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HomeMy WebLinkAboutBuilding Permit # 9/15/2015 BUILDING PERMIT of�o°T 6��o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION oVL _ A Permit No#: °'' Date ReceivedS ��SSacHuE��S Date Issued:W IMPOR.TA.NT:Applicant must complete all items on this page LOCATION /lam,�� "y Print PROPERTY OWNER R"`t°fAg rd I'lePi r�` t °6 '�� " i Print 100 Year Structure yes o MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No, of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg A Others: ❑ Demolition ❑ Other f k)-Po ,r iir a, / ,.,Y�,��/�!/r„�f-/ro❑„,r�rh.lI�,WfSkA�..,,,�.!H`,6e�'1rda�l��k,�b�p�r,,�'N,rt�ore(,,,.t.,.r1ci Ynl/n�/��,rt/!`�('7fo�r1w i1r✓�rfyn,E��,,i�,,!iJ��,r,�!:e e�7Hri,`t/.�,..'l,l'�,�f�//,I�/�r/i/,rr>��F/✓/%'��/�,ir,f rr////�/fi/�,�r!l�/,Di�G,ir��/o,//1,✓,/r/.�.l//,r,1 . .i.t,.�......�,// / i/�❑ FWa�,❑Wetns, o���%� ters ed Oist� ���-/, � fool, 11101111 "W6 , ;.. : . DESCRIPTION OF WORK TO BE PERFORMED: 0x7'-(`,At71f— kJa7 11 4 Cul ?"t' Identification- Please Type or Print Clearly OWNER: Name: r rLpi 4.vto Phone: 97 - p- /2° Address: 7' o v-� Contractor Name: r-� r I— Phone: Email: Address: 1-,7- "-7:1°� r; Yf t- e)g Supervisor's Construction License: C 10 Co Or Exp. Date: 'Ib1d w Home Improvement License: lo)- Exp. Date: d- a/ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � ��. �� FEE: $ 7 Check No.: ",... Receipt No.: -” NOTE: Persons contracting with unregistered contractors do not have access o th guaranty fund FORTH ' town ofE .,h' ndover ® ' . No. IL ver, Mass 195 .20 its T 0 LAKE ' ' coc"Ic Hl WICK S ll BOARD OF HEALTH Food/Kitchen rrER kv L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .................... .................. .. ..... ..... ..!'�`.... ............................. . .... ..... .. . .. . . has permission to erect ........... buildings on Foundation ............ . ® ....IV.......... ........ ... .. ....... .. .................. v,� ® P... ......... Rough to be occupied as ........ .... . . .....�.TR. ....40. .. �... . .... . . Chimney provided that the person accepting this permit shall 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 EI S IN 6 MONTHS ELECTRICAL INSPECTOR LESS C RUCTIO ARTS Rough Service ....... .... BUILDING INSPECTOR Final 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 Approved by the Building Inspector. Burner Street No. Smoke Det. tjOR7"H 41 4 E. ._ y , - doverown of0i ^KE h ver, Mass, COCMICHEWICK y1. A�RATEU /•4�`�,(5 S V BOARD OF HEALTH Food/Kitchen IIIIF— ER kv Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .......................................... ...... .............. .......... ........ ........ ................... Foundation has permission to erect............ ............. buildings on ...I . ............ d... .. ....... .. .................. ® A Rough to be occupied as ........ . . ��II ... ..... ..... ... ....40.41g .. . .... ..... Chimney provided that the person accepting this permit shall 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOARTS Rough Service ............. .... ..... .. fit................. 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 Approved by the Building Inspector. Burner Street No. Smoke Det. Federal ID If RISE Engineering RI Contractor Registration No M1 MA Contractor Registration No A division of iflelsch Is"ngineering CT Contractor Registration No 60 Shnwnmt Unit 112,Canton,MA 02021 CONTRACT T T 339-502-6335 FAX 339-502-6345 !!�� 1 Page 1 y �'."" PROGRAM II 1 y^ '" d THIS CONTRACT IS ENTERED INTO BETWEEN R13E CMA-1-IES ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING � � � '.. �• •^" DESCRIBED BELOW CUSTOMER i PHONE DATE CUSIIT9 WORKORDER Richard Ventura 201r.'i (978)580-0195 06/29/2015 401421 00003 SERVICE STREET .. BILLING STREET. 16 Moody Street G� ����°^��^ °��w 16 Moody Street SERVICE CITY,STATE,ZIP _ __. .. . _ DILUNG CITY,STATE,ZIP _.._ ... ...... _. North Andover, MA 01845 North Andover,MA 01845 3DB DESCRIPTION WALLS:Provide Tabor and materials to install blown in Class i Cellulose to(294)square 1`ect of exterior Wails through it surface drill and plug method. Plugs will be spackled and left with it rough finish.Finish sanding anti touch-up priming/painting Will be the cuslomer's responsibility.Subsequent to your payment,its in added service,RISE Engineering will return when weather penins to check for tiny voids with an infrared scanner. Any major voids that may be found will be filled at no additional cost.GARAGE"1'0 I IOUSUFRONf OF HOUSE IS VINAL SLIINGLES.HOME OWNER WILL REMOVE WHERE NEEDED! $5,13.90 WALLS:Furnish and install blown in Class I Cellulose to(1147)square feet of vinyl-sided exterior walls.Invoicing will occur upon completion of installation. Subsequent to your payment,it,;Int added service,RISE.Engineering will return when weather permits to check filr any voids with an infrared scanner. Any major voids that may be found will be filled to no additional cost.GARAGL TO HOUSFIFRONf OF HOUSE IS VINAL SHINGLES,I TOME OWNER WILL RC MOVI's`WI IERE NEEDED! $2,121.95 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 or3'ers 75%incentive,not to exceed$2,000 per calendar year,and an incentive or 100%for the Air Sealing measures Hit to the first S680and an additional.5340 if savings are juAitied by the auditor. For the safety and health of your homc"s indoorair quality,we will be conducting It blower door diagnostic of the available Sir flow in your home both before the work is begun,and after the Weatherization work is complete.We will also conduct it fill a.^ssessment of the combustion safety ofyoun cc7ting system and water heater.'this has a value of$90 and is at Ito cost to you. Totalallowable weatherizatiDn incentive is$3,110. 590.00 Total: $2,755.85 Program Incentive: $2,089.39 Customer Total: $866.46 WE AGREE HEREBY TO FURNISH SERVICES•COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF **"Six Hundred Sixty-Six&46/100 Dollars $666.46 UPON nNAL I EGTI AND AP VAL 0 RYSE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL,INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID B NGE AFTE 10 D ER • SE FOR IMPORTANT INFORMATION ON GUARAtITEES,nIGHTS OF RECISIOPJ,SCtIEDUUNG,Ar40 COPITRACTOR ttEGISTRATIOtI DO NOT SIGN THIS CONTRACT IF THERE AREA Y.13L-," PACES _-. Dsra RAcc_A E AUR SIGNATUR •RISE 00041 11nD 1d :T(IS (TRACT MAY BE WITHDRAWN BY US Ir NOT EXECUTED WITHIN DATE OF ACCEPTANCE "-" ` --- --- ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE "30DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS ouninEO ABOVE m OWNER AUTHORIZATION FORM 11 Rictka/c/ (Owner's Name) � q owner of the property located at � d., t� r..01 (ProAddress) #1-41001tee, ' (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. 4—Y/ Owh'eRure Date The Commonwealth of Massachusetts D gmrtnferrt of Industrial Accidents Office of In vestig ations Tit'r .;-; 600 Washin-ton Street Boston, MA 02111 www.nlass.gow(lia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibhv Natne (BLIS iness/Oreanizat ion/individual): PO gad- A ea )-)'10 V, 'v Address: Alig, XRO X F$778 City/State/Zip: Ad®tleIM) Phone #: S_ Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with —7 `l• ❑ 1 am a general contractor and I employees(fit(I 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 ship and have no employees These sub-contractors have 3. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.= required.] 5• ❑ We are a corporation and its 10.r_1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [\o workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]' c. 152. §1(4),and we have no employees. [No workers' Li.&Other MhS,�/� J`�a vl comp. insurance required.] Any applicant that checks box 41 nwst also fill out the section beloca shoss ine their workers'compensation policy information. I lonteowners who submit this affidavit indicating they are doine all work and then hire outride contractors must submit a new affidavit indicative 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 have employees. If the sub-contractors ha%e emptoyees.they mist pro\ide 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: 0 t-a U Q ri _ Policy#or Self-ins. Lic. #: P O UJC_ T_ C2�j $� Expiration Date:���� Job Site Address:...,/r, — d City/State/Zip: , eA. 1 C-1Kr,� 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. i do hereby certify ruiner the pains and penalties of perjury that the information provided above is live and correct. Signature: x Date: Phone ?,F V 0 Official use only. Do not write in this area, to be completer/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 -I. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: OP ID:SS DATE(MM/DWYWY) CERTIFICATE OF LIABILITY INSURANCE03/13/2015 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 endorsements. PRODUCER CONAME:NTACT Durso&Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue Alc xo we No: North Andover,MA 01845 EL Durso&Jankowski Ins.Agcy. PRODUCER us MER ID s:POLAR-1 INSURER(S)AFFORDING COVERAGE NAIC d INSURED Polar Bear Insulation Co.Inc. INSURER A.Penn America 32859 P O Box 958 INSURER s:Safety Insurance Co. 33618 Andover,MA 01810 INSURER C INSURER D: INSURER E INSURER F, COVERAGES - 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 HE 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 POUCYNUMBER MCYEFF P WMSYEXP DDUMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,0001 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY PAC7052023 03/2412015 03/24/2016 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATELIMITAPPUESPER: PRODUCTS-COMP/OPAGG $ 1,000,00 PRO POLICY LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO 2100926 01/04!2015 01/04/2016 (Ea accident) BODILY INJURY(Per person) $ ALL OWNEDAUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) S X NON-OWNEDAUTOS $ ri $ UMBRELLA UAIS X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS UAB CLAIMS-MADE AGGREGATE $ APAC6906385 03/2412015 03/24/2016 DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION WC STATU. TH- AND EMPLOYERS'LIABILITY YIN —TORY MI E ANY PROPRIETORIPARTNER/IXECUTIVE NSA E.L EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedute,if more apace is required) Insulation Work-Mineral;Additional Insu��d fot enerai(lability kl►' nsineesring ork performs on their beha f by theabove insured(s i hielsch CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Thielsch Engineering ACCORDANCE WITH HE POLICY PROVIS ONSE WILL BE DELIVERED IN Columbia Gas 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE 464;1- ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 9/14/2015 Print certificates:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCE �ju/1sQoia� 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:Ifthe certificate holder is an ADDITIONAL INSURED,the policy(ies)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 endorsement(s). PRODUCER CONTACT NAME: PHONE Automatic Data Processing Insurance Agency,Inc. N Ext): (A,c,NoI, 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIL M INSURER A: NorGUARD Insurance Company 31470 INSURED POLAR BEAR INSULATION CO INC INSURER B: DBA:Polar Bear Insulation CO Inc INSURER C: PO BOX 958 INSURER D: Andover,MA 01810 INSURER E: ELIJ INSURER F: COVERAGES CERTIFICATE NUMBER: 291629 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 AUDI. LTR TYPE OF INSURANCE INSDSUHH POLICY EFF POLILY EXP WVD POLICYNUMBER (MM)DDXYYY) (MM,OD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE FlOCCUR PREMISES(Ea occurence) S MED EXP(My one Pers..) S PERSONAL&ADV INJ URY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AG GREGATE S POLICY PRO- F)ECT LOC PRODUCTS-COMP,OP AGG S OTHER: S AUTOMOBILE LIABILITY CO BIKED SINGLE LIMIT S ANY AUTO BODILY INJ URY(Per Person) S ALLOWNED SCHEDULED BODILY INJURY(Per acciderd) 5 AUTOS AUTOS HIRED AUTOS AUTOSSWNED PROPEKl(Per acridenU S S UMBRELLALIATT OCCUR EACH OCCURRENCE S EXCESS LT. CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION X1 PER y/N STATUTE ER ANY PROPRIETORrPARTNER,EXECUTM E.L.EACH ACCIDENT S 11000,000 A OFFICERAEMBEREXCLUDED? N/A N POWC660990 01)01/2015 01)01J2016 (Mandatory in NH) E.L.DLSEASE-EA EMPLOYEE S 1+0, 0 If yes,desuibeorder DESCRIPTION OF OPERATIONS Wow E.L.DISEASE-POLICY LIMIT S 1,0001040 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 10L Additional Remarks Schedule,maybe attached if more space Is required) Columbia Gas massachusetts CERTIFICATE HOLDER CANCELLATION SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,R102910 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014,01) The ACORD name and logo are registered marks ofACORD https://adpia.adp.com/icertcf/#/run/printcerts/283910 1/1 } JCS - y usiness Regulation office of Consumer Affairs Suite 5170 0 10 Park Plaza $oston,Massachusetts 02116 Iin ent Contractor Registration Ome l�rovemRegistration- 102726 Type: DBA Tro 252249 Expiration. 7/2/2016 POLAR BEAR INSULATION CO. — Vincent LeBianc P.O. BOX 958 ----- ------- n MA 0 18 10 Lost Card Update Address and return card. �,�pym nt n for change ( Address Renewal J DPS4kl ca RM-04104-G101216 i ssach ovArd of �3r��w��ng Re a�G¢ e�acws „ u°q ac on7G^at'G ucti-1 SuperI mama'SPeCiscit) kc7.4"n se: CSSL-106017 ' PETER A LEBLANC 2 EAST PME STREET _ Plaistow IVH 03865 (prat t cue 04/28/2018 c°xut��rb6�wx�cadcw.��