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HomeMy WebLinkAboutBuilding Permit # 5/6/2015 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ArEP gSSMC Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION *4 n u' ) r orf' e­ Print PROPERTY OWNER Ar e 5-4 t�zln r V) Print 100 Year Structure yeso n r' MAP 12-7/—.-.� PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building [I One family [I Addition [I Two or more family [I Industrial 11 Alteration No. of units: 11 Commercial [I Repair, replacement El Assessory Bldg El Others: El Demolition El Other — i&l` —,— IV,'-r�pep, iJi 4 10 W., 111 11,1`04"a I'll 01, 11,SIR- DESCRIPTIONIll).l,lr�finJ!nus;nuD (%�.ill�l s rti�»�''�lI!�,�LI,�9,/�J)'e�r1/f(idd',f./ ff»m,JI,.�,(�,,'iJ/i)��ri/c,i.,��r.:i,:/,G!,if,f/1t�%r i11 i�,1�;�;,, OF WORK TO BE PERFORMED: C 5�0 4 (f no 64 e re 4A'y1Q 4-) 11, Identification- Xlease Type or Print Clearly OWNER: Name: n r C e 57 k A/PK Phone: Address: Av day-,"I-- Contractor Name: Pe 'L ta-v%-c Phone: -?C3 A Email: Address: e-qi,-r- X vue I' rn-r 0 Supervisor's Construction License: lo G qt 2 Exp. Date: '!1",2! Home Improvement License: 10--- 21-(g Exp. Date: 2 44 .0d ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINGPERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 33? 0-0 FEE: `1 Check No.: G., '2-) Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the'guaranty fund t%ORTH Ilk V X Uwnnd "� - E. ...'.., ® - " 0% Air' 0 No. z _V ver, MassQVA, ® LAKE �• COC NIC Nf WICK � U BOARD OF HEALTH PEKMIT Food/Kitchen Septic System M .. . . .. BUILDING INSPECTOR THIS CERTIFIES THAT ........... ....Al! ........... .......... ®. ............ ............�....... • Foundation has permission to erect.......................... buildings on ... ................. . ... 4.................................... Rough tobe occupied as .......... ...... .. k... ......... ...... .................................................................. chimney provided that the person accepting this permit sha 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT ELECTRICAL INSPECTOR Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® OccupV Building Rough Display in a Conspicuous Place on the Premises — Do Not Rem ove Final No Lathing or all oBe one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. AIr CONTRACT FOR Conner atlon 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 lesh Amin Ni NConservation Services Group(CSG) 20 Anvil Cir North Andover,MA 01845-3366 Attn:RCS 50 Washington Street, Suite 3000 Site ID:S00002274584 Westborough,MA 01581 Project ID:P00000280369 Reg. No. 173484 Customer ID:C00000284680 Contract ID:20141208_WORK Federal Ile 22 act to a 0 (Mail completeedd 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 reconunendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location 66 N/A $122.64_ Attic Floor Open Blow Cellulose 4" -- _- 1,218 Living Space _ J $1,632..12^ Dense Pack 12"Cellulose In Garage Calling__ _,—,-, , 484 Living Space $1,616.56____ _ Sub Total: $3.371.32 Utility Incentive Share $2,000.00 Customer Contribution $1,371.32 C"]f`D 0 � For office use only Printed:12/6!2014 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows;Payment Nl:s 457.10 as a Deposit payable to CSG upon signing the Contract(not toe��je�y ll3 of the total retail costs).Mall check&contract to CSG,Attn:RCS,60 Washington St.,Ste. 3000,Westborough,MA 01681.Ftinal Payment:$ 91 .L as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisfac °,{�(VQ pletion of the Work.Customer understands that helshe will not be required to pay the Utility Incentive Share of the Contract price in the amount of s 2v V V•�� Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Ili. DISPUTE RESOLUTION The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contact,the I10 may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Afraus and 13asinescs Regulation and Customer shall be required to subn-dt to such arbitration as provided in M.G.L c 142& 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 busin7�� the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. j 9n� �1 � ��� C�,r4,=7}�LX7L-tr:JCustomer SignatureDate Indicate your selected IIC here,if applicable (OR) initial here if you want teye2�eC& 12/8/14 Steven Peccithe Program to assign a CSG Signature Date Name of CSCT Representative(Printed) I'suticipaling Contactor TERMS AND CONDITIONS APPEAR ON THE REVERSE. 3114 save PARTICIPATING lo—Hass CONTRACTOR Sddiri�s thrcki�ii r-net�y.-<{fx:i,:rn::y PERMIT AUTHORIZATION FORM 1, Nilesh Amin ,owner of the property located at: (Owner's Name,printed) 20 Anvil Cir 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 Owner's Signature Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: L -T Participating Contractor Date I For Office Use Only Rev. 12132011 rThey Conttnonit ealth of Massachusetts ._ Department of Industrial Accidents ... `'r= Off ce of In vestig,ations 600 Waslrin;ton Street Boston, MA 02111 _- ►vtviv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PO int' A ec, �ry\$d JA)YO n X)n�C Address: P-1 ig- A O X f4c City/State/Zip: do M Phone #: 7�- (,- ala S'— Are you an employer?Check the appropriate box: Type of project(required): 1. ,46 Type am a employer with_-_ 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑'Ne�+ construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling shipand have no employees These sub-contractors have P 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [\o workers' comp.insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [\o workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152. 51(4),and we have no employees. [No workers' 13.[�Other comp. insurance required.] °Am applicant that checks box=1 must also till out the section below showing their workers'compensation polies information. I lonteowners who submit this affidavit indicating the\-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 wheiher or not those entities have emplo\ecs. If the sub-contractors have employees.tbe\ must provide their workers'comp.polio number. 1 torr art emplgt,er that is providing workers'compensation insurance for rpt'ernplgl�ees. Below is the policy and joh site information. Insurance Coin pany'Name:_/Ao na U 4(`p� Police#or Self-ins. Lic.#: %D® U1G S—.1—/!jd& 5 Expiration Date:�� �6 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 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. do hereby certij•miler the pains and penalties of perjurl•that the information provided above is true and correct. Signature: Date: Phone-: C17�" Ua >- O. ficial use onr. Do not write in this area,to be completed 41•citr or town ofrcirrl. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Toren Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: AR ® CERTIFICATE LIABILITY INSURANCE DATE(oal2812016a/ao15 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 A DITIONAL INSURED,the policy(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Automatic Data Processing Insurance Agency,Inc. AICNNo Ext): At No): IL 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER: 338194 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDI EFF MPOWD P LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE D OCCUR PREMISES IEa occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JEa LOC PRODUCTS $ POLICY❑ OTHER: $ AUTOMOBILE LIABILITY Ea COMBINED SINGLE N E M $ ANY AUTO BODILY INJURY(Per penton) $ AALED SCHEDULED BODILY INJURY(Per accident) $ S AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER AND EMPLOYERS LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBER EXCLUDED? rY N/A N POWC660990 01/01/2015 01/01/2016 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICE GROUPS ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET Westborough,MA 01581 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD AC40RDO CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) iIo.� r 044/28/212812015 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(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency,Inc. A/C No, o Ext):NE ac No): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 338194 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ADDLISUM POLICY EFF MM/DDfYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE D OCCUR RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ]PRO JECT F—]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? N/A N POWC660990 01/01/2015 01/01/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICE GROUPS ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET Westborough,MA 01581 AUTHORIZED REPRESENTATIVE �')'t 7)IL'_ A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD lation Office of Consumer Affairs and VUSiness IZegu 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home improvement Contractor Registration Registration: 102726 Type: DBA Tc# 252249 Expiration: 7/2/2016 POLAR BEAR INSULATION CO Vincent LeBlanc P.O. BOX 958 _ ANDOVER, MA 01810 - Mark change update Address and return E ployment n[JrLost Card Address Renewal OPS.CA1 C, 5OM44104-G101216 afety Board of Buhcfing RegWafioms sand St aar Lauds Cuataatt-aaa`thm aspen isor pudaiam License: C SSL-106017 PETER A LEBWC 2 EAST PINE STREET Plaistow NH 03865 o,. kxC�kaau Aaaat e:a�o�t�a�u�aa:�na�taa,u 04/28/2018