HomeMy WebLinkAboutBuilding Permit # 1/19/2017 jA®RTFj '9
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COCHICHIIWl[K tior V
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BOARD OF HEALTH
Food/Kitchen
�T T L L) Septic System
THIS CERTIFIES THAT ...... .... ............... BUILDING INSPECTOR
has permission to erect .................. ... buildings on ... .� ...... �. � ............,,..,. Foundation
,... % ........
� i Rough
to be occupied as ,..., ..t .....� . .. ............. .. ............ �. chimney
provided that the person accepting this permit shall in very respect conform to the te�ms 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESSAnk
CTZ
Rough
Service
............. ... . .... ....................................... Final
' BUILDING INSPECTOR
GAS INSPECTOR
ccupanejE Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises e Do Not Remove Final
No Lathing or Dry Fall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the wilding Inspector. Burner
Street No.
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PROGRAM
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Notal Andova4MA 01845 NoMAadover,MA 01845
JOB DESCRIMON
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RISE Engineering III Contractor Rogletretton No 0100
MA ContractorNegtatratton No 120970
CTCnntractpr RoOEctr+tlaa Ma02012a
RISE
bD 5hawasof Road,Canton,MA 07021 CONTRACT r� II
330502-6335 FAX330-502-345 1.d RAC
Page 9
PROGRAM
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Joseph Dadiego (979)&O 74 f0/19 016 43995$ 23582
BIRV=67taar RtaanW ng864
534 South Bmdf ford Sheet 534 South l3tazl%rd Sttetst
OEMMOcm:e7xus~at+ sum cm Ovki:rav
North Andover,MA 01845 North Andover,MA 01845
i JOB UESCRWnON
RPALTH&5AF&'i'Y: Have your heatftgstom tuned up,end rctesred to be sure that the.undilated Due gisse5 do not exceed 100
Pam per million(ppm)carbon uMottoxido.Weatherimtion%oris cannot proceed until this is fixed
SO.fl0
HAZARD RAMUL We have idmt(fi od Utas thtue aro recessed lights pt+csent in your home.unlim Ito recessed lights are cer'lifted
as 10rated Orisutation Contract Rated)%e ws71 crate a 3'clearance space around the fmturs by ging fiberglass blanket Insulation as
a damming material,no insulation will be installed across the top and clonal cavities%hitt contain recessed fights will not be
butuisted.
$0.00
AIR MALIM Provide labor and materials to seal areas of your home against ssestefltl,excessair leakage. This mark wal be
perfnrmod in canaart with the tete of special toolsand diagnostic tests to am=that your home troll be IcR with a healthful level of
aur etchang�and indoor aur quality.Materials to be u iedto seal your homo can incdude caulks`foams and other products. Primary
area for sealing include air leakage to attics,baseae is,attached gtutigct and other rsahested areas(WAdoiw arc not g eget ly
addressed)This will r"ufro(10)uorking hours A rcWIon in cubic feet per minute(o£m)of air infiltration trill occur.but the
actual mmnber ofofm is not guaranteed.
At the completion of alta%eathtrizetion rwrk,and at no 00tion111 cost to the homeawtuer,a final blovxr deer andlor combustion
safety analysis 011 be conducted by the sub-contractor to ensuro the safety of the indoor air quality.
585D.00
DAWWNQ Provide labor and mntaiafa to install it it Bayer of R-38 unfaeedrfbagless bates to(106)square feet for damming
purgasmKEHP DMGNATED FLOOR.
5217.30
ATTIC FLAT:Provide labor and materials to inslaif a 6'layer of R-22 Class I CeHulow added to(1008)square feet orogen attic i
Wee, E
p KEEP DESIGNATED FLOOR.
VEN'T'ILATION:Provide labor and materials to install(3)insulated exhaust hose with root'mounted napper veal to exhaust f
exisingbatluou n tots).
$356.25
VMrILAT1ON:Provide labor and materials to install ventilation chutes In(142)rafter boys to maintain air now.
5204.00
RISE Bngnearmg will apply all applicshit,eligible Imxatives to this eDnirat:t. You vk11 only be billed the Net amount. Cmrerttly.
for eligible meaaop,Columbia On offers 7S%ineattivcy not to oxcood 67,000 per cdtn&w year,and an Taceartive of 100%for
the Air Sealing measures up to the Elrat 5680 and an additional$340 if savings ate jnstlfted by the w1mor_
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RISE 60
Shawmut Road,unit 21 Cmftn,KA 02021 1339402-s335
ENCINEERINT www.RiSEangineering.com
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OWNER AUTHORIZATION FORM
I, (roil f ,
(Ownees Dame)
owner of the property located at:
(Property Address)
(Pro rty ) i
hereby authorize
(Subcontractor)
r)
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.
Thor Permit will be secured by the insulation contractor,at no additional cost. It Is the homeowners 4
responsibility to close out this permit by co cling their municipality at the completion of this work.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers
31licant Inform 110l'i Please Priv Z.
Name (Business/Organization/individual): C w,)A\k�cr wqEm—A
Address: ?- () BOX _34q
City/state/zip: �w� uN rl 1111.3& Phone #:
Are you an empioyeO Check the appropriate box: Type of project(required):
1. fl am a employer with 4. 1 am a general contractor and 1 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
2.[] 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
These sub-contractors have 8. Dm
eolition
ship and have no employees
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp.insurance. 10.[] Electrical repairs or additions
required.] 5. [) We are a corporation and its repairs or additions
3.[1 1 am a homeowner doing all work officers have exercised their 11.[]Plumbing
myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c, 152, §1(4),and we have no 13.[] Other--,
employees, [No workers'
comp. insurance required.
,Any applicant that checks box#1 must also ill,out the section below showing their workers'compensation policy information.
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 fir my employees. Below is alae paltry andjob site
information.
Insurance Company Name: U
0 C) Expiration Date:
Policy#or Self-ins, Lie. #:
-
Job Site Address: _," City/State/Zip: '04AIR
\ T,&V
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 I
I do hereby certify under the pains and penalties of perjury that the information provided above Is true and correct.
Si ae. Q
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be co lete fficial.
write ,a
Official use only. Do not W11te in this area,to be completed by city r town o
Cityown. Permit/License
City or Town:
Issuing
A t, e one):ssuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector
6.other Phone
Contact Person:
DATE(MMIDDNYYY)
ACO CERTIFICATE OF LIABILITY INSURANCE F10/18/2016
THI TIFICATE 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 certiflcate does not confer rights to the
certificate holder In lieu of such endorsement(s). CON ACT _
Meg Munroe
PRODUCER NAME;
MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE 41
AM,_,- x1. (0 xt. �13)s3s-0804 ... aco)� —N .
ADDRESS:AIL ITlmunroe@m'Cla ton.Com
INSURER S AFFORDING COVERAGE :1INJA
1649 NORTHAMPTON ST.,RTE 5
HOLYOKE MA 01041 INSURER A; ACADIA INS CO
INSURED INSURER__13.
GAUTHIER INSULATION INC 1NSURERC:
INSURER D'
PO BOX 344 INSURER E
IPSWICH MA 01936 J INSURER F:
COVERAGES CERTIFICATE NUMBER: 94521 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE R THE POLICY PERIOD
FO
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 PPD CLAIMS. LIMITS
LTR TYPE OFWSURANCE
{NSR ADDL SUB POLICY NUMBER MMIDDIYYYY MMILIDNYYY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED
PREMISE�Ea ocwrrence $
CLAIMS-MADE r_1 OCCUR
MED EXP(Any one person) $ _
NIA PERSONAL&ADV INJURY $ _-
GENERAL AGGREGATE
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $
PRO- ❑ LOC $
POLICY JECT
OTHER: COMI3_NED SINGLE LIMIT $
fa accident) -
AUTOMOBILE LIABILITY
BODILY INJURY(Per person) $
ANY AUTO BODILY INJURY(Per accident) $ _
ALL OWNED SCHEDULED NIA PROPERTY DAMAGE
AUTOS NO UTOOWNED Per accident) $
HIRED AUTOS AUTOS $
EACH OCCURRENCE $
UMBRELLA LIAR OCCUR
EXCESS LIAR NIA AGGREGATE $
CLAtMS�MAOE $
DED RETENTION$ X STATUTE POTH_
WORKERS COMPENSATION
AND EMPLOYERS`LIABILITY YIN E.L.EACH ACCIDENT $ 500,000
ANYPROPRIETORIPARTNEWFXECUTIVENA NIA NA MARP300327 10/30/2016 10/30/2017
A OFFICERIMFMBEREXCLUDED?
E.L.DISEASE-EAEMPLOYEE s 500,000
(Mandatory in NH)
If yes describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESURIPTION )F OPERATIONS below
NIA
DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool atwww.mass.govllwd/workers-compensation/investigation sl.
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
1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE
' MA 01845 _
NORTH ANDOVER Daniel M.Crowley,CPCU,Vice President—Residual Market -WCR)BMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
i
ACORD 25(20#4101) The ACORD name and logo are registered marks of ACORD
I
woeMoffice of Consumer Affairs and Btsin
s Regulation
10 park plaza - Supe S
Boston,Massae setts 02116
Home improvementlox Registration
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FtegistrS#ion: 1734
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Type= individual
` ExpirOon: 10/1/2018 Tr# 291324
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KURT GAUTHIER , a
KURT GAUTHIER
119 COUNTY ROAD
IPSWICH, MA 01938
Update Address and return card.Msrk reason for change.
Address [ Renewal ❑ Employment a Lost Card
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SCA t 0 20fJI.05111 i
Ce�poaxmrr�ea�l o� � Registration valid for individual use only before the
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0joce of Consumer Affairs&Business Regulation expiration dste. if bbd return t:Business R�nbtion
HOME IN
IPROVEMEW CONTRACTOR o ee of Consumer Affairs and
Regletratlon;- 10 to Park Plaza-Suite 51"
EXPIMdqP9 Individual �ton,MA02116
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GAU1 IllGRi 11.x_1
i-J!CURT GAUTHIER �,��:- �t_� �;!�, _.
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CSS 222««
KURT ROAS"4pR
R Q Sol 344
Wkb MA 019A
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