HomeMy WebLinkAboutBuilding Permit # 10/12/2016 04 OORTH
BUILDING PERMIT 3r y�� L6a "`�• Qac
TOWN OF NORTH ANDOVER ° 0
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received
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Date Issued:
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IMPORTANT: Applicant must complete all items on this Rage
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IN §61
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
g=' ew Building � ne family
addition wo or more family Undustrial
niteration No. of units: Ebommerciai
epair, replacement lassessory Bldg E Others:
[Ebemoiition M)ther
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1 Identification. Please Type or Print Clearly}
OWNER: Name: 1•l Phone: b . u
Address: 101 0- (,N,,
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ARCH ITECTIENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ L !� FEE: $
Check No.: 104. Receipt No.: _31 _
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty nd
S�gnatuce of ent, Wnel' SiE nater of antraclar
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tIORTH
own of
_ 6Andover
O ti, CA
No.
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CUCNoCNCWOCK
peRATED 0
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BOARD OF HEALTH
PERMIT T LD
Food/Kitchen
Septic System
THIS CERTIFIES THAT .................?C.r.0*..`........... �.L� ,.,......... .... BUILDING INSPECTOR
has permission to erect.......................... buildings on .......... . .?.?.......##34 .ar.... 415.T=... Foundation
p ............. .e.elf ..... .� .r ......... ........ Rough
t0 be occupied as .�........�,�.. ,.. .� .mss... ..,...... Chimney
provided that the person accepting this permit shall in every respect 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MOTHS ELECTRICALINSPECTOR.
UNLESS C®NSTRUCTI® S Rough
�..,. . .. 4UIL�i�G
... ....,.. Service
PE TOR Final
GAS INSPECTOR
Occupancy Perm Re aired t® ®ccu 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, surer
Street No.
Smoke Det.
CONTRACTOR WORK ORDER
CLEAResult
50 Washington St.Suite 3000 Printed: 9/26/2016
Westborough,MA 09581 Work Order Id: S27594P60882C324
Contractor Information Customer/Site Details
Building Science& Construction Michelle Robertson Email:michelle.robertson1@comcast.net
81 Sycamore Rd 197 Abbott St Phone(Eve): 508-904-4187
Phone(Day): 508-904-4187
Braintree, MA 02184 North Andover, MA 01845-4803 Site ID: 500050227594
Total Installed Measures
Location Description Quantity Unit $ Total $
Living Space Attic Stair Cover Thermal Barrier with carpentry 1 $260.23 $260,23
Living Space Attic Stair Cover Thermal Barrier with carpentry 1 $260.23 $260.23
Living Space Perform Air Sealing at Estimated 62.5 CFM50 16 $84.32 $1,349.12
Door Sweep 2 $23.18 $46.36
Attic 2 Propavent 2"or 4' 39 $3.83 $149.37
Attic Propavent 2'or 4' 60 $3,83 $229,80
Living Space Attic Floor Open Blow Cellulose 4" 676 $1.34 $905.84
Damming 86 $2.19 $188.34
Living Space Attic Floor Open Blow Cellulose 6" 992 $1.47 $1,458.24
Damming 34 $2.19 $74.46
Attic 2 Vent bath fan to roof flapper 1 $129.21 $129.21
Installed Measures Total $5,051.20
FINorkQrder Motes
Payments
Incentive Payments
Air Sealing Incentive $1,915,94
Weatherization Incentive $2,000.00
Total Incentive Payments $3,915.94
Customer Share
Total Customer Share $1,135.26
Less Deposit Of $378.42
Customer Share Balance(Due Contractor) $756.84
For questions regarding assigned work: Contractorinbox@CLEAResuIt.com. For questions while performing work: 855-821-2205.
mass save Form
CONTHAC t011
Site ID: 500050227594 Customer: MICHELLE ROBERTSON
MICHELLE ROBERTSON owner of the property located at:
(owner's Name,printed)
197 Abbott St NORTH ANDOVER
(Property Street Address) (CRY)
hereby authorize the Mass Save Home 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.
Owner's Signature:
Date:
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
CLEAResult a so Washington street,Stide 3000 Westborough,MA 01,581 • 1800-480-7472 M,
AC's CERTIFICATE OF LIABILITY ILI INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE 13025 NOT AFFIRMA71ViELY 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 eeetlflcate holder Is an ADDITIONAL INSURED,the polloy06s)mast be endoelaed. If SUBROGATION iS WA—WO,Subject to
the teems and conditions of the lwllcy,certain pollales may require an endorsemerrL A StaWnIont OR thea eertificata does not cuffm rlghtS to the
cerllfftto holder In Ilett of such enddrssenent(s).
PRODUCER Marls#;I' osin0
RONALD F D`AGOSTINO INSURANCE AGENCY INC. E 5os 5aa t)41a FMA X;
E marled rfdinsLnnMCom
7 CHRISTfS LIR SUITE l IN9tl N3t;p1lEIiACiE FIAIC#
BROCKTDN MA 02501 IHSUREkA: HARTFORD UNDERRWRITFRS INS 00 30904
INSURED S:
BUILDING SCIENCE&CONSTRUCTION INC Mumma.-
B UMMD.
300 TRADE CENTER SUITE 3890 E:
WOBURN MA 01801 u F:
COVERAGES CERTIFICATE NUMBER: 52398 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLIGiI s OF INSURANCE LISTED BELOW'HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FAR THE POLICY PMOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDI'T'ION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DUCRIOND HEREIN 18 SUBJECT TO ALL THE TERMS,
EXCLUSIQNS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
PM 5tMR SR TYPE OFINSURAFICE POUCYNUIMM P LIMITS
t:011EMCtALQMR1kLUA1OffV SACHQCCiJRIZENCE S
cwms-mg F�OCCUR PRE oaWJ 8
MRO EXP M ONMOO)
S
NIA PERSONA!.&ADVIMUFtY S
GEN'L AeOREQATE LIMITAPPLIES PER: MERAL&WRESMATE s
POLICY❑j LOC PRODUCTS-OMPIOPAGG S
WHIM. $
AU70RaOVAELL40UN C011IBI Eo kT s
ANY AUTO SO0ILYINJUIkV ftPWWn) S
ALL Uifi W A6r.IiO ULED A BODILY INJURY{Pwacddeno $
NI
HIREDAUTOS
S
tIMaRIstLALIAB OwEACHOCOURREWE S
F)COM LWe CLAIMS-MADE NIA AGOREQATF � s
DED I RETENTIONS $
WORKERS MPOI8ATIOH x
AFDSIPLOYEItS'LL49U Y
IEXC ME YIN E.L. ACHAOCiIN2Nr S
ANYPROPRIETORIPAWMERE,000,000�
A 0FF109RMEff9A 4WUDE04 I WAI NIA NIA 6MUSOF820MIO 0411112016 041112017
(&Iyandstowy In NH) E.L.DISEME-EA 11M.Y9S $ 1.000 000
DESttI C)PE
ELDI9EASE-PcucYLIFIIT s 1.000.000
=N/A
098o 7 vm oR OPERATMOI LOCATIONS l YEWICLES(AC0W 10f,Addld4M R*wM Sdwdnle,mry as aft.anw itmera onlloi in rapuiradF
Walkers'Compensation benefltS will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 W 08 E,no author zewon Is given to pay
claims for benefits to emplayees in states other than Massachusetts If the Insured hln ss,or has hired those employees outside of Massachusetts.
This certlficate of Insurance shows the policy in force on the date that ibis certificate was Issued(unless the expiration dale on the above pollcy precedes the
issue daW of this certlflcate of insumnoe). The stains of this Ooverage can be mor tared dally by accessing the ProOf of COWM99_Coverage Verlfk8tOn
Search tool at www.moss.gov/hNftorkers-oompensallonfinvae%aUons/.
CER71FICATEE HOLDER CANCELLATION
sHouL o ANY OF THE ABOVE nESCRIBED POLIDIBS BE CAKcELI.ED BIEFORE
THE IEXPIRAnQN MATT: THEREOF, NOTICE "LL BE DELIVERED IN
ACCORDMCE WI rH THE POLICY PROVf3IONS.
AUTH ORIMD RLPMENTATNE
MAA 02045 Dania M.C-4.Cp=Moe President—Residua)Market—WGRISMA
0 4988-2014 ACORD CORPORATION. All rights raswmerd.
A0ORD 26(2014;01) The ACORD name and logo are r®gialared mance a4 ACORD
UTDepartment of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017 wwwmass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibl
Name (Business/Organization/Individual): Building Science & Construction
Address:300 Trade Center Suite 3690
City/State/Zip:Woburn, MA 01801 Phone 4:781-353-2455
--—T--
Are you an employer? Check the appropriate box: Type of project(required):
I.001 1 am a employer with 8 4. 1 am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.R I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. E] Demolition
working for me in any capacity. employees and have workers' 9. R Building addition
[No workers' comp. insurance comp. insuranceJ
required.] 5. We are a corporation and its 10,R Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their I I.R Plumbing repairs or additions
myself. [No workers' cornp. right of exemption per MGL 12.0 Roof repairs
insurance required.] f c. 152, §1(4),and we have no
employees. [No workers' 13.QE Other Weatherization
comp. insurance required.]
*Any applicant that checks box 41 must also fill 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:Hartford Underwriters Insurance Inc
---------------------
Policy 9 or Self-ins. Lic. #:UB-9F620983-16 Expiration Date:4/11/2017
Job Site Address: 197 Abbott st City/State/Zip: N. Andover MA, 01845
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure covet-age as required under Section 25A of MGL 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 forin of a STOP WORK ORDER and a fine
of up to$250.00 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.
I do hereby certify under the pains ani!penalties of perjury that the information provided above is true and correct.
Signature: Date:9/27/2016
Phone#: 781-353-245
Official use only. Do not write in this area,to be completed 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#:
. O1"11C�olC�►gagaaer Afatire��ualaerslte�aiwtlan
ft IMF'ROV!ON11 d'E'CONTMWOR
Iep1 {tat : 140279 ToolRxotmdm-. SMOP 17 DBA
THE CARPENTER
PgRNBLL JACKSON
23 CHIPMAN ST. «.
DORCHESTER MA 021124 UndamftfAry
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