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HomeMy WebLinkAboutBuilding Permit # 5/6/2015 V%oRTfj BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 41— Permit No#: Date Received Ar C �SsvcwUS``� Date Issued: i4 IMPORTANT:Applicant must complete all items on this page LOCATION 1r, IVA-, 5 >- Print PROPERTY OWNER a dhePL-y Print 100 Year Structure yes no MAP PARCEL:'62- ZONING DISTRICT: Historic District y s no Machine Shop Village y no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building D One family Li Addition 11 Two or more family Li Industrial 11 Alteration No. of units: 0 Commercial 11 Repair, replacement El Assessory Bldg Others: 11 Demolition 0 Other FV h", V q;0 DESCRIPTION OF WORK TO BE PERFORMED: C Identification- Please Type or Print Clearly OWNER: Name: �2l PJ-L,0A-,5 Phone: Address: ...33 Contractor Name: d (,I P%-c Phone: f,>F-Lf Email: Address: Z T;,Ll r- Y-r Supervisor's Construction License: 10 G a1,;;1' Exp. Date: 4 Home Improvement License: IDA 7OLC Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Lf FEE: $- 5,� Check No.: (0 17, Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund e "'o /o, � QT Town of Andover cn h ver, Mass,I �Q O LAKE COCKICHEWICK p°'ATIE S U BOARD OF HEALTH LD E R rd P IT T Food/Kitchen Septic System THIS CERTIFIES THAT N BUILDING INSPECTOR ............ ................a... ...... �................................................. .............................. Foundation has permission to erect .......................... buildings on ... ... ............®. �. �r ® c 1 Rough tobe occupied as ....... .. ..... ...... ...`.... ......... ......... '` ' .......................................... Chimney provided that the person accepting this permi 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 PERMITIN6 MON HS INSPECTOR UNLESS eTI RTSS Rough Service ............... .:............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises - ®o Not Remove Final No Lathing or all ToBe ®one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. < Federal to# [USE Engineering RI Contractor Restaitualtion No MA Contractor Roglatrallon No A division ofThtthch Engineering CT Contractair Roglistration No 60 Showmat Unit#2.Canton,MA 02021 CONTRACT 339402-6335 FAX 339-502-6345 Pago I PROGRAMENTERED BETWEEN FU TO BETWEEN CMA-HES ZMEM"Cil THE CUSTOMER FOR WORK AS DESOUMUSAW Jason Stephens (978)9944707 03/18/2015 400157 00004 --uwiw 33 Pilgrim Street 33 Pilgrim Street North Andover,MA 01845 North Andover,MA 01945 JOB DESCRtMON BARRIER:A Blower Door Test will not be conducted at your home,due to the presew of asbestos. PHASE ONE-Proposal for this calendar year. $0.00 AIR SEALING:Provide laborand materials to seal areas ofyour home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seat your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached proges and other unheated areas(windows are not generally addressed.)(8)working hours. At the completion ofthe weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion solely analysis will be conducted by the subcontractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING:Provide labor and materials to seal areas ofyour home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be ieft with a healthful level or air exchange and indoor air quality.Materials to be used to seal your home can include caulks,roams and other products. Primary areas far sealing include air leakage to attics,basemcnts,attached garages and other unheated areas(windows are not generally addressed.) (4)working hours. At the completion of the weallicrization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $340.00 AIR SEALING ADDER: (4)working hours. $340.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass burns to(30)square feet for damming purposes. $61.50 ATTIC FLAT:Provide labor and materials to install a I V layer of R-38 Class I Cellulose added to(600)square feet of open attic spa=. $906.00 SLOPES:Provide labor and materials to install a 7"layer of R-25 Class I Cellulose added to(16)square feet of slope area.Wherever possible baffles will be installed to the entire length ofeach bay to maintain ventilation space, $30.08 KNCCWALLS:Provide labor and materials to install i"FSK faced semi-rigid fiberglass or similar rigid board insulation to(280) square feet of kneewull area. $798.00 ForlarallID0 RISE Engineering In contractor Registration No MA Contractor Registration No A division of"rbletscli Engineering CT Contructor Registration No 60 Shawmut Unit 02,Canton,MA 02021 CONTRACT 339-50I-6335 FAX 339-502-6345 Pago 2 PROGRAM T"count"It to EWERW We BETWEEN man CMA-HES ENOtMAM AM VCE CUSTOW"RWWORX AS DEGMED snow MURE DATE NTI Womr?"Wo- Jason Stephens (978)994-4707 03/18/2015 400157 00004 -Invie"f9ref- 33 Pilgrim Shut 33 Pilgrim Street STAM-W North Andover,MA 01845 North Andover,MA 01845 JOB DESCRWTION STORAGE BARRIER:Homeowner is responsible for the removal of the stored item blocking the installation or weatherization work in the kneewall areas. Removal must occur prior to the scheduled work start. $0.00 KNEEWALL FLOOR:Provide laborand materials to install an 8"layer oftlense packed R-30 Class I Cellulose added to(360) square feet ofkneewall floor. $648.00 ATTIC ACCESS:provide labor and materials to insulate the back of(2)attic hatch with 2"rigid Thermax board,Weatherstrip the perimeter. $120.00 AMC ACCESS:Provide labor and materials to insulate the back of the attic door with 2'rigid Thernm board and seat the door's edge with weatherstripping,to restrict air leakage. $73.91 ATTIC ACCESS:Provide labor and materials to make(2) temporary access to an attic area. The opening will be closed with materials similar to those Existing. Finish sanding and painting is not Included. $170.00 VENTILATION:Provide labor aad materials to install ventilation chutes in(30)rafter boys to maintain air flow. $60.00 RISE Engineering will apply all applicable,eligible incentives to this contract You will only be billed the Net amount Currently, for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive or 100%for the Air Sealing measures up to the first$690 and an additional$340 if savings are justified by the auditor. For the safety and health of your homes indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of the combustion safety ofyour heating system and water heater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 Federal ID# RISE Engineering RI Contractor Registration No MA Contractor Registration No A division of'rhietsch EIngiuming CT Contractor Registration No 60 Shownuit Unit 112,Canton,NIA 02021 CONTRACT 339.502-6335 FAX 339-502-6345 Page 3 PROGRAM 11115 CONTRACT IS ENTERED INTO BETWEEN RISE CNIA-HES ENGINEERING AND THE CUSTOMER FORWORK AS DESCRIBED BELOW Mon DATE CLIENtO WORKDRDER Jason Stephens (978)994-4707 03/18/2015 400157 00004 SERVICE STREET UIW14G STREET 33 Pilgrim Street 33 Pilgrim Street ZIP MrOM CITY.SIATF,ZW North Andover,MA 01845 North Andover,MA 0 184 5 JOB DESCR Total: $4,317.49 Program Incentive: $3,110,00 Customer Total: $1,207.49 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUIA OF ***One Thousand Two Hundred Seven&49/100 Dollars $1,207.49 UPON FINAL INSPECTION AGO APPROVAL BY RISE ENGWEEIIING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTERM OF 1%WILL 13E CHARGED MONTHLY ON Any UNPAID DALANCEAFTEn 30 DAM SEE REV55�E FOR IMPORTANT 1ITFORMA710N ON GUARANTEES,RiOtiTSOFREC410ti.SCIfEDUU14O.AtM CONTRACTORAMStRATION, A DO NOT Bill THIS CONTRACT E ANY BLANK SPACES .x,.0 PIDTV.:TlltSCOtilftACTIJAYUEWITIIDFIAWt4tiYUSIFf T EXECUTED WITION DATE OFACCEPTANCE ACCEPTANCE OF CONTRACT-111E ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORVED 70 00 THE WORK ASSPe 30 DAYS. AS PAYMENT WILL HE MADE AS OUTLINED ABOVE NN ................................... ...........�� J i 1 e i 3 i i i OWNER AUTHORIZATION FORM ' f Jay Stephens ; (Owner's Name) owner of the property located at 33 Pilgrim Street (Property Address) ;Se North Andover, MA 01845 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building I' i permit and to perform worts on my property. 16hcus W20,2015 Owner's Signature 03/20/2015 Date Signature: ,n�2015) Email: rgiven@thielsch.com \ The Common ivealth of PlIassachasetts Depru•tment of In(histrial Accidents Office of Investigations 600 Washington Street = = Boston, MA 02111 L tvivlv.inass.gOvAlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/indi\'idual): _ �0 14z(— A ect(` T^5 d 1Q r '0!n e'tl y�_ Address:. �_ ®)t if City/State/Zip: dother4p 01,F10 Phone #: S'°` Are you an employer?Check the appropriate box: Type of project(required): 1.LO,1 am a employer with—_ 4• ❑ I am a general contractor and I employees(fitll and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached_sheet. 7. ❑ Remodeling These sttb-contractors have ship and have no employees 8. E] Demolition working for me in any capacity. employees and have workers' g ❑ Building addition [No 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 l.❑ Plumbing repairs or additions myself [\o workers' comp. right ofexemption per MGL i2.❑ Roof repairs insurance required.]' c. 152. §l(4).and we have no employees. [No workers' 13.&Other r 54/4741 h comp. insurance required.] Am applicant that checks box=1 must also till otit the section below showing their%vorkers'compensation policy information. I lomeowners who submit this affidavit indicating then arc doing all w ork and then]tire outside contractors must submit a next•affidavit indicating such. =Contractors that check this box must attached an additional sheet shoeing the name of the sub-contractors and state whether or not those entities I-mve enip1mees. if the sub-contractors have eniplovees.they must provide their Nvorkers'comp.policy number. 1 at»tttt ettiplot,er tliat is providing workers'coiirpensatiotr itistirance for n{i'enrpki�ces. Below is the police•and job site information. Insurance Company Name:_ Policy#or Self-ins. Lie. #: 0 We_ (,CP & ST Expiration Date:�� I� 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. I52 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. I do hereby certifj,antler the pains and penalties of peritny that the infot•nurtiott provided above is true and correct. Signature: Date: Phone`�: " V a >- ? Official itse onlr. Do not►vrite in this area,to be completed Gr city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. Citi•/Toscn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: .�CDA �CERTIFICATE F LIABILITY INSURANCE 0412812016 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 NOAME:CT Automatic Data Processing Insurance Agency,Inc. aCC r o E:t: A C 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 INSURERC: 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 Sp POLICYNUMBER MWDDI F MMIUD P LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE111 $ CLAIMS-MADE F—I OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $ POLICY❑JECTPRO- �LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY C 0 MBNE S E IT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NPROPERTY DAMAGE $ AUTOS D Peraccident HIRED AUTOS A70S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLWB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION XP R T - AND EMPLOYERS'LUIBILITY YIN STATUTE I ER A ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA N POWC660990 01/01/2015 01/01/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If ges,describe under 1 000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached tr 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 A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD OP ID:SS CERTIFICATE OF.�C DATE(N1M/DINYYYY) LIABILITY INSURANCE 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 poilcy(les)must be endorsed. If SUBROGATION IS WANED,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 endorsements. PRODUCER CONTACT Durso&Jankowski Ins Agcy LLC 198 Massachusetts Avenue PHONE FAx No: North Andover,MA 01845 E-MAIL Durso&Jankowski Ins.Agcy. ADDRESS: CUSTOMERID#:POLAR-1 INSURERS AFFORDING COVERAGE NAIL 9 INSURED Polar Bear insulation Co.Inc. MUMMA:Penn America 32859 P O Box 958 INsuRER a:Safety insurance Co. 33618 Andover,MA 01810 INSURER c INSURER D; INSURERF, INSURER 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. LTR TYPEOFINSURANCE POLICYNUMBER EPF POLICY EXP Llwrs GENERAL UABILITY EACH OCCURRENCE $ 1,000,0001 A X COMMERCIAL GENERAL LIABILITY PAC7052023 03242015 03242016 PREMISES a 0=0009) $ 50,0 CLAIMS-MADE I OCCUR MED EXP(Any one person) $ 5.00 PERSONAL&ADV INJURY $ 1,000, GENERAL AGGREGATE $ 2,000, GERL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 1,000,00 POLICY I I PRO LOC $ AUTOMOBILE UA131U Y COMBINED SINGLE LIMIT $ 11000100 B ANY AUTO 100926 01/04/2015 01/042016 BODILY INJURY(Per person) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY(PeraocideM) i PROPERTY DAMAGE $ X HIREDAUTOS (PER ACCIDENT) X NON-OWNED AUTOS E s UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESSLUIB CLAIMS-MADE AGGREGATE $ A PAC6906385 0324!2015 03/24/2016 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONYVC STATU- OT_H- AND EMPLOYERS'LIABILITYYIN T ANY PROPRIETOR/PARTNER/EXECUTIVE[-- E.L.EACH ACCIDENT t OFFICERIMEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,desalt under DESCRIPTION OF OPERATIONS belm EL.OISEASE-POUCYLIMIT $ DESCRIPTION OF OPERA NS/eI ONIEHICLES(Attach yCORD101,AddlUanWRemaaS~ule,Um spaaterowhod Insula Wlr�a�bt � omelsl s thevftieischc pntnkPertardoilliability_ Is ThLpnsrneer ng CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DATEEOF, NO Thielsch Engineering ACCORDANCE EXPIRATIONWITH THE OLLIICY ROPROVIS DNS E WILL BE DELIVERED IN Columbia Gas 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE 466,1- ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 0/ usrness regulation Office of Consumer affairs and 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Registration Home Improvement Contractor RegLs Registration: 102726 Type: DBA Tr# 252249 Expiration: 7/2/2016 POLAR BEAR INSULATION CO- — Vincent LeBlanc P.O. BOX 958 i _____ ANDOVER, MA 01810 - Update Address and return card.a k re s n�rL4 t Card raptoym',Ii Address Renewal :3 DPS-CAI as 50M-04104-ti101216 sacdiusett� -[ e) p:-trneai� cad D afi,�Ga�a roia � 71 mg m,,i CJcen e: CSSL.;106017 a PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 0380 ✓l J 04/28/2018