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HomeMy WebLinkAboutBuilding Permit #1088-2016 - 91 WEYLAND CIRCLE 4/19/2016 J �1 NORTh BUILDING PERMIT • TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMIN)4�7� - � Permit NO: _C")D/ 1 Date Received '� °qq�o�,�A. > '` c SSACHUSE��� Date Issued: T2) MP RTANT: 4pplicant must om le.te all items on this page LOCATION- PROPERTY OWNER Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building L�-�Sne family J Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial I_ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic WeII Floodplain El Wetlands Watershed District ID titer/Sewer u Identific ion Please Type or Print Clearly) OWNER: Name: f�( Phone: Address:�l CONTRACTOR Name:k. Phone: it :Address: t " Supervisor's Construction License—Vo 9 xp. Date: � a -- . Hoare Improvement License: � 0— Exp. Date: ARCHITECT/ENGINEER A)& Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER00.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ` Total Project Cost: $ 0ITC 2 $1 FEE: $ S�(3a - 00 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty./and Signature of-A _e_n_t10__w_n,_er :s Signatof act Location 1 No. Date LAI �q ll l • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ rJ.-J Foundation Permit Fee $ _ Other Permit Fee' $ + _ TOTAL $ Check# S Building Inspector XAORTH Town of - h ver, Mass oLA.(. � > > COC MICN.W .t Aft P'10 5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System / THIS CERTIFIES THAT .....!.k.�..C+.��.. ..... .�.�.�.�..�..�....................................................... BUILDING INSPECTOR We .\ Foundation has permission to erect .......................... buildings on ...q.1.....�.:1 ey.f.m. d. ..... ..r.'.Cj.:IL....... 1 Rough to be occupied as .......... �..... ...�. .. �..�....�.........�.. f..�................................................ 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 CONSTRUCTION ST7,�4�,i Rough Service ............................ .. . ........... Final IL NG INSPECTOR GAS INSPECTOR Occupancy Permit Required 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. i i i RISE 60 Shawmut 02021 339.502-6335 Road, Unit 2(Canton,MA 1 ENG71N-E RING www.RISEengineering.com OWNER AUTHORIZATION FORM Owner's Name) cwner oi the prope fty located at: f ,'Property Address)— (Property Address)— hereby authorizev--- ;Subcontractor) an authorized subcontractor for RISE Engineering, to act on n-ly behalf to obtain F. building permit and to perform worm on my property. This Term is cniy vapid with a s.gned contract. i t Corner's Signature i.7atP� _._ --- Fodcril tD at�5-04056=9 RISE �.it+,r,IttCl'I itis Ft Ciantracto:hc!Iistritiott No 61 U, l CT Contractor tur kc•}li iratl!i, Nt. 1.U97J o I i w�,i ih Fn,lnei t: CT Contractor Rultlsir,ttfon No "RISE 111:!,11::: _., \I\ CONTRACT oJit'.J.:Pl! 4'\\tsotl'a-3"ltt Page 1 tl�s C�wrK+::s i;r+,n,n�:vtv tlt n•.e.l Nit;" tYYCW.1z M LOW t•�tt' d!.Il,�.*.• croon Ultul rt \\':, \.'.,S\`\, , V \ \tkii+\t.'-T. \1.\01;,43 i JOB USCRIPTION' ! ^:r , ., ,. ....„ .:�: :t,�t:.. ..1;: .. . ,�qtr,;1t.1'\,:�"`ar.•;uJ1 . lr!:\\t[h,t l:c.tllllttli ii\i:,. � . i, )` J \ lwt 1`['ICt.tih i \,":�•.., !`,. dy, fxt ttr. ,.;a, ,1:n ...u' ,...,,:.1::,m w!)",:c:lr,?`rt ,i'. .., ....,. \\, '. ... ,t,'.'li.\ ., +i!ii..Jiff iil\\ •..T.t! 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I ll� Federal 10 X 05-"05629 rFa t ttlllt lit�j RI Contractor Registration No 8186 MA Contractor Registration No 120979 1 di�i.inn of l'hiricch En{intrriu„ CT Contractor Registration No ENGINEERING t10 011a1'nlut t nit:112,t':ntlon,\1 t CONTRACT (40 1)784-37(il) FAX(401)7V4•3710 Page 2 I'IZO GRAM 10tS CONIRACT 4,CNTERCU WTO UETWEI.N RISr i 11A-IIF:S ry ,p yOOwnTE CUSIOwn FOR WO AK As CUSTCurR OA1C CLIr Nib 1VWTK ORni':R P110NC 1N'icolc 11crioldi 02i2()!2()16 •11113+1 00002 SEWX!,STRCEI 1311.1.316 9TRCE1 \Vk�'iand Circic 91 \\rxland Circle SERVICE C1IY,STATr.zlr+ 6K11':G i::TY.S?A11:.7:P \onh :\t)dotc;, 41:�Q1S-1> North Andover,MA 0IN45 .1013 DESCA11910N Yiraarcniatan,u:crnhce 1.$:,110 � J_J tNl)Uq Total: $2,604.38 Program Incentive: $2,100-78 Customer Total: $503.60 WE AGREE HEREBY TO FURNISH SF•RVICGS-COMPLETE iN ACCORDANCE%MTH ABOVE SPECIFICATIONS FOR THE SUM OF '"Five Hundred Three&601100 Dollars $503.60 :PUti FINAL ir:SPt;CTIU!:fNUAPPROVAL OY RISE LNG:!JEEIJI!:i.CU.'.TOtAER REFS TU gE/J:TA!JCINJi OUE IY tU:l,.1..":iLNES-C,F1'A YMLBE CWAI2G!:)Il.�l!,iIt,`!C!i A!lY OAIAtAE AFTER 30 CAYS.Slat.REVERSE FOR W.POR TAt:T 01FORMAMIJ ON GUARANTEES.RhiWTS OF IIMSION,SCM£CUa::G,At:O CO!JTRACTC4R REG:StRATICU 00 NOT SIGN TiI1S CONTRACT IF THERE ARE ANY BLANK SPACES A'JTNORVCO StG!:ATURE f:S("Cny,rrr{inp Cl:ST OA!Ete :'e:U TAt:C F. _ NORAYnIIfV CS i71:OT t%F:GUI EO.'tl TF+:.', CATE Or ACCEPTh.CF ^-,F • I *� ''� ACCEPTAUCC OF CONTRACT THE AOOVE FR ICES SPEC1I:CA11O!:5 AND CO::O1TIUt:G AWL i — SATISFACTORYTOUSAUDARCIIEREBYACCEPTEG YOUARCAUTWO.T4'.'_:A TO 00,11E WCIK L- :, nS SPEC:F:EO PAY!.!F.t:T W.t I.Of!MCI..A.CUI 11!:U;.1OW ' 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 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.® I am a employer with 20 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. + E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition No workers' comp. insurance 5. ❑ We are a corporation and its p 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] ]3.® Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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.#: /E�W�GCC000187715 Expiration Date: 11/08/2016 /71 Job Site Address: 7 City/State/Zip: V Attach a copy of the workers' mp-ensation 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 certify , der the pains and penalties of perjury that the information provided above is true and correct. t nature: Date: 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#: • I AC"R© CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDNYYY) 11/12/2015 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). PRODUCER CONTACT NAME: Debbie MacNeal James J. Dowd & Sons Ins PHONE FAX 14 Bobala Road A/C No Ext: - - A/C No: Oke MA 01040 E-MAIL Holyoke ADDRESS: dmacneal@dowd.com PRODUCER CUSTOMER ID#:COOP INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:HDI-Gerliri America Insurance Compa Co-op Power, Inc. 15A West Street INSURERB:TOYus 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR INR WVD POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS A GENERAL LIABILITY EGGCCO00187715 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE100,000 RENTED— PREMISES Ea occurrence $ CLAIMS-MADE �]OCCUR MED EXP(Any one person). $5,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2,000,000 X POLICY PRO LOC $ JECT A AUTOMOBILE LIABILITY EAGCCO00187715 11/8/2015 11/8/2016 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ Comprehensiv $ B X UMBRELLA LIAB OCCUR 70354QI50ALI 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ X RETENTION $10,000 $ A WORKERS COMPENSATION EWGCC000187715 11/8/2015 11/8/2016 WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N TLIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,0 0,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space 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 IN ACCORDANCE WITH THE POLICY PROVISIONS. CLEAResult Attn: Contractor Services Dept. 50 Washington St. AUTHORIZED REPRESENTATIVE Westborough MA 01581 @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered marks of ACORD f (' j !l gull (3f t;cL �f c�1lsr;mer airs a.nd Business R� atii��l t 10 Park Plaza - Suite 5170 Boston, Massachusetts 02110 !ow'L. improvement Contractor Reg Istrat1011. Registration: 16521 i TVr)E Supplenne! i Card 'a1. `n .71 r^ 4C C,,O-Oi' F OWER, INC. l..FF=A -i C)ANIELS fL.A WEST- ST `ANES7: �-iATFIE:i_i.J. MA00,8 I plate Address aild returnar Cd, M:11-k reayun fi>r '1" `c. Address Rertekjal 1•1111£tioNment lost Card ._ j"l¢_tCdf ion valid for individul use(MINs `�Ofti ;,i t rn+iauV1�.uf N A liti.in4•,I�VLiiLil.��n 1.iC�CnSe or rf. 1UME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of(;onsunrer Affairs and 13asincss Reg"Winn -t'Remstration: s.^^i Type: 10 Par l Plaza-tiuite 5170 Expiration: ;'il20;fi upp e.stent and Boston, t9:1 02116 CU-UP�_Q`ti 1.•_Q. NIC, r ... �... LEAH DANi ,l. WESI } t U Not valid vj ithout sig�`nature __. ni!cr.rcrriari m e n t 0f PU011C 53f& s- ;,zso ? za3atrons and Stannards ;. C5-097409 s,pnsfr;rt:t;z)rr Supervisor 4;,'' LEAH M DANIELS 12 MARCELLA ST ROXBURY MA 02119 05118,12017