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HomeMy WebLinkAboutBuilding Permit # 6/21/2016 UIL I G PERMIT �a®pry o� cT'eD ,6��Y0 TOWN OF NORTHANDOVER APPLICATION FOR PLAN EXAMINATION ® ', Permit No#: Date Received RADRq 7ED PP�y�y CHUS Date Issued: I I POORTA1v1T: Applicant must complete all items on this page LOCATION 3 '5 Print PROPERTY OWNER 7rtSo ✓Ii e 19 r x'15 Print 100 Year Structure yeOno MAP 0 PARCEL: ZONING DISTRICT: Historic District yMachine Shop Village y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg a Others: ❑ Demolition ❑ Other .��5✓J�'��'o 7 f { s❑¢1ll/afers ed Dr Af 7 1� � �� ,., ,f� � � v„ood am y r �❑,Wetlan s , ,� � r, r�., ., jY r We I r,, r � J� �,❑ C _ �. , � �k � ,; � ,,r, ..,, ,,,.v r r, „ , � �tC/ Q I,"s�,r r .�� r .5�/t.. r77 or ,�..:.�..,er .r,F-rr,... r.r�.-.r..kk e-c <r F +'�r„ r7� �,-..,,.`�"�Y r4 .;-�/✓c'/ ,��,,..':�� '� „-:. ,. r,:y rr,.,r l �f ,. t fir, ,x.{ ... „rl'r'r �r>�� ,�;,� d :�','`� .r�*.. s 4r✓:,,„,...pr�,l ,,.:.., „x��,�� /r .,y�2,s,r r��:fF ..w,r ! x. ..1. .,F,1�N, � � rF....,r7�r�rr � ';r. ��i, ,.. f,. x ,r.,,i J -; r rr%,�/.,,� ,r' ..,,,r�' .,��, .. rr frP .✓ 2 ,.w s �.�r r�zr ..�.�"„ r1,�s„�raS:„1:,��p�tx` .r,r r -� r,.F!{�, Y ,r. F., � ��. xr�.�r�' ,r..N� � �. ,.. ��/ � v.✓. r' ,., �. ���. f d�'7.x.r ,� ..., ,. , .;6,✓��/ � -f. ,� :, / i�.�.� ..:... 1rd;., h :� �x �.'°d ;a'1 tf'+rr� r^.:z:�,rf'r,-'� rf � r ,. x'��" r+��1�1%ater/Sewed;���F�,�/'�;k`�:rr,,,,�,'.�R��`,r�, u�:� ,�,���:5,✓,f����Y'.��R�'f,'�z'.rrxs�,,,,'�',> ;o..�,x�'��r�` >X�;t`�x"(,1.F,'i.a",m.r��s „'l`�.A,.t,.,idr �an.r.,,r v..rr ,:xr,.,,,,,,, „a."..;:�;` a..n DESCRIPTION OF WORK TO BE PERFORMED: �k7r f,,'o C L,✓� // l^SdJST�/I�l � ;►'� �-o �S% inS�/��io � . Cf�1.✓iS���Y C'eilr✓� Identification- Please Type or Print Clearly OWNER: Name: 76,Soyj 5T Oh e 11 S Phone: f`V—'/Aa > Address: 33 p% IG r;vw, 57- V1- 0PA d,-r- Peter Leblanc Contractor Name. Phone: Email • PlabtAddress: g ° Supervisor's Construction License: /bee, I Exp. Date: Home Improvement License: Exp. Date: /� ARCHITECT/ENGINEER Phone: 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: $ 00. 6D FEE: $ Check No.: t Receipt No.: � NOTE: Persons contracting with unregistered contractors do not havelaccess to the guaranty fund t%O R TII ndover Town of 1' B ® X41 .Mauna. ®. �O LAKE h Very Mass,o COCHICHRWICK ��• x,95 RATED U BOARD OF HEALTH AF IR D PEKIYII �T� TV Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ................. ... ..................S .... ... ......................................... ..... .. ...... Foundation has permission to erect.......................... buildings on ....... ...... ...1. . .. ........... ® ® Rough u to be occupied as ...... .... .v... ......... ..1 . ....'.. .. ..... ®. ®. . ....1 .. .... .. . .. ....... chimney provided that the person accepting this permit shall in every respect con m 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 MONTHSPERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR UNLESS CONST I Rough Service . .. =9"7 ...... ...... Final BUILDINGEC OR GAS INSPECTOR Occupancy Permit Required t® Occupy By 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 Approvedby the Building Inspector. 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" 1 I i i i ti 3 } OWNER AUTHORIZATION FORM ` 1, Jay Stephens , (Owner's Name) owner of the property located at 33 Pilgrim Street ; r l (Property Address) U ( North Andover, MA 01845 (Property Address) hereby authorize ,b l q�-1)-ec,� C (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. a �V actiens fa'Czo,2otb Owner's Signature 03!20/2015 Date Signature: O'• lRolut cn=(Marso,2ots) Email: rgiven@thielsch.com The Commonwealth oflllassachusetts Department of lndustrial Accidents ®fj=rce oflnvestigationg 600 Washington St-eet Roston,MA 02111 www,mnssgov/d'ia Workers' Compensation Insurance.Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information please Print Legibly Nalue(Businessforganizationgndividual): --Mb�mn LONEE'MR!N8111 Address: PO BOX 358 .City/State/Zip: Phone#: Elam n employer?Check the appropriate box: Type of project(required): a employer with 4. ❑I am a general contractor and Iloyees(full and/or part time).* have hired the sub-contractors6 ❑New construction a sole proprietor or partner- listed on the attached sh%et,t 7. ❑Remodeling and have no employees These sub-contractorslrave 8. n Demolition ing for me in any capacity. workers'comp,insurance. 9. ❑Building addition orkers'comp.insurance 5. ❑ We aie a corporation and its red.] .officers have exercised their 10-❑Electrical repairs or additions a homeowner doing all work right of exemption per MCL 11.❑PIumbingrepairs or additions lf. [N'o workers'comp. c.152, §1(4),and we have no 12,E]Roofrepairs nce required,]i employees.[No workers' comp,insurance required.] 13F]Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Confractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information. Yam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: j D;A d t o Policy#or Set£ins.Lie. Expiration Date; Job Site Address: S City/State/Zip: �n do PY/' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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 up to$250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office of Investigations of the D9 for insurance coverage verification. Ido hereby ce 'y nder thepains andpenalties ofperjury that the infornzationpro vided above is true anti correct. Si ature: Date: ?hone#: Official use only. Do not write in this area,to be eo�npleted 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#: ® �V �+ DATE(MM/DD/YY AC®RDYY) CERTIFICATE OF LIABILITY i INSURANC 6/10/2016 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 Linda BO danoWicZ NAME: g Insurance Solutions Corporation PHONE (603)382-4600 A/C No):(603)382-2034 60 Westville Rd aooaess:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A:Western World INSURED INSURER B:Nautilus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO Box 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1632326134 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 ADDS BR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DnfYYY MM/DD/YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO I A CLAIMS-MADE ❑R OCCUR PREMSESEaoNcurrOence $ 100,000 NPPS274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 CT % POLICY PEO LOC PRODUCTS-COM P/OPAGG $ 2,000,000 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 LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ '.. WORKERS COMPENSATION STATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE ❑ NIA 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 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 1901401 6110/2016 Preview:Certificates of Insurance ® DATE I'Z•M_-_10.7YYYY} AC�" CERTIFICATE OF LIABILITY INSURANCE W10f2016 THIS CERTIFICATE IS ISSUED AS A ATTER 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 NAME: PHONE Automatic Data Processing insurance Agency,Inc. AIC.No.E=t: (A'G Hol, 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE I NAICe INSURERA: No'GUARD Insurance Company 31470 INSURED INSURER e; POLAR BEAR INSULATION CO INC INSURER C: PO BOX 58 Andover,MA01810 INSURER D: I INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 503587 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. LICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUlABER MtNDDNYYY) VAWDDJYYYY LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS2.U,DE D OCCUR PRE.11SES(Eaocc....) S MED EXP(Any one p ra or) S _ PERSONAL 8 ADV INJURY S '.. GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGAT E $ PCLICY❑PRO- ❑LOC PRODUCTS-CC.'.!P:OP AGG JECT 5 OTHER: Lx).181NED N SI GL L.I AUTOMOBILE UABILI (Ea:�citicnli LNO BCDILY INJURY tPer V•2 ) - NEU SCHEDULED BCDILY INJURY IPc-a'.aCartliS AUTOS NON-OWNED FKUIvE idcnll AM.Gc S UTOS AUTOS IF, 5 LA LIAR OCCUR 6\CY.OCCURRENCE S '.. UAB CLAI6ISd,TADE AGGREGATE S RETENTIONS S WORKERS COMPENSATION X O h AND EMPLOYERS'LIABILITY STATUTE ER ANY FRCPFJETCR�PARTIFRFXC-CUTIVE YIN EL EACH ACCIDENT 5 1,000,000 A OFFICERAMEMBEREXCLUDED? FqNIA N POWC772258 01101/2016 01/01/2017 (Mandatory In NH) E.L.DISEASE-6l EMPLOYEE S 1,000,000 Uycs.d—be under ISEASEFOUCV Uf.BT S 1,000,000 DESCRIPTION OF OPERATIONS bd., E.L.D DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St.1 suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https://adpia.adp.comlicertcf/#/run/preview/503597/900012975 1/1 M Office of Consumer Affairs and Business Regulation `We 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, NIA 01810 - Update Address and return card.Mark reason for change. SCA 1 20M-05111ElAddress Renewal F] Employment Lost Card r; t / p �"'1'�/tr°`kNca�,�r���crT✓[a°Rrm��F!n�P"'i�l<7,1.t��c�att�f✓3 Office of Consumer Affairs&Business Regulation License or registration valid for individual use only i G HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102726 Type: Office of Consumer Affairs and Business Regulation ' Expiration: 7/2/2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION CO. Vincent LeBlanc 51 SO.CANAL ST.#5A LAWRENCE,MA 01841 Undersecretary WCNootvalid without signature 1 Massachusetts aaa huasetta Deep artuemeent of Pubic Safety I owe (,:�l of IBamuidi ng L"egut afions and S "edam i 0aar,j rm•6oyl 1rotgp W.°rw ksxm°�tiwa.^m°p�mim� Liiewa-nsee CSSL-106017 PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 03865 an cemmtme s ono mer 04/28/2018 e