HomeMy WebLinkAboutBuilding Permit #883-15 - 337 APPLETON STREET 5/6/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:
Date Received
Date Issued:
IMPORTANT: ADDlicant must complete all items on this
I\� �9 eocrrcwewrc � �/
yesCnyeve
TYPE OF IMPROVEMENT
PROPOSED USE
Non- Residential
Residential
❑ New Building
❑ One family
❑ Two or more family
❑ Industrial
❑ Addition
No. of units:
❑ Commercial
❑ Alteration
Others:
Repair, replacement
❑ Assessory Bldg
❑ Demolition
[IE.E
❑ Other
_
1.
❑'FIood0.an We- nds
[ 'Watershed Distfiet
Septic p,1Ne11
0 Water/Sewer -
�.. r,r- nnornonncn•
UCZ1L*rVr 1 1%J114 yr vvvlxr� v v.. �• --• _._._- _
y¢ AT ! C- yiSt/ (4 � 10 C -IN
Identification - Please Type or Print Clearly
OWNER: Name: �-e tt4vt -< 4 %Qat.ck 1 Phone: �5��-6o4-L►3D�
Address: -
Confracfor Name: t f 8 r4t1C Phone:i
Emai.l
Address: �9�i ►`K x ; Supervisor's Construction Lice_ nse �r�ro e� t 7 ` .-'Exp- Date ��-F�it�/77
Home Improvement License: xp: 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: FEE: $ rZ
Check No.: I � i- Receipt No.
NOTE: Persons contracting with unregistered contractors do not have
-13-3
the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
' Public Sewer ❑ Swi
Tanning/Massage/Body Art Elmmin g Pools El
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF o U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
Reviewed On Signature.
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
_ ,,Planning Board Decision: Comments
t .
rConservation Decision: Comments
Wafter & Sewer Connection/Signature & Date Driveway Permit
DPW 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
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Bnilding Pennit Revised 2014
ILI
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
)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
4, 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 a
,4. Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include 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
Doc: Building Permit Revised 2014
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"..,. Federal ID#
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thielsch Engineering CT Contractor Registration No
60 Shawmut Unit #2, Canton, MA 02021 A
COPITEll PACT
339-502-6335 FAX 339-502=6345
It I S E PROGRAM Page 1
THIS CONTRACT IS ENTERED INTO BETWEEN RISE
CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS
ENGINEERING
DESCRIBED BELOW
CUSTOMER PHONE {-T DATE CLIENT
WORK ORDER
Jeanne Bianchi (978)604-4301 02/12/2015 405135
00002
SERVICE STREET�y BILLING STREET V
337 Appleton Street 337 Appleton Street
SERVICE CITY, STATE, ZW BILLING CITY, STATE, ZIP --
North Andover, MA 01845 North Andover, MA 01845
JOB DESCRIPTION
AIR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This work will be
performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of
air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary
areas for scaling include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally
addressed.) (10) working hours.
At the completion ofthe weathcrization work, and at no additional cost to the homeowner, a final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality.t GIANT CHIMNEY CHASE !
$750.00
DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass batts to (60) square feet for damming
purposes.
$123.00
ATTIC FLAT: Provide labor and materials to install a 6" layer of R-21 Class 1 Cellulose added to (1078) square feet of open attic
space.
$1,293.60
KNEEWALIS: Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to (20) square feet of
kneewall area.
$66.20
ATTIC ACCESS: Provide labor and materials to install (1) easily moved, insulating cover for the attic access folding stair. A small
fiat surface of plywood will be created around the opening within the attic. This will allow the cover's integral weather-stripping to
restrict air leakage.
$237.65
VENTILATION: Provide labor and materials to install ventilation chutes in (34) rafter bays to maintain air flow.
$68.00
RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently,
for eligible measures, Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the
Air Scaling measures up to the first $600 and an additional $300 if savings are justified by the auditor.
For the safety and health 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 work is begun, and after the weatherization work is complete. We will also conduct a full assessment of
the combustion safety of your heating system and water heater. This has a value of $90 and is at no cost to you. Total allowabic
weatherization incentive is $2,990.
$90.00
Federal ID #
RISE Engineering RI Contractor Registration No
MA Contractor Registration No
A division of Thiclsch Engineering CT Contractor Registration No
60 Shawmut Unit #2, Canton, MA 02021 CONTRACT
339-502-6335 FAX 339-502-6345
I SPage 2
}'ROGRAM
THIS CONTRACT IS ENTERED INTO BETWEEN RISE
ENGINEERING CMA-HES DESCRIBED BELOWENGINEERING AND THE CUSTOMER FOR WORK AS
CUSTOMER PHONE DATE CLIENTS
WORK ORDER
Jeanne Bianchi (978)6044301 02/12/2015 405135
00002
SERVICE STREET BILLING STREET
337 Appleton Street 337 Appleton Street
SERVICE CITY,STATE, ZIP �^ BILLING CITY, STATE, ZIP
North Andover, MA 01845 North Andover, MA 01845
JOB DESCRIPTION
Total:
$2,628.45
Program Incentive:
$2,143.84
Customer Total:
$484.61
WE AGREE HEREBY TO FURNISH SERVICES -COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF
*'*Four Hundred Eighty -Four 8N 61j{/100 Dollars
$484.61
UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1% WIZ BE CHARGED MONTHLY ON ANY
UNPAID BALANCE AFTER 90 DAYS. SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES, RIGHTS OFR ISION, SCHEDULING, lyllD CONTRACTOR REGISTRATION.
DO NOT SIGN THIS CONTRACT IF THERE E ANY BLANK PACES
AUT IZED SIGNATURE • LSE Engl g n TOMER ACCEPTANCE
10 NOTE` THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT - THE ABOVE PRICES, SPECIFICATIONS AND CONDITIONS ARE
30 SATISFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK
DAYS AS SPECIFIED. PAYMENT WILL BE MADE AS OUTLINED ABOVE
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
3 3 e6al e 4'6 i lS-�`
9
(Property Address)
N Ott ' weal l -r- r. 1?/1 ra_ -:. , s?f S
Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my prop
.
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ivivlv.mass aov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): (0 LQf- & 'ea r yjls J L4 r'o t/) C o
Address: K
it):
Phone #: Q
Are you an employer? Check the appropriate box:
1. Z I am a employer with _7
4. ❑ I am a t3eneral contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I atm a sole proprietor or partner-
Iisted on the attached_ sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[\o workers' comp. insurance
comp. insurance.=
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
mvself. [\o workers- comp.
right of exemption per..MGL
insurance required.] {
c. 152, § 1(4). and we have no
employees. [No workers'
comp. insurance reouired.]
— 5—/4F S�
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.&Other =nS4/4T%Ih
*Am• applicant that checks box =1 must also fill out the section heloxv showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all pork and then hire outside contractors must subunit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showine the name of the sub -contractors and state %%fiether or not those entities have
employees. If the sub -contractors have employees. the%- must provide their workers" comp. polis% number.
I mm an employer that is providing workers' compensation insurance for ntv emplopees. Below is the policF and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #:d? 0 wc— $—s'"'L'd % $— Expiration Date:
Job Site Address: 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 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 S250.00 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 perjuo, that the information provided above is tare and correct.
r1%, _I
Official use onli•. Do not write in this area, to be completed br vitt, or town official.
City or Town:
11'ermit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cit'/Tosvn Clerk -t. Electrical Inspector i. Plumbing Inspector
6. Other
Contact Person: Phone #:
A� U® CERTIFICATE OF LIABILITY INSURANCE
°�'�1282016
oalz6/2o1s
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 1S 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
Automatic Data Processing Insurance Agency, Inc.
1 Adp Boulevard
CONTACT
NAME:
INC. No F(AIC, No),
AIRESS
INSURE AFFORDING COVERAGE MAIC S
Roseland, NJ 07066
INSURERA: NorGUARD Insurance Company 31470
INSURED
INSURER B
POLAR BEAR INSULATION CO INC
PO BOX 958
INSURER C:
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY E]JECOT_ M LOC
OTHER:
Andover, MA 01810
INSURER D
$
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 338194 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
TYPE OF INSURANCE
AUM
WEIR
POLICY NUMBER
POLICY F
MWD
P
LIMITS
AUTHORIZED REPRESENTATIVE
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE D OCCUR
EACH OCCURRENCE $
PREMISEREDS (Ea ocwnence $--
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY E]JECOT_ M LOC
OTHER:
I GENERAL AGGREGATE $
PRODUCTS - COMPIOP AGGR$
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS AUTOSNWNEDaccident
m $
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
$
UMBRELLA LUU3
EXCESS LWB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION$
$
A
WORKERS OOMPENSATION
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED? ❑Y
(Mandatory in NH)
ff yeS, describe under
DESCRIPTION OF OPERATIONS below
NIA
N
POWC660990
01/01/2015
01/01/2016
XAND STATUTE ER
EL EACH ACCIDENT $ 1,000,000
EL DISEASE - EA EMPLOYEE $ 1.000.000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be aCached If more space is required)
CERTIFICATE HOLDER CANCELLATION
A cU 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CONSERVATION SERVICE GROUPS
ACCORDANCE WITH THE POLICY PROVISIONS.
50 WASHINGTON STREET
Westborough, MA 01581
AUTHORIZED REPRESENTATIVE
A cU 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
I
4
OP 1D: SS
^'C„®�® CERTIFICATE OF LIABILITY INSURANCE
�
X03 „
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 owe holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. It SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this ceftede does not confer rights to the
cer8ficate holder ht lieu of such s
"RODUDurso & Jankowski ins Agcy LLC
198 Massachusetts Avenue
North Andover, MA 01845
Durso & JankowsM ins. Agcy.
THE M(POIATION DATE THEREOF, NOTICE WILL. BE DELIVERED iN
PHONE
Eck
A ar k
r POLAR -1
INSURERaFFDRDING oOVERAGE NArC a
--Polar Br i Inc.
P O Box 9558
Andover, MA 01810
52859Lamw Raueel:
Munn ,S. In wrance (o. 33618
msumc:
USURER D -
E-
RSURER F:
MA RAGES _w=TIpCATF NURMER! REVLSInN 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 CLAW.
IT
TYPE OF U7SURANCE
ThletSCh Enlneering
THE M(POIATION DATE THEREOF, NOTICE WILL. BE DELIVERED iN
PDIWYNUISSL
J�FMWM
195 Francis Ave
Uun
AUTHORIZED RARE- @iTAMM
66NERALt1AeluiY
EACHOCCURRFNCE__ S
PREMISES $ 60,
MED EXP (An one PWW S 51
A
X commERmALeamAtuAwry
CLAIMS4MEEK OCCUR
AC700M
0312IMS
0&02A 76
BAOVINJURY $ 5,000,
afX;RElsATE $ 20001
GENLAGGREGATEUMFTAPPUESPER
-COMP)OPAGG S 1,000,00(POLICY
rpRoO;UClrS
SAUTOMOBLLBUABrLRY
PROLOC
ANYAuro
00926
01/0402015
01104=6URY
INGLE LIMIT S 1,000,00B
(Per Person) $
ALLOWNEDAVTOS
X SCHEDULEDAUTOS
X HIREDAUTOS
BODILY INJURY (peteCOTdeflt) S
TYOAMAGE
(PERA=Enm $
$
X NON4)WNEDAUTOS
a
UueLm,LA LIAs
X
OCCUR
EACH OCCURRENCE $ 1,000,0
AGGREGATE $
A
MWESS U"
CIAMS*IADE
Afr'6906385
0304=5
032402016
DEDUCTIBLE
$
S
RETENTION S
YYORramw COMPENSATION
ANDEMPLOYEWuABRR9 YIN
ANY PROPRIETDRlPARTN
� EXCL.UD� M
in
yya8ss,
'D'M OPERATIONS below
NIA
WC STATU
EL EACH ACCIDENT(Mands
EL DISEASE -EA HNP $
EL DISEASE-POUCY LIMIT S
II u on �lllork - rain-, d 'Ional i� org e� re I a it'ft wf°ith ' u e m ` °*
r.tQectso WYO Perfor� on flair by t[tg above nsus is Thieisch
CERTIFICATE HOLDER r-Awr Cr_r_A nnm
THIEM
---------- ----
SHOULD ANY OF THE ABOVE oesc IBED POLICIES BE CANCELLED BEFORE
ThletSCh Enlneering
THE M(POIATION DATE THEREOF, NOTICE WILL. BE DELIVERED iN
Columbia Gas
ACCORDANCE WnH THE POLICY PROVISIONS.
195 Francis Ave
AUTHORIZED RARE- @iTAMM
Cranston, R102910
019N-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and top are registered narks of ACORD
and
office
usiness Regulation
Office of Consum
er
lOP k _ Suite 5170
Boston, Massachusetts 02116stion
Home ImProvement Contr�f-tor Reg
Registration: 102726
TOW DBA Tr# 2=49
E)cpiration: 7I21Z016
POLAR BEAR INSULATION Co.
Vincent LeBlanc _ P.O. BOX 958 mark reason for change-
ANDOVER, MA 01810
Update Address and return Employment [� Card
i Address Renewal :J
ops -CAI a 50M p41 -GI01216
11113 Massachusetts -"Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
License: C!4L_106017
PETER A LEBLANC
2 EAST PINE STREETF _
Plaistow NH 03835_ l r
�' i•,i Expiration
04/2812018
Commissioner