HomeMy WebLinkAboutBuilding Permit #765-2017 - 20 ENGLISH CIRCLE 2/10/2017AAW 4 1/r BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 9017
Date Issued:
IMPORTANT:
Date Received 9 _/ D , d'td / 7
must complete all items on this
LOCATION 2_e e I rc It
Print
PROPERTY OWNER t4 SS b
/I Print 100 Year Structure yes
MAP PARCEL: ZONING -Historic Distriyes
ct
e yes
Mach p 9
`* -9_-- ..w ��/
no
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
❑ One family
❑ Two or more family
Non- Residential
❑Industrial
❑ New Building
❑ Addition
No. of units:
[i Commercial
El Alteration
Others:
/� iv/alio �
[I Repair, replacement
❑ Assessory Bldg
❑ Demolition
El Septic ❑ Well
❑ Other _ _
❑ Floodplain p Wetlands
,%
❑Watershed District
o Water/Sewer
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1.
UtsVrur i wig yr vv%J"%F% 1t/ (*,» G9N9r ce"I;✓tq �,hSY
Identification - Please Type or Print Clearly Phone: gid 33 - SSS'
OWNER: Name: Src V -e rn 110,"5 5 0
Address: ' d Eno /►5ti
ContractorName: Phone:
Email:
Address: was'% P%mac 5r/a'stoc.✓, i'I
Supervisor's Construction License: /o6oi7 Exp
Date: v2> -f/ ff
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:_
Address:
Reg. No.
. i.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 1167&_,00 FEE: $ ? o- 00
Check No.: ?0 (p ) Receipt No.: 31-S-/ G
NOTE: Persons contracting with unregistered contractors do not have accesstothe guarantyfund
Location rll,:i f 1 S C / /-
No. '7&S- U /-? Date � 40. a V i-?
Check # 7ty 62
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee !0 :3
Foundation Permit Fee $
Other Permit Fee
TOTAL $
�j' Building Inspector
J
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
F
EWERAGE DISPOSAL ❑ Tannin Swinunin Poolsg/MassageBody Art ❑ g ❑ ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Pennanent Dmnpster on Site ❑
THE FOLLOWING SECTIONS. FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
1•
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning 3oard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning _Board Decision: Comments
t
Conservation Decision: Comments
Water & Sewer Connection/signature &Date
Driveway Permit
DPW Town Engineer: Signature:
Located - _
DEPARTME _ te` _
Y _ e Osgood Street
1NT TempDumpster,onsi -ayes tiioe
t;Locatedat°;1241MamStreet r
� �ire�Department�s`i'gnature/date i_ �` r#go i -
3
.CQMMEN
TS -
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
No
Doc.Buildinb Pennit Revised 2014
F
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
OTE: 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/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
TE: 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
4, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 I ECC Energy code
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
Doc: Building Permit Revised 2014
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Fedarat iD A 060006824
IUSE,Engineering M contractor Reptttlon No Vl
MA Ca 'Iffic'n 11,9915todlo s leo 1
,' � �,;. CTContraetorRegistra8ors
RI� � 60 Shawmat Road.Caatoo, MA 02021�+EERING CONTRACT
334-302.6335 FAX X39 -5014M
Page 1
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Steven Grasso, (978)337-8559 10/05/2016 425710 23905
MUM VVNW ,, RHM
20 English Circle 20 English Circle
SEW= CW.ZTAMZW W" CM.UATL
Noah Andover, MA 01945 North Andover, MA 01845
JOB DESCRUMON
T1EAI.TH dt SAFETY; WtaUteization work cannot proceed until the insufficient draft issue is fixed
50.00
GARAGEE CERMC Provide labor and materials to insw 10' R-35 densely packed Class I Cellulose insulation to 575 square feet
of garage ceiling located below a heated tlom area, by drilling holes in the ceilingfrom below. Hoks drilled will be plugged. Plugs
will be speckled and left ins relatively smooth eardition. Finish sanding and touchup primingTpemft will be the custom ees
rn 1; o i uility.
$1096.75
RISE Engineering will apoy allappliehble, eligible incentives to this conmad: You will only be billed the Net amouat Core niy,
for eligible measmvs, Columbia Cas offers 7596 incentive, not to exceed 52,000 per calendar year, and an incentive of 100% for
the Air Seeling measures up to the fast SM and an additional $340 if saves me justified by the auditor.
For the rrofety and health ofyour home's indoor * quality, we will be conducting a blower door diagnostic of the available air now
in your home both before the work is begun, and atter the weatherbmdon work is complete. We will also conduct a full assessrrennt
of the combustion safety ofyow heating system and water heater. This has a value of $90 and is at no cast to you Total
allowable weallmization incentive is $3.110.
$90.00
i
� 2016.
Total: $1,476.75
Program Ince e: $805.06
i:uatotmer alai: $274,69
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NOV 5 2015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
POUR BEAR N
Name (Business/Organization/Individual): PO BOX 958
ANDOVER, MA 01810
Address:
Phone #:
Are you an employer? Check the appropriate box:
1. N I am a employer with (o
4. E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
required.]
5. E] We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
msurance
Y- C T L - S -45 -
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
*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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: igT j� V d : "y S v f i W r' 6-d tM N W
Policy # or Self -ins. Lic. #: Pow, k"f 0 Expiration Date: at lei Lao jb'
Job Site Address: 0 CK9 fi`S 1 !`r be City/State/Zip: 11
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.
1 do hereby certify under th_ pains and penalties ofperjury that the information provided above is true and correct
i�i� ��- Date: - - - �', IO'
Phone#: �I %�^ ydi" nlp
Offkial use only. Do not write in this area, to be completed by city or town offkiaL
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
Contact Person: Phone #:
t=om wolvmom�'."aa
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Nome Improvement Contractor Re&tration
_ Registration: 102726
Type: DBA
Exi*ardon: 712MD18 Tr: 419291
POLAR BEAR INSULAT[ON CO.
Vincent LeBlanc
P.O. BOX 958
ANDOVER, MA 01810
SCA 1 0 MM-Wtt
�fc `�r• unrrarnnrr�l/� a�C-' f�nsrr��r�sclL:
omce orconsumerAmirs &Boniness Regulation
HOME IMPROVEMENT CONTRACTOR
.. Reglsftfion: 102726 Type:
Expiration: 71212oi8 DBA
POLAR BEAR INSULATION CO. .
Vincent LeBlanc
Update Address and return card. Mark reason for cbanaae.
Address p Renewal p Employment 0 Lost Card
License or registration valid for individual use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regnlialon
10 Park Plaza -Suite 5190
Boston, MA 02116
51 SO. CANAL ST. 45A. «,>
LAWRENCE, MA 01841 Usderseeretary I<iotvalid withoutsignatare
? �caSSaCt?ii5c 5-�i8?i~rar,en t ?u,•i,,°f c3a%il
Board Q:- `,S' Tullditia Regulations and .s.?and irds
C.,SL=106017 k
PETER A LEBLANC
2 BASTPM STREET
Plaistow NH 0388 -
=X., �;-a.;on
04/28/2018
'4� o CERTIFICATE OF LIABILITY INSURANCE
FDATE(MNYDDIYYYY)
TYPE OF INSURANCE
b/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(Sj, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the polioyrme) 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 etdorsened s .
PRODUCER
Insurance Solutions Corporation
60 Westville Rd
NACAV. cT Linda Bogdanowic2:
PHONE (603)382-4600 FAX No): (603)382-2034
��:lindabDisc-insurance.com
INSURER AFFORDING COVERAGE NAIC 0
Plaistow NH 03865
INSURER A Mestern World
INSURED
INSURER s Mautilus Insurance (iron
Polar Bear Insulation Company Inc
PO Box 958
INSURER C:
INSURER D:
INSURER E
Andover MA 01510
INSURER F:
-- - - -- - --- — --------...---- ---- --- - .1" V wrvn revmocn.
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.
INSR1LIA
TYPE OF INSURANCE
D
POLICY NUMBER
POLICY EFF
POLICY �
LIMITS
R COMMEROAL GENERAL LIABILITY
ACLAIMS
MADE ❑$ OCCUR
EACH OCCURRENCE $ 1,0000000
DAMAGE TO RENTED
PREMISES a occurrence S 100,000
MED EXP Anyone n $ 5,000
NPP8274967
3/24/2016
3/24/2017
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
% POLICY [:] JEC)- LOC
GENERAL AGGREGATE $ 2,000,000
PRODUCTS-COMP/OPAGG S 2,000,000
OTHER:
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
accident
ANY AUTO
ALL OWNED SCHEDULED
BODILY INJURY (Per person) S
BODILY INJURY (Per accident) S
AUTOS AUTOS
HIRED AUTOS AUTOS
PROPERTY DAMAGE $
Peraccide
$
BEXCESS
X
UMBRELLA UAB
UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
DED -RETENTIONS
$
AN026107
3/24/2016
3/24/2017
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNERIEXECUTW
OFFICERIMEMBER EXCLUDED? H
N/A
per_
STATUTE ER
E.L. EACH ACCIDENT $
(Mandatory In
If yes, describe under
E.L. DISEASE -EA EMPLOY $
EL. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space Is required)
Town of North Andover
1600 Osgood St, Ste 2032
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRFSENTATFVE
th Maglia/SJA�- �T-
O 1988-2014 ACORD CORPORATION- All rinhtr. raaearwa
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 onlanit t
1/3/2017
Insurance Services
ACC v� CERTIFICATE OF LIABILITY INSURANCE
°"�(o�i'
TYPE OF INSURANCEINSD
yYY)
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 endorsement(s).
PRODUCER
CONTACT
NAME:
Automatic Data Processing Insurance Agency, Inc.
1 Adp Boulevard
Roseland, NJ 07068
PNo No, ExthA1C No
ADDRESS,
WSURER(S) AFFORDING COVERAGE NAIC0
INSURER A: NorOUARD Insurance Company 31470
INSURED
POLAR BEAR INSULATION CO INC
INSURER B:
INSURER C:
PO BOX 958
INSURER D:
Andover, MA 01810
INSURER E:
GENL AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JECT LOC
OTHER:
INSURER F :
PRODUCTS -COMPiDPAGG $
VV• -WG I. n rriumre mtjmmwK' an831u WG ff wl/ w mllaan=n.
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.
SR LTR
TYPE OF INSURANCEINSD
VD
=1
PW]CY NUMBER
MM DD
MID
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE DOCCUIR
EACH OCCURRENCE $
PREMISES Eaoocunence $
MED EXP (Any one person) S
PERSONAL S ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JECT LOC
OTHER:
GENERAL AGGREGATE $
PRODUCTS -COMPiDPAGG $
$
AUTOMOBILE LIABILITY$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NOWOWNED
AUTOS
Ee aoddent
BODILY INJURY (Per person) $
BODILY INJURY (Per soddent) S
Per accident $
$
UMBRELLALIAB
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION$
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERlEXECUTIVE
OFFI ERIMEMBEREXCLUDED? Y❑
(Mandatory
If yes,in a
describe under OFOPERATIONSbNow
DESCRIPTION
NIA
N
POWC840361
01/0112017
01/01/2018
X STATUTE ER
E.L. EACH ACCIDENT S 11000,000
E.L. DISEASE -EA EMPLOYE S 1,000,000
E.L. DISEASE -POLICY LIMIT S 110001000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101, Add tIorW Remelts SclyduM,may be attached Nmorespace Is »quired)
Contractor License: CSL 108017 HIC 102728
Town of North Andover
120 Main st
North Andover, MA 01845
ACORD 25 (2014101)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
The ACORD name and logo are registered marks of ACORD
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