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Home My WebLink AboutBuilding Permit # 8/29/2016 BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received TED i. S�c6aus Date Issued: IMPORTANT: Applicant must complete all items on this pale LOCATION zs-s—_ j3 nicon A/,- Print PROPERTY OWNER r5:e- Print 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 ri New Building ri One family E Addition ri Two or more family [I Industrial E Alteration No. of units: T Li Commercial —------ E Repair, replacement 11 Assessory Bldg Others: 0 Demolition 11 Other 01 �� r , „ � / , , �/,,/fir / �,��%//� �� a��a /� .fey,, '��, �r��/�sf��r/�f�e%,%��/%/f% �//��i��i/��/ii� DESCRIPTION OF WORK TO BE PERFORMED: ;7 Identification- Please Type or Print Clearly OWNER: Name: Ur in r C4 e- Phone: Address: / Peter Leblanc Contractor Name: .% -ff-,, 4 "- Phone: , E-2i t I we Streew Email: Address: plaistow9N.M. 03865 n 978-407-7638 Supervisor's Construction License: 4QG 0 I Exp. Date: Home Improvement License: l0 k W4 Exp. m Date: 2,& ARCHITECT/ENGINEER Phone: Address: I Reg. No. FEE SCHEDULE.BULDINGPERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $_ Check No.: Z*_(00 Receipt No.: NOTE: Persons contracting with unregistered contractors,,/do not have access guarantyfund ".......... ............ 7 ',pL 77/1 77, pL WWII a-we",177 T ,_9 toRTa1I own of s 6 ndover 0 » _ M No. a.D(�-�a1 - n fl, h ver, Mass, A� cocracnc w+c.c y1• - - T� 7�AORATED PPP��S S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ..... ... ..,.:1�.L..�I.� r.......... ................ ..... ...... . .. . BUILDING INSPECTOR has permission to erect .. . ... . ....... ulldl . . *.�+ ► Foundation ngs on ... .. Rough to be occupied as ., !��.�.. .t. .. .. .r............................. chimney provided that the person accepting this permit shall in every res ct 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 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 PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS CONS lO T Rough Service ........ ........ .. ......... Final BUILDIN SP CTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Approved by the Building Inspector. Burner Street No. Smoke Det. DocuSign Envelope ID:D73F1 9513-4601-4180-85130-1 2E54528A878 CLEAResult" CONTRACT FOR PRODUCTS / SERVICE WORK This service is brought to you through support from your local utility This Agreement is made by and among Ruth Caisse and 155 Beacon Hill Blvd CLEAResult North Andover,MA 01845-3932 Attn:HES Site ID:500050170925 50 Washington Street,Suite 3000 Project ID:P00050195639 Westborough,MA 01581 Customer ID: C00050172240 Federal ID No. 222457170 Contract ID: 20160304-1 WORK (Tylail completed contract to address above) 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional mariner and in accordance with the terms of this Contract,including the attached recoraniendations/work order describing the work in detail(the"Worl<')which are incorporated herein by reference: Description Quantity Location Insulate Vinyl Sided Wall With 4"Dense Pack Cellulose 928 Living Space $2,236.48 Insulate Rim Joist with 6.25"Fiberglass Batting 102 Living Space� $244.80 Sub Total: $2,481.28 Utility Incentive Share $1,860.96 Customer Contribution $620.32 R1 MOT. For office use only Printed:7119/2016 Page 2 of 2 11. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Sharo of the Contract Price as follows:Payment III:$__ 10Q.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceel 6/3 of the total retail costs).Mail check&contract to CLEAResidt,Attn:RES,50 Washington St, Ste,3000,Westborough,MA 01581.Final Pay....I.—. .32 —as the final Payment for(lie.Work shall be payable to the ludepeudeut ItistaUationCoiitractor("IIC")ttpoxisattsfacto completion of the Work.Customer understands that lie./she will not required to pay the Utility Incentive 1,8 63 , increase y Share of the Contract price in theamount of 1$----'-'--'-; .96 Cliiiigestoiiidividti�,tlliiieitkii)sa.Ti(Vc)rpr(-vioiisijiceiitiv(�,,tiiav rease or decrease the size of(lie Utility Incentive Share.. III. DISPUTE RESOLUTION The IIC acrd Oistorner hereby mutually Itually agree in advance that in the event,drat the IIC has dispute concerning this Cmitrad,the ITC n tay stibiiiiL such dispute to a private arbitration service which has been approved by the Officy-,of Consumer Affairs amid Business Regulation and Customer shall be required to submit to such arbitration as provided in M.GJ,c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 7/24/2016 08:42 EDT TBD r�'q t Date indicate your selected IIC here,if applicable (()It) nitial here if you want Geo,rae -woods 7/19/16 George Woods the Program to assign a ...... Participating Contractor CLEAResult'Signature Date Name of CLZAResult Representative(Printed) TERMS AND CONDITIONS APPEAR ON TIKE REVERSE. 2200-1`L 121.16 DocuSign Envelope ID:D73F195B-4601-4180-85[30-12E54528A878 ttPtfro" 'iii � r s 00 N, F PARTIVIPA"I NG mass save CONTRACTOR 1411111111wwl PERMIT AUTHORIZATION FORM I, RUTH CAISSE ,owner of the property located at: (Owner's Name,printed) 155 Beacon Hill Blvd No. Andover (Property Street Address) (City) hereby authorize the Mass Save Horne Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. _—Docasia„ed by; ""�a,. X _..__ Owner's Signature i i 7/24/2016 1 08:42 EDT Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date i For Office Use Only Rev.1.2132015 _2tl �rYr'A'' E�'�d"/�G ay, '[..f i1"Y�ff'!Y„..+id"'C/♦!, c�''C/ ' - y= Office of Consumer Affairs and Business Regulation 10 Parr Plaza - Suite 51.70 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, MA 01810 Update Address and return card.Mark reason for chance. Address n Renewal [] Employment Lost Card SCA 1 0 20M-05111 urrrarrrae�rrl(l r��'-ALrrr.t.tr'n�Iro.te/ft J� _. Office of Consumer Affairs&Business Regulation License or registration valid for individual use only C qZ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 102726 Type: Office of Consumer Affairs and Business Regulation Expiration:. 71212018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION Co. Vincent LeBlanc 51 SO.CANAL ST.#5A LAWRENCE,MA 01841 Undersecretary Not valid without signature zv 9 Massachusetts Department of Pubhc Safety Board of Buiidhig Regulations and Standards ',mrlwas il�iiQan aapl�a'�isor speciaahl cense: CSSL-106017 PETER A LEBLANC ALN 2 EAST PINE STREET Plaistow NH 03865 a:r�umrouiaaaaa:r 04/2812018 0 The Commonwealth of Massachusetts m' Department of IndustrialAccidents Office of Investigations 1 Congress Street,Suite 100 ' Boston, M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name (Business/Organization/Individual): PO BOX 958 Address: ANDOVER.MA 01810 -- City/Mate/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.IK I am a employer with_ !� 4. [] I am a general contractor and 1 employees(full and/or part-time),* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ;. ❑ Remodeling ship and have no employees 'Mese sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 LJ Building addition [No workers' comp. insurance comp. insurance.t required.- 5. [ V.'e are a corporation and its 10.❑Electrical repairs or additions t 3. officers have exercised their 11.❑ Plumbing repairs or additions ❑ I anti a homeowner doing all work f myself. (No workers' camp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no ' employees. [No workers '13.1 .1 Other comp. insurance required.] *Any applicant that checks box#1 must also Ell out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContrartors that check this hox must attached an additional.sheet showing the name of the sub-cor.*`acars and slate.whether or no,those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I nm an empltver that is prof-sding workers'conapensathen Ins urarre for city employees. Belo:'is the poHey and job site ipformation. I� Insurance Company Name:_ O C6 Uh K A $ tr `4 t-G r d Yy1 Nf VL>- Policy#or Sclf-ins. Lic.#: ?04)C I Expiration Date: pI A, be,1 .lob Sitc Address: /��r ��gfan �/r�� l�di Lity!utate!Zip: � MOP de l'tr' 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 of MGL c. 152 can lead to the imposition of criminal penalties of a 3 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WOFS ORDER and a fine of up to$250.0:a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 0 A do hereby cerci-.under the aims and. enallie.�o' er u that the in orination provided above is true Rnd correct. Signature: Date; Phone#: y " 7& 36 Of acial use only. Do not write in this area,to be completed by city or town official City or mown: PermitrUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other i' Contact Person: Phone#: r: s 611012016 Preview:Certificates of Insurance ACCORL11 CERTIFICATE OF LIABILITY INSURANCE DATEIIIII 'y`"' 061102046 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions Of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsementis). PRODUCER CONTACT NAME: 11 Automatic Data Processing Insurance Agency,Inc. PHONE E.+: IFA Nak 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER($)AFFORDING COVERAGE HMO s INSURER A: NwGUARO Insurance Company 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC INSURERC: PO BOX 958 Andover,MA 01810 INSURER D: 4 INSURER E; 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 503587 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 TH;S CERTIFICATE MAY BE ISSUED OR 61AY 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 n1 POLICY EFF LTR TYPE OF INSURAHCE RiseAVULtYVp POLICY NUMBER MWDDA'YYY WDIWYYYY LIMITS COMMERCIAL GENERAL LIABILITY rA OCCURRENCE I v CLAe.tS-f,1A0E n OCCUR PIiE1,4lSES IED neeurroncn) 5 MED FXP{Any one person] S PERSONAL&ADV INJURY S (,ENL AGGREGATE LILM APPLIES PER! GLNERAL AGGREGAI E S POLICY❑PRO ❑LOC PRODUCTS-CC!.fP.OP ACO _ JECi OTHER' $ AUTOMOUILE LIABILITY ANY AUTO BODILY INJUNY IP-tar=os y ALL%VLIEU SCHEDULED BODILY INIURY IPu—u-I) S AUTOS AWOS WNOWNED ..L $ miRED AOros AUTOS IPr a deq UMBRELLALUIB OCCUR EACI!CCCU',k04CE S EXCESS LIAII CLAIMS-MADE AGGREGATE S OED I I RETENTIONS S WORKERS COMPENSATION XPER AND EMPLOYERS'UAe1LnY STATUTE ER A NaYPRCPRIETOW'PARTN'EREXECUHVV YIN E.L.EACHACCIDENT 5 1,000,000 OFFICER�'EMBER.EXCLUDED' 0 NJA N POWC772258 01101/2016 011D112017 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE 5 Ir �,describe wider 1,DDD,DDD DESCRIPTION OF OPERATIONS tu'— E.L.DISEAS E-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,AddHIonal Remarks Schodute,may bo attached H mmespaw 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 Norah Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St.I suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE O 19882014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and Ingo are registered marks of ACORD i 9 I https:tiadpia.adp.comlicertefl#/Tttnlprevicwl503587/900012975 113 I ACI RL® CERTIFICATE OF LIABILITY INSURANCE DATE(MNWDJYYYY) 6/10/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO14 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(lee) 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 endorsemen s. PRODUCER NAMIEACT Linda Bogdanowicz insurance Solutions ora Corption PHONE �bog)382-4600 FAX (603)392-2034 Ex1s: AIC N4: 60 Westville Rd ADDa1ESS:lindab@isc-insurance,com INSUR_ER(Sf AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A Western World INSURED INSURER B MautilUS InsuranceQ�roup _ Polar Bear insulation Company Inc INSURER C: PO Box 958 INSURERD: INSURER E: _ Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER:"-L1632326134 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 WTH 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 DDL SUER POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE POLICY NUMBER YY M Y X i COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO p, CLAIMS-MADE [_�]OCCUR PREM SES Ea Decor enee $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Anyone person) $ ,�. 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN`LAGGREGATE LIMI€APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY jga LOC PRODUCTS-COMPlOPAGG $ 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 S X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000'.000 B EXCESS LIAR CLAIMS-MADE AGGREGATE S 1,000,000 DEO RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION STATUTE ERH 6 AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFF€CER/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,AddMonal Remarks Schedule,may be attached If more apace le 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 — �� -- O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NS025 0(1140 1�