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Home My WebLink AboutBuilding Permit # 4/22/2015 OORTH Town of Andover 0% ® - - �� ver, Mass, 4 COCHICKEWac" �1. A°;�Area �5 •(C;) S � BOARD OF HEALTH PEKMI T Food/Kitchen Septic System THIS CERTIFIES THAT ..... BUILDING INSPECT®R ........................ ..... .. .. . ................. . . . ................................. has permission to erect ... At . .. buildings on ......... Foundation % Rough Wft to be occupied as ..... ... ......S4.410,1.... .... . .. .. ........ .........,.................... Chimney provided that the person accepting this permit II 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 MONT ELECTRICAL INSPECTOR ® UNLESS CONSTRUCTION ST Rough Service ............................. .............................. ......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin Rough Displayin S ePlacePremises — Do NotRemoveFinal No Lathing r Dry Wall To BeDone FIRE DEPARTMENT Until Inspected ve Building S ra Burner Street No. Smoke Det. Cons0GCONTRACT FOR eraltion PRODUCTS SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Piter Jules Conservation Services Group(CSG) 49 Longwood Ave Attn:RCS North Andover,MA 01845-5217 50 Washington Street,Suite 3000 Site 111): 500002316548 Westborough,MA 01581 Project ID:P00000326572 Reg. No. 173484 Customer ID:C00000326687 Federal ID No.222457170 Contract 11):20150120WORK (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work')which are incorporated herein by reference: Description Quantity Location Insulate Vinyl Sided Wall With 3"Dense Pack Cellulose 1,240 Living Space $2,777.60 Insulate Interior Buffered Wall with 4"Dense Pack Cellulose 182 Living Space $420.42 'Blower Door Test Only(Diagnostic Testing Part) I N/A $65.70 Sub Total: $3,263.72 Utility Incentive Share $2,000.00 Customer Contribution $1,263.72 'Sol For office use only Printed:112212016 Page 1 of I Ill. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ 421.00 -as a Deposit payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CSG,Attn:RCS,50 Washington St.,Ste. 3000,Westborough,MA 01581.Final Payment:$ 842.72 as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisf toompletion of the Work.Customer understands that he/she%vill not be required to pay the Utility Incentive Share of the Conti-act price in the amount of$ Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The TIC and Customer hereby mutually agree in advance that in the event that the TIC has a dispute concerning this Contract,the TIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L.c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. f X TiMrjws X 1/29/15 X POLAR BEAR INSULATION Customer Signa t,.... Date Indicate your selected TIC here,ifapplicable (OR) Initial here if you want 1/22/15John HerrinE the Program to assign a CSG Signature Date Name of CSG Representative(Printed) Participating Contractor TERMS AND CONDMONS APPEAR ON THE REVERSE. 3/14 AV it mas �; pA1�CIP�NG PERMITCONTRACTOR UTH I TI 1, PITER JULES ,owner of the property located at: (Owner's Name,printed) 49 Longwood Ave NORTH ANDOVER (property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work-on my property. X ..L r ' Owner's5ignature .• Dat FOR CSG OFFICE USE ONLY. Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Ofd r For Office Use Only Rev, 12132011 Th e Coninion wealth of Nltrsslrclr rrsetts Deprn-trnent of LrdtrstrialACcidents Office of Investigations � " 600 Washington Street = =:r, Boston, MA 02111 tvtvtv.nrass.govVia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ,t Name (Business/Organization/lndi\'idtial): �® 144— &eCc r Y\ 01 0. Ji _ Address:® igo X fr City/State/Zip: &Pdother M Phone #: �`,�' �a �� a l Are you an employer?Check the appropriate box: Type of project(required): 1. I am a Nvith employer d• ❑ I am a general contractor and I � 6. ❑'yew construction employees(full and/or part-time).* have hired the sub-conn,actors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workino for me in any capacity. employees and have workers' p ) 9. ❑ Building addition [No workers' comp. insurance comp. insurance.= required.] 5. ❑ We are a corporation and its 10,El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [\o workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.] c. 152. §](4), and we have no q ] employees. [No workers' 13.MOther r 5v A 116 V _ comp. insurance required.] *Am applicant that checks box 41 nmst also till out the section below showing their workers'compensation police information. I tomeowners who submit this affidavit indicating the\-are doing all\\ork and then hire outside contractors must submit a neer affidavit indicating such. >Couractors that check this box most attached an additional sheet shociug the name of the sub-contractors and state whether or not those entities have employ ees. If the sub-contractorshave employ ees.thc\•must provide their workers'comp.polis} number. I!un an enrp1g),er that is providing workers'compensation insurance for rrrp errrphgees. Below is the polio`lard job site in formation. Insurance Company Name: q rA — Policy#or Self-ins. Lic.#:_ 0 tr c— &b Expiration Date: l - / .lob Site Address: V HR /nhg Wato #9,./t City/State/Zip: !1_ yq-1iQ !ow- 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 S1,500.00 and/or one-year imprisonment,as vvell as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 da hel'el)r certif1,under tkep®airs and penalties of perjurt`that the infonnation provided above is true aur/correct. Signature / Date:k* Phone': !q?,F" IJD �- �� Ofricial use onlr. Do not write in this area,to be complete!//tv citt`or town official City or Town: Permit/License# Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk -i. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone#: OP ID:SS CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDm'Yv) 03/13/2015 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(les)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 CNAME:NTACTO Durso&Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue N arc No North Andover,MA 01845 EMAIL Durso&Jankowski Ins.A ADDRESS: gcY- PRODUCER POLAR-1 C ERt INSURERS AFFORDING COVERAGE MAIC C INSURED Polar Bear insulation Co.Inc. INSURER A:Penn America 32859 P O Box 958 INSURER B:Safety Insurance CO. 33618 Andover,MA 01810 INSURERC: INSURER D: INSURER E INS RER F COVERAGES CERTIFICATE NUMBER: 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 POLICY NUMBER MMMINDR EFF MPS Y EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,00 A X COMMERCIAL GENERAL LIABILITY PAC7052023 03/24/2015 03/24/2016 PREMISES Ea occurrence $ 50,0() CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GEN ERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICY PR0. LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,OOD,00 B ANY AUTO 100926 01/04/2015 01/04/2016 (Ea accident) _ BODILY INJURY(Per person) $ ALLOWNEDAUTOS BODILY INJURY(Per accident) $ X SCHEDULEDAUTOS PROPERTY DAMAGE $ X HIREDAUTOS (PER ACCIDENT) X NON-0WNEDAUTOS $ UMBRELLA UAB X OCCUR EACH OCCURRENCE $__11000,00 EXCESS LIAR CLAIMS-MADE AGGREGATE $ A PAC6906385 03/2412015 03/24/2016 - DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU• OTH- AND EMPLOYERS'LIABILITY RY LIFIN I :R ANY PROPRIETORIPARTNER/EXECUTIVE YN/A E.L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-FA EMPLOYE' $ Ifyyes describe under DAWIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ IDESCRIPTION OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) i�nsu ion r Nine al d G g? �t a rvat ce rou NSTAR pn National dri ar add bionai insured on enf a 'y po cy. overage is rimary an on- ontr utory CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Conservation Service Group ACCORDANCE WITH THE POLICY PROVISIONS. Contractor Services Dept 50 Washington St Westborough,MA 01581 AUTHORIZED REPRESENTATIVE 46910- @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement C`oiltractor Registration Registration: 102726 Type: DBA Expiration: 7!2/2016 Tr# 252249 POLAR BEAR INSULATION CO. Vincent LeBlanc, P.O_ BOX 958 -� ANDOVER, MA 01810 - Update Address and return card.Mark reason for change. -- Address Renewal F-1 Employment Lost Card DPS•GA1 0 50M-04/04-Gt01216 t '+,lassac:�usetls -neo, a ` r;�X .��.y�l1ti.�C'?S ill i.s .'`.ia•.:i�'f_is Board of S- u;SCII. Cun,truction Snpery i%or speclnit� c rSL 106017 PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 03865 04/2812016 t