund
Sl ... . � gH� re of contractor
Signature oencaner Signature ato
; .a n
;....
NORTH
Town of Andover
00
z
o No. 261
IT , ver, Mass, 41"..
COCHICKEWICK y1.
`S U BOARD OF HEALTH
Food/Kitchen
�rERMIT LD Septic System
�. ai C.THIS CERTIFIES THAT BUILDING INSPECTOR
••jj ••••• •• • Foundation
W
has permission to erect .......................... buildings on .L�.O .... 1.t1.Y. .l. .. .... �. ••
p Rough
to be occupied as ......... . . ...
... ..r. Tx.suT0. .:fJ..0....... !...!............................................. 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit:
Final
PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTION ST RTS Rough
j Service
........................... .. �+� ..�.,/..�,........................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occup 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
p
b
RISE
60 Shawmut Road, Unit 2 1 Cantron ISA 020211339-502-6335
ENGINEERING" www.RISEengineering.com
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at:
(Property Ad e )
(Props y Address)
hereby authorize �•.d-�:
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
0 is Signa e "
bate
Federal ID#05.0405629
9
RISE Engineering RI Contractor ContractoRegisstratioRegistratinn No 124979
RISEA division of Thielseh Engineering
ENGINEERING 60 Shawmut Unit 02,Canton,MA 02021 CONTRACT
339-502-6335 FAX 339-502-6345
Page 1
PROGRAM
7N15 CONTRACT L8 EliTERI-'D INTO aETWEEIV RISE
CMA-HES ENSINMW(;AND THE CUSTOMER FOR WORK AS
DESCRIBED BELOW
CUSTOMER I NE DATE CLMWV WORKORDER
Doreen Deshaiesinn
8}633-5516 02/26/2016 432049 00002
sERvica aTT pel - e 0 STREET
287 Waverley Road VA� Waverley Road
SERVICE crrY,STATE,ZIP aO CRY,STATE,IIP
North Andover,MA 01845 No Andover,MA 01845
JOB DESCRIPTION
HEALTH&SAFETY:Weatherization work cannot proceed until the gas leak issue is repaired.
$0.00
HAZARD BARRIER:We have identified that there are recessed lights present in your home.unless the recessed lights are certified
as IC-rated(Insulation Contact Rated)we will create a 3"clearance space around the facture by using fiberglass blanket insulation as a
damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated.
$0.00
AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be
performed in concert with the use of special 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 generally
addressed_) This will require(6)working hours.A reduction in cubic feet per minute(chin)of air infiltration will occur,but the actual
number of chin 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 safety of the indoor air quality.
$510.00
DAMMING:Provide labor and materials to install a 12 layer of R-38 un cc fiberglass Batts to(84)square feet for damming
purposes.
$172.20
ATTIC FLAT:Provide labor and materials to install an 8"layer of R-28 Class 1 Cellulose added to(504)square feet of open attic
space.I COULD NOT ACCESS OVERHEAD ASSUMMED 6"EXISTS
$690.48
ATTIC ACCESS:Provide labor and materials to insulate the back of the attic door with 2"rigid Thermax board and seal the door's
edge with weatherstripping to restrict air leakage.
$73.91
ATTIC ACCESS:Provide labor and materials to make(1) temporary access to an attic area. The opening will be closed with
materials similar to those existing. Finish sanding and painting is not included.
$85.00
VENTILATION:Provide labor and materials to install ventilation chutes in(54)rafter bays to maintain air flow.
$108.00
COMMON WALLS:Provide labor and materials to install blown in Class 1 Cellulose to(195)square feet of 4"common wall
through an interior surface drill and plug method. Plugs will be spackled and left in a relatively smooth condition.Finish sanding and
touch-up priming/painting will be the customer's responsibility.Homeowner has received a copy of the EPA's Renovate Right Lead-
Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.
Your signature is your acknowedgement of receipt and agreement to proceed.t.BETWEEN GARAGE AND HOUSE.
$360.75
COMMON WALLS:Provide labor and materials to install 2"FSK faced semi-rigid fiberglass board insulation to(112)square feet of
common wall area.
$392.00
Federal ID#05.0405629
q!J�JRISE Engineering RI Contractor Registration No 8186
SP��— MA Contractor Registration No 420979
a� A division of Thieiseh Engineering
ENGINEERING 60 Shawmut Unit#2,Canton,MA 02021 CONTRACT
339-502.6335 FAX 339-502-6345
Page 2
PROGRAM
THIS CONTRACT LS ENTERED INTO BETWEEN RISE
CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS
DESCRIBED BELOW
CUSTOMER PHONE DATE CLIENTO WORK ORDER
Doreen Deshaies (508)633-5516 02/26/2016 432049 00002
SERVICE STF2EET BILLING STREET
287 Waverley Road 287 Waverley Road
SERVICE CITY.STATE,ZIP BILLING CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
BASEMENT CEILING:Provide labor and materials to install(126)linear feet of R-19 unfaced fiberglass insulation to the perimeter
of the basement ceiling at the house sill.
$220.50
RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,
for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the
Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor.
For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of
the combustion safety of your heating system and water heater.This has a value of$90 and is at no cost to you, Total allowable
weatherization incentive is$3,110.
$90.00
Q0
Total: $2,702.84
Program Incentive: $2,177.13
Customer Total: $526.71
WE AGREE HEREBY TO FURNISH SERVICES.COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Five Hundred Twenty-Five&71/100 Dollars $525.71
UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF I%WILL BE CHARGED MO ANY
UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CO GISTRATION.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPA
4RSIG REEEngkwaing MER ACCEPT
NOTE THIS CONTRACT MAY BE WITHDRAWN BY US.IF NOT EXECUTED WITHIN DATE OF ACCEPT CE ---
ACCEPTANCEOF ONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE
3O DAYS SATISFACTORY 0 US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED To DOTHE WOR"
AS SPECIFIED.P YMENT WILL BE MADE AS OUTLINED ABOVE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwmMass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ficant Information Please Print Legibly
Name (Bus iness/0 rgan i zation/l n di v i dual): 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.[Z I am a employer with 20 - 4. El I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
+ 7. E] Remodeling
2.0 1 am a sole proprietor or partner- listed on the attached sheet. + 8. E] Demolition
ship and have no employees These sub-contractors have
working for me in any capacity. workers' comp. insurance. 9, D Building addition
[No workers' comp. insurance 5. F We are a corporation and its 10.F Electrical repairs or additions
required.] officers have exercised their
3.El I am a homeowner doing all work right of exemption per MGL 11.[:] Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.F Roof repairs
insurance required.] t employees. [No workers' 13.® Other
comp. ingurance,required.]
*Any applicant that checks box#1 must also fill out the section below showing then-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 in additional sheet showing the name of the sub-contractors and their workers'comp.policy information,
I am an employer that is providing workers'compensation insurance for•rrry employees. Beloit,is the policy and job site
-information.
Insurance Company Name: HDI Gerling America Insurance Company---
Policy 4orSelf-ins. Lic,#: EWGCCO00187715 Expiration Date: 11/08/2016
Job Site Address: City/State/Zipfi/.A-Pa')Qu I 10A
Attach a copy of the workers' compensation p licy declaration page(showing the policy number and expiration date).
Failure to secure covet-age as required 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 Lip 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 do hereby certify,under the pains and penalties qfperJu that the information provided above is true and correct.
Siianature'.,_
4-Date: z I /
Phone 4: 4, / 7 — c) 79 —
Official 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#:
DATE(MMIDD/YYYY)
CERTIFICATE LIABILITY INSURANCE
11/12/2015
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
certificate holder in lieu of such endorsement(s). ONTACT
PRODUCER NAME: Debbie MacNeal FAX
James J. Dowd & Sons Ins PHONE
AIC NoExt:413-5 -7444 _—_-
14 Bobala Road E-MAIL
ADDRESS: dmacneal@dowd. o
cm ---
Holyoke MA 01040 PRODUCER
CUSTOMER ID#:COOP
INSURERS)AFFORDING COVERAGE _ _L_NAIC#
INSURED
INSURER A:HDI-Ger11ri AmerlCa Insurance Compa-
Co-op Power, Inc. INSURERB:Torus National Insurance Company__ 25496
15A West Street
INSURER C _ -- - - '
West Hatfield MA 01088
INSURER D _ -- — - -- --�.
INSURER E:—
INSURER
:INSURER F:
COVERAGES CERTIFICATE NUMBER:1503274623 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
TIO
PERIODTHIS CERTIFICATE MAY SBE ISSUED OR MANG ANY YPERTAIN,HE INSURANCE IAFFORDED BY THE POLICIES DESCRIBED HEREIN IN OF ANY CONTRACT OR OTHER DOCUMENT TSU SUBJECT TO
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -
-- POLICY EFF POLICY EXP_7.
--- ---- __--—— - ADDLSUBR .-- - _ LIMITS
(LTTYPE OINR POLICY NUMBER MMIDD/YYYY MMIDDIYYYY
F INSURANCE SR WVD
EGGCC000187715 11/8/2015 11/8/2016 EACH OCCURRENCE 51,000,000
A GENERAL LIABILITY I DAMAGE TO RENTED _
PREMISESEa occurrence) 155100,000
AL LIABILITY S
X COMMERCIAL GENER5,000A
{ X MED EXP(Any one person)
CLAIMS MADE OCCUR
-J
PERSONAL&ADV INJUR
GENERAL AGGREGATEY 1,000,000
2 000,000
LS
- - -_--- -I r_PRODUCTS-COMP/OPAGG 52,,000,000
l GEN'L AGGREGATE LIMIT APPLIES PER. I g
X POLICY� I PECOT LOC
11/8/201
EAGCC000187715 5 11/8/2016 . COMBINED SINGLE LIMIT 51,000,000
I
A AUTOMOBILE LIABILITY(Ea accident)
BODILY INJURY(Per person) S
ANY AUTO
BODILY INJURY(Per accident) S
ALL OWNED AUTOS
PROPERTY DAMAGE
----
X SCHEDULED AUTOS 5
(Per accident)
X HIRED AUTOS
X NON-OWNEDAUTOS
-
IS
Comprehensiv
I70354QI50ALI
11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000
- --
B X UMBRELLA LIAR OCCUR -
AGGREGATE i $1,000,000
__. _
EXCESS LIAB --_-. -... _CLAIMS-MADE(
----. DEDUCTIBLE -III
5
X RETENTION $10,000WCSTATU- OTH
WORKERS COMPENSATION EPIGCC000187715 11/8/2015 11/8/2016 'I_000 -DORYLIMITS:_ ERL, ---
A 1,000,000
' AND EMPLOYERS'LIABILITY y I N E.L.EACH ACCIDENT S _
ANY PROPRIETOR/PARTNER/EXECUTIVE - _T
OFFICER/MEMBER EXCLUDED? � N/A E.L.DISEASE-EA EMPLOYEES $1,000,000
(Mandatory in NH)
If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Certificate Holder is named as Additional Insured per written contract in regard to general liability
only.
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.
Thielsch Engineering, Inc.
195 Frances Ave.
Cranston RI 02910 AUTHORIZED REPRESENTATIVE
@ 1988-2009 ACORD_LCT ORJPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
� F
rr rlr r l rr�m, ld 1 t.r .)
[ rtr �r
10 Park Plaza St,titc, 5 170
I costo ri,, 1' �sss.R,h WiCtt.S 02 1 1
11mne Ire pro veyncoit Contractor Registration
n
Rt,ctKCr<ttic>rr; M521
Tyrl:wc Supple',�rrwmt Card
POWER,
F xF;rir�a brt MUMS�w:;<:�) (�.)F" f_.r O VVE f��ti, I N G
DANIELS
"I",ilk lN S..I_.
VVE-<S'l HAITIF.i...i.:), MA 1088
i pdMe Addrex" and rerturn rand. Mnrlk reraawn IN change.
Address Renew:11 Vinployrarent Lost Gard
bila a oFe uri^�uinci toric;tis tSusinc k ddt.t„rrlariurM
lKens"r reom 6nn v and for mdntdol me only
S!
before the expir ate<rn date tt Bound return to
Sr� :f1("YYVY9'r.lYU14'RC)Vti1VYLl�`L C';C)f*!-(i�2�,(:;lC)F"
,� (Moex erg t onsunur affairs and Rn!,nreawv Re(gelation
1 Fte y�..}irstraation: 6t:St I17 .1.ype: LO Park Plaza w4uitt� 170
Lxpoaafion: VI 112018 ,`upplena-;ret Card flostorr,"t'I.A 02110
f;t)- 7fa FIOVV( k, 1P11J.;,
F
15A VUF V I 51 �;�=-
s'” � 1
VVE T IIF PH H1 I') 10/1,01()811,;
I'rad�r�rrrararr} � Nrrt valid v&btrrrt vWrratnrr
of i'arlit a1H;i,�
CS097409
LKAH M DAP R-S OF
12 MARCEL.L_A 5T '10ma
ROXBURY MA 02119
OW 181017