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HomeMy WebLinkAboutBuilding Permit #661-15 - 96 RUSSETT LANE 2/3/2015W i 0 BUILDING PERMIT3� a,"o- TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION- �� e Permit NO: �� Date Received y (� ` -•- �gwieo Date Issued: �21 rn'''�` �SSACHU IMPORTANT: Applicant must complete all items on this pate LOCATION t � °, 1-4�- S Set L Print PROPERTY OWNER Li st Print MAP NO: PARCEL: ZONING DISTRICT: Historic District Machine Shop Vil yes I no ves I I no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building WOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer %_ h S U a k— 3 s— Identification Please Type or Print Clearly) 3faAdOWNER: Name: LI s N\a-,A a V � Phone: 17 695-- 3,3/,P- Address: dress: ''b R-,\kss;A �--v\ , A -k 0 1 CONTRACTOR Name: t, t. ` �� i _ Phone: � ( 1--- ^ 33�- Address:'76 t , kA 02-1 30 Supervisor's Construction License: cs , u, Exp. Date: Home Improvement License: . _ iExp. Date: ��7 2t 2a1 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: $ ���5' FEE: $ Check No.: 2-i Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access he guaranty nd Signature of Agent/Owner _ Signature of contractor / Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPF-OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 364 Usgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date J COMMENTS Location C, �e 11 4 No. W\—V5 Date 2� t9 I V5 Check# 2 t 3 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ bui ing Inspector 0 Eq* H Q W LL O QOO m cu=n LL,) Y \O O LL O1 Ln '�, Q !n LCL d z Li z J CGA 7 LL O w N C E U t _ LL a z zco E J d to = cr _ LL CL Z Q U W J Ly CA O W U i Ln _ LL cc a z tw O K _ m LL z LLJ Q w LU LL i m z N N N Y O In 3 0 H O r. y (DN r O O O LLJN • w O •0 • � 3 aL CL Cc cn y Z C ■ CD > O • O O i cu Q : 0 o 3 0 H O - N O t •y 5 y.. ■ • 0) > O .o~ CL cc ■ cc �- ,� c o = c Q ca r. y (DN r O O LLJN E tm t 0 c LL •0 • � 3 aL CL Cc cn y Lt O 0 r-. � ;r � � ■ CD > O • O O i 0 y _ d 0 -0 O U) O 'C Q U) d Q '4c L y �..,: 0 - N O t •y 5 y.. ■ • 0) > O .o~ CL cc ■ cc �- ,� c o = c Q ca 2 Z m CD Z W a W W CL C. I ti it W O O O Z � O w 0 ._ .E m m CL -a Cc jo O CD �0 0 � O � CL CL �a o _ =cc Cc .0 J 'a Q O }) =z � U U) Cc U) 0 W_ O O LLJN LL •0 • L Lt O 0 r-. � ;r LU E V V v Q O� 0 v) y mo O I— t *Z Q. 0 Cm) 2 Z m CD Z W a W W CL C. I ti it W O O O Z � O w 0 ._ .E m m CL -a Cc jo O CD �0 0 � O � CL CL �a o _ =cc Cc .0 J 'a Q O }) =z � U U) Cc U) 0 Date Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 5b —,�C) 6e 2 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1.600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845 Federal ID # RISE Engineering RI Contractor Registration No Iff MA Contractor Registration No A division of'rhielseb Engineering CT Contractor Registration No 60 Shawmut Unit #2, Canton, MA 02021 CONTRACT _ 339-502-6335 FAX 339-502-6345 R I S Page 1 PROGRAM ENCONTRACT NiG AENTERED INTO ENCWEERAND THcroMR OK WORK AS E NG I N E E R I N G DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT II WORK ORDER Lisa Martelli (978)685-3312 01/09/2015 409580 — - ---------- SERVICE STREET BR.LMG STREET - 96 :Russett Lane 96 Russett Lane "\VjVjl SERVICE CITY, STATE, ZIP 'BILLING CITY, STATE, ZIP North Andover, MA 01845 North Andover, MA 01845 JOB DESCRIPTION AIR STALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. This work will performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful ke air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams, weatherstripping andproducts. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (win not generally addressed.) (2) working hours. At the completion of the weatherization work, and at no additional cost to the homeowner, a final blower door and/or combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. $150.00 GARAGE. CEILING: Provide labor and materials to install 10" R-35 densely packed Class I Cellulose insulation to 616 square feet of garage ceiling located below a heated floor area, by drilling holes in the ceiling from below. Holes drilled will be plugged. Plugs will be spackled and fell in a relatively smooth condition. Finish sanding and touch-up priming/painting will be the customer's responsibility. $1,275.12 RISE En&ccring will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount, Currently, for eligible measures, Columbia Gat offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the Air Sealing measures up to $600. For the safety and health ofyour 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 we-atherization 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 $2,690. $90.00 Total: $1,515.12 Program Incentive: $1,196.34 Customer Total: $318.78 WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ***Three Hundred Eighteen & 781100 Dollars $318.78 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1% WILL BE CHARGED MONTHLY ON ANY UNPAID a AFTER 30 DAYS. SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES, RIGHTS OF RECISION, SCHEDULING, AND CONTRACTOR REG TION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANKISPACES - ..............-- .-........ ___ AU SIG RE.RISE En dng CU M ACC E NOTE: T141S CONTRACT MAY BE WITNORAWN BY US IF NOT EXECUTED WITHIN DATE OF ACC TANCE __.._._ ------ ACCEPTANCE OF CONTRACT -THE ABOVE PRICES, SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. AS SPECIFIED.UTHORIZED TO 00 THE WORK AYMAENT WILL SE MADE AS OUTLINED ABOVE OWNER AUTHORIZATION. FORM ' 40r -r / (Owner's Name) 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, Date The Commonwealth of Massachusetts Department of Industrial Accidents h Office of.Investigations a 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legible Nahne (Business/Organization/in(lividual): 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: I. ❑■ I am a employer with 20 4. ❑ 1 am a general contractor and i employees (,full and/or part-time).* have hired the sub -contactors ?. ❑ 1 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.] r a 152, § 1(4), and we have no employees. [No workers' coma. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑Roof rep irs r 1M-11AM-1 Other //15 *Any applicant that checks box #1 must also till 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Policy # or Self -ins. Lic. #: WC5-31 S-388245-013 Expiration Date: 11/02/2015 Job Site Address: `5 �(+ '� ©/ City/State/Zip: / v " ' " " �7 —l------ 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 certify urjerphe pains that the information provided above is true and correct. Phone #: Oficial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # //;26 // 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 #: r ��O�� 1--;s Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration CO-OP POWER, INC. MICHAEL SUTER 12A WEST ST WEST HATFIELD, MA 01088 SCA 1 Co 20M-05/11 '''/1r� 1c rarranet�nux.rll/z �'•:>�a�nac/uwelt<. Office of Consumer Affairs & Business Regulation { HOME IMPROVEMENT CONTRACTOR r + r , , Registration: 165217 Type: Expiration: 1/21/2016 Corporation CO-OP POWER, INC. MICHAEL SUTER 12A WEST ST WEST HATFIELD, MA 01088 Undersecretary Registration: 165217 Type: Corporation Expiration: 1/21/2016 Tr# 256968 Update Address and return card. Mark reason for change. n Address n Renewal ❑ Employment n Lost Card License or registration valid for individul 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 r` i' �ot var _i signature 10) fii'lassechutsetts - Department of Public Safety Board of Building Regulations and Standards Con0ruction Sul)vn icor License: CS -107864 MICHAEL SUTER-' 94 PRATT COMER ROAD Shutt-sbury MA 01072 y r i `!;;,-4... _zy, ,, , Expiration Commissioner 04112J2018 A�RdO CERTIFICATE OF LIABILITY INSURANCE 1�i6i2014 ' 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 James J. Dowd & Sons Iris 14 Bobala Road Holyoke MA 01040 CONTA NAME: Debbie MacNeal PHONE FAX AIc No Ext): 413-538-7444 A/C No): E-MAIL ADDRESS: dmacnea1@dowd. com GENERAL LIABILITY PRODUCER CUSTOMER ID #: COOP INSURER(S) AFFORDING COVERAGE NAIC # BGKZQR INSURED INSURER A: Commerce Insurance Company 34754 Co-op Power, Inc. 15A West Street INSURERS: INSURERC: West Hatfield MA 01088 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1394068863 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 LTR TYPE OF INSURANCE ADDL INSR UBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY BGKZQR 11/8/2014 11/8/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $150, 000 CLAIMS -MADE Fx -] OCCUR MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2,000,000 POLICY PRO X LOC $ A AUTOMOBILE LIABILITY BGKZNW 11/8/2014 11/8/2015 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X X SCHEDULEDAUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) $ X NON -OWNED AUTOS $ Comprehensiv A X UMBRELLA LIAB HCLAIMS-MADE OCCUR 417215 11/8/2014 11/8/2015 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 EXCESS LIAB DEDUCTIBLE $ $ X RETENTION $10,000 WORKERS COMPENSATION VVC STATU- OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMI R ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Workers' Compensation Certificate of Insurance to follow separately from the carrier. Certificate Holder is named as Additional Insured per written contract in regard to general liability only. --cm I Irik m 1 C 1'1VLUCK Thielsch Engineering, Inc. 195 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. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 11/7!2014 6:251:08 AM PST (GMT -8) FROM: 100005 -TO: 14135170300 Pacie: I-; of 5 A� !rte® CERTIFICATE OF LIABILITY INSURANCE DAT11/7/2014 Y) 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 JAMES J DOWD & SONS INS AGCY INC 14 BOBALA RD HOLYOKE) MA 01040 NAME:ACT PHONE FAx A/c No Exti, A1C No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: LM Insurance Corporation 33600 CLAIMS -MADE � OCCUR INSURED CO OP POWER INC INSURER B : 15 A WEST STREET INSURERC:___ INSURER D: WEST HATFIELD MA 01088 INSURER E : INSURER F: COVERAGES CERTIFICATE NLIMRFR• RFVICIr1N NIIMRFR- 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 SUER rPFF - POLICY EXP LTR INSD WVD POLICY NUMBER MMIDOIYIDDIY YYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE � OCCUR DAMAGE TORENT PREMISES Ea occurrence $ urr MED EXP (Any one person) $ PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: _$___ GENERAL AGGREGATE $ P01_ICY D PROJECT ❑ LOC PRODUCTS - COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTYDAMAGE $ fPeraradent UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / NH ANY PROPRIETORiPARTNERlEXECUTIVE OFF ICER/MEMBER EXCLUDED? NIA WC5-31S-388245-014 11/2/2014 -11/2/2015 ,/ STATUTE ET E.L. EACH ACCIDENT $ 1000000 E.1-, DISEASE - EA EMPLOYEE $ 1000000 (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This certificate cancels and supersedes all previously issued certificates, only as they relate to workers' compensation coverage Workers compensation Insurance coverage applies only to the workers compensation laws of the state of MA. t_.CK I Irit,A 1 C MULUtK I;ANI;LLLA I IU IN THIELSCH ENGINEERING, INC 195 FRANCIS AVENUE 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. AUTHORIZED REPRESENTATIVE r 1,14 LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD CF,RT NO.: ;...-52959 I.—y Gatf—ld. 11.(7/2014 9:23:19 AM (EST) Fag. 1. of 1