Loading...
HomeMy WebLinkAboutBuilding Permit #792-2016 - 154 HIGH STREET 1/7/2016 1 NORTH q /01H BUILDING PERMIT o �LEo ti o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7° Ia N � Permit No#: Date Received �R°°R�rEo '4SSgc Us�t Date Issued. ItH IMPORTANT:Applicant must complete all items on this page LOCATION /Sal / r Ul► 1 Z)16- ..'Print, ) G- 'Print PROPS. TY OWNER C :k Lr'_S 7t'we` � .� .. �, $ .. - j)a r Pnnt 4 100 Year Structure yes no MAP PARCEL:- �'- —ZONING DISTRICT: Histone District' yes no Machine Shop Village yes o 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 N Others: ❑ Demolition ❑ Other min S v(R rr o S'eptie ❑'1/l/ell s Flo Cp—raiWetlands; . ❑° Ware shye ll®i�trstctl DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: C h f,�5 T'y' -e Phone: 5i 7F ''�V' A Address: /�`� /�r C% Contractor Name: �Tr d` i�� (�vii P.hone: g 7�Yoh -7G3� Eiiiail: fg Address< - � -e 95T - f`✓r � .., 5'� � � �d(A/ Supervisor's Construction License: / d Co.a. ►7. .. Exp.,- Date: .. Home Improvement License: Exp. Date: 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: $ On�� FEE: $ Check No.: 1 (D�'� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the duarantyfund �_. Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4E Building Permit Application 4. Workers Comp Affidavit 4� Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4� Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit � Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (if Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit One To Be Returned Include Two Sets of Building Plans ( ) to Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 4� Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 Plans Subrnitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL k Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ ,Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS A CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS a Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I �. i-lanning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Ternp ®W ste on siteyes; Located at 1►24 Main Street ` y • ..,�,t.:-�.:--..��,-. Fire De , ''� ..•.� ,��.. . �;:s ,, , ,rte` a ' �t� `�,`�- ��`' • ,, t partment gig ature/date r r "i w�, �.• _ �y, a (.,,,j.-IF �,1$.te. jam# h"tyya;( 'y. �� _ _ [+1h__._. T� fl t' •ti _ �•�''{. Y`1.`]�T "�ife�T.li1�.• �.,�'.{)1i��l,i�brEyr��'4]�w ' j g'D'r . " - t .. c•..Nr,-ft r�`:iS'...TE.'�.° ^ '�+.._"g'h:s�.4�.:�+Y Xt"'t'e. !'". a i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 en ,, ' Locatio 1'A-fI � No. � Date 1 r . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ " Building/Frame Permit.Fee $ r Foundation Permit Fee $ A Other Permit Fee $ "' TOTAL $ Y x Check 29 89 6 Building Inspector NORTH own of _ Andover O y+ 0 No. ". hver, Mass, COC"1C"2W1CR9 �ipIA�0 ATEO PP�`��y 1V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .............. .,, ... ..... .. .. ...................:................ ........................... BUILDING INSPECTOR Foundation has permission to erect .......................... buil ings on ... .�.J.'�:.�.. .: .. .. .. .erk........... Rough to be occupied as ............ %. . . ... .... ... '. :. ....................................... Chimney provided that the person accepting this permit sha 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STS Rough ' Service ........................ .... ................!inR ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. , `CQs Wr-( to 72901 Federal ID 0 060406829 RISE RISE Engineering IV Contractor Roglatrallonlar conaaeror n No i re A division of Thlelaeh Engineering ENGINEERING 60 Shawmat Unit 42,Conran,MA 02021 CONTRACT 339.3024115 'FAX 339-502-045 PROGRAM Pogo 1 DEC 1 8 2015 CMA->K>is � roll DATE CUMM wmhxormsh Christine.lee d � `�`– t,.9 -(978)902-0526 12/15/2015 423608 00001 SUM 57REBT - — -- 154B High Street i Rig 154B High Street I Rig aemca WTTAra av OIL"am.BTAMZF North Andover,MAO]845 North Andover,MA 01845 JOB DESCRIPTION AIR SEALING Provide labor and materiels to seal areas of your home agaInst wastem,ezass air leakage.This work will be performed in conoert with the use of special tools and diagnostic testi to am that your home will be left with a hcalthfrl lend of air exchange and indoor air quality.Materials to be used to seal yyour home can include caulks,foams and other products. Primary areas for sealing include air lesimge to attics,basements,anached garages and other unbeated areas(windows am not generally addressed.)This will require(S)working hour A reduction in cubic feet per minute(c6n)of air infiltration will occur,but the actual number of ofm is tet guaranteed. At the completion ofthe weatbetizasion work,and at no additional coat to the homeowacr,a final blower deur and/or combustion safety analysis will be conducted by the rob-contmet r to error the safety of the indoor air quality. S42S.00 DAMMING Provide labor and materials to install a 12'layer of R-38 untaxed fiberglass baits to(90)square fieet for damming purposes. $184.50 ATnC FLAT:Provide labor and materials to install a 9"layer of R-32 Class i Cellulose added to(612)square fed of open atic S87S.16 WHOLE HOUSE FAN:Provide labor and materials to fabricate and install a rigid food Insulating cover for the whole house fee - S209.21 ATtIC ACCESS:Provide labor and materials to install(1)easily moved,insulating cover for the attic access folding stair.A small flat surface of plywood will be created around the opening within the attic.This will allow the caves integral weal erstripping to restrict air leakage. $237.6S VEN U ATiON:Provide labor and materials to instal(1)insulated cthaust base with soffit rmamued napper vem to exhaust eodsting bathroom f m(s). $118.75 VENTILATION:Provide tabor and materials to instal ventilation chutes in(33)miter bays to maintain air flow. 566.00 RISE Enginecriog will apply all applicable,eligible inccmlves to this contract.You will only be billed the Not amoum. Currently, for eligible measures,Columbia Gas offers 75%incentive,not to usroced$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional$340 if savings are Justified by the auditor. For the safety and heath of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the wort is begun,and after the weatheri ation work is complete.We will also conduct a OA assessment of the combustion safety of your treating system and wafer heater_This has a value of S90 and is at no cost to you.Total allowable wemheriration incentive is$3,110. 590.00 RISE Engineering need ID 0 osa"509 M 4 N com� RISEA dMsloo of Tbielseb Eng[mring M►cllt,�� ENGINEERING' 60 Sbawmat Unit 02,Canton,MA OMI CONTRACT 339-92-WS FAX 339-302-fiM Pegs 2 PROGRAM "ascommermEN. WrOBETVmmme CMA-HES aVOMOMM AM WECUS7015M FOR As DEBUMMBELOW euBfWtla PROM CATE CU080 WORKnRB Christine Jee (978)902-0526 12115/2015 423608 00001 WwimsTTTkTT NUM GTMMT 154B High Sbva I Rig 154B High Street I Rig BUM OW.SUM M North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $2,20627 Program Incentive: $1,783A5 Customer Total: $422.82 VM AGRM HEF&W TO FURNM BEWIM-COMPLEM IN A0WR2ANW VMABM SPECRMT10ta MR DM SUM OF 'Four Hundred Twenty-Two$182!100 Dollafs $422.82 LWMFMMPECUPU4PAMMALBYFMENUVgXRMCWTMMAGRMIORM.AUCM=MtNF"DrM=CPIILV"M!CHAR=ACDVMY=AW 0 NOT OW THIS C0NMCT1F7NM ME AM SLAW SPACES- UM'M COUTWAXTM AY BE WfnWPJMW of W F NW SGRARM%TM nATE CV ACLU AW ACCMAMM OF CONTRACT-"M ADM MeWWAYMMAND CD 'm 4==7 U3A AVnmft=DToDor4VVm 30 DAY& DEC 1 8 2015 it OWNER AUTHORIZATION FORM �, C lir zst� u � 7�-• (Owner's Name) owner of the property located at 16 y 4 Zi;Z k7 3' ( Address) ret VKS (Property Address) hereby autlzorizs (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to Perform worts on my Pr'olerty. Ovmaes, Signature 1215 1 �5 Data The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-20-7 7 www.mass gov/dia Workers'Compensation Insurance Affidavit:Buflders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORM- _Applicant Information Please Print Legibly Name(Busincss/Organiration/IMividual): Address: I)- C), 8 0, Y- City/Stateaip: A r v•-t I— �'1 lgD' Phone#: Are you an employer?cheque tie appropriate bos- Type of project(required): Lal am a employer with ( _esrployoes(fun audlor part-time).• 7- []New construction 201 am a sole proprietor or partnership,tmd have no employees working for me in 8. O Remodeling any capacity.[No workeri comp_insurance required) 3.01 am a homeowner doing all work mysdt:(No workers'comp.insurance required.)t 9. ❑D 10❑Buildildingg OD addition 4.[]]am a bomoowner and will be hiring contractors to conduct all wgxlc on my property_ 1 will easutre that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions S Q 1 am a general contractor and I have hired the subcontractors listed on the attached sheet 7b se subcontractors have employees and have workers comp.ins raocet 13.�Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c 14. Other 152,§1(4),and we have no employees[No workcrs'comp.insurance requited.] 'Any applicant that chocks box#I must also fill out the section below showing their workers'compensation policy mformatiom t Homed n3cs who submit this affidavit indicating they arc doing all work and thea hire outside contractors must submit a new affidavit indicating such. rContractors that check this box mut attached an additional sheet showing the name of the sub-contracrnrs.and sate wbclbe or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: j7e�(�JG 7 ,�. �' Expiration Date- ._,q/ ,11-,2012 r Job Site Address: I '�`<< lf'j?A l`/ 1 ok t'C- City/State/Lip: n ,i� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as rewired under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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 5250.00 a Jay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. ►do hereby certify under the pains and penalties of perjury that the information provided above is cue and correct 'ziziature: �r, Date 'hone 07 —j(d 06kial use only. Do not write in des area,to be completed by city or town oak-&L City or Town: Permit/License# Issuing Authority(circle one): I_Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5 Plumbing Inspector 6-Other Contact Person: Phone#: POLABEA-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE A 1isrzols 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(ies)must be endorsed. If SUBROGATION IS WANED,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). CONTACT PRODUCER NAME: _ Durso&Jankowski Insurance Agency PHONE 978 688-7000 N _ : 978 688-7001 11 Saunders Street ac No.Win):( ) _ _ Noy ( )-- North Andover,MA 01845 E-MAa _ ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC/f _ INSURER A:Nautilus Insurance Co. 17370 INSURED INSURER B:Safety Insurance Company 33618 Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc P 0 Box 958 INSURER 0: Andover,MA 01810 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR AD�DL SUBR POLICY EFF POLICY EXP LIMITS LTRkT TYPE OF INSURANCE t SD 1 p POLICY NUMBER MM/DD A X I COMMERCIAL GENERAL LIABILITY 1 I EACH OCCURRENCE Is 1,000,000 X NN538691 03/24/2015 03/24/2016 AD�ND $ 50,000 PREMISES Ea occurrence I CLAIMS-MADE OCCUR ( ) _.- 5 000 i MED EXP An one person) $ , (Any _ _ PERSONAL&ADV INJURY $ 1 x000,000 GENERAL AGGREGATE _ I s 2,000,000 ENT AGGREGATE LIMIT APPLIES PER: __ —_ _— X POLICY JEC7 LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY f _(Ea accident) 1$ 11000,000 01/04/2016 01/04/2017 BODILY INJURY(Per person) $ B ANY AUTO 2100926 I ALL OWNED (v SCHEDULED l BODILY INJURY(Per accident) $ AUTOS ^ ANON-OWNUTOS O I DAMAGE $X HIRED AUTOS PerraccidenAUTS ------ - i UMBRELLA LIAB X OCCUR I EACH OCCURRENCE E $ 1,000,000 A EXCESS LIAR CLAIMS-MADE IAN019284 03/24/2015 t 03/24/2016 AGGREGATE $ DED RETENTION$ I _ WORKERS COMPENSATION i STATUTE I I ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTIVE ❑ E-L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L..-D.ISEASE-EAEMPLOYEEI$ _ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 ACCORDANCE WITH THE POLICY PROVISIONS- 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE' Z 00 1/412016 Preview:Certificates of Insurance ACORo® CERTIFICATE OF LIABILITY INSURANCE GATE(MMIDDIYYYY) lk-.�' 0110412016 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(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 endorsement(s). PRODUCER CO N C NAME: PHONE X Automatic Data Processing Insurance Agency,Inc. Arc.No.Ext): ac.Not 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC d INSURER A: Nor-GUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC PO BOX 958 INSURER C: Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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 REOUIREN-1ENT.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. INSR LTR TYPE OF INSURANCE IN SD WVD POLICY NUMBER AUUL (MM`DOtYVYY POLICY i (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS WOE FlOCCUR PREMISES iE occurrence) S I IEO EXP[An one —M S PERSONAL&ADV INJURY S GENL AGGREGA FE LIMIT APPLIES PER: GENERALAGGREGATE S –1R POLICY E C LOC PRODUCTS-COI.IP:OP AOG S OTHER: S AUTOMOBILE LIABILITY uoi;iBiNEu SI'GL .0 S (Ea—dents ANYAUTO BODILY INJURY IPr.W.oni S ALL O.-VNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per mcidenU S NON-OVINED i0't AT: L S H:IREDAUroS AUTOS (Pu amdenll S UMBRELLALWB OCCUR EACH OCCURRENCE s EXCESS UAB CLAIMS-AMDE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION U AND EMPLOVERS'UX ABILITY 'iK TUTS ER MY PI2UPRIETOR�PARTNEREXECUTI%E YIN E.L.EACH ACCIDENT S 1,000,000 A OFFICER3$TJBEREXCLUDED? Y❑N/A N POWC772258 01101/2016 01/01/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1.000,000 It ve$.descdbe undue 1.,000,000 DESCRIPTICNCFOPERAn ONSb&— E.L.OISFASE-POUCYUMIT 5 DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(ACORD 101.Additional R—k.Schedule.may be amehed if rn.—pace is requBed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TheilSCh Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,R)02910 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION-All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD l ijj)eSSRegdefion pC of Consumer Aff�s an Suite 5170 10 par kPlaza- 02111 BoSton,MosachuseUs tovem� �tor Rei °n e Conga. :_ ljom � Reg�,OaT 102726 --- Type:. DBA Tr# � irmsor TI?1Z016 POLAR BEAR 114SDLATIoN co, Vincent LeBlanc P.O. BOX 958 = -__ ressonfor ettang- ANDOVER, MA 01810 :. - -"_ Upda#e AddrM and retara cs Lost cera i suiployment Address OP5_CAt €+ 012ts " 9 �{}3S53C1eca=m=no 1istys ;�ts en?duitisliac(iSiaasr=c=tS� Board a B:; cj-rig Regu;aty C„nstruccilm Sureni+jfr Specialty ') cssLmrsc ? f PETRA I.BBIA!C 2 TPIQ� yitETT . IFAS h Plaistow iK 03W vumrniss�uner TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:_� Date Received Date Issued: zo -11 IMPOR ANT:Applicant must complete all items on this page LOCATION 000 PrintPROPERTYOWNER - ,�'`� Print MAP NO: 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 Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: c / , Identif!nn. Please Type or Print Clearly) 177 OWNER: Name: ktiv,�� Phone: 7- Address: CONTRACTOR Marne:. C � ' Phone: 01 y Address Supervisor's Construction License:: Exp. Date: Home Improvement License:, Exp, Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. n Total Project Cost: $ 0 FEE: $ r Check No.: O 7�U=5 Receipt No.: 2ZJ y NOTE: Persons contracting with unregistered contractors do not have access to he guar ty fund ignature,of Agent/0wner Signa#ure of contractor 4 i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to'lnclude Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe: Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans RA DISPOSAL TYPE OF SEWERAGE D S OSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales . Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 6 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes y no Located at 124 Main Street Fire Department signaturel:date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date i---................. --._..._._............._....................---..._.....__.........................--—...--.............---.._.._..__...... .._............----.............. _....................------.....-..............__._........... Doc:.Building Permit Revised 2008 Location/ No. Date MORTN TOWN OF NORTH ANDOVER - � �h O F � 9 * ; ; Certificate of Occupancy $ J�CNUs Building/Frame Permit Fee $ ter Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22541 Building Inspector NORTH T0 0 4Andover No. 3// _-_ = dower, Mass., Z-0 O LAKE COCMICMEWICK V 7�ADRATE `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System /C `�� BUILDING INSPECTOR THIS CERTIFIES THAT.... ..-I.....q...................... ....... .............................. ........... ............................ .................................. Foundation has permission to erect.... .................... ......... buildings on ..,�.� .......�tl.................................................... Rough t0 be occupied as.......... .. .�.. Chimney p' ...... . .............................................kc, ,n .....,Si G...��t.. . .....:......... provided that the person accepting t i permit shall in every respec" t diinform to the terms of the application on file in Final this office, and to the provisions of t e 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 CONS U N STARTS Rough ::.....:.... Service BG INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. - s DATE ACORDTM CERTIFICATE OF LIABILITY INSURANCE `MWDDNYYY) 09/10/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Prescott&Son Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI LATE 963 Eastern Avenue HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Malden, MA 02148 ALTERTHE COVERAGE AFFORDED BYTHE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER fA Savers Property&Casualty Insurance Corn an 1 31771 Dempsey, Eric INSURERB: 7 Richardson Sreet INSURER C: — Billerica, MA 01821 INSURER D: INSURER E 6 COVERAGES tI THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWI7Ht3TANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR[MAY PERTAIN, THE INSURANCE AFFORDED'BY THE'POUCIES-DESCRIBED HEREIN IS'SUBJECT TO'ALL-THE-TERMS,EXCLUSIONS AND CCINDITIONS-OF SUCHPOLIC.ES.--= -- ----- AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. y ISR ADD11 TYPE OF INSURANCE• POLICY EFFECTIVE POLIO EXPIRATION f LTR INSRD -'POLICYNUMBER DATEIMWDDIYY) DATE(MMMDIYY) LIMITS 1 GENERAL LIABILITY EACHOCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(Each Oceurence) CLAIMS MAGE❑OCCUR MED EXP(Any one person) ( $ it i ` PERSONAL&ADVINJURY { $ _ GENERAL GATE i -s GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG � $ �. POLICY JEECTT LOC ...:. _ ..__. .., .. -'"` .. _ _..... AUTOMOBILE LIABILITY COMBINED SINGLE LIMB l $ .. _ __._. ._ ......_... _ _... _.:.. ... _ (Each accldent) . . t. . ANY AUTO ALLOWNEDAUTOS - - BODI LY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per acddent) PROPERTY DAMAGE (Per acoidortl) $ GARAGELUU3ILITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHERTHAN E%,ACC $ AUTO ONLY: 'AGG $ EXCESSRIMBRELLA LUIBILTTY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE v - - AGGREGATE I $ . 1 DEDUCTIBLE i P $ RETENTION $ $ WORKERS COMPENSATION AND WC STATUTORY OTHER EMPLOYERS LIABILITY UMTTS i ANY PROPRIETORIPARTNERIEXECUTNE $'100,000 OFFICER/MEMBER EXCLUDED? �t E.L.EACH ACCIDENT Ryes,describe under AR0426077 09/16/2009 09/16/2010 E.L DISEASE-EA EMPLOYEE SPECIAL PROVISIONS Belau I $ 500,000 E.LDISEASE-POLICY LIMB w $ 100,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS).VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - -- - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL J Q DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE SLI TION OR F ANY KIND UPON THE INSURER, AGENTSITS OR ! AUTHORIZED REPRESENTATIVE 'I.} 1988 46, GTl��anvmonu�ea n�.✓�aaacu/uraeQ2.,. Board of Building Regulatloas and Standards = HOME IMPROVEMENT-CONTRACTOR - Registration: 150272 Explrat�on 3121/2010, Tr# 265538 `Type individual _ ,rte DEMPSEY CONST&ROOFING ERIC DEMPSEY `i 7 RICHARDSON ST `_ BILLERICA,MA 01821.--_, Administrator: A Y Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 99681 Restricted to: RF,WS,DM ERIC DEMPSEY 7 RICHARDSON STREET BILLERICA, MA 01821 Expiration: 5/2312012 Conunissioner Tr#: 99681 i 1 i •f i Sep 24 09 05:07a OEMPSEY ROOFING 978-362-3102 p.2 Dempsey Construction & Roofing Specialists 7 Richardson Stnmt �Wbhgille►i(�,Wp1821 878670-8804 Proposal �. Cu9tomer marne Gale Apkariart Date 9/2.5/09 Address 134 High Street Order No. City Nath Andover State Me ZIP Rep, Phone 978407.3829 Fax 978.682-8869 .08 City Right sift only.dols not ins.beck porch roof Unlit Price TOTAL ' Install V mill aluminum dnp edge around entire perimeter. Instal IKO Aristocrd Duet Brown roMing shingles over existing one layer, Install new stiingle over ridge vent. Re-use base fasitirtg/metal vent. Caulk around 4 skylights. Remove all roofing debris. This Is a labor,materials,dump and pemWr proposal. Proposal Is good for 30 days from above date: Please make all checks payable ID Eric.Dempsey Payment DOW$ 0 TbMs Balance Check A6nus TOTAL L $2,900.00 , $4,280.00 down for materials' remain0ar due upon completion Office Use Orgy Signature of wcept+snea The Commonwealth 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 Please Print Legibly Name (Business/Organization/Individual): —<se' a"-V- Address: a City/State/Zip: .�,� �I .G i��'( Phone#: Ct.7 (� ]O Are you an employer? Check the appropriate bog: Type of project(required): 1.[ I 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. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.]. 13.[:] Other *,-sy 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.. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: 4.1 a C, z5 7 7 Expiration Date:_&Ib )o _ I Job Site Address:_ I � y l-t t Cs I� �� City/State/Zip 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 de he aims and penalties of perjury that the information provided above is true and correct Signafore: // Date: • 1 ) p Phone#: 9 -7 �_ (.� 7 d " -je 9 v L� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Liceuse# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of.a.deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s), address(es)and phone.number(s)along with their;certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. .The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current . policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in . (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.21.11 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-72.7-7749 www.mass.gov/dia