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HomeMy WebLinkAboutBuilding Permit # 3/2/2015Permit No#: -Date Issued: IMPORTANT: Appl can ,mti§tcomplete:altiterns.on 'spage BUILDING PERMIT. TOWN OF NORTH ANDOVER. APPLICATION FOR PLAN EXAMINATION', Date Received:?,'4 ,i111.004'edsol,1»ioi) W0064411* II id,411A'ip gOIIA A o Ni Nty,Airl,111111d0P11 ,AN,y, o'no o o 0 0 Yi '0 AVOAMOdAddliA Addl I dA Ald0IiMIVIAIIYIT1110A0 TYPE OF IMPROVEMENT PROPOSED USE R Residential Non7, Residential 0 New Building 0 Addition 0 Alteration 0 One family 0 Two or more family • No, of units: .'' 0 Industrial D'Commercial 0 Repair, replacement 0 Demolition 0 Assessory Bldg ' 0 Others: 1hr rraiviworeopr-vmemommo - Nm64-o P f " 0 Other Al i ,11' t 'i''' ' OM fr 0 6440041,0vw DESqRIPTI . P-1 6- 5 eit-I irk 6L. k--(5 Pr-1 ) 6 0-) pe or Print Clearly OWNER: Name: Address: toto44,0q'i,4,?,41 OOLFNI*0091;101 414',40Ilt ARCHITECT/ENGINEER Phone' Address: FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000,00 OFTHE TOTAL ESTIMATED' COST BASED ON $125.00 PER Total Project Cost: $ 306 Receipt No.:. NOTE: Persons contracting with unregistered contractorsdo,not have access to the g Check No.: ;Nr7ryTiTro, ,dAdAddAdddd d-77- Signature 'Y ent/ w 7 ® 5. ▪ O Cl) 0 13 O CD CI Z O .Cl) CL =.• O O ED Ci CD O CD O CD w• v3 C C. CD O Cl) CD n 0 0 70 ▪ CD 3 O CD WOO 0J padln 210133dSNI owning m cn Cl) co0 73 0 -12 55 ill Cl) 0 VIOLATION of the Zoning or Building Regulations Voids this Permit. 0=10 CD fD 0 n • o_ .��.�a o =. a 0 0 Q, 03 n CDVi c <D CD • o co o_ to o . wcoBfi CD V 0 o c0 o -h •a cn o .y, " , ai = DCecD �' p O 0 ® CQ CD y =.® n. W 10 0' r• � Cl) CD 0 0 rto coa O 0 �3 aaa o} uolss!uaaad sey • cn cc. -a -g 0. Ccn 0 �rt > CD CD. al. MS a- fri 0)s 0 1VH1 S31d11N30 SIHJ CD SE Engineering A division of Thielsch Engineering 60 Shinvniut Unit 02, Canton, MA 02021 339-502-6335 FAX 339-502-6345 Is ENGINEERING . . CUSTOMER Gregory Penney SERVICE STREET 102 Bradford Street SERVICE CITY. STATE, ZIP North Andover, MA 01845 PROGRAM CMA-HES PHONE (508)245-0831 BILLING STREET 102 Bradford Street WILING CITY. STATE. ZIP North Andover, MA 01845 JOB DESCRIPTION Federal ID # RI Contractor Registration No MA Contractor Registration No CT Contractor Registration No CONTRACT Page 2 THIS CONTRACT IS ENTERED UIT 0 BETWEEN RISE ENGINEERING AND TIIE CUSTOMER FOR WORE AS DESCRIBED BELOW DATE CLIENT LI WORK ORDER 12/08/2014 404079 00003 Total: $2,393.00 Program Incentive: $1,967.25 Customer Total: $425.75 WE AGREE HEREBY TO FURNISH SERVICES • COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ***Four Hundred Twenty -Five & 751100 Dollars $425.75 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING. CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL. INTEREST OF VA WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS. SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES, RIGHTS OF RECISION, S CE IdOULII40, AND CONTRACTOR REGISTRATION, DO NOT SIGN THIS CONTRACT IF THERE ARE Y BLANK SF, S AUTHORIZED SIONATWIE • RISE ENGINEERING NOTE: THIS CONTRACT MAY DE WITHDRAWN BY US IF NOT EXECUTED WITHIN DAYS. DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT- THE ABOVE PRICES, SPECIFICATIONS MD CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED. PAYMENT MILLIE MADE AS OUTLINED ABOVE TI I, Crfle1114P `i/ (Owner's Name) �, owner of the property located at f0 5 gr• dam` (Property Address) lid ff14 1jL7,v-tv1 FklQ• O If (Property Address) hereby authorize a a (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. eFis <anrmoncaeuia o/P/groadusefiu Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistraiion:-.104800 Type: xp'rab0n: --=7f 5 201& Private Corporation HUGH'S ENERGY COI PORAT4( DANIEL DRISCOLL 259 MILTON STREET DEDHAM, MA 02026 Undersecretary Massachusetts _ De Board ment of Building ga ation a d S � tic datefy =1ruo License: cs-osoze¢ ThomaspD . `.�sj::n:, 259 Amon Street ogre Dedham MA 02026 License 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 Not valid without signature Commissioner Expiration 10/2212016 CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD SION NUMBER: 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. gi EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1YPEOFINSURANCE " Il=al4 U COMMERCIAL GENERAL UABIU1Y POLH;YNUMBER :. ,,,fa w , a l,,kJ :■ CLNMS•MADE ® OCCUR OCCURRENCE 41360 - CERTIFICATE OF LIABILITY INSURANCE TDlnls-1 OP ID: MR ' DATEjMMIDDlYYYYj THIS CER71FICATT: IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE 10/06/2014 AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEAN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the oertifcate holder is an ADDITIONAL INSURED, the policy5es) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A atatemem on this certificate does not confer rights to the PRODUCER certificate holder in lieu of such endoreeme s . TYG Insurance Agency, Inc. 88 Freeman Street Arlington, MA 024744814 INSuRm TD insulation, nc. 259 Milton Street Dedham, MA 02028 COVERAGES GENT. AGGREGATE LEMTAPPUES PER: POLICY WC CPS2020SS2 1020032784 BS0044410 R2WC513035 r 'au r SS: 781.6414002 IN$U A:Scottsdale Insurance Com . an mem=s,AmGuard Insurance Com • = y nlaupe c:Arbella Protection Ins Co. rm�n—s INSURER F. 08/14/2014 08/14/2014 10/07/2014 08/12/2014 08114/2015 08/14/2015 08/14/2015 08/12/2015 LIMITS EACH MEDEXP Any orte person PERSONAL &ADVINJURY GENERAL AGGREGATE PRODUCTS-COMP/0PAGO CO IN ED BODILY INJURY (Perperaon) BODILY UMW (Per aeddael) PEFt STATUTE EL. EACH ACCIDENT EL DISEASE -EA EMPLO s 1,000,00 $ 50,00 5,00 S 1,000,00 s 2,000,00 S 2,000,00 S S 1,000,00 S s S $ 500,00 S 500,00 s ' 500,00 DESCRIFrLONOPOPERATI.ONS/L.00ATNNS/VEHICLES mono on, ACd[6Dtpat Rowe soutdWa,playbo+Legat Hamra spate le . - - requited) ■.a• AuroMoau.E UAWLrr( ■ ANYAUTO AN'IOWNED vr*** © SCHEDULED HIRED AUTOS : AUTOSNED ■ UMBRELLA LIAB U OCCUR ■ EWERS UM , CLAIMSMADE _■�© RETENTIONS 10000 WORKERS COMPENSATION piandatorytrt NH) AND EMPLOYERS' UAWUTY ANY PROPRIEWRNiARTN�p(E YIN OPPICERNEmBEI EXCLUDED? DESCRIPTION uner 1111111111 oPERI:MONS:Mew CERTIFICATE HOLDER ADRRCHE CANCELLATION E.L. DISEASE -POLICY LIMIT SHOULDANY OF THEABOVE DESCRIBED FoUcIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED US ACCORDANCE WITH THE POLICY PROWSIONS. AUTHORIZED REPRESENTATIVE ei(aaffiee, ACORD 25 (2014/01) The ACORD name and logo are registered maa►ks of ACORDRD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name (Business/Organization/Individual): Address: Please Print Legibly Hu Ht.5 gN &/ C)/,L ) City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1,®-Iea employer with ` employees (full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance t 6. Q We are a corporation and its officers have exercised their right ofexemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. EI Remodeling 9. ❑ Demolition 10 Ei Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13. Q Roof repairs 1 ©<her *Any applicant that checks box #1 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. tContractors 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: /)_/),A 6,c) (--ir4 Policy # or Self -ins. Lic. #: Loci-)---- (3 6 Expiration Date: F / 5� Z-c) /S Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th Signature: Phone #: ndpnaltie eijury that the information provided above is true and correct. Date: `) _ �- (c 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 #: