HomeMy WebLinkAboutBuilding Permit # 4/26/2016 BUILDING PERMIT o�TL aT 6,6
TOWN OF NORTH ANDOVER �6
APPLICATION FOR PLAN EXAMINATION � �
Permit No#o �r� Date Received Ar C>
� SHCHU5��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION � 6 r
Prin# ..
PROPERTY OWNER
�^ Print 100 Year Structure yes no
MAP . PARCEL: 2 - 1 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE w
Residential Non- Residential
❑ New Building tOfamily
❑Addition ❑ Two or more family ❑ Industrial
®Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
��,, �r.�� ,, ,�, //, ,.loud .Iain ,, ,r❑Wetlands,,,/ ❑,,,WatershedrD�stnct,,
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DESCRIPTION OF WORK TO DE PER
FORIUIED:
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Identification- Please'Type or Print Clearly
OWNER: Name: 1 CA e Phone:(-91 ° (9 p
Address: 0 UJ It l
Contractor Name: ✓ 4' C-1wJ0-\,\T-r- Phone:
Email: �\u-)2
Address. Cab Rsk 'I"I"i VN O» 'S
Supervisor's Construction License: , ``0 - Exp. Date: '5J z- 1 "
Home Improvement License: t , Exp. Date: L a
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ (J 0J . FEE: $ .
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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F AOR TH
Town o-'' Andover
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T O LAKE ♦ `/i ' ��A79
COCMICHEWIC
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ll BOARD OF HEALTH
L D
Food/Kitchen
PEK Septic System
•
THIS CERTIFIES THAT .............. ..... . .............. .....................l.... ........... ... ........... ...............
BUILDING INSPECTOR
has permission to erect .......................... buildings on ....... . .... .. ....... ...... :...... .Q....................... `. Foundation
® Rough
to be occupied as .. ... . ..... .M..... .... ..1. . .. .....9.®!..... Chimney
provided that the person accepting this per shall in every respect conform to the terms or 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
PERMIT EXPIRES IN 6 MONTHSELECTRICAL INSPECTOR
UNLESS CONSTRUCTION T TS Rough
Service
......................r ...,e ......'s�... 4•( --.. .....................
Final
BUILDING INSPECTOR
GAS INSPECTOR
ccu cy Permit Required t® Occupy 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
MOM M W a 051 05OVI
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Futlaral 10 0 05-0405629
MsE Engineering RI Cotitrijelor Rail IstraII011 No 0106
FAA Conlractor RODISIM11011 No 120910
rRISE �k dkisi(ln 41VI'MCINVII 1-:11gilicel-i[IR CT CotitrActDr 110915trAtIO11 No
ENGINEERING` Q)Stummul I 11ii iQ, NJ k CONTRACT
(4(IJJ 784,17t1j) FAX(40 1)784-3710
Pago 2
I It )(I RAN I 11-(ONTRAC I I%"I ffItt"llo""T"t it"`r
cN I A-I I FS tow;;rt RINOA-40 ML cuslour"roll�YD""
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CUSTOMERCLjrNT tl MUM ORAE"
PI R'NIC TIME
Nicole Bertoldi (017)620-2138 ()2,129,2016 431134 00002
ULMCL IlTRCEI BILI.W0,ITIM T
q %Ve\hIIId0rcIc ')I 1krc\hind Circle
SERVICE CITY,STAYF,Zl;l Ujjp,'0 CITY.IIAI(.Z:I`
North Andover,MA 0 18,15 North Antlover%MA 0IS45
joj� I)EISC12IP110N
Total: $2,604.38
Program Incentive: $2,100.78
Customer Total: $603.60
WE AGREE HEREBY to FURNISH SERVICES•COMPLETE IN ACCO140ANCE WITH ABOVE SPECIFICAvW4S FOR THE SWA OF
**'Five Hundred Three&6011100 Dollars $503.60
C(CITOMER AGN1,4,5 TUDVXT MWUNT DUE IN FULL, 1IILREV0
UWAI0DALMXEAFTER 30CAVf
00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
A/
AUTHORIZED SIGNATURE U:Sr 01V'1-1110 CUS1OM111 LE'NANCr
OW Or ACCEPWXF
DOTE,THUS,CONTRACT MAY Ot WITREMAVOI TAY(13 IF P40T WCUILD MMIN
ACCEPTANCE OPCONTRACT 111rAf1YVrPA10Et,
GATirFACTO(RY'OU,A74LARE firfkCB)(ACCEPTED
DAY' A5SIlEC;F:EDA1AYfALf.1WA1 UI MAN ASOUILPiLUADOW
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68ShawmutRoad, Unit | Canton. MA 02021 339-502-6335
ENG|NEER|NGwww.FUSEemginemhngzom
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(Owner's Name)
owner ofthe property located at:
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(Property Address)
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hereby authorize —
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an authorized subcontractW for RISE Engineering, to act on lily behalf to obtain a building ! �
permit and to pertorm work on rny property.This form is cilly valid with a signed contract. �
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Owner's Si(Pla'Llre
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_n_______ l�_�-�- -- ---- — ---- -------
Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Qfliee of lotresik-ations
I Congress Street,Suite 100
_311:1-
Boston,:M A?114-017
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WorkersC ompensation Insurance Aftidasit: Buiiders.iContractorsTlettricians..Pin mt>ers
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Cit} or Than: ----
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1.I3uard of Itealth 2.Building tlepartmrnt 3.tT "Nmn(Perk 4.IActrical hapemw 5.Plumbing Inspector
6,Other
Contact Pers<nt:-____-- ____ Phone tt;
CERTIFICATE OF LIABILITY INSURANCE
rEr,TjF:C,%TE I'S Ae A t'A- CNL'4A'.
DCE5`QT -:1- �i,,T-FPT--E �'�Y T,,[
PFPq
ESENTA71-VE 0�DPCI).-II-i MqD 1HE
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C,; s an I cc 7d,trj,�s cf tne foh� cert�P Tr-y r,,q v� A�tETSN cr, "rfe, t3:h.>Ce' i.01
k� er ;cry
Clayton Martin J Ins Agency Inc 21 s,ned Pi-.k
1649 Northampton St PO Box 989
f
Holyoke MA 01041
i x. 7—
Gauthier Insulation Inc
PO Box 344
Ipswich.MA 01938
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER,
I h (�ST C.,CEc TI-Z- P,771CIGS OF I�< '<ht -.hV�t8 7-F IAPED FO�:-7�i7 FC.-.
L
AN'
T1z1'ATE MABE L1C:,-,1S,---E--R,-?,,is T E 4
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GEIEPAL L
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CERTIFICATE HOLDER CANCELLATION
Clearesult f 71i -zoTil.,ti
Contractor Svcs
50 Washington Street
Westborough. MA 01581
-!4!2'no!05" BRAC"31;9
A l TIFI AT F LI ILITY IIV U DATE(MhVDD/YYYY)
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 Nano Usher
NAME: y
Martin J Clayton Insurance Agency, Inc. PHONE (413)536-0804 bac�ueJ:(419)s34 7e74
(A —J Ext) .._....._._ _........_. -.._..
1649 Northampton Street E'MAIL-ADDREOs:_ .-_._.__-
P. 0. Box 989 INSURER(s)AFFORDING COVERAGE NAIC.#
Holyoke MA 01041-0989 INSURER A:Nation_wide.-Mutual-Harleysville NATIO
INSURED INSURERB:Allied World Natl Assurance Co
Gauthier Insulation INSURERC:
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.
-- -iADOL SUER — POLICY EFF POLICY EXP
INSR --
LTR TYPE OF INSURANCE POLICY NUMBER �MM DD YYY M DD LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
� PREMISES
50,000
A _ .] CLAIMS-MADE L^ OCCUR PREMISES_La occurrence) $
........ ....._.... ......___—.
X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY u PRO- F LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident) ...,........ .
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident_ _
$
X UMBRELLA LIAR _H
OCCUR EACH OCCURRENCE $ 1,000,000
B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1r 000.1.000
_
DED F— RETENTION BE020792125-194985 10/18/2014 10/18/2015 $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY ..STATUTE OERH....
ANY PROPRIETOR/PARTNER/EXECUTIVE YINN/A E.L.EACH ACCIDENT- $
OFFICER/MEMBER EXCLUDED? --
(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,may be attached if more space Is required)
TEI, AND ANYONE ELSE REQUIRED ARE NAMED AS ADDITIONAL INSUREDS) 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
51988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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mass'Ich usetts
E30"'rd Of BulJdmg RcgLjjatlo,,,,; and Sl'irldaros
License:CSSL-10,2562
KAT R GA U7Wj
IMP
P-0-801344 -- j W
IP-w-ith IMA 019j%
0&25/2017
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>µ Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Req i:strati on: 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
re
IPSWICH,MA 01938 Undersecretary of valid wi out signatu