HomeMy WebLinkAboutBuilding Permit # 4/26/2016 �161�DINO PERMIT S 0,eo
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 0 �
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Permit NC7o / Date Received RAp0WPp,4�`�
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Date Issued:
im ORTANT: Applicant must complete all items on this page
LOCATION LA C .,a"A-
r Print
PROPERTY OWNER � l() - h o's()✓"1 �
Print 100 Year Structure yes no
MAP ' PARCEL U"� ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no 10
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential _
❑ New BuildingOne family
❑Addition ❑ Two or more family ❑ Industrial
F"Alteration No. of units: i ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
rr m e/ rrr ./ii./r, .,.,,„/ .::�i ,.r.,/„//. in ✓. .,....<.. // /. ... rP//%/O rL �r,,r,. .,,r/ /r.,... ,/._„
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/ e is �❑ Well/„ // , /%r „/ � / r �.,// (r�/ // //�r,
DESCRIPTION OF WORK TO DE PE FORDED:
Identification- Please Type or Print Clearly
OWNER: Name: (Li(\ �C)Ja jj�On Phone:q ') I-101ko
Address: �' ` t SV 0 0 61”
Contractor Name: ✓ - �` Phone:
Email: "\u i r\.sQr . OYa M-Ck,t t ✓”
Address:"PO 1' \y. S4q Jj( (V\ ClA 0A719
Supervisor's Construction License: ` Exp. Date:
Home Improvement License: I ` Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$92,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ ( J U FEE: $ 3
Check Na.: Receipt No.. 2ekL�,
NO'S'E: Persons contracting with unregistered contractors do not have access to the guaranty find
-. _ -
-- ��gnature of Aaent/owner Siana�ur�of'cQnt�--_—
ttORTH
Town of Andover
® 0
C, h ver, ass,
o
LAKE ,�
COCMIC Nl WICK
40
L D
S V BOARD OF HEALTH
Food/Kitchen
PERI I �T� T Septic System
THIS CERTIFIES THAT ..l....... 6450r) .. , ., ,, .. BUILDING INSPECTOR
............. .. ..... ..... ......®............... . ...........
has permission t0 erect g Foundation
.......................... buildings on .4 ... .. .`Jl,l.. .. ... .. :..... .... .....�4.
® Rough
to be occupied as ........... .. .�.. .. ® ....I ...�!'. Chimney
provided that the person accepting this permit In every respect conform to the terms of a 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
MONTHSPERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
......................y..... .j� c ._..........................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Polecat ID H 05-0405629
RISE Engineering 13i Contractor Registration No 8186
PAA Contractor Registration No 120979
RISE A division of"I'llielsvIi Engineering CT Contractor RogIstrallon No 620120
ENGINEERING*
60 ShawnitO,Camon.MA 112021 CONTRACT
339-502-5197 FAX 339-502-6345
Page
rt mmom
11115 CONTRACT IS 01TERED HITO BETIVEfitt RISE
CNIAlm-IIES ENUMEETTRIG ARD THE CUSTOMER FOR WORK AS
DESCRIDEO OrLOW
CUSTOMER PHONE DATE (3.1151110 WORK OTHIM
Nadine Johnson 78)979-7616 04/0212016
429428 00004
SZ[Vice-synerr
Ult-UnG SIRE
48 Cottift Street 48 Comfit Stretel
SERVICE CITYSTATE.ZIPBILLING CITY,STATE,ZIP
North Andover,NIA 0184. North Andover,MA 01845
JOB DESCRIPTION
AIR
SEALING:Provide labor and materials to seal areas ofiourhome amillst wasteful.excess air leakage. This vsork will be Pcirlbromed in
conceit with the lose oI*spcciaI tools and diagnostic tests to)X'sum that your home will be left wish a ficaldiftif level of air exchange and indoor
air quality.Materials to be used to scat your home call include caulks.11mum and otboar products. Primary areas for scaling include air leakage
to anics,basements,attached garages and ollicr tudie-ated ateas(windows are not This wilt require(0)working hours.
A reduction in cubic feet per minme(el'in)ol'air infiltration will occur,but the actual number of cin is not guararnecd.
At the climpIction ol'tie weatherivation work,anti at no additional cost to file boulcovvilur,a final blower door and/or combustion safety
analysis will be conducted by the sub-contractor to enSurt:the Safety of the indoor air quality.
5510.011
DANINIING:Provide labor and materials to install a 12'layer of it-38 unlaced fiberghiss batts ill(66)square feet for darnming purposes.
5133,30
ATIX ULM%Provide labor and materials to install a M"layer of It-35 Class I Cethdow added to(3149)sittlate fev.1 of open nitic space.
$370.36
ATPC ACCESS:Provide labor and materials to install(1)tasily moved,insolatiri.,-cover for the little access folding stair. A small flat
smrfarcc of plywood will tae crcatcd around Iho opening within the attic. This will air
leakage.
5237.65
VENTILM10M Provide labor and Illaterials to install(1)insulated exhaust hose will ruafmonned flappervent to exhaust existing
bathroom Aln(s).
$11833
VI'�vrtuvriam:Provide labor and materials to install ventilation clailei.;in(42)rafter bay,,to Inainlain air flow.
RISE 1:11ginueling will apply all applicable.eligible incentives III Illis Contract. Yon will only be billed the Net amount. ('intently,for cligible
incivalrei,Columbia Uas offers 7595,inceinke,not to exceed 52,000 per cakodar year,and an incentive ol'1001'6 for file,\it Scaling meastites
ill)to the first$080 and;in additional$340 ifsavin,,,s are,jitilifieJ by the auditor.
For(lie safety and health ol'your home's indoor air quality,we will be conducting a blower door diagnostic of the available air now in your
hollne both bel'ore the work is begun,and after the weatherization work is complete.We will also conduct a]IM assassrloeat(11,11le
combustion sareiv orvolar locafiog system alld wawt lualler. hats a Value of s%)quad is al no ct).ij to you. TtKaj allowable weallicrizalion
incentive is S3,1 io.
590.00
RISE Engineering will apply a credit ofSI00 towards this contract,in acknowledgement off ic deposit yon inade to Next Steil LivilK.,
lowards your original wcathcrization contract.
50.00
Fedoral 10 f$05-0405629
RUSE Enghicering RI Contractor RegIstration No 0106
1-.1 MA Contractor Registration No 120979
RISE A division oll'hielseb linginvering CT Contractor Registration No 620120
ENGINEERING'
611 Shawnint,Canton.NIA 02021 CONTRACT
339-502-5197 FAX 339-502-63-15
Page 2
PROURANI
77II3 CONTRACT IS VDIERED INTO BETWECD RISE
CNIA-HES EUClUEEnING MID Tile cusTwErt FortwoRK As
vEscrunconstow
CUSTOKIER PHONE DATE CuElff 0 WORROADER
Nadine Johnson (978)979-7616 04/02?2016 429428 00004
lilt E REET VILLRIO 57REET
48 Cottlit Street 48 Cotuil Street
SFRVIGr Tf'�STAJE.bp UXLWG CITYSTATE.ZIP
forth Andover,MA 018,15 North Mdover,MA 018,15
.JOB DESCRIPTION
Total: $1,746.06
Program Incentive: $1,659.55
Customer Total: $186.51
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE RA ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUIA OF
'"One Hundred Eighty-Six&51/100 Dollars $186.61
UPONFINAL 11SPECT101)MIDAPPROVAL BY RISE EUCIIIEERRULCUSTOUERAGRUS TO REUIT AnOWAr DUE DlFUFt.IUjERESYOF ItiVALLITE CHARGEDUOUIDLY Oil ADY
UUPAJO tlA WCE AFIEB 30 DAYS.SEE REVERSE FOR IMPORTMIT ParoRMATIOD OU
0 NOT SIGN THIS CONTRACT IF THERE ARE ANY SLANK SPACES
Illy
AUTHORIZEDI CUSIOUTRACCEPTANCE
NOTE:Fill$CONTRACT IAAYDE VfinI0ftA4`I1J BY US H'14CITEXECUTED VARIIN DATE OF ACCEPTAPICE J
ACCEPTANCE OF CONTRACT-THE ADOVE PRICES,SPECIFICATIO?15 Mill COtIVITIDUS AnE
30 DAYS, SATISFACTORY TO US Alin ARE DEREDY ACCEPTED.YOU ARE AUTHORIZED 70 00 lilt VIORK
AS spEctrIED.PAYPIEFIT VALLOE MADE AS OUT1,1110 ABOVE
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.......... ......... ..............................
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OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
(Property Address)
(Property Address)
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform;work on my property.
Owner's Signature
Date
The Corrnnonweallh of Mossachusctts
Department of Industrial 9ceide nts
llf/ice ref htrestigations
arm'y I Congres's.Street,,Suite 100
r`
Boston-VIA 02114-2017
,'F li'H't4',1I1t1SS.ntll;idla
Workers' Compensation Insurance Affidasii: Ituilder,;iC-untractors?Eli-eirici:anslPiumhers
Aim icant Information { Please Print L�
Addre-•s: ("_13 0 x 1511
t tti `stitlt dip: lS %e_( _ 1( �1�1
-
Are xou an cmpiwW?Check the appropriate hot: � F+pe of project (required!
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I ant an emploYer that A providing,IftJrt e'r,1 l'(1 tt1pNt741atftJ/f imurairce for ii tr entpin•ret'i. Below A the palicY and jots site
in.forfnation.
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r Snit-n5>. i i V1 A 111
—p 30Q3 -11 _ F.ti.l i :o:i Dark
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kttach :a copy of the%%orkers'compen%ation policti declaration page tshtmin°g the policy omnbcr and expiration datui.
l`lifurc .r,e�`utc _,:•er t�2 a; rc<i.atri sl asl,l�r titi_ttr= = -t :�t(iE. `_�.4,; ,c Iltc Irnt�u,I:1!Ia 7.=i�r�11l1I A p.aaltit<.17,l
Iint_Itr To S, ;- tm1 t_?tl:1ti 1 ur i�to-...Ir ;rr�;i,ilr-n,n:. as r.lA as Cl1.a In Ow :.-r rt;r.=`a S It'11'1i t 1RK t_TDF R xiJ l
rfti't tnllit,`r iii.1di 11C.1 ILLI it LOP% 0! 1!111 111.!1, hC fol'kal iCia`o tllc t r
I!Ilt�tt�attpn�inthe MA tier mti..rc.nc�.�ur•.Crd+', n ii Imo.
I do hcrebe ccrrify tinder the paint and penalties of perjury that the it!fnranatit)n pre vide above is true and c+JMeCt.
Oficial fccc onlY. Do not is rite in f1m area.t()be c omplc ted hw cite'or towel n ff:tial
C"itx or Town: _ __---__._-- Perutit/l.icensc _---_-_--_
Istiuing Authorit, [circle oner.
1.Board of ilealth 2.Building Department 3.City'foss n Clerk a.Huctrical Inspector 5.Plumbing inspector
6.Other
Contact Person:_ _T. ---- Phone It:
MIISS-kchusc,ttv 7r'�S<artmr t f Pu bbic safer,,
Board 0BuokIM 9 ��gulata snci sr.�r car s<
t_icerl CSSI-902562 f
KURT R CAUTfffpR
P-0.BOX 344 � i
IP"ith!MA 0193Wn�v I'
P-:A'thiYlfly n
Cor arrt�ssit ner 0512512017
/o�
j Office of Consumer Affairs and Business Regulation
�a 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 173410
Type: Individual
Expiration: 10/1/2016 Tr# 257812
KURT GAUTHIER
KURT GAUTHIER
P.O. BOX 344
IPSWICH, MA 01938
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
' Registration: 173410 Type: Office of Consumer Affairs and Business Regulation
Expiration: 10/1/2016 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
KURT GAUTHIER
KURT GAUTHIER
44 ESSEX RD
IPSWICH,MA 01938 Undersecretary of valid wi out signature
CERTIFICATE OF LIABILITY INSURANCE
16,
THJS CERTTF:CA7E IS ISSUED A,-A MATTER C , 4L-N, I;'eC S C*N--fE Zc,'T 1FT,7A—<)_F,CP T)4;S
C7, F:,'--AT[DOES',C1 T A t11 Z PA7:V_ '�''-'_! P, 1,�'(L, _)!7 Z,,TLP,T E A ;C=DrO T,I P02c'I
5CLCI'.', li 1S FILA'E C' INSURANC' -D(_-r�'S ",,7 C:-)*.F-1T:FT-,C I;TL
-LIS 11;
P 4E'5E'JA7TvE OP �'N_DTH,��EK7 1 P IC -.1
_F 11-75P,ANT, If tlle hkl sn A_,DITF-%k %Jv; t G fS-=✓7 t'FQG.AT'�C'N`s"VIA[lizo, _t t7l thti
rr- aac culd tons cf Me pli,f,cert �Acse_i) t A N;it, lct- c,'ccnfer n tL,
h_Ce"i,he,j ci
Clayton Martin J Ins Agency Inc r As,,g,ed R,4,
1649 Northampton St PO Box 9119 77'
Holyoke MA 01041
3
Gauthier Insulatio
n Inc
PO Box 3"
Ipswich,MA 0193$
COVERAGES CERTIFICATE NUMBER REVISION NUM—BER -
1 H tS T(-,CER-T;C'v -' PCIUCI ES OF 74 RAN EJ SSLIE1) 7_� %APLD ABO'v=F�-'P T�j7 r K
�7,
'Q',_P,41__T.--P D7 Ek RFSPF_-7 7_1 7t--
MA BE S_.,_n C-P VAi TH-, ;oI PI)l- DLSCT11E, D`C R�-N SSUB
X;7.LNIC'N5 Arj)('YtN'-3 So_f'�il' MIT_ t,
IT.
AUrOMOOILE UAJIIun
z
f IC
EX'l
'771,
WaRXER ICU`EHY f
F
CERTIPCATE HOLDER CANCELLATION
Clearesult i 711 FXJi'A-E
Contractor Svcs
50 Washington Street
Westborough,MA 01581
A,C0P,1j 25(21`!0!05' B.cAc 3 1 9
I DATE(MMIDD/YYYY)
AC"R" CERTIFICATE OF LIABILITY INSURANCE
7/7/2015
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).
PRODUCER CONTACT Nancy Uaher
NAME: Y
Martin J Clayton Insurance Agency, Inc. _PHiONN Ext) (413)536-0804 ac No) (413)534-7874
1649 Northampton Street ADDRESS:
RESS:
P. O. Box 989 INSURERS AFFORDING COVERAGE NAIC If
Holyoke MA 01041-0989 INSURERA:NationWide Mutual-Harleysville NATIO
— — - ..
INSURED INSURERB:Allied World Natl Assurance Co
Gauthier Insulation INSURER C:
- ..... .... ......... ............ ...............
44 ESSEX ROAD INSURER D:
INSURER E:
IPSWICH MA 01938 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL157701379 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 ADOLiSUBR - - - POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER. DD DD LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
� DAMAGE TO RENTED 50,000
A CLAIMS-MADE L^J OCCUR PREMISES(Ea occurrence),..... $ ......
..-.-.__. _ ......_..
X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000
....___ ....... ........— .._._..__. -. ......... _....... _.._._...----
PERSONAL R ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:PRO- GENERAL AGGREGATE $ 2,000,000
_._....._._.. ........._...--
X POLICY _ JECT
PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $ '.....
ALL OWNED ISCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS 1Per-accldenQ
$
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000.,,000
B EXCESS LIAB CLAIMS-MADE AGGREGATE _ $ 1,000,000
BE020792125-194985 10/18/2014 10/18/2015
DED RETENTION $
WORKERS COMPENSATION PER DTH-
AND EMPLOYERS'LIABILITY Y/N ._-..._STATUTE...... ER .
ANY PROPRIETORIPARTNER/EXECUTIVEl E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ..I N/A ----
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required)
TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSURED(S) ON A PRIMARY AND NON-CONTRIBUTORY BASIS
TO ANY OTHER INSURANCE CARRIED BY TEI, UNDER THE SUBCONTRACTORS GENERAL LIABILITY AND UMBRELLA COVERAGE,
30 DAYS NOTICE OF CANCELLATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THIELSCH ENGINEERING, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 FRANCIS AVENUE ACCORDANCE WITH THE POLICY PROVISIONS.
CRANSTON, RI 02910
AUTHORIZED REPRESENTATIVE
Daniel Sullivan/MEG �f `
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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