HomeMy WebLinkAboutBuilding Permit #135-13 - Permits #135-13 - 38 TURNPIKE STREET 8/13/2013 TOWN of NORTH HANDOVER
APPLICATION FOR LAEXAMINATION
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Permit NO:
� Date Received
Date Issued.
IMPORTANT: Applicant must cowplete all items on this page
LOCATIONs . . _
Print
PROPERTY Y OWNER )�,jA-U 9_.._Q A( Unit
C
rri
OZ3
S ■ rrr ■ nt
��'� ■ PARCEL,■ � � ���I ��T'��T�. Historic District
Machine Shona Village yes
too year-old structure yes
TYPE OF IMPROVEMENT PROPOSED s
Residential Non- residential
❑ New Building Kne family
❑Addition ❑Two or more family ❑ Industrial
IQ Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ others:
❑ Demolition ❑ Other
..................::.:.......
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. ............... ❑.:::.:were
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DESCRIPTION OF WORK TO BE PERFORMED:
UU211
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C__4L.h-A_
(Identification Please'hype or Print early) �.
o LET : Name: kA.." •q)�P�xe.
Address: L)iL r, C L "s
CONTRACTOR Name:_UZ k[ Phone: �k,) 2 63 5�
Address.- AA:'t"d W 4 X)
Supervisor Construction License: � 9A(fx . Date:
Hone Improvement license; Exp. Date:
ARCHITECT/ENGINEER 'hone:
Address; re ■ No.
FEE S CHEDUL1.,..1 UL DING PEf•:_ IT-m$12,0 0 PER+ 1000.00 OF THE TO TAFL ESTI A T D COS T BASED ON$125.00 PER S.F.
• J� J
Total Project t■ $ #tn' FEE:
Cheek o.: No.;No.;Q, e �
econtractorsco not have �c to the u ra t ■N Persons contractingu e i
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Location
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TOWN OF NORTH
I
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i // e'nit, Fee
Building/Frame Pen
Founda
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T DIAL
Check#
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b
ilding Inspect.or
II
1
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T of� ndover
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IAORTH
No. ~It
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` ver Mass,
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L A K&
COCNAK"t wick .V
'rr,ID
BOARD F HEALTH
Food Kitchen
r I 11F ir Septic System
THISCERTIFIES THAT ..... a:s . ��,�"��_ "rr r r ■:■�■ .t... .s■■■■■#t.....:■..... ,■■■ ■s.....�■ ■■""■ *R"""■■A ipRhr0A vtF0Fhas BUILDINGINSPECTOR
permission Q /'� Fo�r�dation
erect x■■■■■■■■rsx■"■■"�x""■■w"� buildings n r.. as ■■f TAK■■ s�■ s■■■■Rar■■■■■Rs■■■■■arw"""■■■x#"M M rrtttmsrr
% Rough
I ■r x ....... ■4■■■■ ■■s■■■■■�■ "■ �r ■■■ """"■# "■ .� i r t r r: rrr■rxx rrrr*rrrrsr h�T711e
to be occupied w��
provided th t..the person accepting this permit shall in very respect conform t the terms f the do Final
on file in this office, and to the provisions of the Codes and -Lanus relating to the Inspection,Alteration and
Construction of Buildings in the Torn of North Andover. PLUMBING INSPECTOR
VIOLATION oft the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
A&I Ella
N L F 3 U
TK UT Rough
Service
r r r■■!■■r r 1*N■■r■! ■■■11 r■■3 f x■■■■3 IE■■■■f s■■■■■#s■■■■■IE■■■■■:F;■■■■■■i■■■■■r i■■ Final
BUILDINGINSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BuildingRough
Displayin a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To B Done FIRE DEPARTMENT
lentil Inspected and Approved the Building Inspector. Burner
Street No.
- Smoke Det.
SEE REVERSE SIDE
PAR 1 1,D1,/6
3
ass
I
PERM ITAUTHORIZATION
FORM
sham august , owner of the property located at-
(Owner's Name,printed',)
38 tu rnpi ke st north andover
(Property Street Address
hereby authorJ!ze,the Mass Save,Home Energy Services Program assigned Participating C,ontractor
listed befow-to act on my behalf and obtain a building permitperform n lati and
weatherization work on my property.
Ow..
3613
Date
FOR CSG OFFICE USE ONLY,
Conservation Services Groin his assigned the following ass Save Home Energy Services Participating
Contractor to the,above,referenced project.
1
i
Participating Contractor Date
i
Rev. 1213,2011
Office of Consumer irs&Business Regulafion-Mass.Gov Page I of I
The Official Website of the Office of Consumer Affairs&business Regulation A
Consumer Affairs and Business Regulation .t.
Homo Consumer Home improvement Contracting
Home Improvement Contractor Registration Lookup
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r
You can search/filter the registration list by any of the criteria below. }
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Search by Registrant Name POLAR*BEAR INSULATI
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The list is current as of Sunday, May 1 , 2013t
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REGISTRANT RESPONSIBLE REGISTRATION EXPIRATION
DAME ' INDIVIDUAL ADDRESS STATUS
� il� E SATE
POLAR BEAR LeBlanc, Vincent 102726 P.O. BOX 958 07/02/2014Current
INSULATION A COVER, MA 01810
01 Commonwealth of Massachusetts.
Mass.Gov@ is a registered service rn rk of the Commonwealth of Massachusefts,
LevC- s t.ru Ll per%i or Pec
k L 10
VINCE T LESLANC
24 LANDING DR
NIETH U EN MA 01844 }
-' xPratior�. 'i1f 't
: se i s. ca. tat .r a. s is ' n eelist.as x 1 2 13
P ID:SS
DATE(MMID01YYYY)
CERTIFICATE LIABILITY INSURANCE
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 A 1END$ EXTEND ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE F INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S)5 AUTHORIZED
REPRESENTATIVE E R PRODUCER,,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is are ADDITIONAL INSURED,the poli (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 certif Icate doss not confer rights to the r
certificate holder in lieu of such endorsernen#s.
PRODUCER Phone: 78-888-7008 A E AC r
Durso&Jankowski Its Agey LL Fay.9� -88 �'OD� FAX Flo;
y �H1,f3Y� #
'19 Massachusetts Avenue - Are � ��t
E-MAIL t
North Andover,MA 01845 ADDRESS:
Durso&Jankowski Ins.Agar.
CUSTOMER ID M POD„AR-1
INSURER AFFORDNO COVERAGE NAIC
INSURED Polar Bear Insulation Co.Inc. INSURER A:Fenn America 32869
Box 9 618IN ERE : t
Andover,'MA 01810
' INSURER
INSURER D
INSURE E
[INSURER.F
COVERAGES CERTIFICATE NUMBER: REVISION UMBER:
THIS IS TO ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED GAMED ABOVE FOR THE POLICY PERIOD
INDICATED. TWITH T�ANE)I ANY REQUIREMENT, TERM CONDITION F ANY CONTRACT OIL OTHER DOCUMENT T WITH RE PELT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE ANCE AFFORDED BY THE POLICIES DESCRIBED ISFD HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWNMAY HAVE BEEN REDUCED ED BY PAID CLAIMS.
Ihl D 8 POLICY EF Ir FOUCY EXP LIMITS
TYPE OF INSURANCE POLICY NUMBER MI1rIJI�f}IMY I4J WDDlYYY
GENERAL LIABILITY EACH OCCURRENCE 1 poi 00
AGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PAC6974504 031 4l D1 031 4/ 014 PREMISE Ea oocurrence 600001
mm CLAIMS-MADE 1XI OCCUR MED EXP(Any one person) $ ,
00
PERSONAL&ADV INJURY 1 roc , o
GENERAL AGGREGATE $ 290OOoOOO
ENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP A C $ 1 5 ,00
:D POLICY..F PRO- LOCJECI
mm
AUTOMOBILE LIAMUTY COMBINED SINGLE LIMIT $ 1 Vg D3g0
B -- ANY AUTO 12100926 11412 1 01/0 1014 (Ea accident)
BODILY INJURY(Par person) S
x�. ALL OWNED AUTOS BODILY INJURY(Per accident)
X SCHEDULED ALTOS PROPERTY DAMAGE
} HIRED ALTOS
Par accident)
X NON-OWNED AUTOS
UMBRELLA LIAB a OCCUR EACH OCCURRENCE 110003,000
F-] EXCESS AS CLAIMS-LADE AGGREGATE $
PAC6906385 03/2412013'0312412014
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION Vile STATU- DTH-
AND EMPLOYERS'LIABILITYY JQRYLiMiTS E
IN
ANY PROPRIET RIPART ERIE E uTIVE E.L.EACH ACCIDENT
OFFICERIMEMBER EXCLUDED? N 1 IA
(Mandatory In H) E.L.DISEASE-EA EMPLOYEE
byes#oesuiba under
DESCRIPTION OF OPERATIONS betow E.L..DISEASE-POLICY LIMIT
DESC1 IP n0N OF 0PE RATION S J L CATIONS J VEHICLE (Attech ACO RD 101,Add i#Ronal Remarks Schedule,If more apace Is requl re d)
Insulation Work - ►in ral
S r NSTAR and National Grid are additional. on General Liability policy
CERTIFICATE HOLDER CANCELLATION!
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
�� o"l rid I tatC THE EXPIRATION DATE THEREOF, NOTICE Witt_ BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
x
ClooS9
400 Washington St Ste 2000AUTHORIZED REPRESENTATIVE
Westborough,MA 01581
f
1 - 009 AC RD CORPORATION. All rights reserved.
ArwOR3
D 00 1Q ) The ACORN name and[ago are registered larks of AC RD
f
E
PLABA- 4 TAA1
DATE(Iw1 WDDlYYYY)
CERTIFICATE OF LIABILITY INSURANCE
11212013
THIS CERTIFICATE IS ISSUED AS A MATTED OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND D ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN SURE ( ), AUTHORIZED
REPRESENTATIVE OR PRODUCER,E ,SAND THE CERTIFICATE HOLDER.
IMPORTANT; If the eertifi ate holder is an ADDITIONAL INSURED, the polio (ies) must be endorsed. If SUBROGATION IS 11 AIVED,'Subject to
the terms and conditions of the policy,certain policies may require an endorsement. A stater ent on this certificate does not confer rights to the r
ortifi ato holder In lieu of such Ind rs ment .
}
PRODUCER CT
I NMTE
Automatic Data Processing Insurance Agency,Inc PHONE Al{ }
ADP B le a'd Info xt: � N0: }
Roseland,NJ 7068 ADDRE
SS:
INSURER(P)AFFORDING COVERAGE NAIC#
INSURE A:NorGuard Insurance Company
INSURED
Polar Bear Insulation COIncINSURERS:
1 South Canal St INSURER e
PCB BOX 958 I
Lawrence, MA 01843. INSURER E i
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES F INSURANCE LISTED BELOW HAVE SEED ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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.
IN SR TYPE OF INSURANCE AUDLSUBR PO EFF POLICY E
.T POLICY NUMBER MMf#}DNMI (MODOM LIMITS
GENERAL LIABILITY EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence)
CLAIMS-MADE OCCUR MED ESP(Any one person) $
PERSO AL&ADV INJURY
GENERAL AGGRE ATE $
ENI AGGREGATIw L1M1T APPLIES PER: PRODUCTS TS+GOMPf0I''AGE
Ia'QLCO PRDL]-
I= T' LOO
AUTOMOBILE LIA131LITY COMBINED SINGLE LIMIT
Ea ari�fe�t
ANY AUTO soDILY INJURY(Par parson) $
ALL AUTOS QED S SCHEDULED
AUTOS 80DILY INJURY(Per accident) $
HIRED T -O� IVED a PROPERTYDAMAGE
AUTOS Per accident
$
UMBRELLA LIAR i OCCUR EACHOCCURRENCE
EXCESS I.IAB CLAIMS-MADEAGGREGATE
COED RETENTION r
WORKERS COMPENSATION 10TH-
AID EMPLOYERS'LIABILITY f
A ANY PROPRI TOMPARTNERIE ECUTI E POWC441336 111112013 1111 14 E.L.EACH ACCIDENT 1100 JO0
FFICERIMEMBER EXCLUDED? NIA ,
fMa n d atory Ire NH)
E.L.DISEASE-EA EMPLOYEE 110009000
If�+es,desefts under
0 SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 10000,000
D ESC RIPTION OF 0 PERATI ON S I LOCATIONS I VEHICLES(AltoCh ACORD'101,Additional Remarks Sc Adele.it more space Is requlred)
Special Instructions• INSULATION AND AIR SEALING
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE b S RIBED POLICIES BE CANCELLED BEFORE
ATI NAL GRID THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Att ntionMASSAVE CONSERVATION PROGRAM
50 WASHINGTON ST. AUTHORVED REPR ENTATIVE
Westborough, A 81-
1 - 01 A RD CORPORATION. All rights reserved.
AC RD ( 1 The A RD nalme and logo are registered marks of ACORD
C 0,i,,V
R
A CT F0
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4�raRti
w�'cW1WflNN,1NN1iNVA�n
�. n Il�'1Mb74NANu91�
n at io,n a I g r i
ation
ConserHEREWITH"
w FOR,
YOU.
PRODUC"S,
EaRVICE WOR"
Services Group
This service is brought,to you through support from your l ac l utility
,
wnd
Conservation S es Group CS,G
A-U,RCS
Shiia Agu� �
sal Suite
'North,Andover,,MA '0 1 845-503 1, 1 38'Turhpike St
e9
r 0 2 5 C � 20130511�'WORKFeder � .2245 17'0
Site M.,S00002122260 completedriunact to adidress-Above),
o
z w,
t:aDESCRIPTION WORK TO BE, PERFORMED
M w. wfollovd,R19 Work on these iiiinaivierirlwiLh,the tenils of
w� . describing
, " �, , "Work")
w w
xif by
Description Quantity Location
Attic Floor Op!�O,pIqw Cellulose 8 970, Living,�;pi�qe $1,416.20
Insulate i l Sided W 1w With me "a Cellulose 1 Li in § °° �
Pry � `or ' 46 Attic $161.00
Blower Door Test Only_ �i nosti ' s Pad N/A
19g, 2 NIA ,a $44-40
Sub Total'. $13,4:63.610
Utility Incentive Share, $2,000.00,
Customer Contribution $1,463.,60
Printed.61103 page I of I
H. PAYMENT
Cuslxxmer a " r a Deposit payable
t W� , m x t�� vw,
aetvxd cost;-ofspecial ordus, Mil cheek&contact to CS0,
AttwRCS)50 St,Ste.30,00,W t.N)r ugh,MA 015SI.Final aYjll rltw '
payment
on,the pack g
w.
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P tiv dli;� as , . wig .r iduat ill ern r p vi t i tines n rea ,. r � w aa, as a a..
111. DISPUTE RESOLUTION
11 + ;M lm-r heml%y nuitually:agreein advwmw thtn icl the�w��rC�� � .�� "� � ���t, �x ���� ��� ���. �� �y w`�� ��.a,�,such p
binnarion.m;prmidedin,M.GL c M-2-k-
w ` " w � �t: wSm
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You may,cancel this agreement *if "it has been signed by a party there to, at,a place,other than an address of the seillier,
which s main office or a branch there of,, provid,ed,you notiffy the seller iin writing at his main, office orbranch
y mail posted, y delivery,, not liater than, midnight of the third business,day following the
nib this a t. S1 S T Y K .
Jun 2 , 2013
.
w,�,'A .. _ " w a r y.� ... irada ��1L w z) here if... A« 91`T' .....
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46
CONTRACT FOR
nationalgr'I'd
aio
PRODUCTS SERVICE WORK F'WJT�j t HCRE FOR YOV,
Conseer
Services Group
I['isiti ii pAcs�.i hmi.ght M yot thfou*h I P.po r#from*10:1r;0 CF-;i `iIfty
T/i is Agreement is made by and among
d R\ i
Conservation Services Group (CSC)
Ate'RGS
Shang Augustin aslibi S'ueel Saito 3000
Noxth Atidover,MA" 1 _ f Red.No, 173484
r je ID:P0000Q1263.58 Contractt 20130511 reedenal M No.222d57170a
Site ID:600002X22Z60 Wall oll)plet d eontxacL to ad ire nlAwo
1. DESCRIPTION F WORK TO BE PERFORMED
•�o SIT rf rtii or�` ti v I Ix.Ix-doI�1ml 111e.t flov,.#tip; `olio CIA I�7t':.4 ITIVIIIE;A."Ell : ►'*� 4 �`all)-nor-LIM 1J����� �������•��������0W W;-I of
this;("1 0I���':,t��!:1tkdlxdiyl,IIM!w vbvk:C�''���;1��1�`�31���1:[t��;������1'+ orl-k 1�E';��`4`l��l�ti�:►bw t1 Ot[-J1I�kl' kfl:,OT '-Wk% "# which'mh i1xvivori3:e(I botv- l by
r`ptlt Quantity Location
Poi(rm Air$ ling zat Estf at a 61 S OP-1'050 Per H our a Li-eing SPA .
]+ r MIA S4 .
4xlolor Door 2 WA MAD
Attic, l.r Cover Th armI-SaMer w4l QrF wry I Living Spoice $237.65
Sub Toto1: 46-39
Enorgy Effi clency Incont]v ,
Not Safer.Tax Aftor M=nti re S0100
TOW 140
95
Page 2 of 2
It. PAYMCNT
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;ELM,IWS.1.10��`-mili��gtoll t.tSte.;000,WAIdlilharought NTA 01.18t.11111:0 I';t�"of-IlI� .�,. ���fi.N�t+.� �'t���a4�`it��ti�1�±���'tlEf}�i�{�?CiC���;t���:�+��ii��it lid
= w� 1, �c r t� *lt t: ` i .., upon ":f�: t s ct t *tk��IV �:'k�.s1�:�r.�it �` #: t <t c will � �c x;
KIIr. I I I I I y IIIui',It:1 v 8111o��of kI 1,,�,'0t:EMOt ICI`I1*kn I Itv.#�1t;[��llvf��'� � f ..�'w}�it'.����;1�;.'ln('6IIivl%I.qI v-11i�#ep(11-Kk,Eli��x}�N5� �]t:kt' �,�C!�kt��{'��:�'�`i�t�1Y�����r
`{ y " ` '* '.? f[t� E<i#iF 1� � L' ti *�Il ?C'' 1``1'�k' rx 7�7 f' 1'[;C''.?i*f l'414LSejt�K;.St.Ou,x4'IL o9f the Iyr1bly II)evnii
11).DISPUTE RESOLUTION
' K►: ;{,14ti :�. f.�tr' at a� l + 'K� '� cxlrur ;�tl�� lr �����!:lk� %J[t' ct• ���i ��lit,c�: 1x�t#�+tioo p'c�skl� c•1,11'i����yi ��:1 �; � [ 1k±1x �� x►�1iiCr`�► �
roe ti t s 1#I�, �� pm x�i C 1 f►s ��r,�lr.['k`r i"4Iits ill�ikl'.11tqi�**�Jt'���t�i,ll�;��3�i�{,'�1�:�+rl����l'.�l;a����+� rV�tU:1yx1 ft)w,t it)��iit# �'�,��'k1:ul4itv1i1Fti ti t, :�i �:tl� ����t,�i I� ��};2:1.
+ . F Y 41 1 }' rY 1
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{ i t�■7 F F kX;1'77`
You ter cancel this agreement i it has b signed party there try Cc tr [� r � llr.
{ r i h his rain office r a r rl h there ., provided yore notify the seller ire uritin his main ff r branch
}
y by ordinary mail pasted,, by telegram sent or by delivery, not later than midnight of the thfrd businessday folio in the
} = signing f this agreement.,DQ NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES./<
.'1 Ek}t `' a'1���It''. ik 4` ���:c•�l;l V01 Wgt' 'i:1'4 lit. n ilfta K-M'5f VOtI W,
1lie P'"Ign%Ita IOr;Issie.C1 a
a-,X1, Elardel flag col I lr-xtutt
5 -
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CONTRACTOR WORK ORDER
so washhvton St.suite 3000
Printed-, 7/212013
Work Order Id: S2226OP26358C238
` � �.'� � :��#��: .• may ��, �
- - ,�.'�'""w=�:�- Iti ''�� � -}.-r'='� ;.*.•�_�- .'`Y' - =-ram.':`�-•r's. �r' '`F`*•r+_ __k_ _ Y .y fJ Y k'r+.,
�Y { =5'=�#r, r^: _ *{{ '.wF�.:{ {!� �f•'•ti'.•r. :.i.+ - +Y-`` .. `F•!r } ,.ti" ,
Polar Bear Insulation Shana Augustin Phone(Eve): `y -.PO 425
Box 958 38 Tumpike StPhone(Day): 978_809�-142s
Andover, MA 01 0 North Andover, MA 018454031 Site 1D; S00002122260
Wd
�eas4i1 ilk 4
+,'��. .r•�` - ..
Location Betio
Quantity Unit$ Total
Attic Pro pavent 'or 4' 46 $3.50 $161.00
Luring Space Insulate vinyl Sided Wall With 4"Dense Pack 810 $2.20117 2, 0
L+iVin Space Attic Stair Corer Thermal Barrier wi th carpentr
Blower Door'Test Only1
Door Sweep 2 $21.17 $42.34
Living Space Attic Floor Open Blow Cellulose '� r T $1.4 1, 1 r 0
y Luring Space Perform Air Sealing at Estimated 62.6 CFM50 8 $77.00 $616.00
Exterior Door weather SMpping
2 $25.20 $50.40
Installed Measures Total $4,409.99
,.y ~�!• .�{� ..;_ .r. `-r;..,�•, rk.�` _ .:r- '.'t`-" r - _ R' _ ;r=1'. ,.f�.•5 •1- +,r•..+.' ti': r-
+F r`� `•Ir i
.y. '�y+� ti � 4.4`.i �r� ��;.•.�Y' - 'r�+i,'+�1.` ^i�.+�i,` 'r= .1
Type status Notes
yMoisture FIXEDhole In root leaking in kitchen
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Incentive Payments
Air$ealing la n e $ .3
Weatherization Incentive $2,000.00
Total Incentive Payments $2,946.39
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Customer Share
Total Customer Share, $1,463.60 �.
Less Deposit Of $0.00
Customer Share Balance(Due Contractor) 'I, 63.L 0
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Conservation Se i es Group-50Washington Street Suite 3000-Westborough, MA 01581 -(5 - 5 0
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{
} The Comitzottivealth ofAlassachusefts
D p r-ineit t of M dit snial A cc}id it is
Office of Itivest' adwis
19
oo Mashbig ion Street
oson, MA 02111
y ' ) jvivanass. a dia
Workers' Compensation Insurance Affidavit: Builders Contr tors Je trx fans lu .be s
Api2fleant Inforination Please Print Legi
Name (Business/organizationlindividual):—P I V (C) C.
jo 4,a
Address:
City/State/Zip: &CID (2 e-Afe Phone
Are you anemployer? Check the-appropriate box: Type or project(required):
i.El I am dem to cr with . El I am a general contractor and I •
� New construction
employees (full ajid or part-thee .* have bared the sub-contractors
.El I am a sole proprietor or partner-
listed on the attached sheet. 7. Remodeling
ship and have no employes Iliese,sub-contractors have 8. Demolition
WOTkiing for me in any capacity- workers' comp. insurance* 9. E] Building addition
work ers' comp. insurance w are corporation rid its[No .1 .ElEletrieal r it or additions
�
re uird.] oCeers have eere�� ed their��r
1�
. I any a homeowner doing all wort ri lit ofexemption per MG l I. Plumbing biz repays or additions
myself [No workers" comp. e, 152,§1(4), and we have no 1 .0 Roof repairs
insurance required.] t employees. [No workers' F
. 13.W comp. insurance required.]
Other .. )�iS
.
'Any applicant that cheeks box H l must also sill out the sect lun below showing their workers"compensation policy in formal ion:
t 11onicowners who submit this affidavit Wicating they are doing all work and then hire outside contractors must submit a new afridavit indicating such.
C on traclots that check this box mast attached an additional sheet slowing tlje nwne ufthe sub--contractors and their workers'comp.policy injr rrr tion.
are are errrployer that is pro vidin )ijor•ker•s competisatiorr insurance for my employees. Below IS the policy a nd job site
Prf orynafiM
insurance Company Name: �' �. �� l WC C(C)
Policy ft or Self-iris. Lie. ; Expiration Date:
Job Site Address: tuK j Vol, 1.�-& City/State/Zip: .
Attach a copy of the workers' ompeus Lion QUey declaration page showing the policy number and expiration date).
Failure to secure coverage-as required under Section Aof MGL e. 1. ears lead to the imposition of criminal penalties of a
e op t 1, oo.00and/or ore-gear i Y pri o nxeu� as well as civil penalties in the fo n of a STOP WORK OR-DER axed a fine
of up to$250.00 a day against the violator, De advised that a copy of this statement may be forwarded to the Office o
Investigations of the DIA for insurance coverage verification.
o i"ereb eer-ri;it rder the paurs andpenalties o, 'per;ur i that the information proioided above is Ir ue and correct.
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�i ature: Date:
Phone
off c a Sri rr o rr �*ire in this area, to be completed by elttp r�to wit o,, iclal.
City or 'own: erinit/License
} Issuing Authority (circle one): =
{ 1. Bo of Health 2 13 uilding D epar ment 3. c ity nro wu C Ierr k 4 El e c.tric.at Inspector 5,Plumbing Insp ector
..other
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Contact Verson: Phone
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