HomeMy WebLinkAboutBuilding Permit # 3/2/2015 BUILDING PERMIT. o1 "°RTH °
TOWN OF NORTH ANDOVER', ."
APPLICATION FOR PLAN EXAMINATIQR.,
Permit
° � Date,Received: ° `' '° `
P0i'llllt IUO#: � 7,9s RRTEo
SACHUS
Date Issued:
IMPORTANT: Applicant must complete.,all--.items on.thispage
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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 ❑ Others:
❑ Demolition
Demol�iSt.ioer,n Other
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DES RIPTION OF WO K:-T E PERFORMED:
dentifcatlu 42� nPleaeTY
Type orPrint Clearly
OWNER: Name: �
Phone:
Address: ' J .6
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ARCHITECT/ENGINEER Phorle:,
Address
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000,00 OF THE,TOTAL ESTIMATED'COST BASED ON$125.00 PER S.f
Total Project Cost: $
Recei t:No �
Check No.: p
NOTE: Persons contracting with unregistered contractors,: do,,.nat have access to t1te g ty f" d
Signature of UAgent/Qwrier ;,��«, r �, ,. ., � ,Signature�of�eantra�ct`c�zr�r�" �� l° '7
� Nt�RTFi
own of' .2' - jaclover
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C'O LANE h ver, (A�7�7y 1�
w [OC HICHEWICK 1'
I,A� R/ITED PP
U BOARD OF HEALTH
Food/Kitchen
PEKmmmlT Low Septic System
THIS CERTIFIES THAT �Q �. BUILDING INSPECTOR
...... ....
Foundation
has permission to erect.......................... buildings on .. t l(4.... .. .. . .
...... ...P��A... .........
0
to be occupied aS ,..,� � lt, .. 6.4S ' '� ch mney
Rough
............. .. .... ...................................................
provided that the person accepting this permit h.all 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS C STRUCTIONA S Rough
Service
................................ .............................................. Final
BUILDING 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
41
Federal ID t1
IZIE TEItgilteering RiContractor Registration No
MA Contractor Registration No
A division orThictseh Engineering CT Contractor Registration No
60 Siawnnut Unit 112,Canton,MA 02021
" r
339-502 Y335 VAX 339-502-6345
page 1
PROGRAM THIS CONTRACT IS EmERED INTO UETWEETI RISC
CMA-HES ENG
INEERING AND THE CUSTOMER FOR WORK AS
ENGINEERING oEscRIBEOBEaow
CUSTOMER ,,,�»'""° \'E PHONE ,... DATE CUFJT0 wORK.ORDER
Jahn Niceforo (978)687-0560 12/08/2014 402821 00002
SC14RVIVI..,_..._.. r CE STREET 1 �,',� �"�"V .,_.. BILLING STREET ....._._
100 Great Pond Ro 100 Great .Q11dRoad
.M
SERVICE CITY.STATE,7V UIUINO CITY,STATE,TJP
North Andover,MA 4. North Andover, MAO]845
JOB DESCRIPTION
BARRIER:A Blower Door Test will not be conductod at your home,due to the prescnse ol'ashcstos.
50.00
AIR SEALINt;:Provide iRtrnr and materials to seal areas ai'yaur hone agahist wasteful,excess air leakage.e. This vvork will be
perforated in concert with the use ofspeciai tools and diagnostic tests to assure that your home will be left with u healthful level of
air exchange and indoor air quality.Materials to be used to seat your home can include caulks,I`nams,weatherstripping and other
products. Primary areas for scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are
not generally addressed.) (6)working hours.
At the campbxion orale weatheriraitian work,surd at no additional cost to doe homeowner,a final blower door and/or combustion
surely analysis will be conducted by file sub-contractor to cnstire the safety of the indoor ah-quality.
5450.00
CRAWLSPACE:Provide labor and materials to install (279)square ret of R-10 rigid Thermax insulation to the crawlspace
perimeter wall up to the sill and against the band joist.
$982.08
13ASEMENT CEILING:Provide labor and materials to install(178)linear feet of It-19 on faced fiberglass insulation to the perimeter
of the basement ceiling at the house sill.
1311.50
BASEMENT DOOR:Pravidc labor arid materials to insulate the back of the basement door reading,to the bulkhead wall 2"rigid
board that erects file sections R-316.5.4 and 316.6 requirements of building code. 5carl all edges arid scants with FSK tape.
$72.22
RISE Enghieoring will apply all applicable,eligible incentives to this contract. You will only be billed die Net amount. Currem ly,
for eligible measures,Columbia CTas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive or 100%for tiie J
Air Scaling measures tip to 5600.
For the safety and health ot'your home's indoor air quality,we will be conducting;a blowcr door diagnostic orthe available air flow in
your home both before the work is begun,and atter the wendierization work is complete.We will also conduct it full assessment of
the combustion safety of your heating system and water heater."Chis base value or590 and is at no cost to you, 'total allowable
wcadaeri7ation incentive is$2,690.
590,00
Federal In d
RISK Engineering RI Contractor Registration No
RIA Contractor Registration No
A division oCrhicisch Engincering CT Contractor Registration No
60 Shawnuit Unit 92,Canton,11IA 02021
339-502-6335 FAX 339-502-6345
CONTRACT
Page 2
PROGRAM TTHS CONTRACT is ENTERED Into DETYIHEN RISE
ENGINEERING CMA-IIES E RUNEERING ANDTHE CUSTOMER Fork WORK AS
UESCRIDEO BELOW
CUSTOMER PHONE DATE CLIENT$ WORKORDER
Jahn Niceforo (978)687-0560 12!08/2014 402821 00002
SERVICE STREET .. .. _... UILUIIG STREET ......
100 Great Pond Road 100 Great Pond [toad
SERVICE CITY,STATE.ZIP BILLING CITY,STATE,ZIP
North Andover,MA 01845 North Andover,MA 01843
JOB DI!SOUPTION
Total: $1,905.80
Program Incentive: $1,564.35
Customer Total: $341,45
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Three Hundred Forty-One&451100 Dollars $341.45
UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AORCES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY '..
UNPAID BALANCE AFTER SS DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,NIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REOISTRATlOfO, '...
i-4<
DO NOT SIGN THIS CONTRACT IF THERE ARE t3LANKSPACES
AUTHO EDSIONATURE-It CUSTOMER ACC CE
NOTE:.THIS CORTTUSCT MAY pE WITHDRAWN BY US IF tTGT EXECUTED YATIiitl DATEOFACCE� ICE ...._...
%,,rJ+� ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,DPECIFICATIONS AND C0140MONS ARE
C L.' SATISFACTORY TO US AND ARE HERESY ACCEPTED.YOU ARE AUTHORIZED 10 DO THE WD RK
DAYS, AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE '.......
OWNER AUTHORIZATION FORM
1, L)-Oh W r G G, Z90 n-,*Jl
(Owner's Name)
owner of the property,located at
I G2 47 y Y��G� �o 1t� gel
�( `
(Property Address)
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to ob I bail ing
permit and to perform worst on my property.
Q�-L r-\I H�-/
Own is Signature
Date
�a�a;•�c��tanroealf�a��asarc�usel�
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 10480D Type: Office of Consumer Affairs and Business Regulation
® xpiration:: _7/�5(201Ct Private Corporation 10 Park Plaza-Suite 5.17__0
HUGH'S ENERGY C.OR:PORATjpN'`'- Boston,MA 02116
DANIEL DRISCOLL
259 MILTON STREET - �^
DEDHAM,MA 02026
Undersecretary Not valid without signatu
Massachusetts_De
Board of 8U;u rg a Partmenf of Public r
o; 54,ation Safety
75t7'tiCt`7fiir�3_1---.lit; and
'"S0784
ThomasP
259 11to;Z S ZVO
Dedhatneet� da
m 111A 02026 =
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Comersssiio'nner !�XPiration
1012212016
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TDINS-1 OP iD:MR
CERTIFICATE OF LIABILITY INSURANCE DATERUWATV)
�TH's CERTIFICATE IS ISSUED ASA MATTER OF I1 RMATION ONLY 10/06/2014
CERTIFICATE DOES NOT AFMI MATAMLY OR NE IF AND CONFERS NO RIGIiTS UPON THE CERTIFICATE HOLDER TH►S
BELOW. THIS CERTIFICATE OF INSURANCE DOES B[NOT tea' SEND QR ALTER THE COVERAGE gFFORDED BY THE POLICIES
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEN Ft A CONTRACT$Ei�t THE ISSUING INSURER{S),AUTHORIZED
TANT: If the certificate holder is an ADDRIONAL INSURED,the poll
ms and conditions of the policy,certain Poficies m - must be endorsed. If SUBROGATION IS WANED,subject to
ate holderin iteu ofsuoh eadomeemen s, require an endorsement, A statement on this cer&ficate does not confer rights to the
rance envy,Inc. cc a
an Sher
MA 02474.6614 1$7$49.3002 ac No:7$1.541009
REss:
INSURBI[ AFFDRDlNGCOVERAGE NAICO
TD insulation, nc, INS mIRERA:Scottsdale insurance Com n
259 Milton Street INeuReERe;AmGuard insurance Com n
Dedham,MA 02026 mouRenc:Arbelia Protection ins Co.
U11 D: 41360
INSURiVt E
COVERAGES CERTIFICATE NUMBER:
THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABp�FOR THE PODGY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CO RE1f/SED NUMBER:
CERTIFICATE MAY Be ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OFSUCH POLICIES.LIMITS SHOWN MAY NAVE BEEN REDUCED BY D CLAIM DOCUMENT WITH RESPECT TO WHICH THIS
LIR TYPl:OFINSURANCE
A X coWmmmQ1NMALUABIUTY POUCYNUIfiBER
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CLAiMs,MAOE ®OCCUR X X CPS2020992 FACHOCCURRENCE S 1,000,00
0$!1412014 08/14/2045 P B- a s 50100
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aWEXP aywmpemn S 5,00
GENIAGGREGATELiMITAPPLIESPER PERSONA!&ADVINJURY S 1,000,00
P011CY a JECaT ❑Loc MERALAWRMTE S 2,000100
St
AUTOkiOBILE LUIBILrrY PRODUCTS•COWIOPAW S 2,000100
C ANYAUrO GO IN5 S
ALLOWHE 1020032764 N
AUTOS X SCHEDULED 08/14/2014 08/14/2015 BODILY 1,000,00
AUTOS INJURY(Pe�Nemn) S
HUMDAUT08 gUTOSNOWNED eODILVMUURV(PergCCWn,) S
PROP G S
UNBREU A UAB X OCCUR S
A EXCESSLu1B CLA1MSdAADB 0044410 EACHOCCURRENOE s 9,000,00
DE X RETETdTIONS 10000 10/07!2014 08/14/2015 AGGpEOATE
WORKMeoaParNSA- $ 11000,00
ANDS OVEWLiMarrY S
f3 ANYPROPRIETORIPARTNERIpFEOlf71VE YINPeRT
OFF! RfxcLUDma ®NIA R2WC513035 08H212014 08/12/2015 ER
it�yes, t6�er EL.EACHACCIDENT S 500100
DES'FumomOFGPERATtONSbebw EGDiSEASE-EA EMPLOY 5 500,00
GommerciaiAppltCa E.LOiSMgsa-POUOyLiMIT s 500,00
DESCRIFn-CN OFOPERAT(DNSILOCATtONSI VEHICLES(ACORO 101,AddWanet R¢tnatks Stlwduto,
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CERT(F/GATE HOLDER
CANCELLATI
ADRRCI�IE ON
SHOULDANYOFTHEABOYE DESCRIBED POLICIES BE CANCELLED RE
BEFO
THE EXPIRATION DATE THMOF, NOTICE WILL 8E DELIVERED
ACCORDANCEWnH THEPOUCYPROVISIONS: IN
. AmrrNOR1�BD REPRE881rATiVE
AcoRD 26 t2014101j The ACORD name and logo are registered marks OfACORD�CORPORATION.All rights reserved.
The Commonwealth of Massachusetts
Department of IndustrialAceidents
-- I 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 Please Print Legibly
Name(Business/Organization/Individual): co
Address: �t_bai L
City/State/Zip: Phone#: `�7/ 66 �3 C)d
Are you an employer?Check the appropriate box: Type of project(required):
1,Q-PaM—a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 El Demolition
10 ❑Building addition
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 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5. I am a generacontractor and I hhid the sub-contractors lid thtthdht
have hired su -conracors steon e attached see.
❑ l 13.FJ Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.$
6,F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ther
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 2
*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 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: �6�L
Policy#or Self-ins.Lic.#: �-tJ j, �, � Expiration Date: F-1
/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 airs ndp naltie eijuiy that the information provided above is true and correct.
Signature: Date:
Phone#:
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#: