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HomeMy WebLinkAboutBuilding Permit # 2/10/2017 NORTH BUILDING PERMIT oFsT�fo '°��� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * 1 a n O 7� 0 I Date Received g_f f 'ti QOR�r °rf¢y�y Permit No##: Date Issued: IMPORTANT: Applicant must complete all iterns on this page LOCATIONm Print PROPERTY OWNER ��✓e`� "r4 S3 b Print 100 Year Structure yes no MAP PARCEL: / Z—ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg I,Others: ❑ Demolition ❑ Other © Wat `d Distract ' ❑S trc d Well Flooclplarn 'k,❑Ulletands f ersl-�c r E DESCRIPTION Ol` WORK TO BE PERKORMED; Lt t F- C Identification- Please Type or Print Clearly OWNER: Name: og�'r,,.S S c, Phone: Address: -)-to cykb$5k Contractor Name: ?:C ° ! �` Phone: q7,F- yr>- 26.3 Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: /® Exp. Date: 7 i ARCH ITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: v FEE: $ ®- 00 Check No.: '7 Receipt No.: 3t-:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund T 0wn o :AF 6Andover ® ~ •_ No. * _ h ver' Mass, '- /y + 4oRATEO s u BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ................ 0 -1041 . !......,................................. .............. BUILDING INSPECTOR V. • `, has permission to erect.......................... buildings on ...... .,.....,.1�i�!l.s�t '!.�!1.............•• ••• .... Foundation Rough to be occupied as .........1.41.&P(Aft....6.4.*. .to........C0.t...AN.. ................................ Chimney provided that the person accepting this permit shall in every respect conform to the t rms of the application Fine 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. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION Rough Service ... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Ruidd ng Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wali To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ...................... c 001 FordomI1000644M—V 29 In Contrad"R No 81 RISE Engineering MA Contractor R"totratk)lo No 1 toq�� g CTCor*afftrR I on Now RISL60Sbawmul Road,Canton,KA 0202t CONTRACT ENGINEERING r 339-502-035 VAX 339-502-6345 poilo I PROGRAM NO.001=021,UUMMINVOROMIUM CMA-IIES MCIUBEDogtm nrour— Steven Grasso (978)337.8559 10/05/2016 425710 23905 20 English Circle 20 English Circle North Andover,MA 01845 North Andover,MA 01845 JOB DESCPjffION HEALTH&SAFETY:Wentherization work cannot praccetl unkil the irtsuflicient draft issue is(fixed. $0.00 GARAGE CEILING;provide labor and materials to install 10"fi-3S densely packed Class I Cellulose insulatit'"(0 525 Square feet of garage ceiling located below a heated floor area,by drilling holes in The ceiling from below. Holes drilled will be plugged. Plugs will be spackled end left in a relatively smooth condition.Finish sanding mid tauch-uplidminglPainting will be the costo uaces responsibility. $1,09635 S -ginecring will apply RISE -iFelisibl-re - Columbia Gas ofTc'rs 75%incentive,not to exceed$2.040 perYoar,and an incentive of ilJfE}6 for ftire Air SvaIZ1I1:u11S UP to the(that$680 and an additional$3A0 if livings aro justified by tte auditor, For the safety and health or your homes indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherizationAvrk is complete.We will also conduct a full assessment of the combustion safety of your 11000i"S System and water heater,This has a value of$90 and is at no cost to yore Total allowable weatheriation incentive is$3,110. $90,00 Total: $1,176.75 Program Ince UVO: $905.06 Customer otal: $271.69 NAE AWW914EMYYOFURNMI SERVIOCS-COMP IN AC ANCEVU AGM SPECM 71 on oullop 27 6 ***Two Hundred Seven -On & 0 oil 01 .1 E,5ffiW, ;TouERAaafajDktUffAMoMoU5WFU 0OW9.00FAWILLOEMAROMM LYON ANY =LFVO"L QtNg"WONANDAMOVAL T1aUA.TU7N the GUAAAMMEMM-11-111 'got AND co�TOR TVAL 0 AL V R A W 30 &We "POW OT SION THIS C CT IF THERE ARE ANY BLANK SPACES HOW:rM COMRACY THDRAWN UY US IF NOV E)MM"Wn"at DATE OF ACCEPTANCE 10 Ila Ac=%4 Of CONTRACT-THZ AW)ft PPJCM6PZ=fWATW"AXV CMDffVM Ann "A try To W ARDARr NUJM ACcuPTED,YOU ACE AWADRUM YO 004118 WWX 30 DAYS, AS SPICIFUU),PAYUM WU IN MADa AO(WILWO ABOVE OWNER AUTHORMATION FOM 455 -e (Owee's Name) owner of to properly iomw st w . per►�) ma►Addms) hereby aulitori�a �fi��t�t��r ,L�c S✓/a 7� ti (Moonteadtor) an euthollmd sdx onft for for RISE Engine ft,tD ad on my beW to obtWn a MOM permit and to peftrm erode an my lroledy. is Data NOV 5 2015 The Conirnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information MEM N N Please Print Legibly Narne(Business/Organization/Individual): PO 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 (�2^ 4. [J I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have ship and have no employees S. E]Demolition working Forme in any capacity. employees and have workers' g F-1 Building addition [No workers' comp,insurance comp. insurance./ 10.❑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 mright of exemption per MGL myself[No workers' comp. 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 At 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[save employees. If the sub-contractors have employees,they must provide their workers'comp.policy cumber. I am an employer that 1s providing}porkers'compensation insurance for nay employees. Below is the policy andjob site information. Insurance Company Name: V Av p C t Policy#or Self-ins.Lic.#: Powe y 8 Expiration Date: 411 .lob Site Address: :)-'D C t(Pie City/State/Zip: 11 Z 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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: �— rQlr7 Phone#: YO;)- POP Official use only. Do not write in this area,to he 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 5.Plumbing Inspector 6.Other Phone Contact Person: #: 9971W W5�1714uwnwe Office of Consumer.Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 702018 Tr4. 419291 POLAR BEAR INSULATION CO_ Vincent LeBlanc P.O_ BO;:.958 ANDOVER, MA 01810 Update Address and return card.Mark reason for cbanae. 0 Address n Renewal E]Employment ❑ Lost Card SCA S ca 2MI.OSM J/f VrrrllJllC J7flr1.'rI/f/of C��nurrrlrrrefls omee or consumer Affners disease or registration valid for individual use only �e l3vsiuess iteguTatioa before the expiration date. If found return ta: ( -! HOfUII"IMPROVEMENT CONTRACTOR office or Consumer Affairs and Business'Regovlmtion 5 Registration: 102720" Type: �? 10 Part Plaza-Suite 5170 G, Expiration. 712/2018 DBA Briton,MA 92115 POLAR BEAR INSULATION CO. Vincent LeBlanc ; 51 SO.CANAL ST.#aA LAWRENCE,MA 01841 Undersecretary i4eY valid Qrithout signature t �l12S5=Gri.iS ';S-057%i;3i C--!'� •��:.,.. ;G•�ctYSi! _ ;SUhdhil C1. eguleRtta s anCJ.�.c:7 ESniC+5 C,5L406017 1. 0. 1 PETER A LEBLANC 2 EAST PIIS STREET _ Plaistow IVH 0386 r�tGs,nr;ar 04128/2018 4 AC®R a OATf(MNYDO/YYYYJ �+-r' 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 DOLS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: it 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,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endoreamen e. PRODUCER CONEACT Linda Bogdanowicz Insurance solutions Corporation PHONE , (603)382-4600 �No_(603)382-2034 60 Westville ltd ADDRESS:lindab@iBo-insurance.com INSURERS AFFORDINGCOVEHAGE NAICB Plaistow Na 03865 INSURER A West:era World INSURED - INSUREiSMaut;ilus Insurance Grou Polar Hear insulation Company Inc INSURF-RC: PO Box 958 INSURER D: INSURER E• Andover HA 01810 INSURER I=: COVERAGES CERTIFICATE NUMBE,R: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. 1NSR TYPE OF INSURANCE ADD B POLICY NUMBER MPflLICY�F POLICY LIMTiS LTR $ COMMERCIgLGENERALLIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE Tq RENTED100,000 A CLAIMS-MAI) ®OCCUR 15ES Ea ocxurrence $ NPP8274967 3/24/2016 3124/2017 MED EXP Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000r000 GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 x POLICY PRO-CT ❑LOC PRODUCTS-COMPIOPAGO $ 2,000,000 JE 5 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMB S Ea aaWa ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(ParaccWenl S AUTOS AUTOS PROPERTY DAMAGE S HIREDAUTOS AUTOS Peraccdent S X UM9FIELLA LIAaOCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAR HCLAIMS-MAOIE AGGREGATE $ -.....Loa bb0 DED RETENTIONS AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION Sfp E ERH TU AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTNE YE.L.EACH ACCIDENT $ OFFICERIMEMSER EXCLUDED? N/A (Mandatory In NH) E.L_DISEASE-EA EMPLOY S It yes,descdbe umder DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.Add@Tonal Remarks Schedule,may bs attached If more space 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 DELIV€14ED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE J� Keith Maglia/S3A � "- b 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r�mann 113/2017 Insurance Services •� DATE(MMIDDIYYYY) ACCPRL7►® CERTIFICATE OF LIABILITY INSURANCE 0110312017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOLES 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($),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 endorsement(s). PRODUCER NAME; PHONE A1C,No Automatic Data Processing Insurance Agency,Inc. Alc No Exr 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURERS AFFORDING COVERAGE NAIC INBURER A: NorGUARD Insurance Company 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSDRER 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. LTR TYPE OF INSURANCE INSD WVD PODGY NUMB CMMIDIVYYYYLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAINIS-MADE FIOCCUR P REM I S ESUI Eaoccurrence $ MED EXP(Any ono person) $ PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POl-ICY❑JE C LOC PRODUCTS»CAMArflP AGG S OTHER: AUTOMOBILE LIABILITY JEa accident $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(P.accrderd) $ H RE=dSAl1T05 AUTOS AUTOS (Per a ddenl) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAe CLAIMS-MAOE AGGREGATE $ DED RETENTION$ _ $ WORKERS COMPENSATION x I STATUTE ER AND EMPLOYERS'LIABILI Y YIN1,000,000 A ANY PRRIMEMBER EXCLNEREXUDEDX ECUTIVE NIA N POWC$40361 0110112017 01,0112018 E.L.EACH ACCIDENT S E.I..DISEASE-EA EMPLOYE $ 1,000,000 (Mandalory In NH) II yyes,describe undex E.L.DISEASE-POLICY LIMIT $ 1,000,000 pESCRIPTiON OF OPERATIONS b g w DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLESIACORD 101,AddRiorul Remarks Schedule,may be attached Nmoro 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 at North Andover,RAA 01845 AUTHORIZED REPRESENTATIVE Cd 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https:lladpia.adp.comlTSExtemailapplindex-html7clienlid=2037315&requestProm=nin#!home 111