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HomeMy WebLinkAboutBuilding Permit #749-2016 - 270 MARBLERIDGE ROAD 12/21/2015TYPE OF IMPROVEMENT PROPOSED USE Name Residential Non- Residential ❑ New Building ❑ Addition ❑ One family ❑ Two or more family Dindustrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg Others: ❑ Demolition Septic . ®V1/ell'� Water /Sewer ❑ Other ® Floodplain ®Wetland s R .,.,�;•,�. ,,�-fir . tz ®' V1/ater5hed D`istr ct: � •y ..r...�:.:�;�� DESGKIP I IUN UI- VVLJKK I U t5t: t1trcrUM1vir-u: Identification --Please Type or Print Clearly OWNER: Name: Yk*WO `t S f Phone: 197F 4? o34, car mac. WWI Name Con ractor Email::_ .... �.. ' . E p�, ®ate: L ����� Supe" rus rs Construe ion Licenses a: " HomeImprovement ARCH ITECT/ENG I NEE Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED CO TeED ON $925.00 PER S.F. Total Project Cost: • •a FEE: _ $ Check No.: Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignafiure of,� 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 ®TE: 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 DTE: 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 Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report a Engineering Affidavits for Engineered products ATE: 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 Clerics 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 Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tann ng/MassageBody Art ❑ Swimming Po"s ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ 1 Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ THEFOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Zoning Board of Appeals: Variance, Petition No: Planing Board Decision: Comm ature Zoning Decision/receipt submitted yes Conservation Decision: Comments c Water & Sewer Connection/Si�nafure & Dafie Driveway Permifi DP'V Town Engineer: Signature: 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 Im Doc.Building Permit Revised 2014 Location"�� No. ! 2 Date9-- Z t Check # �U 29847 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ v Other Permit Fee $ TOTAL $ Building Inspector CD � , z CD O CLr'- CL 2. D co O o v C� a� CD o CD Q' O CO CD cn 10 CDD n VMIPLO LWJ 10 O y CD cD CD CD v z CCD O CD z m cn 0 cn C= z V♦ v z z Cl) m O m x u m cn z 0) ic z V/ O --I 0 12. < m -0 ti c CL 0 CD n 0 � Q'n � m 0' S 3 VN 'i N CD 0, C0 O N W�CD � cn O CD 2 O O @ S. O � c7 � = O 0 y, O O S n �C (D' • CD -0 v o < co 0FLO .� � ; N OO+. Cr e� D 0 / CL o. CL 0 co O Q — N CD U) o �fu� � CD :.i CL U) r -0 ID y rt O O O rt CD rt s, U) C� CDu rt o -. 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Me The safcn ?i wi health ar»nar hnrae S bednw air.q7jaN. vA:.41 be cm14 ad" a Mmvr doer d:�x+ , of 1F.c as dla> c ais gum in )--w It=c buCh bdinc the,c A isIbm 7o. and ails; r is eoAltlrle. we utill .ilia cmtd» a r6a ac.eczaeat of the hW;:7h=r Ila$la:mT.ln:ofSrr6andir�a+ CCrCta}lr� Teta]slle+aaldc Waifat uu rrttturvr �� 53.:1 p, Sali�l VOW: $4,123.50 Ptega> m tncontive: S3,109-99 Customer Tflta1: S1,G13.61 &WAGRGLat7tEver :13 WRI�I$M^.�RVi"�'$-O�WLCTCatJ.000BOIWCS WRatdOSJL.^w CCn7CATnb1:w rug, l,M;MY Of *"One Thousand Thirteen & 5=1100 ©GIlalrs 51,013.51 gram ►nnta+kneviWa,.Na +.Sirpopc e%r0:ft%,gb s,marrsTOM*TJjMUVrCUCearn.LiWa=TorrrvxunZGtr.=W "MyCUAW URPMSNAV^t;wnP"ADA At3=44 CafWxKrft•REMsaCfi[bSlslys6t[CL;}rQ AIM pp{airZMWCSrC=gL Co $rGN 7T14Scomnucr IF iiiERQ AM AI 6uuK SPACr^ .. /011", �le 1 Ant scnA:a�-ar ,; vuesrr�atcs Q / rmrult�mvruiuervaT�varem w.rnaTtSasutgtmnm ew�vAoee tawge ! (� 30 acecnAerxertra*rtaur•meaamtvwr�.av_ersustonaAvacatrnotsanC ��' s+cTiv�a.w�.KawtNtv+af.eENkNiR('. tvspa6gt�rSIZINXMID90V VIM OWNER R AUTHORIZATION FORM 1, y / nG>yl/ ct owner of the pray ww io - — A Q AJ - hemby euftdze. {Sarbcarrtrsrbr} an authacizad suhcontsactor for RISE Errgirtwf9Q to act on aW baW to min a burl ft Wm a and to perform work an ruy PONAT s srgnatrae ' `/ 2.f -X?& -2%T Date %\�'COrIIri101tlf'L'(Ittfl Of illassttcllusetts Ei _ Depai-fni nt of 1ndfstria1 Acci(1eizts 0fi rce ofnve5fig atiotzs 1t 600 r -ton Street =;- tBoston, zI&A02i1 i :t r :' c�-�'` 1V1VlU.iiYtdSS � (31r%fltfl Work-eirs' Compensation insa ince Affidavit: Buildet-slCopt3 ac ors/ylectriciit-ti§/PiLmbers Name (Business.-Oroanizationlindividual): Vlel'— r -t~ r? cru t e1k n .4ddress- IV;� "nr Phone ' : Cf 7 Are tiou an employer? Check the npproprifite box: 1.A I am a employer with 4- ❑ 1 am a general contractor and I `'li -_ emplovem (fall andior part time)_'' hati a hired the sub -contractor 3_ ❑ I am a so le proprietor or partner- listed an the attached sheet_ ship and have no employees These sub -contractors have working for me in an capacity_ e1»plati ees and hz�°e »orl:ers [No .. orkers= comp- insurance required.] conte. insurance.= 5. ❑ We are a corporation and its 3.0 1 am a horneOU'rier doing all worlc officers have exercised their myself N_ workerf comp. right of exemption per _MGL insurance required.] ' c- 151 11(4)_ and we have no eniviowees. [\o w-orke& comp_ insurance required_] ,ate �- Type of project (required): d_ Fl lett! canstruction 7- Q Remodeling S- Demolition 9- ❑ Building addition 10.❑ Electrical repairs or additions I 1-!-1 plumbing repairs or additions 12-0 Roof repairs l 3.P Other c S -t t' P Ny) `ani' applimar that chcd4s bo\=I mast 31SO fill Oat cite ieClion hehAtw5lto«in=-their[+'ori-yrs compenSation notn:y inrornatio :. ` I lomeotwtters into submit this affidavit indicating they are doing all work and then hirL outside cmnrctors otos[ submiI a neer afirda��t indicating suds. Contractors that ch -,k this bo.x newt attached an additional sheet shoo-in the ,tame c f the sub-conizactors and slate -hether or not dtuse entities have employees. if iltc sub contractors [tare entplavea- tlicg must provide dteir �corLe,;' COME) -policy number _ I run ern_ eauploper Cher Ps prot'irtiitg tvortiers' cofllPerrsatiotr irrst(r(tltce for ort' elltpinl:ee� Beloit, is hire pnllct• w7dJob Sire Irrfortucrinrr_ . Insurance Company Name: Polier = or Self -,IRS. Lie. g 4? 0 eR Expiration Date: i Job Site Address:� (nna d kir r; dq �d� City1State1Zip ill Attach a copi` of the Uorkers' compensation polies' declaration pa a (shavving the policy nun,t er acid expiration date). Failure to secure coverage as required under Section 25th of 1,IGL c- 152 can lead to the imposition of criminal penalties of a fine up to S1-500-00 and/or one-year imprisonment, as. •eI1 as cil-it penalties in the form of STOP WORK ORDER and a fine of up to 5250.00 a daY- against the violator_ Be 2dvised that a copy of this statement tray be forwarded to the Orrice o1 Investigations of the DIA for insurance coverage veffmcation. I r10 Irereht' certifp twirler the pains rand peiraftics of parjtal- tlrat the infuniIation provided abot:e is trite aild correct. i Sianature: ; fiat -rte` Date: - )�/ / rJ— Official arse Oit1t: ii(i IrRt trrlfi' 117 ti115 (Irta. to !ie corirpteterl Gr city nr tott'rt n�citrl_ Citi- or Town: Pertnit/License ff Issuing Authority (circle One): I_ Board of health ? Building Department 3_ CitHTa wE1 .'r lerI: -t. Electrical Inspector- Plumbing, Inspector 6. Other Contact Person: Phone'-: -0 .�a CPMV CER�FICA LE ®F LI INSURANCE IY,TE(�,I3)D.NYYY) ]2/18r2014 THIS CERTIFICATE i5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONf£RS 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 NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, Ute policy(}es) must be endorsed. IfSUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may requite an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER [.O.V1AL 1 NAME. Inc NuEsd: r?G nvk Automatic Data Processing Insurance Agency, Inc. ADDRESS: 1 Adp Boulevard Roseland, NJ 07069 INSURER(S)AFFOROINGCOVERAGE NAIL.+- ENSURERA: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC ENSURER B: INSURER C: DBA: Polar Bear insulation CO Inc ENSURER D: PO BOX 958 Andover, MA 01810 ENSURER E: INSURER F: CUVEKAGEJ CERTIFICATE NUMI3E11: L•JJ. 49 KEVIS ION NUMBER= THIS IS TO CERTIFY THATTHE POLICIES OF INSURAAICE LISTED BELOW HAVE 3^EN IS5UEDTOTHE INS UREDNANIED ABOV£ FOR THE POLICY PERIOD NDICATED_ NOT.YITHSTANDING ANY REEQUIREA4ENT. TERN4 OR CONDITION OF ANY CONTSIACT OR OTHER DOCUMENT ,PITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR A,AY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEMNIS. EXCLUSIONS AND CONOflTONS OF SUCH POLICIES. LI\SITS SHOWN VAY HAVE SEEM REDUCED BY PAID CL IMS_ LTR T'PEOFfNSURANCE ,NSD CYVD POLICYNUNRER (61hLDD+YYYY) B.1unn..-Am lL\llt5 COMMERCIAL GENEIIAL UABLLIIY EACH OCCURRENCE , PREt115E51Excctatcr:Cd CLM.IS-BADE OCCUR GIEDE%PIAn}'crearauri � PERSONAL E A¢ • Jul URY CENERAL ACCRECATE ° CENL AGGREGATE LIGn Al'I'UES I'EIL POLICY PRO- 3EC I L0C PRODUCTS -COEIPAP AGG S OTF£ll S AUIORDBR.E LIABILITYIE2 LUFIBINtU 51K1.11+ S AUt:erII 6GDILY INJURY (Pn Iztscn! 5 ANY AUTO BODILY INJURY (I-V yaiderl 5 ,V.L O:Fti£D SCHEDULED .lU i 05 kUi 05 /Pet tCOder.9 NOK-0YiNED HIItED.lUi 05 AUi OS S UM1SRELL\LbAs OCCUR EACHOCCUIU(ENCE 31 AGGREGATE 5 E%CESS UAB CVU£.1St.U10£ DED RETENTION S S CaMPENSATpM X $TAIUTE ERN ANPOVERS' LuunLity YIN 1.ODO,('OD A ANRIET01t3:UCTf¢(l£XECUi1C•E jtCVFFFlC1Et`1!!.l9EREXCLUDED? Y❑ N IA N POWC66090 O1A12015 0191Q016 EL.EACHACC10.riT 1 ODD.0D0 01.1data,vinm) I El. DISEASE -EA EbU•LOYEE 5 II C'�s. Ceatnbt tcldct GfSCRIPTIOi:OF 01'EItAT10Nc_ Ltius 5 000,000 'ELDIS E+LE-POLICY U611T—T OEsci iPT1on OF OPERIC'nONS iLOG-tnoNS IVEHICLES (ACORD 101 AdM-1 Re—Im Schedule. maY lx aiNched i(mereswCe is nettuindl Columbia Gas massachusetts CERTIFICATE HOLDER raN[ELLATION A'S 1V0O1-ZU3ff ACUKU CUKYURAJIUN. mn llyt'w tcac,vcr. ACORD 25 (2014,01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE OESCRIRED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE IVILL BE DELIVERED IN Theilsch Engineering, Inc. ACCORDANCE WnH THE POLICY PROVISIONS_ 195 Frances Ave AUiHORiZED REPRESENLlT1YE CranSton, RI 02910 A'S 1V0O1-ZU3ff ACUKU CUKYURAJIUN. mn llyt'w tcac,vcr. ACORD 25 (2014,01) The ACORD name and logo are registered marks of ACORD OP lO: SS I aa�trr�nnro''� CERTOFICATE OF LBABOLO ONSUR: NCE D3f73f2D95 TH18 CERTIFICATE IS ISSUER MATTE OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON r E CCATE HOLDER. eat )i5 AS A CEFmFiCATE DOES NOT AFFIRmmvELY OR NEGAI&WELY AMEND, MITEND OR ALTER THE COVEIFACE AFFORDED BY TitiE: POLICIES WELOW. TIS CERTIFICATE OF IFjSU RCE DOES NOT CONSTITUTE A CONTRACT BMVEEN iii~ ISStAINQa BNSIBI�ER 9 AUrHORRM REPRESENTATIVE ®R PRODUCER, AND lu HE CER T IBCA E N ELDER. iMPO.�sTAEU�: Ii the cerlulfr a holder is an ADDITIONAL INSURM, the golicy(les) mem be endcrsrdl_ Ifr SUBRO - ON IS WAIi1ED, Seehject to the terms and conditions of the policy, caftin policies no Moire ala endorsement. A siaielfien'i GH this carlificM does ncat confer rights to the eertifleate holder in lieu of such end orsemei t(s). PRODUCER CONTACT Durso & alar)ftovisM Ices Agcy ILC HONE FAY. 198 Massachusetts Avenue Ona North Andover, NA 01W Durso C'. aianftovasi i Inas. Agcy. PRODUCER CUS70MER IO d• POLAP'l INSURERS) AF"Or ROING COUERAGsE MAID & EACH OCCURRENCE S 7,000,000 tlusuREn IarDlas dear lsasall©at3sa C®. Ist� INSURER A:�eFill Ar�la:rlea 32859 P % sou 958 IesuRfxsSSfetJ' lnSUMEICe Co' 335'18 : Andover, MA 018io PA�i07�2�3 03202015 ,NsuRstc: INSURER D CLAWS-MADE21 OCCUR INSURER E - tit!SUR� F: all unn=c=. rzFr�v,muDna caauaamr��a.. -- _ ooad V Ge,2nOlC•b. yof�i7 a as a..aa-+a as avo+.w+r+.a... - - -- - - THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 7O THE INSURED NAMED ABOVE FOR INDICATED. 1407VOMSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WWII 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 SHOVIN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OFINSURANCE Ng R POLICYNU6M8ER 9C�91LDCDYNt� quaim"P LIMITSGENERALUABiL)TY EACH OCCURRENCE S 7,000,000 PREMISES amerce $ 50,000 rA COMMERCiALGENERALLIABiuTy PA�i07�2�3 03202015 0 =6 CLAWS-MADE21 OCCUR MEDEXP(AnVCn-8P T) S 5,000 I PERSONALBAOViNJURY S 1,000,ODD GENERALAGGR2r-ATE is 21000,000 PRODUCTS-COMPIOPAGG 5 71000,000 GEN'LAGGREGATELIMIT APPUESPFR 5 POLICY PRO- LOC AUrOMOBILELIABILITY COMBINEDSINGLEWIT S 7,0{)0,000 B ANYAUTO 29009266 0910412095 09/04PL096 (Eaacadent) 80DILY INJURY (Pat P--) S ALLOWNEDAUTOS 9ODILYINJURY (Far acddent) S SCHEDULEDAUTOS PROPERTYDAFdAGE S 31 .HIREDAUTOS (PER ACCIDENT) IL NON-0WNEDAUTOS $ 5 UF9BRELW iJA6 7a OCCUR EACH OCCURRENCE S 1,0130(mEXCESS AGGREGATE S �, LIAB CLAt1YS RMADE PAC6S0&� 09/2412075 03124�(P96 DEDUC71BLE S $ RETENTION S WORKERS COI:MPENSATION WC STATU- E ' TORY R I ANDEMPLOVERV UA81LMV S ANY PROPRIETORIPARTNER(ERECUrwEY,N E.LEACHACCIDRE E.LOISEASE-O.5 OFRCERIMEMBER EXCLUDED? a (1:MandataryInNN) NIA EL DISEASE-ppllCY MITIS If yes, describe under DESCRIPTION OF OPERATIONS beleri DESCRIPTIDiJOFOPE-slONSILOCAMDIIS/VEHICLES (AgmchACORD20I,AdoVonrlRwr=ImSchedulo,ifmomepacoiomquirad) Insulation Work - Mineral; Additional insured for general Iiainil'Ity -,Vrh - r acus rft performed their behalf by the aiaove insured Is (eisch ora 9 es t -nmelsch Engineering Calurnalaie Gas 195 Francis Ave Cranston, RI 02910 ACORD 25 (P-009109) TWIRL S2 Si30ULil ANY OF THE ABODE DESCRIBED POLICIES HE CItSUC>_I eM BEFORE gRE EXPIRkTION DATE Tt)EREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH T HE POLICY PROVISIONS. AUTHORgED REPRESENTAMtUE ©1988-2009 ACORD Ti-te AGORD name and 1090 are F8915tc-red rlari(s of ACORD All rights reservedL SeiBiIS at].id�eSsg2tt10Il Office of Consumer 10 ParkPiaza - Suite UZ � 6 Boston MwsachuseUs Regi gaxion �y�nent Cont�a�or . $ome P . _ _-_ _ -__ Reg ° : I EYWIMWOrr POLAR BEAR INSULATION CO- Vincent LeBlanc = _ - = ------- P.O. BOX 958 1810 ,meson for change• ANDOVER, MA 0 - ups Add, and return �a Emrimn 0 i osr card Address 0_ . DPS-CA1 a 58NWWO'C'101216-- SifrA 5 MaSSa�hitSt;ts - iepafiiftent Ot i7 iB-alic charts �zat?dards Gafd vT tie�dfng Regulat ons and Clynstilllt:ltrii Sll]7t'P ttit3F Sjit.'Ci:ili` T.. -. _icense: CSSL-106017 � ? iiAsT lqaWwW NEI 03865 rxgifatifln 0412812018 Comfrtisssonsf