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HomeMy WebLinkAboutBuilding Permit # 10/18/2016 �or�TH. BUILDING PERMIT oF�YLEo TOWN OF NORTH ANDOVER 3 APPLICATION FOR PLAN EXAMINATION o " Permit No#: 1 � Date Received ��S�R,Tto SAC!iU Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION r�nf PROPERTY OWNER ci FC Cir 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 ❑ New Building ❑ One family ❑ Addition ❑ Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement [iAssessory Bldg Others: ❑ Demolition ❑ Other ❑peptic ❑Wel1 % ❑Floodplain ❑Wetlands �❑ V1latershed D�strrct ' DESCRIPTION OF WORK TO BE PERFORMED: L,�elMA9 �,0T Identification- Please Type or Print Clearly OWNER: Name:_ o Ia'Ci-ej + Phone:6)7-Sq%-g-1y Address: L yVVI�P, M ®q Contractor Name: ?e T 1A kx e Phone: va Email: Address: eQ' ; i �: 5 i�� • a 3°` Supervisor's Construction License: 017, Exp. Date: A), A Home Improvement License: ®�?�� Exp. Date: ;? to ARCH ITECTIENGINEER Phone: Address: Reg. No. FEB SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ �-° �� -� C FEE- $ Check No.: Receipt No.: �® NOTE: Persons contractine with unregistered contractors do not have access th guaranty fund ....... .. .... ... .......... t%ORT own of sAndover 4m-ao(i JIL O LAKE h ver, Mass, COCKECKIWK% 1" Rwreo s u BOARD OF HEALTH Food/Kitchen PERMIT .T LD�1�/ Septic System THIS CERTIFIES THAT .....................:4 . 0 ....... ... ... ... ....,................. ............. BUILDING INSPECTOR has permission to erect .......................... buildings on .,... ......4s.mom_ .... ............... Foundation Rough to be occupied as . .� .............................................................. 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 MONTH ELECTRICAL INSPECTOR UNLESS CONST NS T /inal gh ... .. - ..., .... ......... UILDING INSPECT GAS INSPECTOR Occupancy Permit Required to Occupy RuildlnRough 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. Federal 10#OM405629 RISE Engineeling RI Contractor Registration No 0106 MAContractor Registration No 120970 CT Contractor R I t tion No620120 �"j RISE 60 Shimmut Road,Canton,AIA 02021 ENGINEERING' CONTRACT 339.502-(1335 FAX 339-502-6345 Page I PROGRAM IHS ONIRACT13 ENTERED INTO REMM RISE CMA-ZIPS EPICICHOERINGAND VIE CUSION1511 rOR WORK AS DESCRIBED BELOW CUMIMER PHONE DAM CUENTO WORK ORDER Marc Citdi (617)899-8240 M/20/2016 438684 231X12 SERVICE STREET DIUJNG 131REET 18 Lyman Road 18 Ly I nan Road SERVICE CIIY,SIAV,Z)P RIwNO cm,3-MIE,ap North Andover,MA 018,15 North Andover,MA 01845 .JOB DESCRIPTION HEALTH&SAH"ITY: $0.00 Alit W-,A I TN 77,7,5,i7ibo,,7materials—I,,,scal areas ol'your hoine against wasteftil,excess air leakage. This mrk"ill be sand performed in concert with the use of'special tools and diagnostic tests to assure that your home will he tell with a licaltlifol level of Sir exchange and in(loor Sir quality.Materials to be used to seal your home can Include caulks,foams and other products. Primary areas forscaling include Sir leakage to allies,basements,attached garages and other unhealed areas(Nvindom,are not generally idiressed) This Wit require(12)working hours.A reduction in cubic I ect per minute(0,111)of*air infiltration\%ill occur,big the actual nuinIxr of is not guaranteed. At the conipIction ofthe wNuathcrjzation work,and at no additional cost to the homeowner,a final blower door an(vor combustion safety analysis Will be comb"ed by the sub-contraclor to ensure(lie safety ol'the indoor Sir quality. $1,020.w) Provide labor and materials to install 2" FSK paced scani-rigid ILbergla&s board insulation to(336)square fee of knemall area, $1,176,00 7- =77M77,j c—jatw—and mat=,*to—imulal,(2) luck 7 rh, riccwil li,,70 with 2"rigid Thermax board,and scall the edge of'tho hatch with Nwatherstripping. $120.00 RI Sllingincering will apply till applicable,eligible incentives to this contract, You will only be billed the Net amount, Currently, for eligible measures,Columbia Oas olTers 75'Yo intent ive,not to exceed$2,(100 per valen(hr year,an(]an incent ive of 100%for the An-Scaling measures up to I lie first.$680 and an additional$341)ilsavings are jtist ifited by I lie atelitor, For the mtety and health ol'your 11(nnes imloor air qwlity,awv will be ewiduct ing a bloNvu door diaposAic of'(lie available air flow in your home Kith lxrore the vork is begun,and after the"vatherization wank is Complete.We will also COMILIC!,8 I'Lill IISSCSSRICIII. of the combustion safety ol'your heatingsystern and water heater.This has It value ot'$90 and is at no cost to you. Total allowable%Neatherization incentive is$3,110. $90,00 i EOV 2 2 I L`01111w-m-I- Federal ID#06-0405629 RISE' Engineerhig RI Contractor Rogisiration No 8180 MACo"tractor RogistratIon No 120079 RISE61)S hawin u t Road,Can ton,Alik 0202 1 CT Contractor Regisiration No620120 EMEE RING' CONTRACT 339-502-6335 FAX 339-502-6345 page 2 PROGRAM TWIN 00041RACTIS ENRIREO INTO BEYNEEN RISE CMA-I I ES ENCANEE)UNO AND THE CUSXAMR FOR WORK AS CNISCRISECIFIELow PAIV CLIENTS WORrSORDER Marc,("redi (617)899-82,10 09/20/2016 438684 23902 GCRVICC STREET DILLINO STREET 18 Lyman Road 18 Lyn-Ein Road acnvkcr CITY,STATE,zIP Rlww CITY,STATE,21P North Andover,MA 01845 North Andover,MA 019,15 JOB D ESCRINION Tota 1: $2,406.00 Program Incentive: $1,992.00 Gusstorner Total: $414.00 WRAGRUINEREDYTOFURNISH SERVICES.COMPLETCIN ACCORDANCE WITN ABOVE SPECIPtCA'nONS.FOR THE SUM OF ""Four Hundred Fourteen &00/100 Dollars $414.00 ,A UPON FINAL INSPECTION AND APPROVAL BY fU$E rNGINCERINOCUSWAERAGREES IORCf4rAMOU94TOUEttirUL.4tNIERESY(X-'I%Wd.1.13ECHARGED1,011ILY ANY UNPAID BALANCE AFIER 30 DAYS.SEP REVERSE FOR IWORIANTINT'ORMAIJOH 0#4 GUARANTEES,1`601113 OF RECISION,SCHE(mitift AND CoNTnACTom RE(MmAl. 'S DO NOI'SIGN THIS CONTRACT IF THERE ARE MY BLANK SPACE A TH UTH LWY lot 7U IRE E tsaarl A�C�irl L�C NOTE:"IHSS CONTRACTMAY BE WITHDRAWN BY US IF NOrEXECUTE0 WITHIN DAM OFACCEPTANCI! ACCF.P=CC OF CONIRACT-1111 AGOVEPIUCES,SPECIFICAVONS AND CONOW40 ARE 0DAYS. SATISFACTORY 10 LIS AND ARE 14FREDY ACCEPTED,YOU AREAU11ORIZEDK)DO TILE WORK AS SPECIRED.PAYMEN TWILL BE WIDE AS OUIUNEO ABOVE N! " OVE r E cm SEP 2 2 2016 RISE60 Shawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 ENGINEERING" www.RISEengineering.com OWNER AUTHORIZATION FORM C, -C, (Owner's Narne) owner of the property located at: 4Property Address) (Property Address) hereby authorize I?() (A( -e�j— �Subcontractor) 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 municip ty at e completion of this work. OvVnk-SS igh"alLI q6 I p D 001(` Date 6,2016 The Commonwealth of Massachusetts Department of IndustrialAccidents -_ Office of Investigations I Congress Street,Suite.100 Boston,KA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibI NaMe (Business/Organization/Individual): _AR MR INSAN AIM PO - 95$ Address: APd VER �A City/statelziv: _ _ Phone#: Are you an employer?Cheek the appropriate l;ox: Tape of project(required): — 1.91 1 am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or eart-time), * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. i. ❑Remodeling ship and have no employees nese sub-contractor have � g, ❑Demolition workin', for me in any capacity. employees and have workers' [No workers' comp,insurance comp.insurance.t 9• F]Building addition required.- 5. ❑ erre are a corporation and its 10.❑Electrical repairs or additions 13.❑ I am a homeowner doing all work officers have ex?torsed their 11.E]Plumbing repairs or additions myself o workerscomp. right per y � ' ht of exemption MGL p 12.❑ Roof repairs insurance required,]t c. 152, §1(4),and we have no ' employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also ill out the section below showing their workers'compensation policy information. Y Homeowners who submit this affidavit indicating they are doing all work a-rid then hire outside contractors must submit a new affidavit indicating such, tContraetors that check this Nix mast attached?n additional sheet shewip-g the name of the Sub contractors a_nd slate v;hethe:or no:those entities have employees. if the sub-contractors nave employees,they must provide their workers'comp,policy number. I'am an empl?ver th-a:is oro+,;ding workers'ca.,xrpensatisn t rsitrance for city e.slployee;. Below is the policy and job site information. Insurance Company Mame: j� `_ ('4 K i e r D 1M C y' Policy#or Sclf-ins.Lic.4: ?p W C Ex-pirauon Date: hyo I ) Job Site Address: City/Sfatw,'Zip: �I.An�rf r, /w,4 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 fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.010 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lqvestigations of the DIA for insurance coverage verification, do hereby cerci udder the mitts and. enaltie o erjury that liteiti orinatian providedabove is trite end correct .5_'i na.t._.. . v .� Phone#: q Ya)- 7G �6 Qj rrcial use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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#: A��" CERTIFICATE OF LIABILITY INSURANCE DATE(MMrDD/YYYY) 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(lea) 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?). PRODUCER NAMTACT Linda Bogdanowicz _ InNurance Solutions Corporation PHONE (603)382-4600 Al No;(b03)382-2034 60 Westville Rd A-MAIL lindab@iso-insurance. oDDRESS: cm INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A.Western World _ INSURED-.__Tm^...mm.m...�. INSURER B.HaAt_ilu6 Insurance Group �. ------_�__ Polar Hear Insulation Company Inc INSURER C: _W PO Box 958 INSURER D: WY 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 TYPE OF INSURANCE ODL SUER POLICY NUMBER POLICY EFF MMNDrYYYP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE T OCCUR DAMAGE PREMISES TO RENTED 100 000 Ea occurrence $ NPP8214967 3/24/2016 3/24/2017 MEDEXP(Any one person ., .$ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 x POLICY❑JECT ❑LOC PRODUCTS-COMP/OP AGG $ 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 iPer accidents_ R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ X 000 000 DED RETENTION$ AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION I H- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORtPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory,In NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under —.�__,..,....,_..,..,,W_..�.. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,rnay be allerhod If more apace 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 Raglia/SJA ©1588-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 rmtdn t N 611012016 Preview.Certificates of Insurance DATE(MmmoffYYYI ACC]R© CERTIFICATE OF LIABILITY INSURANCE 0611a1201s 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(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,aortaln policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such ondorsement(s). PRODUCER CtINTIMY NAME: PHONE FA Automatic Data Processing Insurance Agency,Inc. ac.No 1:x1: (AIC.Noy 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 IRSURER(S)AFFORDING COVERAGE MAIC 0 INSURER A: NwGUARD Insurance Company 31470 INSURED INSURER B; POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: 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 REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCU41ENT 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 LTR ITYPE OFINSURANCE INSO EXF WVD POLICY NUMBER MINOOIYYYY WDINYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAVAS MADE M OCCUR PREMISETFS[aoocurrance) S MED EXP(A.),onc pars..) S PERSONALS AIN INJURY $ GENL AGGREGATE LII.bT APPLIES PER: GENERAL AGGREGATE S f CLICY PRO, LOC JECT PRODUC[S-CCF.1P:10P AGG 5 OTHER S AUTOMORILE UAWLTTY (Ea ixcidcns) S ANYAUTO 80OILY INJURY(Pm pawn) 5 ALL OPINED AUTOS SCHEOLLEU AUTOS BODILY INJURY IPS asideM) S $QWOHIREDAUTOS AUTOS!",TIED (Pre xrid-, 5 S UMBRELLAUiAB OCCUR EACH OCCURRENCE S FKCESS DAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS I S WORKERS COMPENSATION X STATUTE ER ANY AND EMPLOYERS'LUSB)LIY A OFFI EiiLl.METORE CLUDED7ECUTI� Y�NIA N POWC772268 9110112016 0110112017 E.LEACHACCIDENt S 1.000,000 (Mandatory in NH) E.L.DISEASF-EAEFAPLOYE 5 1,000,000 II Y..dascrb.und, —FT Ems.DISP_nsE.roucv ureic 5 1.000,000 DESCRIPTIONOF OPERATIGIr'S ba— DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICt,ES(ACORD ipt,Additional Rommks Schnd.le,may ho attachod H more spam Is roqul:ed) 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 ftl FII— AO 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https:tiadpia.adp.coinficertcf/#/r-un/previeivl5O3587/900012975 1!1 Office of Consumer Affairs and Business Regulation q. 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home hnprovement Contractor Registration Registration: 102726 Type: DBA Expiration: 7/212018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Update Address and return card.Mark reason for change. SCA a Co 2OM-05111 � Address [-] Renewal © Employment ❑ Lost Card _. _`.. Office of Consumer Affairs Rc Business Regulation License or registration valid for individual use only 41/1 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Registration: 102926 Type. Office of Consumer Affairs and Business Regulation Expiration7!2/2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION CO. Vincent LeBlanc 51 SO.CANAL.ST.#k5A LAWRENCE,MA 01841 Undersecretary iRdot valid wi#hout signature - IF� i assac.lau.usetts -'Department of PuWic Safety Board of Sauk ing Regulations and Standards Q`k�sa�ia trw.te¢tat.`'�aatrar&-,j+;,at�'�Itaa:Fs1k� -ur r'rose: CSSL-106017 a PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 038155 ry ExE l-rations 'rsrr u'aaost as r'ar 04/28/2018 a