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HomeMy WebLinkAboutBuilding Permit # 1/18/2017 BUILDING PERMIT of OORT TOWN OF NORTH ANDOVER 0 rn APPLICATION FOR PLAN EXAMINATION xe, Permit No# i I Date Received ArEv 0 Date Issued:A�11 CH L_ IMPORTANT: Applicant must complete all items on this page LOCATION 9 Q) P 11_A'J.S- V, Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT::_, Historic District yes no Machine Shop Village yes 0 _TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building IK"b" ne,family ri Addition El Two or more family 11 Industrial Iteration No. of units: 11 Commercial L1 Repair, replacement F-1 Assessory Bldg 0 Others: D Demolition 0 Other DESCRIPTION OF WORK TO BE PERFORMED: a. 14-1 v cr\, a-1 r� 1dentification- Please Type or Print Clearly OWNER- Name- �L \,Iu Y3 Phone: Add cess: 1C R� k ------------- ----------------1............. Contractor Name: Phone: cl 'IT) "3 s- Email: b <t M-1) no Address:J PoilbX 244 Supervisor's Construction License: Exp, Date.- sJ -t.rj Home Improvement License: 3�d i Exp. Date: i. ........................... ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3'1 -3 1 - 1,0 FEE: $ 14"'T Check No.: Receipt No.:--- r NOTE: Persons contracting withunregistered contractors do not have access to the guaranty.fiind 'i 7/7,7. M11 IAOR HTown of. '9 2 �� 4Andover . ® �• ?:. R 0 No. � 1 Cj19 a 14 11 co[Hitnlw a h"I" ver, Mass, If S U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System m THIS CERTIFIES THAT ... _ BUILDING INSPECTOR ..... � Foundation haspermission to erect .. p ........................ buildings on ..01%.x... . ...•. ..... ....... �i............ j Rough to be occupied as a Chimney provided that the person accepting this permi 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 IT S ELECTRICAL INSPECTOR As LES CTI - Rough Service .............. .... .......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit REquired t® Occupy 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. Burner Street No. Smoke Det. CLEAResult® CONTRACT FOR PRODUCTS 1 SERVICE WORK This service is brought to you through support from you(local Utility This Agreement is made by and among . 1}t Ytsrl a and r CURARestrlt 9Q Blue Ridge Rd, ' North Andover,MA 01845-2117. Attu HES Site ID:500050237500 � 50 Wasihtngtun Street,Suite 8000 pmjeet ID.POOOS0272490 Westb+3i aug11,MA 01581 � Customer ID:C00050239150Federal ID No.2224671.70, "contract,)D:201d1215_ASHA.) (Mail completed contract to address above) L DESCRIPTION OF WORK TO BE PERFORMEDOf Contractor wilt perform or cause to be performed the following work on these"1?rentises"in professional manner and incoaccorporated ��fire feints n this Contract,inctuding the attached mcommendationslwork order describing the work in detail(the"Warks wlucli are ineorlwrated herein by reference DesrAp lon. 12uafttity I,pcatlon .20 62.5 CFMSQ Per Idnttr 10 Llvi S Perform Alt Sealin $t 1 Lmng SRM260.23 Attic Stair Cover Thermal Barrier with 3 NIA $89.54 Door$+He0 $82.77 ExteriarUaorWealher;sVl 3 WA Sub Total: $1,265.74 utliny Inc,$ntiva Share $1,255.74 Custtanuw ConMbudon $0.00 MIMI ` Printed:12115MIS Page 3 of 1 For afflce use only II. PAYMENT _as a Deposit Wwable Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:� --�• 00 &contract to CZEAReauit,Attn*JWS,50 Washington St-, to Cf EAReavlt upon signing the Contract(not to exc f3 v e retail costs).Man eheck Ste.8000,Westbnmugh,WA 41581.Fina]Payment:b - as the final payment for the Work shalt be payable to the Independent l installation Contractor("nool)upon sa Zenon or the Work.Customer understands tbathe/she wrfl not be regwreo to par �si`z incentive Share la fire Contract price in the atrtoimt of S esus individual line items and/or previous incentives inky increase or decrease the size of the i3tility Incentive Share. III.DISPUTE RESOLUTION thesm4mitsuchdoputrawapsivmsewbitrobon iZte RC and Custamtr hereby mutually agree iai adwanes tiv�tirt the event drat fife ilCl�aReg"an (and rstonrersha0 be fruited to submit to suds adguatm as provided irr M G.l,c 142A service which has been aplaaved Nr the Office of CQZjRanPr l�air5 artd l3�rsiru_� You may cancel this agreement if it has been signed by a party at a Place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third Business day following the signing of this agree ent; DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Alt)�� 1) Indicate your selee Ili Px"7- plicable therwt here"y f yo assign.a Cust r 1dw_y Iafib t 4N � • -Irl 1P�.c p to Contractor m, tgaiatrrre Name of CIAF.AFtesult Rep tative[Printer!) � ruirfroirir ONS f oft TRE r EVER"- 220x12-Ri-16 CLEAResuit� CONTRACT FOR PRODUCTS 1 SERVICE WORK This service is brought to you through Support from your local utility This Agreement is made by and among r s Ilk Yin arnd g€j314e Ridge Rd CLEAResult " North Andover,MA 01845-2117 Attlt:HES Sill te 6:800050237500 50 Washington Street;Sult;e,3000. >D:Pf1P000502'72490 - Westborough,MA 0168.1 Project ; Customer lD:C00050239150 ( Federal ID No.22M7170 Contract ID:20161215_WORK A3sii campletsd contract to address above) I, DESCRIPTION OF WORK TO BE PERFORMED Contractor will perforin or cause to be performed tate following work on these"Premes"isin a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(tile"'Work")which are incorporated herein by reference; Descrlptlon Qua>dliy Lociflon Attic FI 4 SIOW 8lfuktse W 1.336 Llvi $1.863.$2 Or a t]ammf W NIA $131.40 Pro avant 7'or 4' 84 Attic $321.72 Vent bath fan to roofftP9T 2 Attic $258.42 SubTatal:- $2,675.A6 Uttilty Incentive Shane $2,00100 Customer Cort~on $675.46 Pritnted:'1?I15d2IG Page 20112 for office use only II. PAYMENT �S J as a Deposit payable Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as followsPayment#1_ to CLEAIYestrlt upon signing lite Cautr t{not to a ccef the dotal retail costs).Mail check 8'c contract to CLEAReanit,Atte:MS,50 Washington SG, Ste.8W,wesmorough,MA 01581,Fmtd Patyment;$_4$11R. l • as the sinal payment for the Work shall be payable to the Independent Installation Contractor "Inc")upon sa r com�jI tion of the'Work.Customer understan&that hetshe will nal be required to pay the Utility Incentive Share of the Contractpdce in the amount of$ Q z+"Changes tu-individtmI line Items andlarprevious incentives may increase or decrease the size of lite i7tl]fty Incentive share. Ill,DISPUTE RESOLUTION ' 'lbe IIC and Cus(omer hereby mwmanlly agree in advanoe that in the event that the 11C has a dispute�this Contract;the IIG mat subtnits tr ion as to prodded in arbtii q 14 service which has been Nvzoved by the Office of C wwnerAffaim and$nmcss negulatlon and O)aomeretall be regdwed to sabmit to sniclt aitritration as provided in in7 G.L c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. C Ila r Indigte yours ted �ere,i applicable (0 3 menial eg a tyou want o assign a { 5 ! t Va h Participating Contractor. C ngnature Ute Name of CL;AResult Repr a(Printed) } TIERM AND.Cv"i ONS.SRMart IM REVERSE.' 22i1a12I21.1r P AuthorizationPermit M, Save Form {d4 lrigskhmt�7a'.aIt thy,a(E tte4*1 - � I Site ID: 50237500 Customer: lk Yun j l lk yun ,owner of the property located at: (Owner's Name,printed) 90 Blue Ridge Rd North Andover (property street Address) iCltY hereby authorize the Mass Save Nome Energy Services Program assigned Participating Contractor listed below to a.ct on my behalf and obtain a building permit to perform insulation and/or weather�ization work on my property. Owner's Signature: Date: 000000000000*00000000000000000000000 FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Nome Energy Services Participating Contractor to the above referenced project: �'i - --- date Participating Contractor sums 3000 a westb*ro�igh,MA 41581 a 1800-480-7'472 CIEAftesulk m 54 Washington Street, for o fico use Only Rev.102015 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 sw www.massgovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print LIegil.11 Name (Business/Organization/individual): Address: -P-0 (3L_)X__34q Phone 4: 5 ILE _r W i�Lp\ r�11A Ci tate/Zin,..\� Are you an employer? Check the appropriate box* Type of project(required): 1.Vfl 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 7. Remodeling 2.[] 1 am a sole proprietor or partner- listed on the attached sheet. These sub-contractors have 8. Demolition ship and have no employees working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp, insurance comp.insurance.t 10,C) Electrical repairs or additions required.] 5. We are a corporation and its 3. 1 am a homeowner doing all work officers have exercised their 11.[)Plumbing repairs or additions 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 req�ulred] Cell out the section below showing their workers'compensation policy information. *Any applicant that checks box#1 must also work and then hire outside contractors must submit a new affidavit indicating such. t Homeowners who submit this affidavit indicating they are doing all $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. a it d lob site I am an employer that is providing workers,compensation Insurance for my employees. Below isthe policy information. Insurance Company Narne, (L Expiration Date: Policy#or Self-ins. Lie. P� ? 7 Q 0 I City/State/Zip: IN oAS.PSY)&WK 01!\ 01 Gt4 Job Site Address- 1i o r3�U t tl,,A* 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 and penalties of erjury that the information provided above is true and correct. Si at L91 Phone#- (3-'te - -S s 1.0 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 Phone DATE(MWWODIYYYY) AC R® CERTIFICATE OF LIABILITY INSURANCE 10/18/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY EX7ND OR ALTER ONFERS NO TlHE COVERAGE A FORpEDGHTS UPON THEATE BY THEDERPO IC EIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE AND THEDOES NO OLDER.UTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, IMPORTA : If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If OGATION IS WAIVED, subject to SUBR NT y require an endorsement. A statement on this the terms and conditions of the policy,certain policies macertificate does not confer rights to the FMARTIN ficate holder In lieu of such endorsemen#(s), T�OAX R �Munroe 413 536-0804 ��Lc J. CLAYTON INSURANCE AGENCY INC E t: ( )rnmunroe m da ton.com : @ y INSURER 5 AFFORDING COVERAGE NAIC# ORTHAMPTON ST.,RTE 5 — 31325 HOLYOKE_ MA 01041 INSURERA: ACADIA INS CO INSURED INSURER B:—� GAUTHIER INSULATION INC INSURER C: �EL — INSURER D: PO BOX 344 INSURER E. IPSWICH MA 01938 INSUAPR 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 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. —�— ADPL SUER POLICY EFF POLICY EXP LIMITS POLICY NUMBER M INSR TYPE OF INSURANCE MIDDIYYYY MM/DQ/YVYY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eaaccurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ ——— GENERAL AGGREGATE $ I GEN'L AGGREGATE LIMIT APPLIES PER: p PRO- PRODUCTS-COMPIOP AGG $ g POLICY❑JECT LOC $ OTHER: COMBINED SINGLE LIMIT $ Ea accident AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED NIA AUTOS AUTOS PROPERTY DAMAGE $ �� NON-OWNED Per accident FARED AUTOS AUTOS $ EACH OCCURRENCE '.. UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE NIAOT DED RETENTION.-; X ER STATUTE ERH ! WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ 500,000 ANYPROPRIETORIPARTNERIEXECUTIVE I N/A N/A WA MAARP300327 10/3012016 10/30/2017 A OFFICERIMEMBEREXCLUDEDT E.L.OISEASE-EA EMPLOYEE $ 500,000 (Mandatary in NH) E.L.DISEASE-POLICY LIMIT $ 500,004 If yes,describe under DESCRIPTION OF OPERATIONS below NIA DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more apace 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. cae wasration date on the ove poic recedes This certificate of insurance shows the policy in force on the status of this coverage that this cert belfmotrlitoredlda daily bssued y accessing thnless the etProof of Coverage bC ve alge Verification e issue date of this certificate of insurance). Search tool at www.mass.govtiwdlworkers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION L OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TION DATE THEREOF, NOTICE WILL BE DELIVERED IN E.WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE MA 01845 NORTH ANDOVER Daniel M.Crow�ey,Ct'Cll,Vice President–Residual Market–WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD DATE(MMIDW/YYYY) 2016 ACp CERTIFICATE OF LIAB11 IL11 ITY 11 I11N11 S 11 UR11 ANCEaN THE CERTIFICATE HOLDER. THIS THIS RTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIHE COVERAGE AFFORDED GH pUTHORIZi=D BY R ALTER T CERT!FIC ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY N END, A GONTEXTEND ORACT BETWEEt1 lLE ISSUING INSURER(S)THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DQES NOT C REPRESENTATIVE OR PRC?DUCER,AND THE CERTIFICATE HOLDSR• statement on this certificate does not confer rights to the IMPORTANT: It the cert Iticate holder Is an ADDITIONAL INSURED, the paticy(IrleierlmuAst be endorsed. If SUBROGATION IS WAIVER, subject to the terms and conditions of the policy,Certain policies may require an endorse certificate holder in Ileo of such endorsements• lCVAME T usher 1413)534-7874 PRODUCER PHONE (Q13)536-0604AM.�a)-- — Martin 0 Clayton insurance Agency, Inc' EMAIL -- ADDRESS: NAIC 4 1649 Northampton Street INSURER 3 AFFORD1Nq COVERAGE NATIO p. 0. Box 989 INSURERA-Nationwide Mutual•-Har"evi�_ Holyoke MA a1a41�Q989 INsuRER B:Allied World Natl Assurance CO INSURED INSURER C Gauthier insulation INSURERP.O. Box 344 INSURER E: -� C. MA 01938 I suR REVISION NUMBER: IPSWICH CL1663001850 COVERAGES CERTIFICATE NUMBER: RM OR GONDITION OF ANY CONTRACT OR OTHER HARE N S SUBJECT 70 ALL TERMS, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE I�SUR6D NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQ(11REMENT, CERTIFICATE= MAY BE ISSUED OR MAY PERTAIN, THE INSURANC@ AFFORDED BY THE COL I=S ID CLAIM LIMITS EXCLUSIONS AND CONDITIONS OF SUCH ADPL I B LIMITS SHOWN MAY HAVE BEEN REPOLICY DUCED F PAID CLAEXP IMS. 1'0001000 INSR POLICY NUMBER EACH OCCURRENCE $ LTR TYPE OF INSURANCE AM-ATE-T RE TED 50,000 Ea occurrence ES L )[ COMMERCIAL GENERAL LIABILITY PREMt 5,000 CLAIMS-MADE N]OCCUR Oti43a87F 7/6/2016 7/6/2017 MED EXP(Any one arson) $ 1,000,000 A }C PERSONAL&ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 2,000,000 PRODUCTS-C0 p AGG S GEN`L AGGREGATE LIMIT APPLIES PER: $ X POLICY I-�d0 LOC C B OS G I IT $ OTHER: Ea accident '— ABODILY INJURY(Per person) $ UTOMOBILE LIABILITY BODILY INJURY(Par accident)s ANY AUTO SCHEDULED PROPERTY DAMAGE $ ALLOMEOAUTOS Peracoident AUTOS NON-OWNED $ HIRED AUTOS AUTOS1 000 000 EACH OCCURRENCE $ i AGGREGATE $ 100„_dfl 9 x UMBRELLA LIAO OCCUR g $ p B EXCESS LIAO CLAIMS-MADE Bg020792125-194985 10/18/2015 10/18/2016 T DED RETENTION$ STA LITE E WORKERS COMPENSATION E.L.EACH ACCIDENT $ o AND EMPLOYERS'LIABILITY Y/N E,L.DISEASE-EA EMPLOYE $ ANY PROPRIETOMPARTNERIEXECUTIVE {�� N/A OFFICERIMEMBER EXCLUDED? } E.L DISEASE-POLICY LIMIT $ (Mandatory In NH) y as,describe under DESCRIPTION OF OPERATIONS below LISTED AS ADDI'1+I4NAL INSURED ON A PRIMARY NON-CONTRIBUTORY DESCRIPTION 01 OPERATIONS 1 LOCATIONS I VEHICLES(ACOROURL GRID Iticnal�rRemorka Schedule,maY be attached 1I more space is required) CLEARESULT, EVERSOURCE AND IA AT7 BASIS CANCELLATION CERTIFICATE HOLDER SHOULD ANY H DATEVE E SCRIBED GCI;I WILL CANCELLED CDEL iVEREDORIN THE EXPIRATION CLEARESULTACCORDANCE WITH THE POLICY PROVISIONS. 1�TTI+1: CO1+7`IRAC'TOR SERVICES DEPT 5Q WA82fITIGTON STRES'T AUTHORIXEO REPRESENTATNE yEST80ROU( H, MA 01581 Daniel Sullivan/MEG ©998B- i4 ACORD CORPORA-M614, All rights reserved. {tte ACORD name and logo are registered marks of ACORD ACO Rt?25(201g101) tenAAM )7ciffaCtOr,COI'T1 pfflce of Consumer Affairs Ste$ 5170 slness Regulation 10 park Boston, Massac setts 02116 Holme Improvement ctor Registration Registration: 173410 Type: Individual Tr# 291320 Expiration: '101112018 KURT GAUTHIER KURT GAUTHIER 119 COUNTY ROAD 1 IPSWICH, MA 01938 U Address and return card.Mark reason for change. y ❑ �ress Q Renewal i✓mployment Lost Card j SCA1 G 2dNtpSlii ' Registratku valid for individusl use only before the ! Office of Consumer Affairs&uminess Regulation expiration date. If found return to: HOME IMPROVEMENIT CONTRACTOR Office of Consumer Affairs and Business Regulation 10 ParkPlaza-Smte 51711 Regiswatlon;�';- M1 Q Plratl _ �e Individual fin,MA 02116 f; 00 �a KURT GAUTHIER �`"_ --' a1 KURT Gp,Ufhl4ER I..-.--..- /'.II �.� r^r$, ..a nni isrsv Duan __ ,:>, log#k } \. � f��l���� � BU"P'M�E�4�G PACCe