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HomeMy WebLinkAboutBuilding Permit #274-14 - 60 INGALLS STREET 9/25/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION LJ Permit NO: �7 Date Received Date Issued: $f/ IMPORTANT: Applicant must complete all items on this page LOCATION _ 6 40 _ .T.vN Pnnt.i PROPER'TYf®1/VNER'__5 q ,n o�. eM° r Phnt 100yYear O1d,Structure yesnm MAP NO "/OG: PARCEL _, ZONING DISTRICT Histone District e rfn +'MachineShop Village ye no, ; TYPE OF IMPROVEMENT. PROPOSED USE ResLdential Non- Residential ❑ New Building One family Al4ddition ElTwo or more family 11Industrial teration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ ❑jSepticx ❑Well r.F odplan ®,-,Wetlands `t C1 1Natershe&D strict' t �0°Water/Sewer;. DESCRIPTION OF WORK TO BE PERFORMED: �h s.l.,Ae 19 2V& AM 38 e e'6,•l/.t A21, /L- .3o And Pry W,VLLC s fa saflair, wi Identification Please Type or Print Clearly) OWNER: Name: A"fc.*w Phone: 971' 6V- Faoyr Address: LJ �� o .S Phone` l_ 7Sr 2�l 1r _ CONTRA'07TOR`` Name - , _ 7 - . Supervisor'swConstruction'Ltcense �9dso 2' Exp' Dater _i!_. - - • to .,� Y9 Home Irn��*rovement License- `. l _ � � _ _ a fi , a _ • _..� _ExN Date ARCHITECT/ENGINEER Phone: I 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: $ F2 .3. FEE: $ iDD. v o Check No.: 97 ?/ Receipt No.: ;2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i'g -fur e.:of ,y vafaatr Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ TYEE.OF=SEWERAGE DiSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. _ 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 DATEAPPROVED PLANNING'& DEVELOPMENT ❑ F1 COMMENTS -CONSERVATION Reviewed on Signature COMMENTS F HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments M a Conservation Decision: Comments Water & Seger Connection/Signature& Date Driveway Permit ! DPW Tow;-, Engineer: Signature: Located 384 Osgood Street FIRE C3EPARTMENT` -`Temp Dumpster on site yes. no Located at 124;Mair, Street. Fire"®epartmeiit signatureldate`y ` " * ,:.� _ $ X C! 1 COIVM.ENTS . . ,.. s . , .�.`• d _-Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ ..Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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.$10041000 fine NOTES and DATA— (For department use i ® Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department The fol[owing is=a list of the required forms to be filled out-for the appropriate-permit to be obtained. RoofirAg, 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 ❑ 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:+.ted with the building application Doc: Doc.Building permit Revised 2012 i T- Location ��� No. J 7 '/l7' Date - /3 f � o TOWN OF NORTH ANDOVER ° y Y- • _ Certificate of Occupancy $ Building/Frame Permit Fee $A_a,& � fl a:) - 0 Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ r Check# Buildim�Inspector NORT#j Town of tAndover No. ;� Lf_ _ 4ANE h , ver, Mass, ' //,3 CCCHIC Nt WICK ��• �d A0Rg7'E HPA��S S U BOARD OF HEALTH Food/Kitchen PERMIT T LD/ / Septic System sf'jLr�yti�/r+,.. J�/`�G �id,�J BUILDING INSPECTOR THIS CERTIFIES THAT ................. ............................................................................ . ` Foundation .................... buildings on .�a.�., ."p .�/.-s..::?� has permission to erect ...... g .......................................... Rough to be occupied as ......... `...Z7`'rf.ee.e.94 ......:...1 ..5.e........................... .................... ....... Chimney provided that the person accepting this permit shall 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 STARTS Rough .................................... Service .............. ..... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in.a Conspicuous Placeon 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. SEE REVERSE SIDE 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards. Construction Supen-isor License: CS-090902 RICHARD B BORES 28 HAMILTON ROAD . Peabody MA 01940 f , W Expiration Commissioner 11/01/201 ! 1k -0. . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:, 164893 Type: t, > Expiration: �1i/31)/2013 Corporation A AD ANCED ENERG OLUTIQN!31LC. _ .• �) _ �lam+^� RICHARD'BORGES 28 HAMILTON RD.'b PEABODY, MA 0196b, ti Undersecretary I � i joo NUmger 4I VU UA 1 t s-lep l Client SHANNON MCMAHON 978-682-8004 address 60 INGALLS STREET city Itown NORTH ANDOVER MA 01846 contractor ADVANCED 1.WEATHERSTRIPPINGICAULIONG QUANTITY TOTAL AUDITOR NOTES Door Kits Q-Lon or Equiv. 2 91.00 Door Sweeps(Regular) 0.00 Door Sweeps(Automatic) 2 46.00 Reglaze Windows/In.inch 0.00 Window.Weathstr Schlegal per side 0.00 Tenmat Recessed Can Cover 0.00 Attic air sealing per man/hr 2 150.00 basement and living space air sealing 2 150.00 SUBTOTALS 437.00 2A.INFILTRATION/INSULATION AUDITOR NOTES Domestic pipe Hot Water Tank 1 st 6' 1 15.78 Sill insulation R-19 CF 0.00 Sill Two Part Foam w/Fiberglass Batt 0.00 Drape Perimeter R-5Anch.Sq.ft. 0.00 Perimeter 2"T-max or equivalent foam board sq.ft. 0.00 Drape DOOR R-5 or T-max or equivalent on door. 0.00 Tape Joints(Aluma Grip only)per hr. 0.00 Duct Insulation&Tape sq.ft.R-5 0.00 Rigid Foam Board Anch-1"per board 0.00 Hydronic pipe Insulation to 1"R-5 0.00 Hydronic pipe Ins.1.25"-1.5"R-5 0.00 Steampipe Ins.tol.25"iron pipe R-5 0.00 Steampipe Ins.1.5"-2"Iron pipe R-5 0.00 Steampipe Ins.3"iron pipe R-5 0.00 Air Conditioner Meeting Rail 0.00 Air Conditioner Cover 0.00 Air Conditioner Cover Special Order 0.00 SUBTOTALS 15.78 28.INSULATION AUDITOR NOTES Open Unrestricted R 49 0.00 Open Unrestricted R 38 0.00 Open Unrestricted R 30 0.00 Open Unrestricted R 20 572 737.88 Open Unrestricted R 10 0.00 Restrict FL/Sloped R 30 0.00 Restricted FL/Sloped R 20 0.00 Restrict FL/Sloped R 10 192 249.60 R-19 FGB open rafters/walls/kneewails 48 70.56 DAM OFF HOUSE FAN R-11 FGB open rafters/walis/kneewalls 0.00 Attic Stairs(stairwell&common wall) 0.00 Cover Pull Down Stairs Thermadome 1 180.00 Site built pull down stairs 2"foam box 1 180.00 HOLE HOUSE FAN HU V r UK IVU r r_b Attic/Kneewai Floor Transition.Dense pack cellulose 0.00 W.S.Hatch Q-Lon or equal 0.00 W.S.&bat Hatch R-30/Q-Ron or= 0.00 Kneewall R-12 cell behind Per.Memb 0.00 Open Rafter R-20 Cell./w poly 0.00 Open Rafter R-30 Cell./w poly 0.00 Basement Overhead R-19 fiberglass 0.00 Basement Overhead R-30 fiberglass 0.00 Crawlpace Overhead<4'high R19 0.00 Crawlpace Overhead<4'high R30 0.00 i Garage Ceiling cavity filled w/cellulose 504 1058.40 Wood,Shake,Clapboard,Shingles Vinyl 2218 3970.22 Asbestos(single nail)/Asphalt 0.00 Asbestos(doub.Nail)/Aluminum 0.00 Brick/Stucco 0.00 Vinyl over Asbestos 0.00 Multilayered 3 or more layers 0.00 Drill rough plaster or finish wood plug 192 349.44 .Drill finish plaster 0.00 Test Drill Walls(all 4) 0.00 SUBTOTALS 6796.10 2.INSULATION TOTAL 2A.+213. 6811.88 3.STORM WINDOWS/DEADLITES AUDITOR.NOTES Plexiglass up to 88 u.i. 0.00 �- Additional per UI over 88" 0.00 Other(Negotiated Price) 0.00 SUBTOTALS 0.00 S.OTHER MATERIAL AUDITOR NOTES - Ridge vent In ft. 0.00 Vents Gable rectangular 0.00 Varipitch Vent 0.00 Vent Roof 135(1 sq ft NFV)Large 0.00 Vent Roof 865(A sq ft NFV)Small 4 320.00 4 REAR HIGH Vent Soffit Rectangular 6 162.00 4 X 16 Turbine Vents All 0.00 Stack Vent 0.00 Propa Vent 6 24.00 DAM OFF EXISTING TINY SOFFITS Permable House Wrap 0.00 Vapor barrier 0.00 Energy Star R-4 Rigid Vinyl Repl 94-101 U.I. 0.00 SUBTOTALS 506.00 6.17.E.C.MATERIAULABOR 7754.88 Page 3 6a. HEALTH&SAFETY AUDITOR NOTES vent clam r Mcnen ran I ua.uu Dryer vent w/exhaust duct Heartland 1 89.00 OUT SILL A/S OTHER HOLE WHEN DONE Dryer Transition Duct only 0.00 Blower Door Test Pre Post 1 45.00 `AVIIAYSiNC1llbEP�tE AND;P.OST; AL1AfAYS TAKE PIC$OF READiMG$ ..... ....... SUBTOTALS 223.00 8b.REPAIR MATERIAULABOR AUDITOR NOTES Basement outside door only 0.00 Basement outside door w/jambs 0.00 Door Repl pre hung 32-36"Steel"w/Lite 0.00 Door Repl interior solid core 28-32" 0.00 Door Repl pre hung 32-36"wood"w/Lite 0.00 Window Replacement wl SIR less than 1 0.00 Basement Window Repl.Awning/Hopper 0.00 Basement Window Repl.With a frame 0.00 Lockset(door)Schlage or equal 0.00 Repair/Refit Door 0.00 Replace Side Stop 0.00 Replace Casing 12 55.32 FRONT DOOR INSIDE MOLDING Glass Replacement to 64 u.I. 0.00 Glass Replacement per u.i.over 64 0.00 Sash Sidelock/Top Replacement 0.00 Threshold(Wood) 0.00 Threshold(Aluminum) 0.00 Slide Bolts 0.00 Plug Plate Cover 0.00 Cut/finish attic-kneewall access 0.00 Cut/close attic-kneewall access 0.00 close off fascia rear of the house 0.00 Labor Rate Hours 0.5 30.00 TIGER CLAWS TO HOLD UP EXISTING FG Labor Rate Hours 2 120.00 MOVE ATTC STORAGE Labor Rate Hours 1.5 90.00 GARAGE STORAGE Labor Rate Hours Q.00 Permits/Fees(Wap only) 0.00 SUBTOTALS 296.32 TOTAL REPAIR+HEALTH S SAFETY 618.32 GRAND TOTAL WORK ORDER# (A) 4706 8273.20 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before Installation. The Work Order must be complete within 15 working days from acceptance date below: CONTRACTOWCOMPANY: ADVANCED ACCEPTANCE:Company/Contractor AUTHORIZED SIGNATURE: Date AGENCY APPROVALS: CTI AuthorizedSignature: Date GLCAC,Authodzed Signature: Date ya watt'& LWVV t Vt4vV 4V4491"atue%J .QA.oavn i Y Auditor'Renee Tofenelll - - Phone:978-887-7841 Job# A17,0( Date: 9/3•��3 Client First: SH.9.t/,r/o4/ Last: N1G'/�,oe,4 Address: LD s= 1st#r City: ®f/p.�rh+ ,41041vt—.g Zip Codeyi}KS Phone G,?Z - 904V Phone 2 'House Type: Cape Rench Spilt 1 fem 2 fam 3 fam duplex 4 familVictori Co Tenement Siding Type: �Alumn Asb Single Asb Dble Condtlon ( �ozFair Poor Vin sb T111 Brick/Stucco Asphalt Comments: Roof Type Roof Material Hl Flat Gambrel 'A a!t late Rubber Tar&Gravel Condltro Fair Poor Age.of House /91IC5 Heating System Prat w nufacturer: Ulgm— Ag4gg7 EfBcie BD. BACMU11, INC. F�(CBSS Air Fyrite Insight CAZ Base Reading : ft Post: Stack Tem = ___________�___SN: QQ1154 CAZ Worst Reading :Pre Post: ffmaa Temp Time: 11:06:39 Alt r Date: 09/13/13 . . . . . Oxygen a.9 FHW am FHA Space Heater CO 2 x/ Fuel Oil Gas Electric CO —17 - Nat Gas Wood Pellet Coal CO Air Free b Flame Color pr o� 8.9 % Treated Ducts: Yes No Age /Z Co 21 ppm . . Eff q Pipes Yes Y/Z s,s �fc ` lent CO 80.2e,$ Domestic Hof Water Tank Smoke Reading V T-sic 376 OF Gas 4) Electric ank!e Refemsd to HWAP YeA T-AIR 73.7 OF EA 65.4 % Gallons Temp.Sefting► - Date referred CO(0) 37 ppm Draft Spillage Yes / No Spills Differential Pressure Add 6 Feet of pipe wrapYES / NO -0.03 inwe C.omtwmts: . _ ..�......__.... .. _..._. ------------------------------- Number ------------- ----------.-----Number of occupants _ Number of smokers 6 _ Number of pets 0 Ambient CO Readings : Stove �V Oven Broiler ,_ Dryer Ete1- client A14 AAO. Doors _ sw s .ocatton Kits Auto Reg Caulk Caulk Re is leas Comments N OUT rant to out sr.�` tc �E,.S' �" •yt� 01�� rant to Hall bar to out bar to hall o attic o Basement easement io out Location Condition are place; �7s' or GyDamper Yes/No ►pace Heaters 110werbooiIn Pre Post Reason not doing :nob and Tube Y ND Locations We inspector called Blow®rpoorNr Sealing '9�s �ti� psi ,Vs •vow tsr' �a �L 0 eGvOF W d/ tJ�'-/Yd SNS �t �a , /�G�L r1'/N•13 ;r I 1 / 1 ` ■rrrrrrrrrr■ . . . ��arr�rrrrrrrrrr►rrr■ r�rrrrrrrrrrrrrr rr■rrrrrrrrrrrrr MIMMErrrrrrrrrr r�rrrrrrrrirrrr r:mMMmmrrrrrrSE rlmrrrrrrrrrrEM rrrrrrrrrrrrr■ rrrrrrrrrrrrrrrr a rrrrrrrrrrrr■ IMESMUSEEMrrrrrr■ ■rrrrrrrrrrrrr■ IMMENSE rrrrrrr■ ■rrrrrrrrrrrr r■ r' rrrrrrrrrrr■ �., 0.00NErrrrrrrrrr■ rrrrrrrrrrrrrr■ ■rrrrrrMEMErrr■ Emommrrrrrrrrrr rrrrrrrrrrrm rrrrrrrrrrrrENEN rrrr'r�ri�irr®®ri�i®® rrrrrrrrrrrrME 0 rrrrrrrrrrrrrr■ r�rrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrr■ rrrrrrrrrrrrrr rNEENNrrrrrr■ rrrrrrrrrrrrr NE - rrrrrrrrrrrr■ MENNEN rrrrrrr■ _.,. Basement. �.. Mmd/tfoned UncOn"Oned Crawl space Dirt floor Asbestos Yes NO Location .. _ ..,.......,. .� ,. Added R Basement Overhead Garage Overhead 0- TD Sims Drape pedmoler cnwd Space Done Steam hon Steam/Copper FHW 1/2(rich 3/4 fnch _. ....:� _ .............: 11/4 Ruch 1/1/2 inch 2 inch 2.1/2 In _ Ducts Done Yes NoMastic seams hrs Meawwments Square footage rr� rrrrrrn �r�+n��. Basement Airsealin /1y��i,�� Basement Door Drape., Repair Caulk �p �I Y� Floor Plan Comments �9L� ®off 9stCa�okr�� ?o �► Jaw 4o,0 2nd L00014 V . Aloo qq 3rd Sq Feet y Common Ededor wan fst x "AD A w Ekterlor wail 26r _�x/�� 9✓L f���b®09� tease Indicate, Unheated ////I// 1nftdor wen ..� X W!Y cotmrton `+++++ 10,1 V7- /L AIZE mac/ Client ,J� Loose Wool or FIG 12 Cellulose 3.8 FIG or Wool bans 3.2 Vermiculite 2.3 Attic Vents WPO Size Location Amount Present Deeded �x s ,v � e-W Insulation Existing R R Added Square Feet Motes Unfloored 0 Floored Z Slopes Kneewalls - Kneewall Floor lY Flat Roof Hatches WeathmWAgand Batt CutAnd Close Attic Walk up y, T Dorn- Cut and Finish Knob& Tube Yes forage to move Yes No Recessed Lights- /V o.3e nqsm x 0.2 12x12 0.38ex 9B 032 Mr 12x 24 0.06 3 sect all on .98 per 10 ft Turbine 3 ft, 3 sect center open .33 per 10 ft Roaf 138 Lrg .4h Rla Vent .98 per 10 ft 888 sml 0.4 Triangle Gbl with 29114 legsA to.8 At#lc Alr Sealin Notes ,•5' s fes? 9er►eral Name,&Address of mor .Address of Residence; s Date Of bmMLladm pM2Ahmhmuhftd son Flools .ae e afinsuiafian: of insulation: Type ofinsidadon: 7ypManufacturer: Manufedtrrm: manutacturer: • i ' i Rv�aelnstal�ed a,�orrar, uea IRvsere�nsraKea �airroUmtlnstalled �Rvewaars�rae rns�dee f . Part 3 Cer0ficatlon i certifjr that the residence idendfled in Part 1 was insulated assPecMed in Pafrt 2 a ��d the Insulation was conducted in conformance to applicable Codes, Standards, and ncrlatio�ts. signature • Thiscafe tir�,_ust�t g�Om�p►o�f nns>iear a�acent�•fhe eta!Dane/ #/tall WYE%Fw .w .. I -F-�-- Y Address: l -44CZ_,dr it-MAM Date . Contractor : Inspector Attk; NO Level OK No Access OK No y ,g OK No Hatches _OK No Air sealing OK No Bath vent OK No Conww* Basenzertt General Heat Loss Air sealing OK No Door Kils OK NO chimney OK No - Sweeps OK NO .— Locks/Sfdker OK NO MPipe Wrap OK- NO . . Ducts OK NO Caulking in OK NO Sills OK NO Caulking out OK NO Dryer Vent OK NO __ Ghees OK NO Dryer Hose OK NO Glazing OK NO i Comments Walls Windows 2 Hole OK NO lin aNed OK No Dense Pack OK NO Caulked in OK No Plug&Patch OK NO C'au/ked out OK No Density OK NO Dead Lights OK No r Work Comments: Additional Measures Added by Inspector Missed by Auditor Work order to be changed Yes No _ Mandatory for a� InsUNInon. ;. «ent Name st�.va Job# z2e4 Date Section A To be tWd out by WAP auditor during InIftl intervieid Pith client ire Nbere any Mdiiiid1@0•irk thk.d . , �.�... ., .. _.,.. .w.w.: .... _n .. .. .. ..._._. .. .. YES Dont Know wwons: Section B.- 1 :4 Recused Lighting fbds Otherpotet 'Heat producers Section C : To beconretedbythe houraftncontractor atMOOwOf doIL lumber of recessed tights Fwnace flues St►euld wid► Section a, 8dierheatProd'ucers �� .. . Wit Guards needed ;action D: TabesignedbyMs dWan contractor atrercompletion 'have inaftiled guards. Contractor • Dais: —�� signed 30CHOn E To be sired by the weadeerisaSat dieht. agree that the number of Instdatfon guards fndfcated have been Milled as noted above ha�i'iilied -mofi'rae to•the clientthat was�aHaehed•below__._._.__ ...... ... _.._ .._.. ... ._. s1gr�Grre: Date: _ P. .. .. .._..,. ........_...ten.�rw rr•wrrrrww.r.wrrrw,w rw wrw.rr..As..ro... a.. ._.. Mach here and gjV*to Client Votice to Weatheriaadon clients: rhe purpose of the fnsuiatwn guards is to ensure that your dwefng is In compliance whh the Nations!Electric code.The insufadon used meets all Federal test speneggons Kowever since insulation retains heat,it is esswdfal hat heat.produdrig sources be protected For this reason it is important that the insulation guards not be removed IItered or covered.Be sure to use insulation guards#you install new recessed light ttxtures or some similar Mum Also be certain not to obstruct any attic ventlisdon dbvkoL J Greater Lawrence Community Action Council Weatherization Assistance Program National Historic Preservation Act Client File Documentation 1. Client address: 2. When was the building constructed? / --5 3. Is the building 50 years old or less? If yes, agency sign here: , If.no, move to question #4. 4. If the building is greater than 50 years old, are all the intended measures included in Appendix A of the Programmatic Agreement with DOE and the MA .Historical Commission (SHPO)? {YIN} If yes, agency sign here: If no, move to question #5. 5. If a Project Notification Form was sent to the SHPO,what is the date of the SHPO approval to proceed? Agency sign here: ACORO CERTIFICATE OF LIABILITY INSURANCE (M"'°�""") 7/23/13 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). PROWLER ACT NAME: Paul T Murphy Paul T. Murphy Insurance Agenc PHONE 781 321-9700 FAXAIC�No: (781) 324-4253 628 Broadway MISS: Paul@ tminsurance.com Malden, MA 02148 INSURER($)AFFORDING COVERAGE NAIC# INSURER A.Arbella INSURED INSURERS:Safet Advanced Energy Solutions LLC INSURER C:Guard 28 Hamilton St INSURER D: Peabody, MA 01960 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. ILTR TYPE OF INSURANCE ADD SU POLICY EFF P EXP im POLICY NUMBER MMIDD MMIDDIYYYY LIMITS A GENERALLIABILITY X 8500059003 5/7/13 5/7/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENEPAL LIABILITY DAMAGE TO RENTEDwrencel $ 50,000 CLAIMS-MADE DX OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 21000,000 GEN'LAGGREGATELMMITAPPLESPER PRODUCTS-COMPIOPAGG S 2,000,000 POLICY PRO-JECT LOC $ B AUTOMOBILEUABIUTY62171$1 3/19/13 3/19/14 aaccidart)I LELIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLAUTOS X AUTOS BODILY BODILY INJURY(Per accident) $ X X NON-OWNED PR PERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELUiL1A6 OOCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSMIADE AGGREGATE $ DED' RETENTION$ $ C WORKERS COMPENSATION ADWC462376 5/14/13 5/14/14 X WCSTATU- OTH- MID EMPLOYERS'LIABILITY Y!N FI O F CERIMEMBEREXCLUDEANY D? � J" NIA EL.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yyes er RIPTION OF O E.L.DISEASE-POLICY LIMIT s 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTIONOFOPERATIONSILOCATLONSIVEWCLES (Attach ACORD 101,Additional RermrksSchedule,Ifmore space isregdred) Insulation-- Coverage is subject to Policy terms conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Toppsfield ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REREPRESENTATIVE 1 201(1 AC RD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: