HomeMy WebLinkAboutBuilding Permit #1087-2016 - 889 JOHNSON STREET 5/1/2018 � ^• IU 1� ��1�d�V` f NORT►y q
p ���e° �6•ti0
BUILDING PERMIT �? y�.,._ _''••, pL
p
TOWN OF NORTH ANDOVER
) APPLICATION FOR PLAN EXAMINATION
Permit NO: `Q Date Received * °,
Date Issued:
�9SSAC HVSk��y
IMPORTANT: Applicant must complete all items on this age
i
LOCATION'
-11
iv
;Pr1nt
PROPERTY OWNER - A-I
Al, x
Pit
MAP NO PARELZCNI�DtT2JTf 711 tlrib Cstict deg no
hide ShQ ill * es no
4
g _v. p g
3.
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Er6ne family
❑ Addition ❑ Two or more family ❑ Industrial
Iteration No. of units: ❑ Commercial
❑ Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
r
L�Septic WeN Fopitn �1/ 11ad "� C 1t # rse�Dtrt
D Water/SOwer
x. 3.
{� T-TIC lNSIA Lx-TIOAJ _ WSUL ,j_ t
G-I L I (\Jg C a P-W L_ C �A-i Q S&At,&/6.
Identification Please Type or Print Clearly)
OWNER: Name: M GI-A S S l_ E ea✓ �5 Phone:
'Address: -�0� �t� I� "T ' � (��1�1� = CJ1 � ?
CONTRACTOR Natuna; � c ep ?
- IFf
Address: s.
z
s
A
Supervisor}
s Gonstruction l_iense exp Gate:
Hort"Improvement-,License Chat
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: $ D-3 4-q • J FEE: $mop,
Check No.: 3-3 7 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
.r _ _ _._._ �:....^.+e^.•-'�.`-•..cAr,C=��•.'�r---T.s. ,r._ \_.. I-�`-'"^..� -..-.. �.,, ..a. ...,.�. �.��n,.-r,-._h�....T_. �-..._.-s_- .�f
Location
4
r
No. � �a� 1�7 ��' 01 � Date �� � r ...
• - TOWN OF NORTH ANDOVER
Certificate.of Occupancy $
Building/Frame Permit Fee $3CO V
Foundation Permit Fee $
Other Permit Fee $ f
TOTAL $
Check#, 1�-
I .jg
Building Inspector
3025 /,
NORT11
Town of �� : _E : f ndover
No.
1
oh , ver, Mass,
cocMicMewrcw y1'
U BOARD OF HEALTH
Food/Kitchen
,PERMIT T . LD Septic System
d..a.�9�.�......E-d .a. ...S. BUILDING INSPECTOR
THIS CERTIFIES THAT ............... .............................................
T Foundation
has permission to erect 335 �l..abn acr 0"T'
.......................... buildings on ..... .... .... ....................
Rough
t' _L_n C U�,I �. t p
tobe occupied as .............� ....�....�.�....41..........................�.................................................. 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO RTS Rough
Service
------
.............. .......... ...... ................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Building Rough
Display in a Conspicuous Place on 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information l Please Print Legibly
Name (Business/Organization/Individual): Co-op Power
Address: 15A West Street
City/State/Zip: West Hatfield, MA 01088 Phone #: (413)772-8898
Are you an employer?Check the appropriate box: Type of project(required):
1.2 I am a employer with 20 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. + F] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]+ employees. [No workers'
13.[R Other La "ic.-C��- �
comp.insurance required.]
4
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
+Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: HDI Gerling America Insurance Company
Policy#or Self-ins.Lic. #: EWGCC000187715 Expiration Date: 11/08/2016
Job Site Address:_ b (� S 0✓� City/State/Zip: N, 4r�(../l 0VD✓ ,MA 6 C ��
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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c e pains and penalties of per'ury that the information provided above
is true and correct.
Si na u Date:
hon .- 33
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of.Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
i
I
Contact Person: Phone#: i
RISE60 ahawmut Road.unit 2 Canton,MA 02021 339-502-6335
ENGNEEF.INt` www.RiSEengin"riiig.com
OWNER AUTHORIZATION FORM
(D;amer S?4eT8)
cawrx>r of the proper"y located at:
(Property Address)
J iY,�
(Property.Address)
nweb,
Subcon ctur) ..
an aL^;c, zod suocort Gvttvr,_r RIS=ErgI eennr,.:o ac c,- :y bc he:`to ovteln e buOd ng
permit and to pef`..,rn work Cr.mry propar; 3 h:a Ec-ni I's on5y vaild v.it"a signed c r.:act.
,
�f ,r
Je:'er s Sic
�2?a
I
i
RISE gig
� ft
�� 4050mttnnt l�dt0.,cawaa.AlA
(401)7iA4706 FA\t401)7Ni3^i0 CONTRACT
Papa i
lsitMA11AM
t,ataaC111Noarp tetolklralPNsba
CAiA-FIQ$ �wtuatexerrarern
Meliuil4el[s6
1 nq,a atM unlit. rasaMau
a Cdavatr (781249.9416 02/1212016 430436 00002
"MWA rneit
razes stoma
889)otmwn Sued 884 Sohmmf SSret
aeras em.sumt o ansa iar.emtm
tdmth Atm;MA 01945 Nmb Andover.MA 01845
JORDESMMON
.AIli-SF.)LRr(i:FbcaideAAor aeA»ratc5>M wtral saes aryocLemotx>t*fal:'eoe�ay.latc.Tru aata.ta be
pallivodincomenarabthem afspeeiai took andteoUbeaiuft:itxityoarltm+eeikDeiafl�ah k+vdot
+'feaaa.�diw4�0#tp�p.IW1ei>lawt+c tlfod watl parh[mMttto,rce4dtaidktt Aimraand dlcr .PehrmF
seas frKaz�agdidedeair le'dlnetbtYlu's,bamnnmu,taaarhaS� aadatEkrao3cmod areda Mcabn.see sal
ad�at'a�.)71t$,r3a t0q@tr l l>+mrSd�1ums.A tcdapYm bainde pateNaim to0nl tNa+x iNltvat)ou,sEO aomr xival
aaiotp�r el'a9am sot�mmeccd. .
At tls baro kn otma u wYl,:oaf al ao additawP pqt to the hraon+.mc.a raw blam aur:aaix qx ma
tdfrn`anAj�»�ba�t>adtxxd br iRe aoh•mar.�a ewtm 111e ntaYgoFUre imioo:�,q:zrn.
565.00 i
'!tFdt'S1tt74ti,6 FRA1.1,A tltX)R 1VIt5-w L$AWL%PALT.nirr711F(Y1\17tA—rm CAN IAVAATE ..
50.00
1)ASxi�aec,t`.ov10e talc.and a> 6 to iatmll a 1P'.+�afR:d$a�Szd Ubatymr tzen u,r id1 agtnrc rr br dm�i
it PmP�•
S S.70
A777f FIAt;?nwide t�aad rrepn§tli n.i+i:ea0a{•yyr•.nd'R.li'C:tm»'IC'eJnl<wc dAidw lY.'dU�Ptxe fiH afnpm 9tie
Sabli.<tl
VENI1FATtf)7d;Ftiost0a kdulr and tmtcrhit a'kwaG t2)ltrtaAalc0.egiAa(t tea tx�N3 hatlratrm raniz).
C;00.0!1
VM%MA7tfR4:P mfdc bb w mid monists to kma%vmai6enal8r<s Zr76)ono brA to m,6a sit r—
s5a•uu
O&VAOIEhT O.'ri is Pt we lowand bmmcriafs u,h-u n fJl)ibnai rm atw—f emtxeA 1ller0—fawiaiin+lo ttK Mwtimtt
e!•t1x bmm mg attl ft s 014 Maus oll. .
3hV.:5
CRAWiSPACE:1'as+ridelAar and htitite68t:x irtwil,trit5)t4tmf fat e6'R�t9 nnAttd ti;a:rgltns ttexhsau�:a the craakrs
aB1Agb ae is aambC aHb its wblbw ala?otxitp>cktF fd ma j �mvitp w ne!hrzU aith+w joist Nil—Thx L Agh t"
k,"Mand-Wad-Smi oil teams atm FST:fab. -
57yr,.76
RIItiMAU Amine(453 tymre 0.d alba!st?1e huidalia0[eam)be aMubpirce sten
Sit 7<
CPAWLSPACE:taovida ubo ow='j. i,-(1)babaa dw&aahp,•.cc chit%ill Hpd•fnV WxL avid*0ill,
tow orwo 4avA xi@ wxwmdppiw,
SSO.W
1itSEF a®spipfy-ml apt fe arm tnozmiacs ro 11df iilAVda1,t'a1 wiltmly o-4 ;:e Ma a nm m cam.
:Cal;onbia Crn cdKaa 75?:iitbCnbvc,notwasoml'L",000 phi. )ax,salon iu iva ofi0%
lbirdgibe far tba
AG$.ual60 ap w,a,o fml id10 an d as adifidxna15340 itarCfit0x arcJ¢viii`icd b5 the a0dilm.
pot the tufay and.health of Saw Mme's irteonr ac gadhy,.at aitl be aoniivainC a bb eer day.rfisz—k,.f ux—ih"k oh t_.in
war liaise taaE befnie the xrrk b 6ugun,410 atkrdc wquip}ealba a+rak fs •M'a bili a!w cmdw a l'00 aiaistrnoa of
V
i
I
R13E KaRb ecriag
� If n a;rwoa�tyt�ea r.,�;a�rl� car oeaa im
re Sbv-m'g"Is#1
t401)Is4.sron F+x aaU T>a+a7w CONTRACT
pw 2
PR(XRA4i
CMA41ES w°prw roirwpot�ica,
i eemeeaaws
cus+re.�e
77
Wina£dwarris (731)'-)d9.9415 02112/..016 43044 00002
saner srwr ..
389 Jouwon suw ewaas"rcr
839 JOhawn svwt
+xiiwaio axv,ovrr;by
North Andover.MA 01945 8""wr.STAXZV
North Andover.MA 01845
JOB DESCRIPTION
: tae sefapr OTvav
Alt==W 1'Ais�.iS3r�dSW cod RSC int CVA brpt lG`.t C
S9D.0D
i
Total: S3 249 95
Program Incentive: $1,703,90
Customer Total: 5544:05
Yx am�CC"M" TO FQftASH ZUNI= M7COROMGC WITHADOVE SYCCWXA"01R.MXj t$w.Ci
I.
"`Fhre Hundred Forty-Four$051100 IJotlam 5544.05
urewrwti�rbmr�o.rwiw�waraszmacraw�e,ommsmmm�nroxrra�.wec+cs:or,,.ex.�.ac cH.Rmm nose`wve:�,u+s �
1Ri11M11YaygSMtllb OArD,4XAfrldYflYROO[t#llpNOl YMrK11tMJ,NBYfl60IIHyI.1CkaGWsp.ArO CO,(i>t/d:}Ot DYA"tOnnOe.
Dp
TT TMiB tR
TIS AM ANr'MA10C SAACLS
.✓n�aat�rorownrw.mre r.ew�.., ,.ham
arereerz accerrm�
e�wacmcmr+.c-•as.nwcrrm.e.m.rmnc.�owinaa..x
CAYi. .b H�IDrHllhrud,trJ[1l/YMq'ltb NlliN000'Jl 'rOtli111Mi'Y�41(
AC4 7Zo
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
11/12/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF IN 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 CONTCT
James J. Dowd & Sons Ins NAME: Debbie MacNeal
14 Bobala Road PHONEFAX
A/C No Ext: - - A/C No):
Holyoke MA 01040 A66kEss: dmacneal@dowd.com
PRODUCER
CUSTOMER ID#:COOP
INSURED INSURER(S)AFFORDING COVERAGE NAIC#
CO-op Power, Inc. ..INSURERA:HDI-Gerling America Insurance Compa
15A West Street INSURERB:Torus National Insurance Company 25496
West Hatfield MA 01088 INSURERC:
INSURER D:
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:254565888 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 AID_DL UBR
LTR TYPE OF INSURANCE NWVD POLICY NUMBER POLICY EFF POLICY EXP
A GENERAL LIABILITY MM/DD/YYYY MM/DD/YYYY LIMITS
EGGCC000187715 11/8/2015 11/8/2016
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
X POLICY 7PROLOC PRODUCTS-COMP/OP AGG $2,000,000
EC
A AUTOMOBILE LIABILITY $
EAGC0000187715 11/8/2015 11/8/2016 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS BODILY INJURY(Per person) $
X SCHEDULEDAUTOS BODILY I NJ URY(Per accident) $
.X HIREDAUTOS PROPERTY DAMAGE
X NON-OWNED AUTOS (Per accident) $
Comprehensiv $
B X UMBRELLA LIAB $
OCCUR 70354Q150ALI 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000
EXCESS LIAB CLAIMS-MADE
DEDUCTIBLE AGGREGATE $1,000,000
X RETENTION $10,000 $
A WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY EWGCC000187715 11/8/2015 11/8/2016 Wt✓STATU- OTH-
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/NY LIMITS ER_
OFFICER/MEMBEREXCLUDED? ❑ NIA E.L.EACH ACCIDENT $1,000,000
(Mandatory In NH) .
If yes,describe under E.L.DISEASE-EA EMPLOYE $1,000,000
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mores ace is required)
Certificate Holder, Eversource, and National Grid are Additional Insureds on a primary and
non-contributory basis per written contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
CLEAResul t IN ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Contractor Services Dept.
50Washington St.
Westborough MA 01581 AUTHORIZED REPRESENTATIVE
<2 _'- VI+
ACORD 26(2009/09) The ACORD name and logo are registered marks o ACORD RD CORPORATION.—All rights reserved.
Office of Consumer Affairs arld Business Regulation
K 10 Park Plaza - Suite 5170
Basun, Massachusetts 0211.6
Barge lmprovem,emkontractor Registration
Registration. 16521'
Type; Supplement Card
t = Expiration: 1/21/2018
CO-OP POWER, INC, 0..
LEAH DANIELS ___._____ _ __. -- _..__
15A WEST ST
r
WEST HATFIELD, MA 01088 ' 4
3 Update Address and return card dark reason for change.
SGA i t:a 2)M-0,1;1 i
:address ` Renewal 1 Employment j I.;ost Card
j rt rn.r.
�trice ofConsumer onsumer Affairs&Business Regulation License or registration valid for individul use only
pME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration:. 165217 Type:
10 Park Plata,-Suite 5170
Expiration: 1!21/20 _$ Supplement Card Boston,MA 02116
CO-OP POWER, INC.
LEAH DANIELS
`rk.
15A WEST STf''�
f
WEST HATFIELD, MA 011788 ----- -G _ ..._.5.
Undersecretary Not valid without signature `
Massachusetts 0epartrrment of Public Safety
Board of Building l equtations and Standards
License: CS-097409
Construction. Supervisor �
LEAH M DANIELS �
12 MAliC ELLA ST
ROXBURY MA 02119
tom+ Expiration:
Commissioner 0511812017