HomeMy WebLinkAboutBuilding Permit # 3/2/2015 NORTy
UILDING PERMIT: ° ,b^
TOWN OF NORTH ANDOVER,,,.
APPLICATION FOR PLAN EXAM INAT[QN" ,:. -;
Permit No Date Received,.:r I 7¢�A0 Are°PPa°
Sg�CH►�`-'�' i
Date Issued: -
I ` P R ANT:Applicantmust~complete alluitems,- on.1his page
IiC �
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 0 One family
0 Addition 0 Two or more family 0 Industrial
PAlteration No. of units: O;Commercial
❑ Repair, replacement 0 Assessory Bldg ❑ Others:
0 Demolition 0 Other
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0 Ood„ tai, r et ands, Wat"e 5 ed1 rh istr�ct �1 1 '
DES RIPTION OF WOPKIE PERFORMED:' ,
l 6 5 fit- I �► ��I
Identification- Please Type or PAM,Clearly.
OWNER: Name:
Phone:
Address:
ri
u��tl u i,gym i;�m�biSiN�ui miVm i �a�iw�F�num�w,Nnw �� i�,.��x.
ARCHITECT/ENGINEER Y Ph.
Address: - Reg: No.
FEE SCHEDULE.BULDING PERMIT;$92.00 PER$1000.00 OFTHE TOTAL•ESTIMATED'COSTBASED ON$925.00 PER
Total Project Cost: $ FEE $
Check No.: Receipt`No
NOTE: Persons contracting with unregistered contractOFfdo, 6ihavel access to the g tyf 4 d
rim A" ttORTH
I own 0_1 A"Eles
nclover
O691 '
® -
C, 4 �„KE ®ver, ass,
COCNIc"t WICK .(.
U BOARD OF HEALTH
Food/Kitchen
PEKIV IMT T %O L U Septic System
THIS CERTIFIES THAT .® t .....,. , ,......g..14AA.............. .... BUILDING INSPECTOR
has permission to erect .......................... buildings on ...... .I........ uA-,...V9 444X...................... Foundation
Rough
to be occupied asS� Chimney
provided that the person accepting this permit sh 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
3D PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRCTIO , T TS Rough
Service
..................... .. .................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® 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 Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
Fedora[to tf
DISE EnRitteet-ing RI Contractor Registration No
MA Contractor Ragistration No
A division orThiclsch Engineering CT Contractor Registration No
60 Shawmut Unit I12,Canton,MA 02021
CONTRACT� �«
339-502-035 FAX 339.51 - 45
....._.,.,.mm---- a page i
17
(" }iitOGRAM THIS CONTRACT IS EitTERED UA TO DETWEEN RISE
°n CNIA-11US ENniNCERINO ANDmc CUSTOMER FOR WORK AS
ENGINEERING DESCRIBED oELOG4
CUSTOMER `; 1 +}"� PHONE DATE CLIENT WORK ORDER
Bonnie Leblanc v (978)888-3629 12/29/2014 406293 00002
SERVICE STREET ILLV40 STREET
41 Beaver Brook Road I Beaver Brook Road
SERVICE CITY,STATE,ZIP BILL1140 CITY.STATL,ZIP
North Andover,MA 01845 North Andover, MA 01845
JOB DESCRIPTION
AIR SEALING:Provide labor and materials to seal areas ofyour home a gainst wastetal,excoss air leakage. 'this work viii tic
performed in Content Willi the use of special tools and diagnostic tests to assure Autt your home will be tett with a healthful level of
airexchrmge and indoor air quality.Materials to be used to seal your home can include caulks,fatuns,weatherstripping and other
products. 'Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(trindotvs are
not generally addressed) (8)working hours.
At the comiletion of the weatherization work,and at no additional cost to lire hontcowner,to final blower door and/or combustion
safaly analysis will be conducted by the subcontractor to ensure Ace safety or the indoor air quality-CHECK A/C BO(YfSlll I-IOUSE
CLOSE TO BAS111
$600.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaccd fibergloss balls to(92)square rest for damning
purposes.
$188.60
A'PriC FLAT:Provide labor and materials to install a 61 layer of R-21 Claus 1 Cellulose added to('1264)square feet of open attic
space.
$1,516.80
RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,
ror eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive or I utryo far the
Air Scaling measures up to$600.
Por tic safety and health of your home's indoor air quality,we Will tic conducting a blower door diagnostic of the available air flow in
your home both tw1bre lite work is begun,and after the wemlicrization work is compicto.Ave will also conduct a Ibil assessment of
the combustion safety ofyoar heating system mid water heider.'f7ris has It value of$90 orad is at no cost to you, Total allowable
weathcrizxation incentive is$2,6130.
$90,00
FederatIn#
SI, LItg'ineering RfContractor Registration No
MA Contractor Registration No
A,division of'Uhicisci Engineering CT Contractor Registration No
60 Shaivtnut Unit 42,Carron,INIA 02021
CONTRACT
339-502-6335 VAX 339-50U345
Page 2
PROGRAM THIS CONTRACT IS WTT£REO IN TO OLTWEEN RISE
CMA.-HES £NOINCE.MNO ANOTHE CWTOMER FOR WOHKAS
ENGINEERINCDESCrttnrODPLOM1v
CUSTOMER P+JYpdJE DATE CLIENT 0 WORK OPBER
Bonnie Leblanc (978)888-3629 12/29/2014 406293 00002
SERVICE STREET UILLNIO STREST .. ._,,.
41 Beaver-Brook Road 41 Beaver Brook Road
SERVICE CITY,STATE,ZIP DILLINO CITY,STATE,YIP
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
Total. $2,395.40
Program Incentive: $1,965.05
Customer Total: $426.35
WE AGREE HEREBY TO FURNISH SERVICES•COMPLETE IN ACCORDANCC WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
'"Four Hundred Twenty-Sint&35MOO Dollars $426.35
UPON FDJAL IttSPECTI4N ANO APPROVAL NY RISE ENOI!lEERNNO.CUSTO?,4M AOREES TO REMrr WAOUNT DUE IN FULL.INTERE.ST OF i%YALL nE CH ARUED MOUTHLY ON ANY '...
UNPAID HALANC•AFTER 90 DAYS,SCE REVERSC PO IMPORTANT INFORMATION ON GUARANTEED,RIGHTS OF RECISION,SCHEOULINO,AND CONTRACTOR REGISTRATION, '...
DO NOT SIGN THIS CONTRACT IF THERE AR04 N ULAN P CES
AI TH OED SIGNATUINEFAINO i' id iZ ACCEPTAW.E
MM."410 CGNTRACTMAY DE✓WITHDRAWN BY US IF NOT EXECUTED WITHIN DATt:OPACCEPTANCE
ACCEPTANCE OF CONTRACT•THE ADOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE
SATISFACTORYTO US AND ARE HEREGYACCEPT£O.YOU ARE AUTHORIT.EDT tEVN9RK
.._.L_ � ...._... BAYS. AS SPECIFIED,PAYMENT WALL DE MADE AS 011TUNED ABOVE
4t I
��% ,m
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
4! 1 -e_q U.e, I,^
(Property Address)
Qy fI'Llac~1 Yui
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
Je4SIgnsAdre
[date
l
�o�a��r.��taazroetrlf/r•o��a�rc�u�el�
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: -,[04800 Type: Office of Consumer Affairs and Business Regulation
xpiration:, 7J51201fN Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
HUGH'S ENERGY CORPOP'ATION
DANIEL DRISCOLL
259 MILTON STREET
DEDHAM,MA 02026 ---
Undersecretary Not valid without signatu
11
Massachusetts
efts-i)e nie
so 'd of$uilw9rn a Part ant of PublicSafet3j
ioilsti'iiCtifi bt.Qrions nu v aP^+.1ru
1 tSii?
License:C'"507
84
Thomas P D,t+n
259111140
Dedham
���te
Commissioner
expiration
1012212016
a
"-j 'TDINv 1 OP ID:MR
CERTIFICATE OF LIABILITY INSURANCE ®ATE�Io�
THIS CPA"PICATE l$ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIG 10/06/2014
CERTIFICATE DOES NOT AFFIRMATW O-Y OR NEGATIVELY AMEND 1f7�UPON THE CER77FlCATE HOLDER.THIS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CO , EXTEND OR ALTE(2 THE COVERAGE AFFORDLIC T HOLTHE POLICIES
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. TE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
IMPORTANT: ff the cettlficate bolder is an ADDITIONAL INSURED,the poll
the terms and conditions of the policy,certain policies mom)must endorsed. If SUBROGATION IS WANED,subject to
ce(ftfiCate holder in lieu of such andomeme e. raquir a an endorsement. A s�m�on this certificate does not confer rights to the
PRODUCER
TYG Insurance AAg�ency,Inc. cc A
68 Freeman Street
Adington,MA 02474.6614 E 7$1$¢I-auuz ax
EaxAI1 c No:781.541-3009
REss:
lNSUR84( AFZ ORDING COVERAGE MAIC f1
INSURm TD Insulation, na alsuRERA:Sooi'tsdate Insurance Com an
259 Milton Street INeUReRs:AmGuard Insurance Com ny.
Dedham,MA 02026 IueUt> c:Arttena Rrotectton ins Co.
: 41360
INSUPMD
INSIIR82 E•
COVERAGES CERTIFICATE NUMBER: tNsttRERFs _
THIS(S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION Op ANY CONTRAC r OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS ITHdE S TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OFSUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED CIES D CLAIMS.
LTR rMEOFINSURANCE
POLIGYNU14rBEK OY
X COMMIPRG(ALOENERAt.L(ABILi1Y ups
CLAtMsfitaDE ®OCCUR X X CPS2020992EACHOCCURRENCE S 1,000,00
0$/1412044 OB/i4/2015
MEDocP Argrm,eae,wn S 5,00
GENLAQGREQp7ELp APPUESpgI PERSONALSADYRUM S 11000,00
POUCY Q J ❑Loa GENSI .AGGREGATE s 2,000100
PRODUCTS-DMP/OPAGG S 2,00000
AUrOMOSILELUISILIN ,
5
C ANYAUTO CO D3N (, $
AAVUrosoWNm X SCHEDULED 102003276Q 08114/2014 08/14/2015 SODILyle mY 1,000,00
tPeraersa+) 5
HIitEDRUT05 pUTO.gNOWNEO BODILY IMURY(Peraeddano S
PROP C, S ',.....
UMBRaLAUM X OCCUR s
A EXCEauas cuuMsn�aDE BS0044410 EACNOCCIIRRENoe S 1,000,0
DEO X RErENnONS 10000 10/0712014 08/1412018 gGGREflA9E
WORMS COMPENSATION s 1,000,00
AND EWLOYEU?•LIMUM s
13 AN1fPROPRIETOB/PARMMMDMCUME YIN
OFMC MER W=DED? ®NIA R2WC513035 08/12/2014 06112bZ015
(AtandatwinNNj ELEACHACGIDENT ST 500,00
SRI of under
DEO0IRE RAn0Ns pLA S 500,00
COMMercialAppllea ELDISEA9E-PouCYUMIT s 500,00
DESCRIPnorlapopE,RAT(aNS/LacanDNS/vERICLEsIncoRnlar,aediaonalRemarkssehedutp may0oaftnehad3fmoraspata�mquuerll
CERTIFICATE HOt DER
CANCELLATION
ADRIl
SHOULDANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILT. EE D
ACCORDANCE MM THEpoUcypROVISIOM ELflfERED IN
AUlHOR1ZED REPRES8ITA7NE
ACORD 25(2014101) The ACORD name and logo are registered III of ACORD CORPORATION. All rights reserved.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
--- 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 Please Print Letfibly
Name(Business/Organization/Individual): LT C)jry
Address: , ! I / G6ki /11iLt 0,)-
City/State/Zip: Phone#: `7�(' 066 3 8 y
Are you an employer?Check the appropriate box: Type of project(required):
_!Q4—aTfi 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 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. F1 Demolition
3.F1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]Building addition
4.F]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 general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.FJ
we are a corporation and its officers have exercised their right of exemption per MGL C. l4. 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.
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:
Policy#or Self-ins.Lic.#: �,3 63 Expiration Date:
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 DTA for insurance
coverage verification.
Ido hereby certify under th n_ins _ndp nn_ltie erjury 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#: