HomeMy WebLinkAboutBuilding Permit #662-2016 - 73 PLEASANT STREET 11/30/2015S,d1js1A,Eo /.0 -3-/s
Permit No#:
Date Issued: ( (
BUILDING PERMIT
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
Date Received_
F- 1 )IMPORTANT: Applicant must complete all items on this page
P�LeD !6
LOCATION
Print
PROPERTY OWNER rr) t, ,E ,
Print 100 Year Structure yes no .
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes. no
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
kiOthers:
❑ Demolition
❑ Other
vla; i 8 h
ept Q;QK,®,1/11e1 6
i5-1910�d> plains a,� Wet ands :
W� t hetl®ist, ict
DESCRIPTION OF WORK TO BE PERFORMED:
)PIT S -e&, li ^ q 1 " t.vg// 'z N Sv la -)'o y Ar r l Se PA et
Id A -
Please Type or Print Clearly
OWNER: Name: h 7► r- T fn t.) et i Phone: iF -Fo& -
Address: ? 3 � be
Contractor Name
Email:
Address: Z
W
e
(�rT c (` /?I A IA n Phone:
Supervisor's Construction License: /aL o / i Exp. Date:
Home Improvement License: /pI L Exp. Date: 7%a�aot�
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ '� ioo -o o FEE: $ �
Check No.: w t Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access.to the guaranty fund
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
4� Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TOTE: 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
4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4. 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
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
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
Doe: Building Permit Revised 2014
Plans Subrnitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools . '. ❑
Weil ❑
Tobacco Sales ❑
Food Packagiug/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m 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 Decisionlreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wafter & Sewer Connection/signature ®aye Driveway Permit
]DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DE_P`i4 T Durripster'q `sit ' ~ ' 'jam `'
n eyes, � no ..�.�
�Loca`ted at 1'24 1-i—
.-,
a
Fire Department soigrure`��"'
`7 ." �` sFt''•°" . {?-})'#`•P'°sY°°04u
+�:'r �;��`, � '��. =!S'.� }:±•3r;'�i���:�2'�.'4�" �...,i.�sa..a..i...b.�;3.�:..�... `..,Sa,'-,,,c
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL. Movement ofeter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATUR : Yes No,
MGL Chapter 166 Section 21A—F and Glmin.$100-$1000 fine
NOTES and DATA — (For department use
L] Notified for pickup Call Email l
Date Time Contact Name
Doc.Building Permit Revised 2014
Location
No. Date
Check # W�
29744
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $-
Building Inspector
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P/EOG/1
Federal M 60644066
�i RISE Engineering WCo�Registration
RI S E `�� A division of ideiseh F.nginmog dAtAConhaeEor r No 120979
ENGINEERING 60 Sbawmat Unit#2, Canton, MA 02021
� FAX 339-502-6345
CONTRACT
Page 1
PROGRAM
nosoONrRAcr6EMEa6oarro nasi£
CMA -HES Armnaecus10031FORwaxRAa
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Daniel Pietrowski (978)806-5850 09=015 423144 3
SERVICE 8rRM BaAWn 87RaET ! ;
73 Pleasant Street 73 Pleasant Sheet
SERVICE CIIY BrATELP aaiat8 cWt. mn:ap cl
North Andover, MA 01845 North Andover, MA 01
JOB DESCRIPTION
!EE ONE - Proposal for this calendar year.
$0.00
BARRIER: A Blower DoorTest will not be conducted at your home, due to the ase of EsbeswL
$0.00
BARRIER: The following contract is not valid unless accompanied by the Pre-Weatiurtioo Barrier Incentive toms, signed by
yourliCtossed electrician Work will cot proceed with this work ad we receive a copy ofthe fort.
$0.00
AIR SEALING: Provide tabor and materiels to seal areas ofyour home song wasWK excess au leakage This work will be
performed in concert with the use of speed tools and diagnostic tests to am 69 your home will be left with a healthtid level of
air exdange and indoor air gladly. Materials w be used ro stat your home can fnelnrde car ft fans and other podacts. Primary
arm flu sealing include air leakage to attics, boscmcn% attached gattgs and otherunhead areas (windows are not generally
ad&sw&) This will inquire (8) working hours. A reduction In cubic feet per minute (cfm) of air infiltration will new, but the actual
number of efin is not guaranteed
At the completimr ofthe weathaaation work, and at no additional cost to the homeowner, a final blow door and/or combustion
safety analysis will be conducted by the sub-aombactor to ensure the safety of the indoor air quality.
$680.00
STAIRWELL: Provide labor and materials to install tis 1 Celhdose irsuletiot to the shemock or plaster eating mu lla walls of a
stairwell which we eornmon to heated span, through a snot= drill and phng method. The boles are phaW with styrofom t plus,
and speckled to a rough finish. Any sang and painting required are the customer's responsibility.
$175.00
VEMILAMON: Provide labor and maters to install (1) insulated exhaust hose with roof mounted flapper veal to exhaust
existing bathroom fan(s).
$118.75
WAL & Furnish and install blown in Class I Cellulose to (1392) square feet of vinyWded exterior walls. Invoicing will occur upon
completion of installation. Subsequeat to you payment, as madded service, RISE Engineering will return when weatherpermits to
check far any voids with an inkaW scanner. Any major vow that may be found will be filled at no additional cost
$2.57520
CRAWLSPACE: Provide labor and materials to install (108) square feet of 6 rad polyethylene over open good in designated
eras lspacdWithen basement areas
$83.16
RISE Engineering will apply all applicable, eligible incentives to this contract. You will only be bitted the Net amount Currently.
for eligible measures. Columbia Cas offers 75% ince aft not to exceed $2.000 per calerndar Year; and an incentive of 100% for the
Air Sealing measures up to the fist $680 and an add'rtimral $340 ff savirgs are justified by the auditor.
For the sefcty and haft of you homes 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 weadrerimtion work is complete. We will also conduct a f dt assessmmt of
the eombustion safety ofyour heating system and water Water. This has a value ofM and is at no cost to you. Total allowable
wesiha flon incentive is $3.110.
x $90.00
Fedwal M f
41t, RISE Engineering w 00*aCt13rft8ht18fi0U1 No OWS
RISE9:Z- A division o[TbW a6 Enoneaft M ContracW RBgisttatinn MUM
ENGINEERING 60 Shawmut Unit 02, Canton, NA 02021
33 FAXX24M CONTRACT
Page 2
PROGRAM
CHA41CS SAN TTS tNB ' 'IAS
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Daniel P.ietrowski (978)W&5850 09/22/2015 423144 00003
sown $TRW BUM BfREEF
73 Pleasant Stream 73 Pleasant Street
BP.RMCE CRY. STATE. W GUAM CNV.MTB.ZIP
North Andover, MA 01845 North Andover, MA 01845
JOB DESCRIPTION
Total: $3,722.11
Program incentive: $2,770.00
Customer Total: $952.11
WEAL HM8 MRffSMSEMCW-eotrPLM NACCORD CEvmnAWYESPBtX}1CAMMFMWESUMof
'Nine Hundred FiRyf Two & 11h00 Dollars $952.91
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Ad0CDR® CERTIFICATE OF LIABILITY INSURANCE
DATE (119IWDDR'YYY)
03t13f2015
THIS CEITI IFICATE IS ISSUED AS A MATTER OF INFORMA710M ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEIL THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, MMD OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT E3 N TME ISSUING INSURERMI AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cerfiificate holder Es an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, caftin policies may inquire an endorsement;. A statement on this certificate does not, eoufer rights to the
Certificate holder in lieu of such endorsemerrt(s).
PRODUCER
ilurso & Jankawsld Ins Agcy LLC
198 Massachusefls Avenue
North Andover, MA 0184.5
Durso Jankowski Ens. Agcy.
CONTACT
PHONE FAY tto
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ACCORDANCE WITH THE POLICY PROVISIONS.
ADDRESS
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INSURERIS)AFMRDIPIGCOViRAGE nice
INsuRED Pmlar Rear IrLsulatiolt IdO. InC.
A O Bou 958
Andover, MA 01810
tNsuRERA:Penn America 32859
INSURER B : Safety Insurance Co. 33618
INsuRER a :
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EACH OCCURRENCE S 1,000,000
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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.
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ThielSCII Engineering
ACCORDANCE WITH THE POLICY PROVISIONS.
POUMMUSER
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GENERAL LIABILITY
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PRODUCTS-COMPIOPAGG 1,000,000
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DESCRIPTION OF OPERATIONSbeltrrr
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Insulation Worcs - Mineral; Additional insured for general liability vire" h
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SHOULD ANY OF THE ABOVE DESCi4iBED POLICIES BE CANCELLED BEFORE
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ThielSCII Engineering
ACCORDANCE WITH THE POLICY PROVISIONS.
Columbia Gas
195 Francis Ave
AUTiioRtEEDREPawwrA-mm
Cranston, R8 02910
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ACORD 25 (2009/09) The ACORD name and logo are registered rnarlm of ACORD
AC 1 Eo
P CERTIFICATE OF LIABILITY INSURANCE
OATE`°1Mw'YYY"
F12/182014
THIS CERTIFICATE 5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, 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(sb
PRODUCER
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NAME:
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Automatic Data Processing insurance Agency. Inc.
AODREss:
1 Adp Boulevard
Roseland, NJ 07068
tNSURER(S) AFFORDING COVERAGE MAIC e
EACH OCCURRENCE S
INSURER A: NorGUARD Insurance Company 31470
INSURED POLAR BEAR INS ULATION CO INC
INSURER B:
INSURER C.-
:PO
DBA: Polar Bear insulation CO Inc
POBOX 958
Andover, MA 01810
INSURER D:
INSURER E:
INSURER F:
AUTDIADBILE
COVERAGES CERTIFICATE NUMBER: Z91629 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISS UEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY It EQU IREMENT. TER M OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT TO ALL THE TERMS.
EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS.
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INSD
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�SCRB'TION OF OPERATIONS belrnY
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011012015
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EL DISEASE -EA EMPLOYEE S 1•0mow
E1.DISEASE-POUCY LIMIT S 1.�+�
DESCRIP710N OF OPERATIONS !LOCATIONS WEHICLES (ACORD 101 Additional Remarks. Schedule. may be attached Unnare spate is required)
Columbia Cas massachusetts
Theilsch Engineering, Inc.
19S Frances Ave
Cranston. RI 02910
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 2S (201401) The ACORD name and logo are registered marks of ACORD
" cY�" tV1ViV.litaSS 9 ov%dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors/Elect'r-icians/Plumbers
Name (Business.='Organization/Individual): ro Nr A -ea. r 7-niy m r'o01, e v . � �P
Address: Ilam
Phone ig: Q 7
Are you an employer? Checkthe appropriate box:
Tlie Cominionivealtlt of lWassachusetts
4- ❑ I am a general contractor and I
Department of Lidustrial Accidents
D
Office of hzvestig ations
listed on the attached sheet.
600 Washington Street
These sub -contractors have
Boston, 11A 02111
" cY�" tV1ViV.litaSS 9 ov%dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors/Elect'r-icians/Plumbers
Name (Business.='Organization/Individual): ro Nr A -ea. r 7-niy m r'o01, e v . � �P
Address: Ilam
Phone ig: Q 7
Are you an employer? Checkthe appropriate box:
1. ( I am a employer with 77
4- ❑ I am a general contractor and I
employees (full and(r pan -time)."
heti a 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 am; capaci4-_
employees and have » orkcmr
[No .+orkers' camp. insurancecomp-
insurance.
required.]
5. ❑ We are a corporation and its
3. ❑ I arra a homeot+vner doing all work-
officers have exercised their
myself. [\o worke& comp.
right of exemption per MGL
insurance required.] '
C. 152. l 1(4)- and tie have no
employees. [No workers
COMP. insurance required -1
Type of project (required)_
b. ❑ heti.. construction
7. ❑ Remodeling
S. Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.17 Plumbing repairs or 2dditions
12.❑ Roof repairs
1 -mother
`anv applicant that ctttc-k; box = f mte t also hit out rite section 1100w showing their porkers compensation polk% infoanatiott.
' 1 tunteottvzrs •rho submit this affidavit indicating they are dolt._ all 1rorkand then hire outside contractor must submit a new affidavit indicalino such_
=Contractor that check this box must attached an additional sheet showing the name of ibe sub -contractor and slate u'ltether or not tltuse entities have
C17111JOYMS. If tltC sub -contractors !tate employees_ the• must provide their workers' comp_ policy number.
1 am an emplorer that is provitling ivorkers' compensatioa insurmtce for ti r employees Beloit, is t/te policy 111x! job Site
information.
Insurance Comp2ny Name:
Policy = or Self -ins. Li c. �ffi: ;� 0 W-44— ��jt� �®`
Expiration Date: I , A
Job Site Address: 2Z_ laG Sot k7- CilyfState2ip: �. f9Pn7 91dVe0—
Attach a copy of the Workers' compensation polio- declaration page (sho%%ring the policy number and expiration date).
Failure to secure coverage as required under Section ?SA of ZIGL 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 S350.00 a day against the violator_ Be advised that a copy of this statement may be fonvarded to the Office of
Investiggations of die DIA for insurance coverage verification.
I do herehr c_eeft f ' rat rrler the pains and penalties ofperjrary- that the information pro vNed above is trite and correct
Official rise only. Do lint write in this area, to be completed fir city or town of
fcin!_
City or Town-.
Permit/License m
Issuing Authority (circle one):
I_ Board of health 2. Building Department 3- Cityl`fmwn Cleric -I. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person: phone �:
7iness Regul�OIl
Office of Consumer Affairs and
10 park -plaza - Sure 5170 6
Boston, Massachusetts 0 stration
tor Regi
14ome �provemeIIt COOP Re;fttU8on: 102726
Type: DBA16 . hg 252249
Expirafion. 71220
ppg.CAI a 50NW4104al("216
t Massachusetts = Department of public Safety
VMassac
Board of Building Regulations and Standards
Con%tructiun Supen isnr Specialty
License: C'SL-106017
PETER A LEBLAIIC r
2 EAST PINE STREET•
Plaistow NO 03865
Expiration
�� 0,-.,Zr
,, .,tl."0, 0412812018
Commissioner