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HomeMy WebLinkAboutBuilding Permit # 11/10/2015 %AORTH p� IT TEED eb�R� BUILDING P o TOWN OF NORTHANDOVER APPLICATION FOR PLAN EXAMINATION _ Permit No#: Cl Date Received ��4DRATEDB�e¢`�L� SSgCHus� Date Issued: D:0 IMPORTANT: Applicant must complete all items on this page LOCATION t✓ ��°�► i L r` t Print PROPERTY OWNER `qrak /Ce 0 in Print 1 oo Year Structure yes no MAP PARCELV2 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 Others: ❑ Demolition ❑ Other �2���,/ ; �,�,�,, , , ,,,� ,, /�i���I,�/�� ��Flaod atn�� ❑,Wetland ,,,s�/� ,,�,, , a � �!, li����, �r,p Se,�tic � ❑1Nell��� ,/ �i, ,�� ,mfr. ,» , P u �,�,�„a, / �,�;,,��nrlyd, ��J , ,�a� DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: ei Cz�P? eo Phone: r� Address: 111 Pr-"6 Contractor Name: -e 6(c, mac- Phone: Email Address: Supervisor's Construction License: 1060 Exp. Date: Y Home Improvement License: Gd- Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ D FEE: $ Check No.: Receipt No.: DOTE: Persons contracts with unregistered contractors do not have access to the guaranty fund tkORT Town of Andover ® C, h- n ver, Mass, ) &%.w6w 16.M5 LAKI COCHICH@WICX S u BOARD OF HEALTH 'M Food/Kitchen PER IT LD Septic System THIS CERTIFIES THATow 6 e ........................................ BUILDING INSPECTOR has permission to erect .......................... buildings on ............... ... .. .... . . .. . . .11 .. .9..... Foundation ® Rough .. .to be occupied as ...... . .. ...sftko.. .....j ......IN1. . . . .................................. Chimney provided that the person accepting this permit s 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT11 S Rough Service ..... ....:. .. .. .::�.....J............................ 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 Lathingr Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Federal ID 9 05-0405629 E E RISugincering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A division ofThictsch Engineering CT Contractor Registration No 620120 61)ShaNvintit,Canton,NIA 02021 339-502-5197 FAX,339-502-6345 CONTRACT R I S E PROGRAM Page I ENGINEERING THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-IIES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CUEUT a WORK ORDER Smah Keogh (979)699-5533 06/24/2015 416737 00002 SERVICE STREET BILLING STREET 194 Olympic'Lane 194 Olympic'Lane SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP North Andover, MA 01845 North Andover, MA 01845 .1011 DESCRIPTION AIR SEALING:Provide labor and materials to seat areas ol'your home against wwitellut,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 scaling include air leakage to attics,basements,attached garages and other unheated areas(windows are not generallyaddressed) This Will require(8)Working hours. A reduction in cubic fieet per minute(cfm)of air Infiltration will occur,but the actual number ofeli'm is not guaranteed. At the completion of the weatherization 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 offlic indoor air quality. $690.00 AIR SEALING ADDER: (1)working hours. $3-10.00 ATI'W FLAT:Provide labor and materials to install-I T'laver ol'R-25 Class I Cellulose added to(784)square feel of floored attic space. $1,40336 DAMMING:Provide labor and materials to install a 12"layer ol'lk-39 untraced fiberglass balls to(144)square feet for damming purposes. $295.20 ATTIC FLAT:Provide Tabor and materials to install an 8"layer of R-29 Class I Cellulose added to(594)square feel of open attic space. ..1800.08 A'1'1'10ACCESS:Provide labor and materials to install(1) easily moved,insulating cover for the attic access fold in,,stair. A small flat surface ol'plywood will be create(]around the opening within the attic- This will allow the cover's integral Nkcathcr-stripping,to restrict air lcakag,c. $237.65 VFNTILATION:Provide Tabor and materials to install(2)insulated exhaust hose with roof niounted napper vent to exhaust existing bathroom Jan(s). 5237.50 VFNTII ATION:Provide labor and materials to install ventilation chutes in(66)rafter bays to maintain air flow- S 13 2.00 WSI:Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount- Currently,for cligible measures,Columbia Gas offiers 7i')N4,incentive,not to exceed$2,000 per calendar year,and;in incentive of 100%for the Air Scaling-measures III)to the first 5680 and air additional 5340 if savings arejustil-k-al by the auditor. For thesaliety and health of'your)ionic's indoor air quality,We will be conducting blower door diagnostic of the avail ablc air flow in Your home bodi before the work is begun,and afler the weatherization work is complete.We will also conduct,I full assessment orf the combustion safety of your licatinp system and water healer.This has a value ol'N90 and is at no cost to you. Total allowable weatheri-iztion incentive is 53,1 10 S90.00 Federal ID#05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A division of` hielseh Engineering CT Contractor Registration No 620120 61)ShawnHit,Canton,NIA 021)21 339-502-:1197 FAX 339-502-034-5, CONTRACT R I S E Page 2 PROGRAM ENGINEERING 7HIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENTS WORK ORDER Sarah Keozgh (9710688-5533 06/24/2015 it 10737 0 0 2) SERVICE STREET BILLING STRUT 194 Olympic Lane 194 Olympic Lane ..... SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP ...... Nortli Andover, MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $4,215.79 Program Incentive: $3,110.00 Customer Total: $1,105.79 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***One Thousand One Hundred Five& 79/100 Dollars $1,105.79 UPON FwrLVsPecTion AND APPROVAL AY RISE ENGINEERING I ME AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%VALE 86 CHARGED MONTHLY ON ANY UNPAID D"�E AFTER 3D DAYS.SEE REVERSE FOR[UPQ=-rJ.5110=11ON 014 GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. ------------------ --N—— ----,----------- DO NOT SIGN THIS CONTRACT VF THERE ARE A Y BLANK SPACES ---------- AUTHORIZED NATURE-RISE Enflin-mg CUSTOMER ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF HOT ExECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORT( AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE I \ 1 OWNER AUTHORIZATION FORM Sarah Keogh (Owner's Name) owner of the property located at 194 Olympic Lane, North Andover, MA 01845 (Property Address) 194 Olympic Lane, North Andover, MA 01845 (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. Owner's Signature.. �l'(Lly Date OP ID:SS CERT.� DATE cMbvDOnwY) IFI LIABILITY I 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 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. CONTACT PRODUCER NAME: Durso&Jankowski Ins Agcy LLC PHONE 198 Massachusetts Avenue A/C Ne No): North Andover,MA 01845 a4MEss: Durso&Jankowski Ins.Agcy. PRODUCER CUSTOMER ID e:POLAR-1 INSURER(S)AFFORDING COVERAGE NAIC C INSURED Polar Bear Insulation Co.Inc. INSURER A:Penn America 32859 P O Box 958 INSURER 0:Safety Insurance Co. 33618 Andover,MA 01810 INSURERC: INSURER D: INSURER E: 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. ITR TYPE OF INSURANCE POLICY NUMBER MMID/ YY 6PMID /OLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY PAC7052023 03/24/2015 03/2411016 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ 5100 PERSONAL&ADV INJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,00 POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO 100926 01/04/2015 01/04!2016 (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) $ X NON-OWNED AUTOS $ $ UMBRELLA LU18 X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LU16 CLAIMS MADE AGGREGATE $ A PAC6906385 03/24/2015 03/24/2016 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION INC STATU- TH- AND EMPLOYERS'LIABILITY T Y IMI E IN ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Insulation Work-Mineral;Additional In ur d for ggeneral(lability with En in is to work performed on their behai by th€above Insured is Thielsch CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Thielsch Engineering CCORDANCEION WITH THE POL CY PROVISIONSE WILL BE DELIVERED IN Columbia Gas 195 Francis Ave AUTHORIZED REPRESENTATIVE Cranston,RI 02910 46�,L ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD (AID7DD;YYYY) Cl:RWICATE OF LIAGILFFY INSURANCE DATE 12/18014 ` 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 f REPRESENTATIVE OR PRODUCER,ANDTHE CERTIFICATE HOLDER. ; IMPORTANT:if the certificate holder is an ADDITIONAL INS URED,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 notconfer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LO.IAL) NAAIE: Automatic Data Processing Insurance Agency,Inc. inc NaE<O: (A xC Nak 1 Adp Boulevard AWRE55: Roseland,NJ 07068 INSUREII S)AFFORDING COVERAGE NAIC: LvsuRER A: NorGUARD insurance Company 31470 INSURED POLAR BEAR INS ULATION CO INC INSURER B: DBA:Polar Bear Insulation CO Inc L95URER C: PO BOX 958 LVSURER D: Andover,MA 01810 INSURER E: LVSURER F: COVERAGES CERTIFICATE NUMBER: 291629 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 SUBJ ECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSMAX CLILY bXF LTR TYPE OF WS URANCE INSD I'VD POLICYNUAIBER RIALDONYYY) O.IAIDD;YYYY) LLAflTS COAUIERCIAL GENERAL UABILITY EACH OCCURRENCELw- S CL+VALS-i3AUE F-]OCCURPREtII5E5 IEa cuwterm) 5 LIED EXP[Any une peraarl S PERSONALEADVR)JUIl1' S GEnt AGGREGATE LIMIT V'PLIES PER, GENERAL AGGREGATE S POLICY. PRo- JECT F-1 LOC PRODUCTS-COAtPAP AGG s OTP.ER S AU)OMORILBLtABILnY IEa.c INLU S ANY AUTO BODILY INJURY IPe,fnnan) 5 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per xcciderti S HIfIED,YUT05 )NON4IYNEU AUrOS [Per xccidenO i 5 UASRELLALMU ECL EACHOCCURRENCE S I =All AIDE AGGREGATE DED IIETENT10N s - IVORKEnS C0AtPENSAnoN X STATUTE ERS ANDEMPLOYERS'LIABILITY Y!N 1.000,000 ANY PR OPRIE70RPARTNERExECUTIaf E1_EACHACUDSNT S A OFFICERAelEMBER EXCLUDED? Y T.IAN POWC660990 Olpl(ZO15 01,01/2016 01-dataryi"IM) EJ-DISEASE-EA EAII'LOYEE 5 1.000'000 If yes.t!xmW-du000,000 DESCRIPTION OF OPERATIONSL'etas EL.DISEASE-POUCYULIIT S 1+ DESCRIPTION OF OPEI5,TI045)LOCATIONS(VEHICLES(ACORD IOL AtUtiun9 Remaw6 Schedule,maybe atUched irmore space is requved) Columbia Gas massachuseus CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIB ED 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,RI 02910 AUTHORIZED REPRESENTATIVE l' I AV 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014p1) The ACORD name and logo are registered marks of ACORD l i =�\ The C01111nonivealt1t of Massachusetts Del)artMent of Industrial AccitlentS • + Office of Investig atiolU ivyt —• 600 fflaSllill;t0t1 Street .=`'Y= Boston, JVA 02111 `�'�-~_•��� tV1t�lU.171t1SS.y0v�t/itt 4.Z i•� Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Al2plicatit Information Please Print I,eQibh' tame (Business=0reanization/individual): PO 14r A -ea�" ��i�tr l a Address: Cit1-/State/Zip: X JOtjam r4 Phone 9: Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with'— 4- ❑ 1 am a_general contractor and I have hired the sub-contractors 6- ❑New construction employees(frill andior part-time)." . 2_❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have p S. ❑ Demolition working for me in any capacity- employees and Kaye workers` [No.workers' comp.insurance comp.insurance.'- 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3_❑ I 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_❑ Roof repairs insurance required.] c- 152. S 1(4).and the have no employees. [N0 workers' 13•[ Otiter l '9d� 11�d tfi comp,insurance required.] `Anx applicant drat checks box=t must also fill otu the section below showing their�+orkers compensation policy inronnatitm. 1 lomeou-ners.who submit this affidavit indicating dtey are doing all x ork and the»hitt outside contractors must submit a new affidavit indicating such. =Contractor.that check this box trust attached an additional sheet shotviue the name of rite sub-contractors and state whether or not those entities have entplovetrs. If the sub-contractors have employees.they must provide their workers*comp.polices number. 1 ani an employer that is providing workers'conipenstttfair instirmrce for nit'eniplgreem Belo it,is the poliri'and job site information. Insurance Company Name: (j q Ci�Q Policy':or Self-ins.Lic. 1ic--655—tgep Expiration Date: P Job Site Address: t9 q ®ki'1`�tQ/tet ` � Cih!/State/Zip: r;1 91� ,if t/i'(-- Attach a cope 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 5250-00 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 t10 hereby certif"i1r:,ler the pahis and penalties tYl;erjttt�•that the infortization prot:i led above is trite and correct. Signature•_ Date: l L/1911f Phone - O(ficial itse onh: Do itut write in this area,10 be Completed 41•city lir tarutl official Citi•or Town: Permit/License n Issuing Authority(circle one): 1. Board of Health 2. Building Department 3-City/Town Clerk 4. Electrical Inspector• 5. Plumbing inspector (. Other Contact Person: Phone�: ]ation �ffalrS a11(lWusiness Regulation Office of Consumer 10 park,Plaza- Su_ 5170 etts 02116 Boston,Massachus Registration ement Contri*ox Home Improv 102726 Re a Type: DBA Tr 252249 Bycpiration: 71212016 POLAR BEAR INSULATION CO- Vincent LeBlanc - - p.O. BOX 958 $10 rd.Mark reason for change. ANDOVER, MA 0 Update Address and return caEmployment Lost Card Address Renewal OPg CA1 a 50M4W04_a101216 9 Beard or Buri did i egaal�ti�auuw �uuu� �.w construction SIIi1C2,11,ior Spvc3.�it� LiceflsE': CSSL406017 PETER A LEBLANC 2 EAST PINE STREET Plaistow NIL 03865 �, •�- 04/2812018