HomeMy WebLinkAboutBuilding Permit # 6/13/2016 11ILDl PERMIT o� �aoery �qq-�
Zt LED 16 'Y
TOWN OF NORTH ANDOVER
o
APPLICATION FOR PLAN EXAMINATION
nD _ mtl
M ^�
Permit No#: ' d Date Received �gSsgcHus��RS
Date Issued:
YM ORTANT: Applicant must complete all items on this page
LOCATION Z 3L1 G101
Print
PROPERTY OWNER (wit mckn
_ Prin 100 Year Structure yes no
MAP PARCEL: �, ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition 11 Two or more family 11 Industrial
CKA teration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
1Nate�sheclG District
❑ Septi ,n ❑Well f ❑ Floodpla n3❑ I rNuf M� n
-:v m d,r- `'".- F F, �-;r7,.-'✓"n^^,�,�,vr .m;.r ./r f ,.y r .t i + -k rr ��-,f n`i �t'rN' �+a.: w' ,t.Z.r:Siur 2x'c 1�:r.:. �'r
:...,:. P.,.��r t. c. .,,.1 .rid a ..,�✓.r .�� r.. � t ! � l: r`�'r9t' ,' Ty. ,.� �i �,� rk a�r�r .� r
F �Water 5e�vrd err �, , a � �tiw f�r. r r ,�,
b, t
u
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: r-Vh < cLr i C n Phone:
Address: 2.3 A PDQt
Contractor Name: \ �4-il Phone:
Email: V i C,(
Address: b
Supervisor's Construction License: Exp. Date:
Home Improvement License: 1 T �1 I Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.-$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COT BASED ON$125.00 PER S.F.
Total Project Cost: $ , ��1� FEE: $
—it-5>
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
rpt
Town of
Andover
?.of"
0
w' 1
.(� �� ^C% SS9
LAKE
COCI
PQo �\V
®� SAICK
TE®
BOARD OF HEALTH
Food/Kitchen
PER IT T LD Septic System
THIS CERTIFIES THAT ... ..... .. ........ ,..... .. .. BUILDING INSPECTOR �\
has permission to erect Foundation
p .......................... buildings o
.... .... ... . ... ...... ... ...........................
® ARough
........9. .. ....
to be occupied as ......... .................... . ... ........... ....... .. . . .. .. .. ............ Chimney
provided that the person accepting this permit h II in every respect conform to the terms of the a (cation Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the sp tin,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 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST Rough
Service
. .... . ..... . .. . ....r6�iy7w
FinaBUILDIN
GAS INSPECTOR
Occupancy Permit Required to Occupy Rough
Display a Conspicuous Place on the Premises — ® Not Remove Final
No Lathing r Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected andApproved a Building Inspector. Burner
Street No.
Smoke Det.
Y•'t7. TOIb 4:U1�� • '�o. X737 P. 3/3
CONTRACT
Baum PW a .
.
4UMID
n4 ,
m �m •
e� esE�oal�aap�rmD
esMGM—
acmet�os�lad�rm rm�ce�oaar, E
?flitaa�S+iq�p�oodi�p0o aodm o[100liRn�a
�ta+�►�ojw�oe�►tAaa�
t6rd0�Oftm6oa�e�r4�dY wa�Oa Ot�tleat al�ee�btoRir�4
yaatOm�oOo�po�edm■4debbog�esde�� rrodcbma�a14gS9moap�slE� �.
' ttraao�o�an�q�Orbo� 1�tme adb�aoaos�aa��d '
k�0�e6�,1taC
• oo Room emu
Mag-25. 2016 4:01VM VIN 1/i• .
q_j
nota
CONTRW
PAP
® i
Pi41( 4ftff MW
smi
# :
lt�ow4e�+1 0 fla��amdwRa
a 'b�aes���` �pOtlo+�o�EralrtBao
sm
tm>»l,00 � eopadoo>a�se ta�eA�n �+aBl�o
sm
i�ALYi► 'jag';of tantsQ L
A�88AL�?f�0ogboeesOtttolederml Oaat o9r '[tdtagdEa�316o
v�se4mwaoeari�d+ooma�a�aad tn�arsxat�l�ewsso�f0e��ltT�pdtaafaf
esramt�pwonteo�e�► a,�:Aaoa,� t+ r
�te�+rQle�troieot�sa � � b�� •, ��bas
ttm�otafa0obaa .
Atdmmm
A wlm�aa�t�atollbltCE:tt1 tlee3W �R e f .
son
WIMMAW
Ups
t
}
r n m
a otr ti ® �qK
n ^�
RISE60 Shawmut Road,Unit 2 1 Canton,MA 02021 1339-5024M
ENGINEERING www.PJSEengineMng.com
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at:
(Property ddress)
it, 4YAjaP
(Property Address)
hereby authorize at ter w,
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.
e SiSignature
Date
F120,6
Thi'C utntnonwealth of Massachusetts
Department of Industrial Ace idents
QRive ,t l n restigations
I Congress,Street.Suite 100
Boston,MA 02114-2017
ww"w,tnatiK'."111`1(ia
NV(wker+'Compensation Insurance Affidavit: Builders,`Contractorsl'Tlectricians{Plurnhers
Applicant Information, Please Print Ledhlti
aSII 0&1"A\-0— �\=�La
Address: C, C3 g K 311
City stile,Zip: : t 1 Plyotye S l"` 39`d 3
Are you an eniploFer" Check the appropriate box. l'�pe til'prtijtet(reyuircd)
k:nlpiov s I ..16and 'r srs i+RT:'t s 11dC�. h3rt€.�iil ♦ 1 �€'+IiT Yi tLir'� _
t i'tl a t,ti'Pr7c.tor or pri.lar- tf*,tei1 n€11� i Itfntw'*t1kC'I. trri^t ilc ilrit
tihiv and hf1%C n. I tide J--Cocllacio.s ® ityc?tarsi
tkorkrw ti!r nT' m urs' � liIAL;11;
1 ®Buddi-n i addition
[No',.i'tir4rti comp. Irl�ilruiliC ti:lfrtj� `,nZ:irJ IC t, (
�
{{ Z�i.tri a,:orp rftioa and i-S sii.�i�4:o<tCll3'r�ITsi r f?i"itt'itil tik rye
rtic�llirt.d.j �.d
1:Silt:J tiYllfii;:i7ttI'.i:r, dc,ttt� �i. th;. 1,C] t'lttl�iz?ttl-.i r%:J airs !t aAdwlo!--3
i11vS,J . iNo+.lark r�' Lo-nk,, ri'�1h ek It°lzttt•>I r2,114:,L j
tn.,:urunc r;:quir,:J.j f1 ,10 1and t;: lia -,10
....t.® i
[No,uvrktJs' i C,ifi4r �T
n_6i,_Ffi.!dtt� df
t';t•}:+ ..'_ :.ts '4h:.:r.1',t, .�^t;1':4 T (':tet.. ;" tF Ca. r;sy toot;iner ,.
1 ant an etnpho'er that is pros idinr ivorke:rs'contnenwtitnt insurunce Jnr mt'a otplot'vE's. ileloii"is MepoticY and job sire
itlfortnanon.
Ir= ur n e C'o rrgrttlE`'t tri; �_{ t L4 �t1S 1`d7l-tali` t
30
or S, .-iii,•, t_1�. '- s. i .�. .3.-�. _,_.. 1 �.(4�s,ctu.1 1%1tc,_ 1k f
Goll Atte Address
Litt 4rtttit �p i VV �J OL V1
Attach a cope'of the workers'conipcwivion pniicN declaration page(Nhorsing the policg number and expiration datet.
I'Atltlr o secure �_i t1 i�cgiiin:d widt�r.`j,nion_'5A o; #$(ii.t." i i_t_jrt l it+d w (17k:mi[,w inon of sltalit
(Ilia'11?10 4i._ik).i! 1;1134 Oi its well iii s:rfl( itaitt ri Illi'-Ik4i S o a`ti i 011 WORK ORDER and a'fill.
oil _Ft'11Y S-�0 dl+l i d ty irpaiittii tt:;S wlat_Y. Iii'ith i`,Cd tI131 a cojlt CO !;ws lit ;arr4NardLd`t}The f7,,cc o
[roe� titi:lr;ryty �1'the C}I'� tsr in .r,:nc tc.:4rd;:�' t.�rti�sti�ut.
1 do herebs•certiJ_ij under the pains and penallies ofperjure hest lite itrfcirination provided above is true and correct,
Official us only'. Do not emit(in this area,to by completed bt cin'or town off c iaL
City or Town -_--� Perntitil.icensc
lssuinp authority(circle one+:
1.Board of Health 2.Building Department 3.{'iii;"I own Clerk 4.P"Iectrical Imspector 5,Plumbing Inspeclor
6.Other
Contact person: _ Phone ?:
r 4``( 3b[7►µ CERTIFICATE OF LIABILITY INSURANCE ,.
- -Hi_ ._Ez,TCF t�TE L'- cS✓�=J a.:.A t-;?''`Tt _ —`41r`A-10%C ! ';v r,. C��.>':-C R�! .'_ ..I _(,:R.THi7
fFTF_ATE TES,Yit n4�Ir:1'A __. _F. tiE_,tT.tiF?x . -.1.� .I;,_.',k Tr Y',E C:ICTES
FiL M1 1=1!5 ER.xIF rAE - fWSURAV,E t r J '+CJIrT r9 HT i!c% - G.tzED
_ FrF,.E=.FNTA IVE Opt C_�_C;-R.M4.-j T H L ELT1.IES - 's.C_r=.,
i F _NTIf F`+e ctr9 a h A 1 vA
'r s d d rcncl rrjr�5 Cf 11,e r11'f,..cprt-a P�*�t�__. 9-_, x 7 --a A_.ZtE _r`.Cr, r„_ ,t:{(v itvt_ n_
.rt!?'.cate Fn-6er i�liFf G sCn Pr `ee Sic
i
Clayton Martin J Ins Agency Inc t 5L �sgr.t
8 e, ��� ,1
1649 Northampton St PO Box 989
Holyoke MA 01041
Gauthief insulation Inc =
PO Bax 344 j
E,^,smch,MA 019"s8
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
1�—H{TO[ v`t' V-4EOF1 P� .:E c 4V-K7NssijEID rlri,tiyLL'A.&OVE F F
'7En T ,t: PF.-7 ilr
7 "ATEt BE 5 7 R VAx Th i RA?,c tEE,
,.PT F �ic1C,C N I...0
LY U 1(:FAM)l:f rx ) r3} t 4IT I u-S PJ r!: E1 '.? d
. .
i
1 YSvA-K£HS C44&FK'Y.ttKsv : } r •
kS7 lN�l4.TFRb tlk�xi.'T ''` I
- r r� v --`-_ - l - t.'ltGD ✓__. '."T.3 ' �a ..:t;_ L -
i
- -..:
I
i
CERTIFICATE HOLDER CANCELLATION
xr[-.lam :. � _- rl✓tL � � -E 1 .:ti_f-��
Clearesult
Contrattor Svcs pJd. T, s att=
50 Washington Street
Westborough.MA 01581
PA C 31;9
® DATE MM/DD(YYYY)CERTIFICATELIABILITY U ii2o15
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 endorsements.
PRODUCER CONTACT Nancy Usher
Martin J Clayton Insurance Agency, Inc. HONN._EXl) (413)536-0504 -_.-- n(AiXc.Ne () 413)534-7874
---------...
1649 Northampton Street A fW oAIL
P. 0. BOX 989 INSURER(S)AFFORDING COVERAGE NAIC#
Holyoke MA 01041-0999 INSURERA:NatlonWide Mutual-Harleysville NATIO
- _... ....._ _..... ---- ....- __.---
INSURED INSURERB:Allied World Natl Assurance CO
Gauthier Insulation INSURERC:
....-._..._ .._.. ......... ........ .. ........
44 ESSEX ROAD INSURER D:
INSURER E:
IPSWICH MA 01935 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 ADDL SUBRr POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE wvn POLICY NUMBER M D D LIMITS
X COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 50,000
A _ CLAIMS-MADE X OCCUR PREMISES(Ea accurrenc_e)... _
X GL43487F 7/6/2015 7/6/2016 MED EXP(Any one person) S 5,000
PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
'..
PRO- — —- -__.__.-- --
X POLICY .�JECT L— LOC PRODUCTS-COMP/OP AGO S 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
.,,_(E_a id
acc_ent)__
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
1HIRED AUTOS -......... AUTOS _(Per accI ent)....._..
X UMBRELLA LIAB -EACH OCCURRENCE _ $ _1,000_,000
H EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000"'000
DED RETENTION L BE020792125-194985 10/18/2014 10/18/2015 $
WORKERS COMPENSATION PER 0TH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER_....—_...
ANY PROPRIETOR/PARTNER/EXECUTIVE 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,may be attached If more space Is required)
CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS.
50 WASHINGTON STREET
WESTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE
Daniel Sullivan/MEGA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
p ry ' r�.p(mff f g( . �°n
�i'��t�d with dfF�cto trial version m
Department«Paye Wy )
6' wBujjdlflg gmmoa«ate m=e\
-
r na: CSSb,■26
y w r. x .
UTIf « , {
0�� f
'A hMA 019 "'VI
\ (
-or ,m« Dgr±m (
am, > OV251209
1
(')e/° '(e'3` f;'A°
Office of Consumer Affairs and Business Regulation
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
i/ r
Office of Consumer Affairs S 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: 10/1/2015 Individual 10 Park Plaza-Suite 5170
Boston.MA 02116
KURT GAUTHIER
KURT GAUTHIER /
44 ESSEX RD g -
IPSWICH,MA 01938 s_
Undersecretaryv4.1 valid wi out Si nature