HomeMy WebLinkAboutBuilding Permit # 9/30/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:.'y`• C/ Date Received
Date Issued: 'q-30 t
IMPORTANT: Applicant must complete all items on this page
LOCATION 1 Sbr
Print
PROPERTY OWNERS
Print 9 DO Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
no
no
no
DESCRIPTION OF WOKK I U t5t r1--K1-UK1vir-v.
A;%r -_I!Aa iAdZfJ " baU nzt,,� Cal;rten._ 6a aF Ohk door io
Identification - Please Type or Print Clearly
OWNER: Name: Ponc0d V.O55 Phone: (o{ (PI -7
Address:
Contractor Name:
Address:
hone: MV) 382 -
Supervisor's Construction License: IMLAk .-Exp. Date: ?It L Zola
Home Improvement License: l8
ARCH ITECTIENGINEER
Date: -7
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASE/D� ON $125.00 PER S -F,
Total Project Cost: $ JqS . &S FEE: $
Check No.: C Receipt No.: 3 0 CZ p -Z _
MOTE: Persons contracting with unregistered contractors do not have access to thearanty fund
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Workers' (Alatponse6on Insunince AfhdnvU: General 1Wshiesses.
TO HE RLED WFIII Im PEnmrFANG AIN110RITY,
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AlAIJILWaut ---, -.- _2 Edut,
Addres,s- PO Box 6411
;amgy KNIT City EneMy
NI -i 03108
Phone, 1i.:603 -,39t N it92 3
Are you area eolployer? 12heek the apprupVto box:
1 1 un as C,jployej• witll "12 e.;ujployee I I/
s (I'Llll al I.
or pastima*
I am a sob pnq)dcwr or paimmAip and lowe no
working 16r ine in any capacuY.
P o Nyof C0111P. i11Sffl-a,UGC rC4jUir0dj
We are a corporation and its officets have exercised
their right ofoxoniption 1wr c. 152, §!(I') and we Owe
no emphyms. [No wca*aW emm. Womw rupirtal]"
e1' wo "Ire a non-profit by V0fiAo1V,(,GS
with no cinployees� I No worhers' comp. insinance, rcq'i
Wzwss 11pe (requKed):
5. Retail
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it. Notypront
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U O"Mmmw OEM WW "W"M Tomwn bw 010, corpovalion has othvv corvqvn"Mioll jloh(,Y is wylia(A tIwl smll seen
omm"Mm"NMW dWA law N I
wwromm cm"Mj boms Ob" hmm awe
Insur(w's aW(hvss: One MmdU /Ww-me We 302N
Mancbes'ie't!. NI -1 03,102,
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Failure to secure covo-age as ralSed under Sec-thn 25A of MG1. e. 152 can lead to dw imposition ofahninM pettaRies of a
Ow up W S hN0.00and/or one-year as �vclj as ejol penaHNs h, we Mon Ma 9MW VAAWJJR DER and a One
of up to $250JK) a day agahm Me &Mow. Be Wsed INO as ajV v! His stormarn nary be lJorwardalto Me Ance A*
hwomigations offlio f)li\ for insurance eov=age verific"ation.
7 jwn et Ides e?fperjnt,,y that ffie !qfiirvnWo)t 1movided, above Iv inte and corred,
do herel�) � I Vio 'I&I , "';;i
60M(14520
Q/ " 7 or town of
'fivial list, on�t�. Do not w4te in this anui, to be conipleted /�,e t46 jici(J
CAI or Town:
Penn W! Arme tl
011Aomu,
Vulng AnHuMly PIK ono:
,, ,,, art , I (,/awl's at. lAmming Umrd I SdeehnmN 011%
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Contnet Porsoll., Phone
MILLCITY-1 AGOULD
HCORO'
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
711912016
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 INSURERSS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy{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 endorsement(s).
PRODUCER License # AGR8150
Clark Insurance
One Sundial Ave Suite 302N
Manchester NH 03102
Manchester,
CONTACT
NAME:
PHONEFAX
WQc No. Extt: (603) 622-2855 tarc, No ; (603)622-2854
E-MAIL
ADDRESS: a ould clarkinsUrance.Com
INSURER(S) AFFORDING COVERAGE_
NAIG #
INSURER A: Arbella Mutual Insurance Co _
17000
INSURED
INSURERB:AmGuard Ins co
43290
Mill City Energy
106 Joseph St
PO Box 6411
WSURERC:
-__..___
—-.._......___.___...._
ENSURER D :
_._......._..
INSURERE:
PMAGE TO RENTED
REM SES Ea occuTrence $ 300,000
Manchester, NH 03102
INSURER F :
COVERAGES CERTIFICATE NUMBER: 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 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
!NSR
LTR
TYPE OF INSURANCE
ADDL
!NSD
S BR
WVD
----�_-i'4L.ICY
POLICY NUMBER
EFF
MMIDD
POLICY EXP
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE$ 1,000,000
CLAIMS -MADE OCCUR
8500065735
0412912016
0412912017
PMAGE TO RENTED
REM SES Ea occuTrence $ 300,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE S 2,000,000
GEN'L
I
POLICY JEC LOC
PRODUCTS-COMPIOPAGG $ 2,000,000
OTHER:
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident $ 1,000,000
BODILY INJURY (Per person) $
A
X ANY AUTO
1020050919
04129/2016
04/29/2017
ALL OWNED SCHEDULED
_ AUTOS AUTOS
X X NON -OWNED
HIRED AUTOS AUTOS
-----.___...................._._,._..—_ __—_ __
80DILYINJURY(Peraccidennt) $
PROPERTY DAMAGE $
(Per accident
X
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
A
EXCESS
CLAIMS -MADE
4600065736
0412912016
0412912017
- __..
DED I X I RETENTION$ 10,000
.__........-.._...........,_._._,
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
OFFICERIMEMBEREXCLUDED?
(Mandatory In NH)
NIA
MIWCi791896
04129/2016
04/29/2017
X PER
STATUTE ER
___ _
E.L. EACH ACCIDENT $ 6600,000
E.L. DISEASE - EA EMPLOYE $ 500,000
If es, describe under
DESCRIPTION OF OPERATIONS below
�.--...--..-�_......_...__._,..._,-.,_...__.- ___.__...._W_....,_,..
E.L. DISEASE •POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is requlred)
CFRTIFICATF FtOLnFR CANCELLATION
ACORD 25 (2014101)
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover MA
1600 Osgood St.
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover, MA 01845
AUTHORIZED REPRESENTATIVE
ACORD 25 (2014101)
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
60 Shawrnut Road, Unit 2 ( Canton, MA 02021 1339-502-6335
www.RISEengineering.com
(Owner's t
owner of the property located at:
— (Property Address) 'o i
(Property Address)
hereby authorize JW� -- "
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.
Ther Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
Owner's Signature
Date /
62016
redoral It) n 05-0445029
IZ� 1; l;ll IItCL'1'1€€ RI Contractor Ragistration No 8186
�" MA Contractor Reglstration No 120979
CT Contractor Registration No
KISE(it)
131ni1%n111t load, t'lnllon, N1;A CONTRACT
A
ENGINFERING"
(401) 7t94-3788 f!,%\ (401) 784.37111
Page 1
11ROORAN4
(-\��/ TIM CONTRACT IE ENTERED 111TO UETWEEN AME
.,�
i�iA-11f 1�5 E!$OIf1EERINS ANU THE CUBTtlMER FOR WORK AS
-� i�' V (`,
DE3CRInEfl REl.05Y
1
CUSTOMER PHONE DATE CLtENTi YlQatI ORDER
Donald Ross ;.' (W)697-998109/2012016 439U14
35UU2
SERVICIt STREET -�- MLLINO STREET
IS Stevens Street 18 Stevens Street
SERUME C1TY,STATE, LP SILUNO ttlY, STATE, LP
North Andover, MA 01 45- North Andover, MA U I8�15-
JOB DESCRIPTION
AIR SEALING: Provide labor anti materials to scall areas Or your ]ionic against %Ya-slcfu). cvicess air leakage. ')'tis work will he
performed in concert widt the use of sl:cciai tools and diagnostic test. to assure flint your home will be left will, a hcalthrul level of
air exchaii6c :Lad indoor air quality. htalerTals ill be used to sea) Ynur bonne can include Caulks, f trans. and other producLs. Primary
areas for Sealina include air lcaknec to allies, basements, attached garnges and Other unheated areas (windows am not generally
addre,tscd,i This will ref(uirc (2) %forking hour..;. A reduction in cubic feel per mnlnte (clnr) of-air in Ill hrntiorl will nCCUr, but the
actual munber of crin is not guaraill ed.
:\I the Completion of the %1-Catherimluln work, and ,it len additional cost to the lionicowacr. a final hlower door and/or Conibustlon
tiarC3}' analysis %fill he condoolCd by the Suh•Conimclorto ensure like Safely of the indoor air quality.
1711.�U
ATTIC ACCESS: Provide labor and matcria)s to insulule the back of the attic door with 2" rigid Thermaxx board and scat the duor's
edge with weatherstripping, to restrict air leakage,
X73.91
VENALATIOM Provide labor and malcriniti to install 1 E )insulnlcd exhaust hose with gable "al l mounted flapper vent to exhaust
existing balltrooin
S[ 1S.7i
VENTILMIGN'': Provide Iahor and malcri Ids lu inwal) (I ) insulnlcd exhaust host %vith roof mounted flapper vent to exhaust
existing badiroom rnn(c).
S13S.7�
13ASE'Vir-NT CEILING: Provide Inbor and inalerials to install (60) lincnr feet of it-19 unrated tillerghLsx institution to the perimeter
ofthe basement ceilioL at the house sill.
13ASE:'vtl-NT l](X*: Provide labor ;old nialeduls to insulate the back of the bmumcnl door Icadint; to the bulkhead with 2" rigid
board Ih,lt i31LYa5 the tiCChnnti ]t-31 �i.�rt told 3 1!L(1 TCE1iklrtFltelllti Ila bnildmg Code. Scal :ill Cdgo Rod Sc:nlis with FSK laps.
572.22
RlSF; f{ng,inecring will apply all applicable, cligibic incentives in this contract. You will only be billed the Net aniount. Correntiy.
ror ch gihle mCasures, Colombia Oas OlTcrs TM incentive. not. to exceed 52,000 per Calendar year, and alt rilcetitive of 100% illr
the Air SCulintt mvtvL w-es up to the ilrtit 5690 and an additional 5340 if,mvings urc jmaill d by tilt audittir,
For the safety grid heulth of your honic's indoor air quality, %1i: will be conducting a blotter dour diagnostic of the available .lir lltm
in your honic both belbril the %York k beewn, told afier the %%eatherizaliun work is complete. We w ill also cornhlet a full SItitiV`i?inClll
of the cornbllstion safety elf %'Our licaling system and wilier. hrner. This hiss a value of 594 and is at no cost to you. Molal
allollublu weatherization incentive is 53.1 10.
590.00
ENGINEERING'
CUSTOMER
Donald Mass
SERVICE sTReEj
18 Stevens Street
RISE Engillee1,i11g
fit) Sha%InIII ttUnd, ('RNtuN, 1t,\
(4111) MI -3700 FAX (401) 784.3710
SERVICE CITY, STATE, ZIP
N01111 Andover, MA 018'15 -
Fedoral1D N 05-0405529
RI Contractor Raglstratlon No 13186
MA Contractor Registration No 120979
CT ContraCtor Rogistration No
CONTRACT
JOB DESCRIPTION
Total: $748.63
Program Incentive: $626.47
Customer Total: $122.16
WE AGREE HEREOY TO FURNISH SERVICES -COMPLETE IN ACCORDANCE WITH ABOVE sPECIFiCATIoNS. FOR THE SUM OF
"'One Hundred Twenty -Two & 161100 Dollars $122.16
LIPOIi FINAI,iTlSPECTIDN A40 APPRPYA4 RY 1tISL TJiG1NEERF4G CUSTOMER AGRLFA TOREANT AMOUNT OWWFULL. WTEREST OF 1% VALL OE CIW{GEO MQ?0+ILYON ANI'
UNPAID EUILANCQ AFTER 30 DAYS. SEE REVERSE FOR IMPORTANT SRFORLIATION ON GUAAANTEES, RIGHTS OF REC410N, SCVEDUEJNG, AND CONTRACTOR REGISTRATION,
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
AUTHOR0-?LATURE• RISE EAD.fflt r* CUSTOVER ACCEPTANCE
NOTE: TIPS CONTRACT MAY Or. VATIIGRAWU BY US IL NOT EXECUTED Ya7Nl11
C)
DAYS.
OATEPPACCEPTANCF, ry/ \ 3'r+1 70 A •
ACCEPTANCE OF C04TRACT -THE An0VE PRICES, SPECIFICATION'S AND CONDITIONS AAL'
SATISFACTORY TO US AND ARE NFROY ACCCPTEO. YOU ARE AUTHDRaF.0 TO DO THE WORK
AS SPECIFIED PAYMENT VALE. DB MADE ASOUTIINEO ABOVE
Page 2
t1ROGRA1Vt
T1E15 CONTRACT is ENTERED INTO 1JE:T7YEC1! A19E
C NIA-IIE:SFToINCERUIp
ANG TIS: CUSTOMER VOR WORK AS
GESCRKIED BELOW
PHONE
GATE CLIENT WORK ORDER
(617)697-9981
09020/7016 439014 35002
MLL140 STREET
18 Stevens Street
RILLINO CITY,STATF-WI
North Andover, MA 01945 -
JOB DESCRIPTION
Total: $748.63
Program Incentive: $626.47
Customer Total: $122.16
WE AGREE HEREOY TO FURNISH SERVICES -COMPLETE IN ACCORDANCE WITH ABOVE sPECIFiCATIoNS. FOR THE SUM OF
"'One Hundred Twenty -Two & 161100 Dollars $122.16
LIPOIi FINAI,iTlSPECTIDN A40 APPRPYA4 RY 1tISL TJiG1NEERF4G CUSTOMER AGRLFA TOREANT AMOUNT OWWFULL. WTEREST OF 1% VALL OE CIW{GEO MQ?0+ILYON ANI'
UNPAID EUILANCQ AFTER 30 DAYS. SEE REVERSE FOR IMPORTANT SRFORLIATION ON GUAAANTEES, RIGHTS OF REC410N, SCVEDUEJNG, AND CONTRACTOR REGISTRATION,
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
AUTHOR0-?LATURE• RISE EAD.fflt r* CUSTOVER ACCEPTANCE
NOTE: TIPS CONTRACT MAY Or. VATIIGRAWU BY US IL NOT EXECUTED Ya7Nl11
C)
DAYS.
OATEPPACCEPTANCF, ry/ \ 3'r+1 70 A •
ACCEPTANCE OF C04TRACT -THE An0VE PRICES, SPECIFICATION'S AND CONDITIONS AAL'
SATISFACTORY TO US AND ARE NFROY ACCCPTEO. YOU ARE AUTHDRaF.0 TO DO THE WORK
AS SPECIFIED PAYMENT VALE. DB MADE ASOUTIINEO ABOVE
Massachusetts Department of PLAbliC SMfety
Conslowlion Supemsor
Restricted to:
Board of BuRding He. rah
aml Standarl¢ Is
Unteslikled - 13uildfitgs oI any use group which contain
License: CS -110041
iess than 35,000 cubic feet (091 cubio rneters) of
ConstnxfiW.,m Supcir,,.omDr
enclosed space
MICHAEL JOY
lal
106 JOSEPH STREET
MANCHESTER NH 03,102
Failure to possess a current edition of the Massachusetts
Slate Buildirg Code i% cause fovmvocafiori of this license.
comnllissioncr
08107/2019
OPS Licensing information visit: WWWWASS.GOVIOPS
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Offi(�c of ( omumer Affai(s arM 111011v%10"VOMi011
H) Park Plaza su4v 5170
Bwacn, MA 02116
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