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HomeMy WebLinkAboutBuilding Permit # 1/4/2017 NORTH. BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �ro en Permit No#: 6 9CDate Received / ' I Sys ATn•� �c� SgCHU Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 7d e 1-0 v� UZ Print PRO TY OWNER L� 1ti ,, 4 �� 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 ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodpla�rr ❑Wetlands ❑ Watershed ©►strict ❑Wateriewe F n^ DESCRIPTION OF WORK TO BE PERFORMED: Qt) P4 - V e v.'f e ova i /4 ► 3D �� !t V,- 'A G rpt r Identification- Please Type or Print Clearly OWNER: Name: to o L1 Q;c. v\ a Address: 7a � 1k1PA1J/Y,VY' /?) n p, 4, r f Contractor Name: e-rr �` °t 8 (A vi Phone: Email: Address: J- P� 5 i ept4®s )1e w Supervisor's Construction License: 0 6 7 Exp. Date: Home Improvement License: -Exp. Date: z P ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PEJO S.F. Total Project Cost: $ 03 �� , ata FEE: $ 3 Check No.: 76F 7& Receipt No.: r `�(o NOTE: Persons contracting ith nregis eyed contractors do not have access t^thiOguaranty fund WORTH own of ndover . No. _ oLAKE h , ver, Mass, ®� CpCKK Kl WiCK 1' RAreo U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ...,. ....4_b.btomc.................. ..... .., .. ......... BUILDING INSPECTOR ...... ..... . �� Foundation has permission to erect ........................:. buildings on .,..... ......... .......... ..... .. .., ., .,........... Rough t0 be OCCupled aS ..................�� ....,. ... ... .... .c....I.CO.1 00/4 V......... Chimney provided that the person accepting this permit shall in very 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT A Rough Service .. ..... .. ....... £BUILDING INSPECTOR Final r GAS INSPECTOR Occupancy Permit Required to OccupyBuildin 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. rad lea this rr reemc}nt is ral;icic. byrand rr actin f I I TICIPATING CONTRACTOR I I.co 1,opia no 705 Middleton Rd North Andover,MA 01845-6341 Site 117:500050267105 Project 1D:P00050307137 Customer 117: C00050268885 � ,In 7 +r����� '/ Lo�i� Contract 117:20161203 WORK 68 Cummings Park Dr.,U obUrn MA 01801. Office: (781) 305-•3319 Ext. 1.20 Contracts can bo sant to; Description Quantity Location Propavent 2'or 4' 36 Attic $137.00 Attic Floor Open Blow Cellulose 7" 554 Living Space $047.02 Vent bath fan to roof flapper 1 Attic $120.21 Damming 100 hllA $210.00 Sub Total: $1,333.71 Utility Incentive Share $1.000.20 Customer Contribution $333.43 Printed:12/3/2016 Page 2 of 2 Total '&".ailtrrrlt�1� Nice arid �tyt"ttC.i"11„ C�"1Ot'�ttirr W Flon`leWorks Energy a1;1 e(n to perform the above described work, furnishing lhe' n,iaterial ;1nd l abol"for the list("a4:1 total price, ["ayme nt of the customer c;earltrih7tlt.iorl is expected upon completion of the work. Custorner: i netum Date. 1J/3 Cell l`h011e. 11 (uscef fia�.s�e:i edllllr�lrl purposes nrtly): � �(� � _�'���� ��� > Contractor Signaturry: Date: LIMITED TIME OFFER:The prices and incentives offered in this contract are subject to change in accordance verity the sponsoring Utility Mass Save Home Energy Services Program offers. I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street z� Boston,MA 02111 wipw.mass.gov/dia Workers' Compensation Insuralnce Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information POLAR BE IN900MON Please Print Legibly Name(Business/Organization/individual): €'O BOX 958 ANDOVER,MA 01810 Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with_( 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI, 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 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. tContractors 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 arts an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: S1 A� :7'Yi o f4 Ict e 1 t Policy#or Self-ins.Lie. 1>ow C y 0 Expiration.Date: gyt Job Site Address: 7 D -- r­-4a vk U City/State/Zip: 1 lA J1Y r P, WA 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 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. 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 andpenalties of perjury that the information provided above is true and correct. Si nature: 12A� �^' _� Date: ! Phone 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 Cleric 4.Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: 113/2017 Insurance Services AC R CERTIFICATE OF LIABILITY INSURANCE bATE(MRV°DlYYYY) 01/03/2017 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)leu of such endorsement(s). PRODUCER cUNTACT NAME: Automatic Data Processing Insurance Agency,Inc. �uNc No Ext): k'C,No): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERIS)AFFORDING COVERAGE NAIC# INSURER A: NorGUARD 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: 598370 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. ALFULLTR INSR TYPE OF INSURANCE INSO NIVD POLICY NUMBER MWDDIYYYY MMIDDOYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S '. CLAIMS-MADE n OCCUR PREMISES Ea occureence $ MED EXP{Any one person) $ PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY I JECT PRO- ❑LOC PRODUCTS-COMPiOP AGG S OTHER. $ COMBINED SINGLE LIQFT— AUTOMOBILE LIABILITY Ea w6dent S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Pe(accident) $ '. AUTOS AUTOS NON-OWNED S HIRED AUTOS AUTOS Per aeddenl S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE DED I I RETENTION$ I S WORKERS COMPENSATION X I ER 5FA7U7E ER AND EMPLOYERS`LIABILITY ANY PROPRIETOR+PARTNEWEXECUTIVE Y r N E.L.EACH ACCIDENT S 1,000,()00 A OFFI:EFUWNIBF.R EXCLUDED? YD N I A N POWC840361 01/01/2017 01/0112018 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 11000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS bdow E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Addilienal Remarks Schedule,may be attached if more space Is required) Contractor License:CSL 106017 HIC 102726 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. 120 Main st North Andover,MA 01845 AUTHORIZED REPRESENTATIVE )TI ILL Q 19882014 ACORD CORPORATION.All rights reserved. ACIDRD 25(2014!01) The ACORD name and logo are registered marks of ACORD https:lladpia.adp.com)ISExtemallappluidex.html`7clientid=2037315&reg1IestFrom=run#!home 111 A�®0 DATE(MWDaNYYY) CERTIFICATE OF LIABILITY INSURANCE 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(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 endorsemen s. PRODUCER NAnA°T Linda Bogdanowica insurance Solutions Corporations PHONE (603)3$2�ii6t10 No):(603)302-2034 60 Westville Rd E-MAIL ADDRESS:liudahC�it3a-iasuranae.aam INSURERS AFFORDING COVERAGE NAIL# Plaistow No 03865 INSURER A:Western World INSURED INSURERB.NautiluS Insurance (3rOu Polar Bear Insulation Company Ino INSURERC: Po Sox 458 INSURER D., INSURER E: Andover MA 01810 1 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, NOTWNTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CON'T'RACT 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. INSRTYPE OF INSURANCE S POLICY NUMBER MMm Y yy LILY YlY LT LIMITS S COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ®OCCUR PREM SES Ea.&E.nce $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Anyone person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL_AGGREGATE $ 2,000,000 POLICY❑JECOT- LOC PRODUCTS-COMPIOP AGO S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accUent _ ANY AUTO BODILY INJURY(Per Person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NOWOWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Paraccklant $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1 000 000 B EXCESSLIAB HCLAIMS-MADE AGGREGATE $ 1 00.'000 DEDRETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORrPARTNERIEXECUTIVEE.L.EACH ACCIDENT EJ $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORO 101,Additional Remarks Schedule,maybe attached It 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 3600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ( �/ Keith Maglia/SJ'A O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(901,101) Office ®f Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 :borne Improvement Contractor Registration Rspistra#ion: 102726 Type: DBA Expiration: 7/2/2015 Tao 419291 POLAR BEAR INSULATION Co. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Update Address and return cares.Mark reason for change.. sca a 0 sarA•0r17 ®Address ®Renewal ® Employment Lost Card ��c`'r'r`rfirrrnr:nrrrrrr/fr<a�C'%frjrrcrrrrfrrreffs ` Ofnec orConsuruerAffairs&Business Wgiiiniion License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: lo2726 Type: Office,of Consumer Affairs and Business Regulation Expiration: 7/212018 DBA 10 Park Plan-Sante 5370 Boston,IVIA 02316 POLAR BEAR INSULATION CO. Vincent LeBlanc 51 SO.CANAL.ST.45A LAWRENCE,MA 01841 Undersecretary igotvaiid without signature s Massachusetts e Dapartr9 ant of P¢au:ak:Safety w BOWd Q'SUhrling Regulziticaras and StanrLirds �, sarc'tl'�E`CdA"EYt5T3"�3,;L3�,}j"&trasQ'e��a:+atCi�'�' - _ arsa CSSL.A06017 2.EAST TINE STREET Plaistow NH 0380 9121 76(aGC10EaGP srs��sa�ssmaaar 04125/2018 6 i i