HomeMy WebLinkAboutBuilding Permit #926-2016 - 20 ENGLISH CIRCLE 3/1/2016,,A(o� I y A -kW 4 Lr -
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 9z(, -7,61r
Date Issued:
Date Received
I IMPORTANT: ADDlicant must comDlete all items on this Daize I
LOCATION I C PC le -
Print
PROPERTY OWNER 57 7-e (je V,
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT-- Historic District yes
Machine Shop Villaqe ves
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
El Addition
El Two or more family
El Industrial
0 Alteration
No. of units:
11 Commercial
11 Repair, replacement
El Assessory Bldg
JK Others:
El Demolition
0 Other
El Septic El Well
0 Floodplain El Wetlands
11 Watershed District
[I Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
V\ a .4T -*7-1'C '1t15'v1.-71'r1V1 ry 0, —
Identification - Please Type or Print Clearly
OWNER: Name: 5"It V'e'4. (� I -el 5 5' 0 Phone:
Address: -'Io C1\01*'54 CI'I'r
r
Contractor Name: Phone- Peter Leblanc
2. mast Pine Street
Address:
978-407-1638
Supervisor's Construction License: 4&(, Exp. Date:
Home Improvement License:
ARCH ITECT/ENGI NEER
Date:
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost:$ D-000-00 FEE: $ 36-
Check No.: -11 -�) 2, Receipt No.: r-3 6 b (& I -
NOTE: Persons contracftn�wffh unregistered contractors do not have access to the guarantyfund
r\ J - A / 0
Signature of Agent/OlAmer Z Siqnature of contT�cioir
I V
5
Location
No. 2 Date �,v
Check # -�Tj Z,
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $-i-
Building Inspector
Plans Submitted [I Plans Waived [I Certified Plot Plan [I Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art F]
Swhmning Pools
Well
Tobacco Sales
Food Packaging/Sa I les
Private (septic tank, etc.
Pennanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
CONSERVATION
COMMENTS
Signature_
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: -----Zoning Decision/receipt submitted yes
F r' Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/sianature & Date Drivewav Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster -on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
yes—
LOcatea �b4 usgooa z�areei
no
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 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use
LJ Notified for pickup Call Ema
Date Time Contact Name
Doc.Building Pennit Revised 2014
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. 1. 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
o Building Permit Application
ci Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
Lj 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
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
• Workers Comp Affidavit
• Two.Sets of Build in -g 'Plan's (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Copy of Contract
Li Mass check Energy Compliance Report
o 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: Building Permit Revised 2014
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RISE Engimring 10 Contractor RqMmftn ft SIN
RISEN A division of Tbldsch Engineering
ENGINEERING 60 Sbavrmut Unit A Canton, MA OMI CONTRACT
339-5024= FAX339-502-"
page I
P.ROGRAM
rMCCORWreell -
CMA -MS
cufflom via= QAM cuarr# VIOM
Steven GMSO (978)337-8559 10/2942015 425710
00002
BERM STOM SMAM SMMT
20 English Circle 20 English Circle
S8MMcffV,STAT%XP BWWCFMSTAMEP
North Andover, MA 0 1945- North Andover, MA 0 1945 -
JOB DESCREMON
BEALTH & SAFETY Weada=on work cannot proceed until the insullicteol: draft Muc is find. HOT WATER HEAATER
SPW UNDER NATURAL CONDITIONS.
SO.00
AM SEALING: Provide labor and materials to sod am ofyour how against waoft amess; air WabV. This work will be
Pufmcil in concert with the use of special tools and diagnostic tests to assure that your home will be left with a hWMd level of
air cwhange and indoor air qual4. Materials to be used to sed your home can include cmft foams and other products. Primary
wen ibr scaling include air leakep to affics, basements, atlached garages and other unheated areas (windows am not generally
addressed.) IU will require (8) wo*inghoum A reduction in cubic fed per minute (efin) ofair infilMdon will occur, but the actual
number ofcfin is not guaranteed.
At die completion ofthe weathaization work and at no additional cost to the homeowner, a final blower door andlor combustion
saky analysis will be conducted by the sub -contractor to ensure the safety ofthe indoor air quality.
$690.00
$D.00
DAKANG: Provide labor and materials to install a 120 laya ofR-38 unfaced fiberglass batts to (64) square feet for damming
PUTPOSOL
$131.20
ATTIC FLAT. Provide [a" and morials to install a 4" layer ofR-14 Class I Cellolose added to (978) square fed ofopen attic
Spam
SM.14
A7MC ACCESS: Provide labor and materials to install (1) easily moved, insulating cover fbr the affic seems folding stair. A small
flat surface ofplywood will be created around die opening within die attic, This will allow the coveYs intepal weether-stripping to
restrict air leakage.
S237.65
Nov 2015
f— . % /I 'I" .,
Fednal ID 0 0644MM
RISE En&eering M Contractor R"buldon NO 8186
RISE
A dlyWou of ThieIsch Enoneering MA Contractor Registration No IMM
ENGINEERING
6D Showmat Utdj #2, canton, MA OMI
CONTRACT
339-� FAX &W4924015
page 2
PROGRAM
INSCONTRACITIS 9REDINFOSEMEWRIBE
CMA -HES ENOWEEM AM "MMI CUSTOMER FOR VIM An
DESCIODED
CUSTOMER
PHONE DATE CLOW0 VIORK
Steven 02M
(978)337-8559 109015 425710 00002
BERME Unaff
20 English Circle
OILUM 6TRW
20 English Circle
SEWOE CffV.SYAM ZIP
CnY.STAWnP
North Andover, MA 0 1845- North Andover, MA 01845 -
JOB DESCRIMON
Total: $2,040.99
Program Incentive: $1,700.74
CustomerTotal: $340.25
wr-Aam Hmawirommw somm-commzmoiA=RDmcEvmAwammmAT=& r.0RUESUU0F
*"Three Hundred Forty & 261100 Dollare $34026
UMM"DMPECTMAMAMMALSYfMENGMMMCUSTOMAORMTOR=s
UWAMBALMM_$="CAV&MMREWBOFMUWMMrMMMMON
AIMMOMINRO.LINNERS81 CFj%MLBEQWtMWMMYCNANY
GUARWFEM ROM OF RECOWSCHEDUUMAND COWRACIORREGATTRAWL
DO NOT SIGN TM COKWIACT F THM ME AW W.AXK SPACES
g
UNT90FACCMqMCE
30 DAYS.
ACCEPTAUM OF CONTRACT -TNE ABOVE F 11PPq WECMAICM AND *ONWTtO"g ARE
89FURA"ORY TO US ANDARE HEREBYACCEPTED6 VOU AREAUTHORSOM TO 00 THE WORR
AS BPECWtED6 PAYUMVELSE WADE AS QUYLOW ABOVE
2015 1
OWNER AUTHORMATION FORM
11
owner of the propedy kcalBd at
(Plopelty
177-7-7 -97TT-7;
C(T*e--
8n authDTkmd sdxGnbdOr tw PJSE Enakwft, to act on my beW ti) obbdn a bdft
PwWd and tD peftm vmtk on my papMy.
Date
NOV 5 2015
The Commonweiddi ofMassachuseas
DeparMent 0jr1ndustrialAccidenis
I COngrw Sfree4 Suite 100
Boston, M4- 02114-2017
www-massgov1dYa
Workers' Compepsation Insurance Affidavitz BuflderdContraclors/ElccWcianVPlumbers-
TOBEI,�ILEDWIA-HT,ILIEPERI�fiTrjfVGAUh-HORrrY- �
Name (BusincssfOrpnization(Jndividual):
Address: X /3
City/State/Z4Y-_
Phone �9;
A- you no cmploycr? Cbcch cbe ap9wprb[c bez:
LCE I am a cwplaycr itb_/-;) _,.� (full =ftr part-timc)--
2-0 1 am a solc proyr;aor or pau=3bip Wd bavc no cmployccs working fbr me in
any cap-ity- (No —rkcm' comp. in==- roquired-]
301 . . bo. doing .11 work M, --,df [No w0%+cr--'00mP- insm—c rcquimd-1 t
4-[]l am a bomwwncr and will be hiiugco o-bactom to conduct all work on my popcty- lwill
cusum tbm 811 C0DUActGMci1hCrbzvr wotcrs'CGmP=S3fion inp"aacc Ora= sole
PTVPriC10rS With DO C3MPJOYCC_&
5-D,I--g---a—m--W'-Wlb..bb-cdtb-su'b-connmct=listcdoutb--anachcdsberL
Tb= sub-cosawtors havc cmptoycm and haveworkers'comp- inswmtio-t
6-E] We am a cGlPoration nod ift offic= bvc excreisod 6cirright ofc—nption per MGL c-
- 157, §1 (4), sad we bavc no employom [No workcrs'comp- innuamerrquim&j
-S
TY.De of project (required):
7- 11 New construction
8. Rernodeling
9- D=n0litio.
10 F-71 Building addition
I I -E] Electrical Mairs or additions
12- f-1 Plumbing rr-pairs or additions
13-E]Roofrepa7us
14.E30thr-r
-Anyapplkant that cbccks box 91 n1tw —alo fill ow tbesccdon bclow sbowing —dicir
Workem, MUIP�on Policy infommaon-
Homeourncrs wbo submit this affi&vft iod;ntingthcy amdoing a work and tben biroutSi&couW!:Ct0M must sub=ft a nc� M&vi, i.&Csfing such-
lCooft=ors dmit cb=k tWs box must attach�d = zddWm=J shcc, showing the n2mac of lbcsub-conaze'013 and =we -bctbcr or not aw5c ,tftxs have
cmployces- If the sub-conusciors have =IpSoyces, thcy urtw provide their workcm, comp. policy numbcr-
f Mr, arR MW10yer that Z�S'Providjng Workers'CompenSafion in$Mrancejor my empfoy-em Bdow is thepoficy andjOb site
Lasurance Company Name__r-i
Policy # or Self -ins- Lic- Expiration Date: 0 r'//
lobSiteAddress: 1--o 'CKkljr-�r k co"t-ri-e- citystateop: p4 kk dveo"
-L �dvev�—
AMch a copy of the workers, compensation policy declaration page (showing the policy ---- expiration date).
namber and
Failure to secure covcragc as required undcr MGL c- 152, §25A is a criminal violation punishable by a fine up to S1,500-00
md/or one-year imprisomment, as well as civil penalties in the fonn of a STOP WORKORDER and a fineof up to $250-00 a
lay against the violator- A copy of this statement may be forwarded to the Office of Investigations of -the DIA for ins—nee
�overage varification.
r do hereby cerfify under dwpains andpenatd= ofPedwy thaeffse informadon provWd above ps &ue and eorrect
mature,
"hone 5,c
ofi7cial Use OnfY- DO not Write in thft 4rea� W be -COMPlefed AY city or town offieW
City or Townt Permit/Lkense 9
Issuing Authority (circle one):
I- Board (if Health 7 Building DVsrnnent 3. Cafty/Town Clerk 4- Electdc2l 1RsPec&r Plumbi,g Inspector
6- Other
CoiDUact Person: phone #:_
POLASEA-01 JONEILL
CERTIFICATE OF LIABILITY INSURANCE 11W016
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, s�b—j—ectto
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
UuNlatll
Durso & Jankowski Insurance Agency
PHONE (978) 688-7000 (978 688-7001-
No.
11 Saunders Street
North Andover, MA 01845
-fAIC,
E -MAL
......
1A6110ESU B If.; --_
LTR 1 TYPE OF INSURANCE INSD liV6 i POLICY NUMBER
_ADDRESS:
INSURER(S) AFFORDING COVERAGE --NAIC*
INSURER A: N3U[tlIUS Insurance Co. 17370
INSURED
INSURER 8: Safety Insuranc� Coqjpany 33618
Polar Bear Insulation Co. Inc.
C;
Peter Leblanc & Steven Leblanc
-INSURER
P 0 Box 958
-INSURER D:
Andover, MA 01810
-INSURER-E:
1,000, 000
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 POFICY 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.
1A6110ESU B If.; --_
LTR 1 TYPE OF INSURANCE INSD liV6 i POLICY NUMBER
I i -Pu
A M D LIMfrS
A X COMMERCIAL GENERAL LIABILITY
1 EACH OCCURRENCE
1,000,000
CLAIMS-MADE i X I OCCUR INN538691
DAMAGE TDRE1N—'rED'--
0312412015 03)24/2016
P�REMISE
- - --
MED EXP (Any One Person) IS
5,000
PERSONAL& ADV INJURY IS
1,000, 000
i GEN L AGGREGATE LIMIT APPLIES PER:
1
GENERAL AGGREGATE 1 41
1
2,000,000
[--] PRO-
JITPOLICY1. — JECT LOC i
PRODUCTS - COMPIOP AGG
OTHER:
s
I AUTOMOBILE LIABILITY
I COMBINED SINGLE UMIT i S
Eaaccidegj------ i
1,000000
B ANyAuTo 2100926
01/0412016 0110412017 BODILY INJURY (Per person) is
A Vt'N
LLO ED SCHEDULED
BODILY INJURY (Per accident) I S
AUTOS AUTOS
X X NON -OWNED
PERTY 5AMA—GE--''---
IPRO :S
HIRED AUTOS -AUTOS
I -(Pqr accidetp
UMBRELLA LIAB X !OCCUR
EACH OCCURRENCE-_ s
11000,000
A EXCESS LIAB ms-mADE AN019284
03t2412015: 03124/2016 AGGREGATE is
DED i RETENTION$
;WORKERS COMPENSATION
i PER I OTH-
1.S �ER_
TAL
EMPLOYERS'LIABILnY
Y/N'
AN PROPRIETORIPARTNERIEXECUTIVE
A
E.L. EACH ACCIDENT is
OFYFJCER/MEMBER EXCLUDED? IF
!(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE $
If,yes. describe under
DESCR IPTION OF OPERATIONS below
E.L. DIS E - POLICY LIMIT S
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 resperts to work performed on their behalf
by the above insured is Thielsch Engineering
HULUhK
Thietsch Engineering Columbia Gas
195 Francis Ave
Cranston, RI 02910
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQEID RF-PRESE14TAMVE
f,% 4000 nn,l A A ��MM d%1%T1011i0i-
11412016 Preview : Certificates of Insurance
-1 .0 1 vATe (ts-sm.w.-YY yy)
ACC111REP 'CERTIFICATE OF LIABILITY INSURANCE' 011042016
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 SUIBROGATION 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)-
PAODUCER
CONTACT
NAME:
Automatic Data Processing Insurance Agency, Inc.
PHONE �AX
! 10 E.t): 'C. No).
INWIL
ADDRESS:
I Adp Boulevard
UISURERIS) AFFOWING COVERAGE NAIC;I
Roseland. NJ 07068
WSURERA: NorGUARD Insurance Company 31470
INSURED
INSURER S.
POLAR BEAR INSULATION CO INC
PO Box 958
INSURER C.
Andover, MA 01810
INSURER 0 -
AUT01MBILIELIABILlIFY
At; I
C-LLEL,
ti
INSURER F.
COVERAGES CERTIFICATE NUMBER- 429703 REVISION NUMBER:
THIS IS TO GERT;FY THAT THE POLICtES OF INSURANCE LISTED BELO- HAVE BEEDIISSUCO TO THE 1NSUREO NALILD ASOVE FOR THE POLICY PERIOD
INDICATED� NOTIOVIT HSTANDr, IG ANY REOU;REL?.E(-IT- TEERL: OR CONDMON OF ANY CONTPACT OR OTHER DOCUtz,E(4TV.';TH RESPECT TO 'V7HICH THIS
CERT!F;CATE LIAY BE ISSUED OR IJAY rCPTA:(14. THE iNSIURANCE AFFORDED 13Y THE POL�CiES DESCR!BED HERE:N:S SUBJECT TO ALL THE TFRLIS.
EXCLUS:ONS ANID COtID;T:O,'%-S OF SUCH POLIC!ES LIVfTS SHO11.114 I.*AY HA%rE sf-:04 REDUCED BY PAO CLA."*S
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DESCRIPTION OF OPERATIONS LOCATIONS f VEHICLES (ACORO 103. AdditionJ RommisSchedtitz. mx/ be atacbed it —.p— L—q.i,W)
Theiisch Engineering, Inc.
195 Frances Ave
Cranston, RI 02910
-SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESENTATIVE
1988-2014
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
All ricilits reserved.
ly,
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poLAR-13EARINSULK-rioNco-
;j-1nma LeBlanc
p o. BOX 958
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