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HomeMy WebLinkAboutBuilding Permit # 12/19/2016 . ._.__. of %tItDr q BUILDING PERMIT �_ �+`_"�`�.�.:�� 6 0� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - - Permit NO: Date Received .f0, Ca„�:s� •>` 7,9 p�A.aTe. Date Issued: 2- SsacHusk IMPORTANT:' P RTANT: A licant must complete all items on this page : °r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ..One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial -Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ogg aeeuA nA&— 2daL N Identification Please Type or Print Clearly) OWNER: Name: - Phone: 7 Address: t'( re- C- o Ty„ ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATE4!rED QN$125.00 PER S.F�`Total Project Cost: $ FEE: $ Check No.: Receipt No.: 1 -'--1 � NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund ' � � .� rr � K-.. �+�' S`� ri �' i� �° � '�"r s'ave' �, x� �e . � lf`�`”" r �' � '-, ,✓ a` � EyORT�y own of nover: * zh ver, Mass oLAKE R- cocmcfttwK[ 7 ` 9 A�R'gTED A4a�,45 S U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .. ...... ........ ... ........ ,. .. BUILDING INSPECTOR has permission to ere .............. ..... buildings on .. .. . ,... ...... .. ,,.. . i Foundation �. Rough to be occupied as ........... ............... ` ,.... .. ..... _ _......... 'ti.... . . Chimney provided that the person accepting this permit shall in every respect conform to the terms of the applcati ;n 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. E IT T D Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT ST TS Rough Service ......... .. ....... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit.Re aired to Occupv Puildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. P'ederelmt« RIM ftharbg ttlOmabreotoralloetfli IffACa►�orlontRoit�9T9 i A dim ot7Tdeltcb Sglawft tV t:arrawHlQiiAC&dea,MAD2ltlf CONTRACT 35040243H PAx3&%SV,4W l0 4 PAOORAM 'Qw&.HcS ULM imil Bow= o (781�695.6f9[� U113013 4W74 mm 94 Brent =d Circle 84 Bsentwalld Gtit cla o � I North Andover,MA Nw h Andover,MA 41$43 ' i �-2 EZ i .TOB D EMON 1�At.'ltidt$At=S1YLw wmiceaflcatpmeeAdwtaut b W&WTWAMHBAm— MLLS ATNAWRAL. I S1A0 V A1fi S$AI.1ri�Pnevide lo>tor8nd matsttela load amorymbmapbsWUMA mm lir lsalaaSe.'1t>i:aardc wIR be ° p iacoaoestwl�khticaaoaalspaaEaltnaieaaddfa oa�ateststocrs edzUyaerlmptaWMbold VMaheaM[arofa! aicaoe>�a�emsdindoe�ratrq�r.Mata�to8aupedfoaealyoaFhaaecaabratudoeeaska,�sndot&erpr .Prfam+7► a ate�fFusealEnSlaeludnalcl�8$e60Rl�i�r�BtfCCIICk� ffiidalltEimt�i�BlC�ta(WfadOMi69�ei6011�y sddrex�ed.)'[tdevrttltagoha;8)waddnStanars.A tedudioA taa�ia6satperadasae(dia)a[atr tn&ltrettoavir[l1 oaar,6W tbo aeduat cuuttber alo8n 1m clot mood. At tlso spaaptetieao[t1;a�vmekaadat noaddttiaaad Costta$aelaaw'.a tinct btowardoarandlarmmbunlen aa9 /e ysTr<wid 6aaandaamd bgl tlawb oant Carta rnaaaibo aft Orilla iii w airgm ttgl. 368MD A K SHAUNO ARUM(4)WW4Wm sum is 1)Alvllvl Prov ta6at amemleisto lot71 ioyaeo[ti.38�ot€�oedlEbaBlos�bausWl� rat fbrdwmft » i13S 10 A'1'RfwPLAT:Provide tebaread inaxrtatsm btisa0 a a"tayeru[1L�14 Ciera!f3ellulose added to(3{+�s�Zixstoiapan atUe $34844 ATTIC F7.AT.Prandetatwrm�d nt�aw le9tatl aa8•ta,)ara[it�3$Clea+11>ethdese�W(i t28)aq�vAxlntoycaalde ppL[1LDi�tQTi1Bi'It�TO A1T1C,WCt'CH'PO SMAtd..P011WD 6"P11181ttit�AS6. St,545.36 1Ct�B9VAl+ISs Fmvldafaborendastoto�allr Psltclinedsemictgldflb�lass so(f2�eaibnlo[ lmmowuflmea.'f=DICVJD11SSBYltWrSHAMANI)13A[$CFMA'�MBiD ROOMVA11L'1'S. S44MD A'17'tCAt'.C�.PravldalalaQrBadatam�lifol4setl(i)GGNr[Ini�adpllnwDad.1�2"ItFgtd7tumnnaitboe�w� , e184apsaeaa�eseMWla 1M�caetm�dfarpatattsaothdudeA. 311540 VtiN'1'1LAYtQbl:PeovMa tetare�camlgleislo fitCall vandtatlastduiies fn(4ta ratter6�tom eft flop►. $8440 eABtlCvl7�T1'CB[LINGe;Ptgrrtde lebotead W taslai](t24)iim�f1'+ctalRrl9 ugil3med ias�dtaato toe petitae�x �t1sa iratease<+doaitingeltbelmase s111. $217 W r-aderal 10 8 054406528 RISE Engineering ftl contractor Restatratlon No also MA contractortionlatratton No 120970 A division afThlotich Engtatering 60 Showinut Vall 02,Canton,MA 02021 CONTRACT 339-M-6335 FAX 339-502-6345 Page 2 PROGRAM TM 0WMtAcrwvrrmwwrP onVeM FM CNIA-HES EM a11MUM CUUMURVIMA4 Pa= "WHI; OATS dams yffinapAdw- C Jason Eastman (791)696-6790 11/13/2015 406774 00003 8 84 Brentwood Circle 4 Brentwood Circle North Andover,MA 01 845 North Andover,MA 01845 JOB DESCRIPTION -j,-SCp4nftdngwilI apply all applicable,eligible inmaws to this contract.You will only be billod the Net amount. cumnITY, fbrellgiblc measures,Columbia Gas afrars 75%Incentive,not to exceed 52,000 parcatandaryea r.and an incerike or Ica%rartha Air Sealing measum up 10 tho first s6soand an.additional 5340 irsavings ape justified by the auditor. V. For the salty and health oryour homes Indoor alr quathy,wo w11I be conducting a blower door diagnostic ortho available air flow ino % your home bath before ftwork is btgun,and agar tho weathcrization work Is complete.%ye will also conduct a Nil mastricat of the combiisdonsakiy oryour hewing system and water heater.This has a value or89a and Is at no cm to you.Total allowable %watberizatIon incentive Is 53,110. 590.00 is � �•d,�� ! � rlr i� �.13 sz �, Total: $4,002.70 Program Incentive.* $3,100.99 Customer Total: $892.71 WEAGRES M%Myro FURNIS)i SERvicss.coMPLEM LN ACCMANC13 WiM ADOVaUgGWICATtONS.FORIMBSUMOF *"Eight Hundred Nlnety-Two&711100 Dollars $89231 IMP A"MALBYRM o=M=iPCUffr0=AOFMTU UWANUM a" 0 NqTgjuN TWS CONTRA IMEREARE ANY GLANT01PACES ACCEFMKCGQFCQ9TRACT SATMPWF13RMVTAOUB AMD AR-KYKM"ACCanMVQU A=AU=R=DT0VUMWQKK 30 PAYS A&dPW,� PYLMWWrLLBRU"13ASOUTUMM ARM t s i OWNER AUTHORIZATION FORM i, a S- OP, QST lata Pf (Owner's Name) ov mer of the property located at i y 6v, eo-J t -.,00d Gid` 'a (Property Address) Tioperty Address) hereby authorize (eubca otar) ii an authorized subcontractor for RISE Engineering,to act an my behalf to obtOln a building permit and to perform work on my properbl. I 01,17 Signature AA�ts' Date The Commonwealth of Massachusetts Department of>lndustrial Accidents 0 1 Congress Street,Suite 100 Boston,MA 02.1142017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. 1 TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name (Business/Organization/individual): Builder Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03060 Phone#: 603-324-1984 Are you an employer?Check the appropriate box: 'Type of project(required): employees(full and/or part-time).* 7. ❑New construction 1.®I am a employer with 100 I 2.❑I am a sale proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.) 9. ❑Demolition u 3.❑I am a homeowner doing all work myself[No workers'camp.insurance required.]# 10 E]Building addition 4.[:]l am a bomeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs i These sub-contractors have employees and have workers'comp.insurance.t 14.®Other Weatherization 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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. tCont€actors 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 for my employees. Below is tire policy and job site information. Insurance Company Name: ACE American Insur nce CoMpany Policy#or Self-ins.Lic.#: WLRC 48151553 Expiration Date: 6/30/2017 t .lob Site Address: City/State/Zip: a ©r8;-[�` Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.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 thepains and penalties ofperjury that the information provided above is true and correct. Si nature: z Z Date: Phone#: 603-3241984 official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License#t Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector d.Other Phone#: Contact Person: 0ATE{OMM7201ffYYY) CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE 15 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 have ADDITIONAL INSURED provisions or 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 CONTACT Aon Risk Services central, Inc. PF€OE• FAJ( Southfield MI Office (AUC,No,Ext): (866) 283-7122 ata No,, (8D0) 363-0105 22 3000 Town center ADDRESS: 0 Suite 3000 Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Old Republic insurance Company 24147 TrUTeam Builder Services Group, Inc. INSURER B: ACE American Insurance Company 22667 d/b/a Quality Insulation INSURER c: A TopBuild company 110 Perimeter Rd INSURER D: j Nashua NH 03063 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:670064230317 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 9 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, Limits shown are as requested iNSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY MWZYffi EACH OCCURRENCE 52,000,000 DAWGE TO RENTED 1 CLA€MS•MADE OCCUR PREMISES(Ea occurrence $2,000,000l S I MED EXP(Any one person) $25,000 PERSONAL a ADV INJURY $2,000,000 I` GENERAL AGGREGATE 54,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 3 X POLICY PRO ❑LOC PROOUCTS•COMPfOPAGG $4,000,000 JECT OTHER: f< MWTB 307519 06/30/201606/30/2017 COMBINED SINGLE15,000,000 A AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) O IxANY AUTO z OWNED SCHEDULED BODILY INJURY(Per accident) d AUTOS ONLY AUTOS PROPERTY DAMAGE r HIRED AUTOS X NON-OWNED Per accident 4= ONLY AUTOS ONLY UMBRELI.ALIABHOZrAIMSAIIE UR EACH OCCURRENCE V EXCESS LIAR AGGREGATE DED RETENTION B WORKERS COMPENSATION AND WLRC478601$0 06 30 2016 06 30 2017 }( STATUTE ETH EMPLOYERSLIABILITY YIN All other states B ANY PROPRIETORIPARTNER/EXECUTIVE NIA SCFC47860209 06/30/201ti 06/30/2017 E.L,EACH ACCIDENT $1,000,000 (Mand toWIn EREXCLUOED7 E.L.DISEASE-EA EMPLOYEE $1,000,000 (MandatorylnNH) wI only If yes.descdbe under E,L,DISEASE-POL 0Y L3MI7 $1,000, DESCRIPTION OF OPERATIONS below _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Town Of North Andover AUTHORIZED REPRESENTATIVE I Building Department Attn: Donald Belanger. 1600 Osgood Street, Suite 2035 North Andover MA 01845 USA 01968-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD (-D97 Office v onsumer airs(d us ess e u atron 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne .lmprovem • ontractor Registration Registration: 179141 Type: Supplement Card Expiration: 612512018 BUILDER SERVICES GROUP, INC M RICHARD SCHWARTZ 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 5�'4 Update Address and return card.Mark reason for change. SCA a xrwt tt Address Renewal E] Employment E] Lost Card tJlte [Gariunu✓iuuea�t/o�G4C�/��rrakrc�ri�aelG1 ice erConsumer Affairs&Business Regulation license or registration valid for individual use only MEIMPROV ENT CONTRACTOR before the expiration date. If found return to: office of Consumer Affairs and Business Regulation Rsgistra n:: ., Type, 14 Park Plaza-Suite 5170 Expl - 8� Supplement Card Boston,MA 02116 is BUILDER SERVICES RICHARD SC1-[WAR ��rf`r 110 PERIMETER RD NASHUA,NH 03063 ,s Undersecretary Not valid without signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-105992 Construction Supervisor Specialty RICHARD SCHW4ARIZ 260 JIMMY ANN DRIVE � DAYTONA BEACH FL..: 2114 ' .� Expiration: Goinmissioner QS?2612418 Construction Supervisor Specialty Restricted to: CSSL-IC-Insulation Contractor Failure to possess a currant ariiflon of the Massachusetts State Building Cotte Is cause for revocation of this license. DPS Llcensing Infonnation visit, WWW.MAS5.G0Vf0PS V 9 d 9 V u u d i I