HomeMy WebLinkAboutBuilding Permit # 6/13/2016 0.1 taosarH
BUILDING PERMIT
�
TOWN OF NORTH ANDOVER -
APPLICATION FOR PLAN EXAMINATION
Permit No#: 1 Date Received ^D �`
q_RA°RATE°P4ayi(�J
7�Ssperaus��
Date Issued:
PORTANT: Applicant must complete all items on this page
LOCATION W'A - G
Print
PROPERTY OWNER r,- ,n
Print 100 Year Structure yes no
MAP /, l 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 ❑ Two or more family ❑ Industrial
AI ration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑1Nell % t❑ Floodplain Wetlands ❑ 1Natershed Dastnctk , ,
x�
r' ✓:fP r' ✓ r t 6r �,n fy. � r .,��x' .fir„ a� � � �
DESCRIPTION OF WORK TO BE PERFORMED:
G�►� t 'ice' m� �lL� int X91
Identification- Please Type or Print Clearly
OWNER: Name: GSI Qe4-\ Phone: • �kp ° 010�
Address: 6 W-A
Contractor Name: A- i Phone: Ct 3
Email: i tri n5Q
Address: P013ok 41-A JWvv0,h MA OtII
Supervisor's Construction License: 0 �?' Exp. Date: S �
Home Improvement License: l �3 Exp. Date: t
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST SED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have 'access to the guaranty fund
t%®RTH
Town of
Andover
® -4 _ -
� h ver Mass,"C-.J"
®QA coc"Ic ewc« A.
®RAT E D PPS
S it BOARD OF HEALTH
PER Food/Kitchen
LD Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
...........L
.. .................... . ....... . ...... ..... .. ....... ® ...
has permission to erect ...... bui dings on .......... . . Foundation
® ® Rough
to be occupied as . .. . ... .. .. . . . ... .. ..... .... . . . . .. . . .. Chimney
provided that the person accepting this a mit shall in every pect 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 Ins action,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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
Rough
UNLESS CONS TI
Service
.. ..... .. . .. .... ...... ....... .............. Final
BUIL NG IN PECT®R
GAS INSPECTOR
ccu,2ancy Permit Required to Occupy Buildln Rough
Display S i S Place on the Premises ® Do Not Remove Final
No Lathing r Dry Wall eDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
RISE60 Shawrnut Road, Unit 21 Canton,MA 020211339-502-6335
ENGINEERING' www.RISEengineering.com
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at:
FG It C-4a ( (-/L f, til � -
(Property Address)
Ivo /41 q - C)
(Property Address)
hereby authorize C-1 W I rV%Q�&k YA
(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.
40w e r lg�na t u r-e
Date
Federal ID 0 05 0405629
RISE Engineering FN Contractor Registration No 8186
MAContractor Registration No 120979
R
IS '1 division of"1hiclsrh 1^:rt);iatrerinp,
Company Address,City,MA 110000
ENGINEERING' CONTRACT
4()1-123-1234 FAX 401-123-1234
Page I
VROGRANI
SIM CC MACTIS
CINIA-1 I FsjrC CUS'Offllt rORWCNRXAS
MCAUMBELCM
C US XVM R MIME DATE CUENTO MOMA ORCE R
Maureen Hentz (978)SWORY) 05/12/2016 434592 00003
SERVICE STREET 9ILLING SVECT
MY)Chickering Road 904 Chickering Road
SERVICE CITY,STA ,Zap OWNG CITY,srm,2w,
North Andover,NIA 018,45 !J
...................
JOB DESCRUMON
III IASI:ONE-Proposal for this calendar year.
sojm
-AIR M:A L I N"J `r*t3VTWT,11fx)-rand ina I cria k I o sea I areas of your I Ioil Ie ap i list%%list c I'Ld.ex w,;s a ir lea k it ge. 'i"his is mo rk rciII IV
perfonned in concert pith the uss.of special U lols and diuplost is tests to assure that your home hill IV,left Will a healthful level of
air exchange and ind,)or air quality.Materials to I>--used to seat your home call include caulks.Imuns and other products Primary
areas for
sealing include air Icakage to allies,[xisconents,ailached Ijaragms and other unhealed areas(%%indom,are not generalh,
addressed.) '['his hill require(12)working hours.A rcduclion in cubic llcvt per unnole(cfIR i of air infiltration hill occur,led tilt:
actual nturiber ofcfm is not pianinteed.
At the completion of the mealherizilion nark.and at no additional cost to the lionreowicr,a final lilomr door andlor comkWon
safety analysis hill be conducied by the mAi-contractor to ensure the safely of the indoor air qmfily.
$1,0200)
DAMMING:Providc laWr and materials to install it 12"layer III R-39 onfaced Fiberglass Knis to(40)square feet for damming
purpose!;.
$82.00
STORAGE BARRIO:I lonicowler is responsible for the removal ofille stored items hjockjljr,lite installation of w:alficrimtion
iiook in live attic. Removal mwi occur prior to the schedule(]vu)rIs start.
SLOIIES:Provide latwor and materials to install a 6"layer ofR-2 I Class I Cellulose a(Wed to(80)walmne feet of stops area.Wherever
possible 1XINIcs"ill tic installed to the entire length pfeaclj hay to maintain ventilation space,
KNEIMALLS:Provide lalor and materials it)install R-13 fused fihcreja.�,i to(262)square f"I of knee%%ull. Then install 2"rigid
Ixiard insulation,Sal all scaniq pith FSK tope.IMMEOWNER TO RI:M0VI-'ALLUMINI IM FOIL.
S'I'ORAGH HARRIER:Ilourcov,ner is rcstionsdite for lite removal ofthe stored items blocking the installation of%watheritat ion
work In the klivoNall areas. Removal rinist occur prior it)the scheduled nark start.
50,00
MAMMA.F1,00k:provide lal-Air and materials to insiall a 12"layer of K-42 Class I(AMulow. a(Wd to(6-4 1 square feet of open
kneckmall floor.
KNITMALL FLOOR:11rovid,lahar and inalerialsto Install a 9"layer of dense packed K-33 Cluss I Cellulose addcdto(224)square
I'm[ol'kneovall floor.
ATJ W ACCFS&Provide it)insulate the Kick ofthe attic door with 2"rigid'I'licrinux board and scal the door's
cd!x%Nilh wcalherstrippingg to restrict air leal4q;c-
$1-14.44
z
rederal ID 9 05-0405629
RISE Engineering RI Contractor Registration Na 8*186
MAContractor Registration No 120979
A disision ol"Ibickch highicering
RISCom party Address.Ci ly,MA 00000
ENGINEER N .101-123-1234 FAX-101-123-1234 CONTRACT
Page 2
VRO(.:i RA NI
nes REE"M Air CUSIMER FORK ACNIA-IIUS E"GEoDE1.DVM *RWS
Escra00
CUSVIER pl"M DATE cu5frr. WORK ORDER
Nlaureen Hentz (978)886-01(7() 05/12/2016 43,1592 M00.3
5ERVICe SIREET INULING STREET
861 Chickciing Road MA Chickering,Road
SERVICE ClTY.STA1E.2)P MWNG CM,SlAr.,Z)p
North Andover,NIA 018,15 North Andover,MA 01 A5
JOB DESCRIPTION
VENTILATION:Provide lalwanti materials to install witilotimi elites in(36)rafter lays to maintain air Ilow
37201)
VENTILATION:Provide later and materials to install(4)4"N 16"rcelarngtlur atumhrmn soffit vents to increase vent flat ion in
attic areas.Specify color:While orGlay.
S100.00
VENTILATION:11rovide install(4) 6'X 16'reclangtilaraltimintun still-it vents to incicase ventilation in
altic areas. :Specify coliw White or Gray,
Slow)()
COMMON WALLSProvide lalmr andmaterials io install 2"PSK raced-Anjii-rigid filvi-ghisslioard insulation Io(32)saline feet of
COV11111011 wall arca.
CRAWLMIACE:Provide latior and materials to install(400)stprin:red ofli ml polvolivicae over open grotind in desavmlcd
craWspace/carthen linsument arms,
5308.00
RISC:lig,will apply all applicable,eligible inceill ives to I his contract. You will only lie billed the Net amotuil. Currently,
for eligible lintrusures,Columbia Gas offers 75%incentive,rot to exceed$2,000 per calendar year.and,at incentive ref 100%for tiro
Air Scaling measures up i o the first SMO and all 3(ldit i01131 S3,10 ifmv inpiare just ificd by I lie auditor.
For lee safety and health of your home's indt)or air ilmlity"tw will tx:conduct ing it blotter door dinplost ic of tine available air flow in
your lionae Kit It lvfore the work is liepin,and all er Ilia mcal licrizat am%%orh is complete.We will also conduct a full assessment(of
the combustion.'altat y of your licat ing system and mater Ileatta This has a value of S90 and is at no cost to volt. Total allow.ible
vtcal herieat ion incentive is S.I.I 111.
590.00
..............1.1.111-11,11.........
r
"EG
......................
The C'vt mostiveaf h ttf Massachusetts
Department of Industrial Accidents
. , Office i�f lnvestigations
1:5 1 Congress Street,Stone 100
Boston-11A 02114-2017
�`�'=4�--='` wx'x,tttttss•.grriyddiu
Workers'Compensation insurance Affidavit:Bitildcrs�C'ontractorss-ElectricianlPlumtters
Applicant Information f 1y Please Print I_e ibls`
address-- 130 6 o x 3'1 1
Citi• Stals 7i yy 1 S"10- 34`� 3
��- 1. '�1� ��r_l._ �� l3ilCiill .e
.-'Itre you an empioFW! Check the appropriate box: 9
7�pc'of project(required)
t Tic=r s ntp9 t er seitlt _ ® l'am a zvc!)CTJI tE+tiy �,at ,<ntil t
ernplovcet and i�rpar tttz��.�
x.i 1..'.'t hied the S t ort AwN
i .�:
(� I am LAC+i,. prop;iom tw PAU&> .mal on the allad,*a dent.
~hip and have no ;tipli y= T hr. .54i t tnnwr,It i.
ilii to l i'ard lt.3Sr \�L7F};fit".
t+iirkin* t�lr ni a;iia;c ipa�:,te p q, ®�iaildiita adt�iiic+n
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.ire u,:rp ir.tioa and i'. 11}.!r„d lec trical rep t.r.s or`kldiiii.nt
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I am a Worn:t.m na doing an w sk OEM>hun e exerysed tit:[ 1 T.[]Phu t.)jap rcTha or,i itioni
riy�ft of excn <hat ci MGL
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I rant an eitiptq}-er Ntrat is providi)et�is nrhers'cnnrpett+utirni insurance lar ntr ctnph-ivve..8. Below is the poticji'andjob site T
itgfornmtion.
h"W:mQ Cm :its!Lvn,-:__[�_ t t}s
j+.rki;t a„eMOW,(�T_(i®t.(�-; ("��11���'i�y�� ��tl��t�yk y t l(
1«i1 She dkess.`®_ l._Chi !µ_ t n titicCl Zip
tT �Y
each a copy of the workers' declaration paste(shod-ing the policy number and expiration datef,
T'3ihire.i'sevum cantage as rc qQrcd under ki'iii?Fi 255 .f NKH,e, 152'k dti ie td: [fir iittT it itlil<(of;grill(?„l p(illit cs i ci
titre 1p to SI-500(Ai:tilt]o ctnc .ar t`+p•i on-ai;.n„&4 e+cil aN ei+,11 y craktin in tits:;aim o a S i(WWORK ORDER xid a tii1
+t''ap to S250 ti i t+1:,1 apairint to t iolahs. He WOW Tat a copy (+''tits,<t..nm nt in, b:: <i ndM io Ic t.}``kc of
ltte*tf 31100.r,r
she=DT 1 t)r it •r:.rtc;:cnyttaLc ticnticrtt':tri.
I tit)hereby certif+•under the pain~and penalti"of perjury that the information provided(above is true and correct.
k'nti�c •-: � "'
QWWAI um ano. 1)u not turtle•ni thb(hers,to be c~outptewd ht•dy or tr%w g#kial.
C'itti or Toxon: ----_,_ t'erniiVLIcellse
l%suing authority(chore ottei:
i.Board of Health 2.Building Department 3.Cityt7'ou n Clerk I EIt+ctricat hapector S.PIumWng Inspector
6.tither
Contaet Person: - — — Picone n"t
FDATEMpYYY)A TIFF LIABILITY INSURANCE 17/7/205
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(les)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 Usher
NAMIMartin J Clayton Insurance Agency, Inc. (AHiCNNa (413)536-0804 FAX (413)534-7874
(413)534-7874
1649 Northampton Street AIL
ADDRESS,____
P. 0. BOX 989 INSURERISJAFFORDINGCOVERAGE NAIL#
Holyoke - MA...___01041-0989 _-- INSURERA Nationwide 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.
INSR -------- ADDL SUBIR POLICY EFF
LTR TYPE OF INSURANCE lumw& POLICY NUMBER (MM[DDfYYYYI tMMIDDIYYYYILIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 50,000
A _ l CLAIMS-MADE n OCCUR _PREMISES(Ea occurrence
S r _
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
PRO- ll ---- --
X POLICY( _J PECTR0- �J LOG PRODUCTS-COMP/OP AGG $ 2,000,000
._.......... .... -------
AUTOMOBILE
$
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident)_
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
__._..- AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS -Per accident)__ $
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 000 000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1J000-000
DEC RETENTION BE020792125-194985 10/18/2014 10/18/2015 $
WORKERS COMPENSATION
PER OTH-
AND EMPLOYERS'LIABILITY Y/N ._._._.._..._STATUTE ER.,__,.,,_
ANY PROPRIETOR/PARTNER/EXECUTIVE —.-- E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? f -, N/A - --- -- -
(Mandatory In NH) E.L_DISEASE-EA EMPLOYEE $
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)
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/MEG
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
MP"dr tbd with pdfFacfory trial version ar um
CERTIFICATE OF LIABILITY INSURANCE
HIS -ERTTF:CATE IS -ISSU D A�-A t,�A 7, Ek ',K�PVA�!-j",C�'L, A!, �C��S I C S—j;1CN 17 -D�P. TN C15
tf
f-, RT:F:CA�C[13E; %0 Af 4rT-kT
T 'A
-,!!S-EkiTIFI-Ai !?,I'URA',CE--C= 'T T;,FT' F,-NT - ELT,';L IAV; AL
P Fp;i ESEN'A��-A-E AND I Ht'--ER7 :!C, —
1 Y,
aid cc7d ton cf tr'. F""-",cell-,P P A�tzte7,_r!-r,'Pli, e+'ice 5
ijelj:)i
Clayton Martin J Ins Agency Inc
1649 Northampton St PO Box 989
Holyoke MA 01041
Gauthier Insulation Inc
PO Box 344
Ipswich.MA 01918
COVERAGES CERTIFICATE NUMBER- REVISION-NUMBER
T
Al"RE'- _>1_.:T 'ERM ��"
DO"tt"V"'7,F Y'Qf, RAI :P -ER
C:`,AT1;1'-ATE PAa BE -,�Su-D C'R VAY P"(-,ATHE I t,,is so�4jzc T 7 ) T
H7;7LjSiCN�ANT) A.2F EC) A
GE4EPAL
uxfi'1'rT
Is
M LPZ.
el K L VIL"e—F L'
-7,
CERTIFICATE HOLDER CANCELLATION
A, 'A-
Clearesult
Contractor Svcs
50 Washington Street
Westborough,MA 01581
Sic
gna,,ure:
25
clepartnIerlt of PuwIC sahLtz
a a n ag- 8UNd9nq I
a S la n da ro
License: CSSL-1025 62
KURT R GA UTffmv \ ®� : « . (
P-0-%z#4
IP,"-icb MA 019
Ccon,wrm,sloilt, EXpir.
0512512017
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
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:
Re istration: 173410 Type: Office of Consumer.Affairs and Business Regulation
9
t
'Expiration: 10/1/2016 Individual 10 Park Plaza-Suite 5170
Boston.MA 02116
KURT GAUTHIER
KURT GAUTHIER
44 ESSEX RD
IPSWICH,MA 01938Undersecretan' of valid wi out signature