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HomeMy WebLinkAboutBuilding Permit # 8/5/2016 tIORsh BUILDING PERMIT OF� `6 14, TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No##: Date Received °AIT&D'pF Date Issued: 1p �ILMPO TANT: Applicant must complete all items on this page LOCATION ES 1`tv ti� Lfi r\f- P ri nt PROPERTY OWNER L►r��Cc�S1'h �® Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ®fie family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other v ..r s.,t�„ ter^r" , .y, '�°,.:r.^ ?' a%"'Y !F l.- ,:s t .ter✓.-d,�k^. m. J . re r.,,u �, p ❑ Flood la[n Wetlands . "1111 teshisrrct DESCRI TION OF WORK TO BE PERFORMED. CA' ,r �-►�t�. is ir 0� u boa n (Y ,\Mon L'� f is Identification- PIease Type or Print Clearly OWNER: Name: Phone: SOS•3`i S 'G'l�{ Address: 0 S tN 01-I e 6t i= UkJ_- Contractor Name: �Wf �"O\i-t r Phone: pl �� 3�1� 3� 3 Email: 1'hi r ir1�ULC�- `a+n % l-Lbw) Add ress q 9 0 ,-.)x y 1 Qiwk L11\ La, b 3 Supervisor's Construction License: �� Z Exp. Date:�z� Home Improvement License: 3` Exp. Date: I 1 ARCH ITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$72.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S_F_ Total Project Cost: $ 2- 3 I FEE: $ Check No.: Receipt No..- NOTE: o.:NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund tkORT� '� Town k,, bAndover No. �7/ h ver, MassAro 61 Al� T AK CO[ U BOARD OF HEALTH Food/Kitchen PERM ! T T LD Septic System THIS CERTIFIES THAT NiZLej.............. BUILDING INSPECTOR has permission to erect............. buildin on . �... W�. � ^^. ..... ,�, ,,, , Foundation ........ g ., p1.... �F!X! . ..71. f . .� .......... �1 Rough to be occupied as . .. �.*-fow . . ,. . Chimney provided that the person accepting this rmit shall in every resperm t the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws telating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. r4�ft PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS C S TI Rough Service .., .. .....,. Final BUILDING ! PECTOR GAS INSPECTOR OccupancE Permit Required to Occupy Buildinp, Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Fall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. . a ENC4NF9�dG �1�Ft &�A FAQ RISECONTMOrftp 4 MOM" �a g tam uuu UU Linda Smith C= ("9)3"77 0 12116 43570 15 Ife -_j1S 1►w&Andover,MA 01845 1wt+ eAwkwarMA0190 E pC3td�. heir �ISAJ.t> Jk�w t�aaak�4 Mdm(eab OfcdPw udnm)orcmabmmgfritowhubombwWWinywhomeXXTSTONMNEMTOMffALLABAlMFAXCAPAKROF 60CFM CONTMOM OMATMTM FAN CAN BBSf:[it GNA TMMTOCVM36MR;.MRL onSUC KFANtSAP / AT . 3 3m scsx#°.ee9ac� d? wiils►gate�3* we tal,a® willDa adeg�ggde d wfaftknumcd lktUwMcutba kwbtei tatw�st� ®t' texg! t4gas#atg�r �ba[�f'�It�� tavdaf tdscIDorm�ltsait �.rt�usodtv9ymgrr.�� f �.d�ce " M far gam tact aEt tows g� : (mac own% 'f�s�l (e'1 baa�,A � faet� ( ot�r�t will .laaidazel atm€g teas A4t&otoft5s wgs�, #gt�a�divana�lm0za .nHBafhta •�re�dmr ynns�ys�ariUlam tsy0tta ca v�da�' girquet0y. ' rVMM:A Frio Mwald m (8J e�f v�ttm S1 l70MON WAM.Ft�a is I g to iii °k8� d t�► ]galaarc fcc9aY wrJtgt�. Y.fes d a m =don al11b4a��Air A an�agn Sam- tmt6#s es�m la " (h% get J* j SE Go Shawmut Road,Unit 2 J Canton,MA 02021 j 339.602.6335 ENGIiNEERiNG7 www.RISEengineering.com OWNER AUTHORIZATION FORM ct s` (Owner's Name) owner of the properly footed at; (Props dress) (P rty Address) hereby authorize '�rt (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building peand to perform wont on my property.This form is only valid with a signed contract. rmit N AAA Si nature Date The (7otninortwealth rtf Mitssttehissells` Department ref I ndu strial.4 ceidetits a I Congress Street,Suite 100 Boston,MA 02 114-2017 n%, .ma.ss.goOdia Workers' Compensation Insurance Affidavit: BuHduWContractorsiElectrieians/Plu nhers ,k >!lieant Information ['lease Print Legibly � r. Are r©u an cnlploYW? f 1re,heck the appropriate box: , 1 ol'project l required is •1 ® 1 �3tr, a�i,rstCr:rl c��rttr���ir�r.tCtd [ i 1. I Lim a l`niployer,,611t .., _ � 4 [] Vii" c(}rl?1.mCIki h3ec hired [lie s1ii-r�;�ttrlCt.srs cnShlrspceti (AH and*p','or:-lirttr)," � ti cn;era4clikdl,� ?.� ] a�n a sLrlc 1?rcayrricCur U�r 1)�rtTtLF- Irwl m we m ielico shem. 1 ship and I�aec no tn�y,lugec� Mac Duh-W tt�� orq hava � 8_ ® �)erttal not) 1 iarpin , atkc3 hTte :5or �t V. [� t 3lriitr<�.ulaiificYn me !Tl.i Fk� Ciil7'li itt". _ i ttS1Tl'�r 1P�,Er�dirt.t _ ticr5r�tr+' ctnr� in>ttrur e ;t,1.� t-lc..Criial rip3:rs stir additfoCd� �_ 1�: :kre a corp r s1k�,sk Cid its T—' lquircd-f ? 3. 1 am a tsartrttowwr M3l: Work u1CutT* hip �.t�L35cci tEtie�r ;l.® 1'lru�t��tlt�;rkh�tir>or rrcicliiiir,ts HAL O iliFT "'t'Ca �.lt.. L 3-1.0 a'�UUt [i f�=11t w r7�t,clf: [No�t'�tr�:crs comp. F ,. c:. 1 _ v t 14).'Ind " 11.' no , tllSUr�inCC r�lll{IiCd,� .. c3tilri�Y Ga'S, �\u'.ttirha�� c0fllp, IrS Ur'ilitCC .`Cil CiitC . r100 amhww Am M.Ism 1 1"AW Ake of do no.Now own!A "Ovs € P mitr n SL["YJ: 11 owl me d ft mi"VA rr s,';'-.t r' u i. no ii il:tiv;.lri bli Esti 41 hf i :I u';MW} mwjmLz su:•t 3-.91 it;ttii 1 ?+Pry iar+ a=hw AWWWK TVries a cd 14 W c-!nw -XA met WMEW;_;r srb;'1;_,>l ti.ino rl<< �,alrs,.i� ._i���trtt:�rii;Ae'•Fk:3.c:-r.-e;;c�5, c�, �,t.;^.Crr.�a�clCtf. tic.r'�.er, � ;ri:{.�.C•.��rt�,:u,�3ftrtii I um an ettrphr ver that is providing in mranc a for at#'enrphr-rees. Below i5 thepolio't'acrd foh site btfortnatioiv t Irs,urtCree Cattrij It> l~::C.Fne:,_ �,�>�L� ik'���]�(G'L-►��A. y - -..._.._� ._.._.._ _..._�______ Policy-3 Lir 5clf-itrs. 1 ic, Job Silt Addrti.;;........_5�4�. L_(r �C > stat. Zip. Y_ Attach a copy of tltr workers'compensalion ptdicr declaralion pa,P;e(shirr+in the pt)[tet' number aRei expiration dote). 1'allllfe`.t?SL:Ll3.1't' L�rVCi�.,E 7-� E-C.s 'il ilnilCr SOLO 115,E o %i(rt Cr 152 can lull o the msftr4iiion of i'Unin:al �1t'I1;3lFil=S 0: lint; up fir`[.;rlrjAO moor�3tre.-y ar i.Fttlrri c}tkn�.nt. as �vcll a.,ck Fl ike�:aifteh i:a tlkt :t ttit it a S1(.11'WORK s_ICZI]L1Z at�Li :t Tits: of up to"250,00 a Q tlf?;1ho dw '.9rtl�om, He a(l;ind Ilial a z-Upy r*1 ililt Sig!€>1C1tRP ITr:i4� 1?�. likrtt111Jit� tt`.)tlic()��1tCc of 1l}Y'C�tl�».3tSL7f)y C1T rlTc' 1)I'� lilr 7FrtiIST:in�� llY1i:T.1?�l' \C'r13i�tlfYIt. 1 dci laereLS'csrtjo under the pain and penaltirs oaf trerjrrra"that the ittfonnation provided above is trot and crrrrect. - x LIJ— Official u.re nn4- Pa mot write in this area,to be completed Ira•city or W-1 4,ficial. Oy ar`row11: --_, Perinitll.icense -- I"suirll :kuthority leircle one,: 1,hoard of health 2.Building Depitrtnluut 3.('itis llurr(`lurk 4.Fleetrical 111spector s.r'irlanhiny, tnspucttYr 6.Other ('nntact Per on:� Plrnne #: AC® CERTIFICATE OF LIABILITY INSURANCE FDATE 6/30IDU/ 6/30/20116 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,certaln 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 Fancy Usher NAME: y FAX Martin S Clayton Insurance Agency, Inc. PHONE_(�a..EXt) 413) (413)534-7874 _.536-0804 AIC,09). E-MAIL 1649 Northampton Street ADDRESS: .. P. 4. HOX 989 _ ENSURER{S}AFFORDING COVERAGE NAIC -- Holyoke MA 01041-0989 INSURERA:Nationwide Mutual-Harleysville NATIO INSURED INSURERB Allied world, Natl Assurance Co Gauthier Insulation MSURERC: P.O. BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: -- COVERAGES CERTIFICATE NUMBER:CL1663001850 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. ApOL SUBR _ POLICY EFF POLICY EXP -, INSR TYPE OF INSURANCE POLICY NUMBER M/OD YVV M /Op1YY LIMITS LT� I $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 j A CLAIMS-MADE �OCCUR PREMISES{Eeoccusrence $ OL434S7R 7/6/2016 7/6/2017 MEDEXP(Anyoneperson) $ 5,000 _ - PERSONAL 8 ADV INJURY $ 1,000,000 �_._ I _. GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000, 000 POLICY(� PRO- {LOC PRODUCTS-CO COMPIOP AGG $ 2,000,000 L_-.fJ SECT _. _ $ OTHER'. iCOMRI ED SINGLE LiM1T $ :. AUTOMOBILE LIABILITY ��asGcident BODILY INJURY(Per person) $ ANY AUTO i. _. ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY E DAMAG $ HIRED AUTOS AUTOS I Rer gpidentl _....., _ _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB GLAIMS-MADE AGGREGATE BE020792125-194985 10/18/2015 10/18/2016 $ DED RETENTION PER DTH- :: WORKERS COMPENSATION STATUTE_ fR - AND EMPLOYERS'LIABILITY YIN E.L,EACH ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE N/A _ ----- OFRCER/MEMBER EXCLUDED? (Mandatory In NH} E.L.DISEASE-EA EMPLOYE $ _ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) TET, 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 ACCORDANCE WITH THE POLICY PROVISIONS. 195 FRANCIS AVENUE CRANSTON, RI 02910 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �y�G� DATE(MMIDD/YYYY) A <-- CERTIFICATE OF LIABILITY INSURANCE1141.1— 1 05!1312016 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 pollcy(tes) must be endorsed. It 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 NOME;CT Kattl n Da sh MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE (413)436-0804 Arc No ADDRES : kd8VShAMiCla512n= 1649 NORTHAMPTON ST.,RTE 5 INSURERS AFFORDING COVERAGE NAIL# HOLYOKE MA 01041 INSURER A; ACADIA INS CO 31325 INSURED INSURER B: GAUTHIER INSULATION INC INSURERO: INSURER 0: PO BOX 344 INSURER E: IPSWICH MA 0183$ 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 52708 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. ILBR TR TYPEOFINSURANCE ADDL BR POLICY NUMBER W PMOnYYY MMlOCDnYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAWS-MADE OCCURA RE ii PREMISES Ea occurrence $ MED EXP{Any one person) $ NIA III PERSONAL&ADV INJURY 5 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S POLICY Jia LOC ! �O&UC�TSCOMPIOPAGG $ 5 OTHER: IN i' AUTOMOBILE LIABILITY (EaCAaBenD QSINGLE L IT $ ANY AUTO BODILY INJURY(Per person) S ALLOS.WNED SCHEDULED NIABODILY INJURY(Per aWdenk) S p� AUTOS HIRED AUTOS PROPERLY DAMAG£ g Fer accld nt $ UMBRELLA LIAROCCUR EACH OCCURRENCE 5 EXCESS LIAB _±:J_CLAIMS-MAOI= NIA AGGREGATE S DED RETENTIO _ $ WORKERS COMPENSATION X gT'ATUTE ERH AND EMPLOYERS'LIABILITY Y1N A FF CERIMEM EREXC UDEO?ECUTIVE WAFWA WA MAARP300327 10/3012015 10/30/2016 E.L.EACH ACCIDENT $ 400,000 (Mandatory In NH) E.L.DISEASE-PJB EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE•POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below NIA DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attacher!It morespaos Is required) Workers'Compensatlon benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts If the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In farce on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this cravarags can be monitored dally by accessing the Proof of Coverage-Coverage Verification Search tool at www mass aovllwdlworkerB-co Densationllnvestigatlgfts/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF GLOUCESTER ACCORDANCE WITH THE POLICY PROVISIONS, 3 POND ROAD AUTHORIZEDFIEPR989NTATIVE GLOUCESTER MA 01930 Daniel 1M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(20141111) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173410 Type: Individual Expiration: 101112016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER P.O. BOX 344 IPSWICH, MA 01938 Update Address and return card.Mark reason for change. Address Renewal Frnployment Lost Card Oltice of Consumer Affairs&Business Regulation License or registration valid for individul use only p1VlE IMPROVEMENT CQNTRACTOR before the expiration date. If found return to: Registration: S'r341q Type: office of Consumer Affairs and Business Regulation 16 Park Plaza-Suite 5170 >wxpirdtion: 101112416 Individual Boston.MA 02116 KURT GAUTHIER KURT GAUTHIER 1 � 44 ESSEX RD „i. . IPSWICH,MA 01938 Undersecretary of valid wi out Signature Board Of iP. an g aJ i ori Tnd Sfirlaari S, U"ll71- CSSL40M2 KURT RGAUTRJf P.Q.Box 344 Ift1wk6 MA 019-V � w f !97-2— Expuat�on Gnr arras soo n.-r M5/2017' I