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HomeMy WebLinkAboutBuilding Permit #720-2017 - 67 RALEIGH TAVERN LANE 1/18/201711 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . h%( Date Received b« N� cocn�cnewrcn , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other "fl Septic iNell =0 r loodplam f etlands d 9 I]1NatershedD�striet¢ �'-� < DESCRIPTION OF WORK TO BE PhK1-UK1V1tIJ: C)Ia1)sz�r-) tri 0 -mL Identification - Please Type or Print Clearly OWNER: Name: P -CY s c � n H a,► Y) &,nye Phone: q �1FS - �el�l - ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BAcSED ON $925.00 PER S.F. Total Project Cost: $ �d3 FEE: $ 3 l Check No.: �e Z Receipt No.: 3MLA NOTE: Persons contracting with unregistered contractors do not have acces o t guaranty fund : nnati m- of AnPnt/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Located 384 Osgood Street umpsterton site Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Penuanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature, Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: -1 Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: LocaIea aL�tlL4;IVlaln{�treet_y =,�„ �^'�-,'�- eco, r 'y s FireDepartment signature/da Y • COMMENTS,:` Located 384 Osgood Street umpsterton site `nOz�,.:.� d _yes��.�; � i' �5:` .b'y�' d.•i''-'.'�'" b"a i :.yq�, :� ��l ax,la3.l''4.d�,.-�H 7 � 'R 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 21A —F and G min.$100-$1000 fine Doc.Building Permit 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.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 o 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 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 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 Location �" �� �� ` 1 �� i AlC_ -' TV No. ! U - Date i 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ R TOTAL $ qJ Check # Cbz 2_ RISE60 Shawmut Road, Unit 21 Canton, MA 020211339-502-6335 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM i, Patricia Hamann , (Owner's Name) owner of the property located at: 67 Raleigh Tavern Lane , (Property Address) North Andover, MA 01845 (Property Address) Merrimack Valley Insulation 23A Sullivan Rd Billerica, MA 01862 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 property. This form is only valid with a signed contract. Patricia Hamann Owner's Signature 12/14/15 Date DEC 7 5 2016 ` 1 _v C � 57 W N 0 '0 O C CD CL 2 _. O �•cn �0 <vCD CL cr _ CD CCD O CD CL 0U) COC � v CO) O a Z 0 rl• O CD a O CD ., Z m cn cn 0 cn --I m X cn Z z cn O D O Z O -« 5 CD N O 5' (Q O co X CD cc 0 y 0 CLCD o="- 0 _ cCD(D0CD 0 m 0 rt Q n m O, =rS y. O O .+ a 0 m �0 c CD CD _ Q. 2 CCD D O O n -1 toQ= N .-r a1 rt CO's � =r0 CD O O CD 'a � p O O 0z CD N O 0 1 a :91 n��: s = 0 CQ Q Q U) o CD C i• CL � CD CU (D r� CD CD 0 40M :L CD CD CD (D N =� O DCD rt� (D -0 @� F 0 _) C O Q � O Mo m N K W T ,i7 T V1 x T O7 O 7 O �' .o O T j (7 O T O N (D T O C � _S T. (D OA OCG 0Oq =� � OOq 7 � Q CD z (D S S S S n rr O_ S r r W (D O T m C W C D c p m n Z Z p 0 G1 O TI Z fm1 LA vi m -Np z n 0 0 0 = O y L� P -l', I (I � Federal ID # 05.0405629 1 RISE Engineering oil Contractor Registration No 8186 MA Contractor Registration No 120979 CT Contractor Registration No RISE- 60 Shawmut Road, Canton, MA ENGINEERING CONTRACT(401) 784-3700 FAX (401) 784-3710 Page 1 - PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA -}IES ENGINEERING AND THE CUSTOMER FOR WORK AS (' DESCRIBED BELOW CUSTOMER PHONES T DATE �.^ CLIENT p WORK ORDER Patricia Hamann (978)697 0298 10/25/201.6 437883 35002 N SERVICE STREET BILLING STREET 67 Raleigh Tavern Lane ,r 67 Ralcigh Tavern Lane SERVICE CRY, STATE, ZIP BILLING CITY, STATE, ZIP North Andover, MA 01845 Z North Andover, MA 01845 a• JOB DESCRIPTION t HEALTH dt SAFETY: Have your heating system tuned up and retested to be sure that the undiluted flue gasses do not exceed 100 parts per million (ppm) carbon monoxide. Weatherization work cannot proceed until this is fixed. $0.00 HAZARD BARRIER: Wc'have identified that there arc recessed lights present in your home. unless the recessed lights are certified as IC -rated (Insulation Contact Rated) we will create a 3" clearance space around the fixture by using fiberglass blanket insulation as a damming material, no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. $0.00 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 he 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 sealing include air leakage to attics, basements, attached garages and other unheated areas (windows arc not generally addressed.) This will require (12) working hours. A reduction in cubic feet per minute (efm) of air infiltration will occur, but the actual number of cfm is not guaranteed. At the completion of the weatherization work, and at no additional cast to die homeowner, a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure die safety of the indoor air quality. $1.020.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass baits to (92) square feet for damming purposes. $188.60 ATTIC FLAT: Provide labor and materials to install an 8" layer of R-28 Class I Cellulose added to (432) square feet of open attic space. $591.84 ATTIC FLAT: Provide labor and materials to install an 8" layer of R-28 Class 1 Cellulose added to (384) square feet of open attic space. $526.08 STORAGE BARRIER: Homeowner is responsible for the removal of the stored items blocking the installation of weadicrization work in the attic. Removal must occur prior to the scheduled work star. SPECIFICALLY REMOVE THE STORAGE AND FLOORING TEMPORARILY FROM BOTH ATTICS. THE FLOORING AND STORAGE CAN BE PUT BACK IN THE AREAS 4 IN WHICH THE INSUALTION WILL NOT BE ADDED. (initials) $0.00 ATTIC ACCESS: Provide labor and materials to insulate (1) back of the kneewall hatch with 2" rigid Thcrmax board, and seal the edge of the hatch with weatherstripping. $60.00 RISE Engineering RISE60 Shawmnt Road, Canton, MA :NGINEERING (401) 784-3700 FAX (401) 784-3710 Federal ID # 05-0405629 RI Contractor Registration No 8186 AAA Contractor Registration No 120979 CT contractor Registration No CONTRACT Page 2 PROGRAM THIS CONTRACT 15 ElffERED Imro BETWM LUBE CMA -HES MGMEE11M AND niE rarSMM FOR WORK AS DESCRIBED BELOW CDMUM PWXE DATE Cl1ENT C WORK ORDER Patricia Hamann (978)697-0298 10/25/2016 437883 35002 SERVICE STIM Blume STREET 67 Raleigh Tavern Lane 67 Raleigh Tavern Lane SEMCE MY, STATE. ZW Blu me CITY. STATE. ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION ATTIC ACCESS: Provide labor and materials to install (1) easily moved, insulating cover for the attic access folding stair. A small flat 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. VENTS ATION: Provide labor and materials to install (2) insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s). VENf1L.ATION: Provide labor and materials to install ventilation chutes in (60) rafter bays to maintain air flow. BASEMENT CERJNG: Provide labor and materials to install (92) linear feet of R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $237.65 $237.50 $120.00 $161.00 . 10 r'"*1 10 # 05-0405629 RISE Engineering RI Contractor Registration No M86 MA Contractor Reglstratton No 120979 CT Contractor Registration No RISE60 Shawmut Road, Canton, MA ENGINEERING' CONTRACT (401) 784-3700 FAX (401) 784.3710 Page 3 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA -HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLMNr 6 WORK ORDER Patricia Hamann (978)697-0298 10/252016 437883 35002 SERVICE STREET BILLING STREET 67 Raleigh Tavern Lane 67 Raleigh Tavern Lane SERVICE CRY, STATE, ZIP BU12M CRY, STATE. ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION 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 1009% for the Air Sealing measures up to the fust $680 and an additional $340 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 allowable weatherization incentive is $3.110. $90.00 Total: $3,232.67 Program Incentive: $2,702.00 Customer Total: $530.67 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICAMOIIS. FOR THE SUM OF ***Five Hundred Thirty & 67/100 Dollars $530.67 UPON FINAL INSPECTION ANO APPROVAL BY RISE ENGINEERING CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL. INTEREST OF 1% WML BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS. SEE REVERSE FOR IMPORTANT 0WORMATION ON GUARANTEES, MGM OF RECISION. SCHEDUUNG, AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE LANK SPACES Nathan Weiss AUYHORREOSWRATURE- RISE Engim.ng CUSTOM ACCEPTANCE NOTE: THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WM41N DATE OF ACCEPTANCE �• I� ACCEPTANCE OF CONTRACT - THE ABOVE PRICES, SPEC OCATIO S AND CONOrttONS ARE 30 DAY, SATISFACTORY TO us AND ARE HEREBY ACCEPTED. YOU ARE AUTHORRED TO DO THE WORK AS SPECIFIED. PAYMENT WILL BE MADE AS OUTLINED ABOVE MERRVAL-03 WEJE CERTIFICATE OF LIABILITY INSURANCE DA:(I 61/93/2Q1312076 THIS GERT IFICATE 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). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency, Inc PHONE _ FAX 9 ADP Boulevard AIC. No Ezi : INC. No : E4.1AIL Roseland, NJ 07068 ADDRESS INSURERMSi AFFORDING COVERAGE 11 NAIC e INSURERA:5Star1J3 AAIG American Alfernafive —Insur'-a-rTk t INSURED 8.ilerr'imack11alley Insulation Corp INSURERS: 23a Sullivan Rd INSURERC: North Billerica, MA 01862 iNSURERD: ---- - - - ��� - INSURER E: COVERAGES CERTIFICATE NUMBER_ REVISION NUMBER: Thlb is TO CERTIFY THKT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE: INSURED NWED ABOVE FOR THE POLICY PERIOD INDICATED. NOIVUrrHSTANDING ANY REQUIREMENT, TERM OP, CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO IJIIHICH THIS CEP.TIFICATE 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- LIWTS SHOWN MAY HAVE RFFN RFDUCED BY PAID CI_AIMIS_ ILTR I --TYPE or- INSURANCE�~— ADDLI INSR UO.Ri POLICYNUP.IBER I F.1 I011JYWY H10AlDD111YVY i - WATTS- i GENERAL LIABILITY ' t i t 1 EACH OCCURRENCE I S RENTED lr� COMIAERCWLGENERALLLABILITY } , PRtI_SES a occumnc> yT� CLAIFAS RADE OCCUR I id.EDE)(P YAnyone person) S i _ ADV IWURY S }i •° GENERALA_GGREG_ATE _ �1 S_ _ _ __ i A GEiGGREGATELtt1IrAPPLIESPER: I ;PRODUCTS -C063Pi0?ACG !'r- 1 POLICY PRO f LOC Is I AUTO?iDBILELABILITY I ; CONISINEDSINGLE Ulttr Ea arcldent S _ BODILY INJURY (Per person) �5 l ANY AUTO s _ I ALL MWED SCHEDULED AUTOS AUTOS i -- 60rYLYINJURY(Per acddenl)I5 NON OWNED HiRF-D AUTOS AUTOS I 4 I i 1 PROPERTY OALiAGE 1(�Psraxid_=n.] l t jS _ J UtIRRELLA UAS OCCUR � EACH OCCURRENCE 5 } EXCESS UA$ l Clhi?riSfiJADE1 i � AGGREGATE S RETE0NS---- 1 DED i Nii g _ } : WORKERS COMPENSATION l WCS`iA U- AND _hIPLOVERS' I.IASILITY Y!N !TORY x EP A AVYPROPRIETOR/PARTN_MEXECUTME VSWC749118 6(9812016 6/1812017 F_L EACH AccmEw S^—�l9,UOU,00 OFFICERR%EidEEP. EXCLUDED? Y NIA — —. _ EL DISEASE -cA EMPLOYEE 5 1,000,000 ( {PRandato[y in NH) i IPKes,descdbeunder E.LDISEASE-?OLJCYUI7n'" S 1,400,00 D::SCRIPitONOFOPERATIONS b a:r _ I 1 7 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (Attacb ACORD 101, Additional Remarks Schedule, irmom space ismquired) I I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EJSPIRATiON DATE THEREOF, NOTICE MILL BE DELIVERED iN Town of North AndoT rr, Massachusetts I ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 ILITHOR17ED REPRESENTATIVE I - - - - - ©1988-2410 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD ACGORDF CERTIFICATE OF LIABILITY INSURANCE WMIDDIINM 11/ro7nols 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 have ADDITIONAL INSURED provisions or be endorsed. I If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on I this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). (PRODUCER i Charles J Coughlin Insurance 14 Dinley Street P. 0. Box 10 CONTACT Carolyn A Coughlin PHONE (97$) 957-35$$ FAX AIc Nu ADDRESS: carolyn@coughlirfins.com INSURER(S) AFFORDING COVERAGE NAIL # Dracut, MA 01$26 INSURER A: N orthland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A. Ryan, Jr. INSURER 8: Safety Standard 39454 23A Sullivan Road N. Billerica,MA01862 INSURERC: Torus Specialty Insurance Company A0159 MAGA RB100,000 PREMISES Ea MED EXP (Arty one person) S 5,000 INSURERD: INSURER E. INSURER F : i UVtKAGtS CFRTIFICAT F NI1MRFR• ocincinra 611r leerzoo. 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 i 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 I LTR I t TYPEOFINSURANCE ADDL SUER POLICYNUMBER POLICYEFF M1DDM'm POUCYEXP 3mmlonnym LIMITS �A COMMERCIAL GENERAL LIABILITY CLAIMS-MAOE a OCCUR WS274182 01/21/2016 1121/2017 EACH OCCURREl1,000,000 MAGA RB100,000 PREMISES Ea MED EXP (Arty one person) S 5,000 PERSONAL s ADV INJURY $ 1,000,000 GE/NL AGGREGATE LINTAPPUES PER POLICY Q JERCT n LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS - CQUPrOP AGG S 2,000,000 S OTHER B AUTOMOBILE LIABILITY NY AAUTO I 6205006 11125/2015 11125/2016 Ir�D SINGLE LIMIT S 1,000,000 Ea xcideM BODILY INJURY (Per person] S 3 + OWNEDAUTOS D AUTOS CNLY HREO NON -OWNED I AUTOS ONLY V AUTOS ONLY BODILY INJURY (Per awideni) $ PROPERTY DAMAGE Per accigep S S C �' UNBRELLAUAS EXCESS U0 J� OCCLR CLAIN&MADE I 87593L161AU I 0112112016 01/21/2017 EACH OCCU;Ft J.CE S 1,000,000 AGATE S 1,000,000 DED i I RETENTION S O S WORKERS COMPENSATION AND EMPLOYERS' LIABILrrY YIN ANYPROPRETORIPARTNERE(ECUTNE OFFCERJMEMBER EXCLUDED? N I A PER OT1+ STAT _ ER EL EACH ACCIDENT S EL DISEASE -EA EMPLOYEE S (Mandatoryin NH) If yes, describe under E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS beknq DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be aMched if more space is requved) Insulation Installation i Town of North Andover, M assachusetts 120 M ain Street North Andover, MA 01845 uPJP] SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE )MLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE U INOO-LU70 Af,;VKI) UVKIrIVKATION. All rights reserved. ACORD 25 (2018/03) The ACORD name and logo are registered marks of ACORD Address: 28 A Sullivan Rd. tate/ZiD.- Are you an employer? Check the appropriate box: 1. X❑ 1 am a employer with 18 4. ❑ 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.'+ required.] 5. ❑ 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' camp. insurance required.] Phone #: 978-888-3495 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.❑ Roof repairs 13.© Other Insulation 1,Am° applicant that checks box # 1 must also fill out the section belo-v showing their workers' compensation policy information. Aomeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet shotiving the name of die sub -contractors and state whether or not those entities have emnioyees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ 5Star V3 AA1C American Alternative insurance Policy # or Self -ins. Lie. #: V9WC749118 Expiration Date: 6/181n2017 Job Site Address:JAq(� 0u2. L*,) ko City/State/7NO ip: ) � � Qg&(&mA 01 jgtb 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 ane 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. I tlo hereby certify tutder the paints artd penalties of perjury that tete information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. 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 The Commonwealth of Massachusetts Department of Industrial Accidents `` � Office of Investigations Iry 600 Washington Street .Boston, .NIA 02111 www.mass gov/dia Workers' Compensation. Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeObly Name (Business/Organization/Individual): Merrimack Valley Insulation Corp. Address: 28 A Sullivan Rd. tate/ZiD.- Are you an employer? Check the appropriate box: 1. X❑ 1 am a employer with 18 4. ❑ 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.'+ required.] 5. ❑ 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' camp. insurance required.] Phone #: 978-888-3495 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.❑ Roof repairs 13.© Other Insulation 1,Am° applicant that checks box # 1 must also fill out the section belo-v showing their workers' compensation policy information. Aomeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet shotiving the name of die sub -contractors and state whether or not those entities have emnioyees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ 5Star V3 AA1C American Alternative insurance Policy # or Self -ins. Lie. #: V9WC749118 Expiration Date: 6/181n2017 Job Site Address:JAq(� 0u2. L*,) ko City/State/7NO ip: ) � � Qg&(&mA 01 jgtb 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 ane 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. I tlo hereby certify tutder the paints artd penalties of perjury that tete information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. 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 wommonwealml fl p t &6a'clwl e� Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvemerit_Contractor Registration Type: Corporation Registration: 180506 Merrimack Valley Insulation Corp Expiration: 11/23/2018 23 A Sullivan Rd - Billerica, MA 01862 - SCA 7 0 20t"5(11 1 Office of Consumer Affairs & Business Regulation NOME IMPROVEMENT CONTRACTOR { i; Type: Corporation ' ur Registration Expiration 180506 11/23/2018 Merrimack Valley Insulation Corp Joseph Ryan 23 A Sullivan Rdc--- Billerica. MA 01862 G Undersecretary Update Address and return card. Mark reason for change. 0 Addrott Q Rsnai.,tm r_l. mployrrnert 1_I !not r`arrl Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not vJ1id ithout signature .t,3SSZ:Z; 1 UsEi:S - Dap;-,>; `m,ei'- . `. ?j C �� ...,mrd o, ...,.,.,, _ � .....�..., ...... .�.. SL. u`<' _?:arise: CS -075541* JOSEPH A RYA -N1. 300 Kind Rail Dr -:Apt 201 _ ,; 02/0412017 9 5 L } NORTp o: Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING r C' • oma• ...� +.'�+ � rte' t SSACMUS� f This certifies,that r....:. ................ . ..... has permission to perform ....................._ � wiring in the building of ..............f ?' / If<........I.. ,. Worth Andover, Mass. .r — Fee..y...`... Lic.No.3S3S.C'................ ,G(.,i�;,•� EL CTR ICAL INSPECTOR Check # � � 2-,� i . K", 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. p. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed ' on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G . c. 143J 3L. Permits shall -be limited as to the time ofongoing construe :on activity, and may be -deemed -by theinspector_of_Wires abandoned.and.invalid.if he--. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. � n f tole 8 — Permit/Date Closed: 0 Permit Extension Act — Permit/Date C * * * Note: Reapply for new permit f 4 Department of Fire Services Permit No. � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) � M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAM TION) Date: �?'%%-/U City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) to % R41 / / 7�?Pv z -) Owner or Tenant ,&9up // '4�y/„e,,14 n Telephone No. Owner's Address S Fl -x--- Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service ,)vv Amps %J u uJ Volts Overhead ❑ Undgrd No. of Meters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus . addle Fans P (Paddle) Tr s Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above 1:1In- Elo. rnd. rnd. o Units Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS TNo. of Zones Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exh' ited proof of same to the permit issuing office. CHECK ONE: INSURANCE E] BOND ❑ OTHER [✓(Specify:) �e ..� L `'Z I certify, under the pains and penaltieserjury, that the information on this application is true and complete. FIRM NAME: i Of M. NJe /u LIC. NO.: 3 5-398 Licensee: Signature_ -� t �---� LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:�97fJ S� S—�' X70 7 Address: l V /J%p.z2,'// 7' L -v pct flelf —1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departffient of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent FPERMITFEE.- $ Signature Telephone No. No. of Dryers y No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heaters Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers p Totals: . . .. ... ... .. . ..... .... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exh' ited proof of same to the permit issuing office. CHECK ONE: INSURANCE E] BOND ❑ OTHER [✓(Specify:) �e ..� L `'Z I certify, under the pains and penaltieserjury, that the information on this application is true and complete. FIRM NAME: i Of M. NJe /u LIC. NO.: 3 5-398 Licensee: Signature_ -� t �---� LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:�97fJ S� S—�' X70 7 Address: l V /J%p.z2,'// 7' L -v pct flelf —1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departffient of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent FPERMITFEE.- $ Signature Telephone No. No. of Dryers y Heating Appliances KW aecurny �ysiems: No. of Devices or Equivalent No. of Water KW No. of -No. of Data Wiring: Qy Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exh' ited proof of same to the permit issuing office. CHECK ONE: INSURANCE E] BOND ❑ OTHER [✓(Specify:) �e ..� L `'Z I certify, under the pains and penaltieserjury, that the information on this application is true and complete. FIRM NAME: i Of M. NJe /u LIC. NO.: 3 5-398 Licensee: Signature_ -� t �---� LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:�97fJ S� S—�' X70 7 Address: l V /J%p.z2,'// 7' L -v pct flelf —1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departffient of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent FPERMITFEE.- $ Signature Telephone No.