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HomeMy WebLinkAboutBuilding Permit # 1/7/2016 .... _..----- BUILDING PERMIT of °%c pr 6 TO OF NORTH ANDOVER 46 APPLICATION FOR PLAN EXAMINATION � n Permit No#: Date Received gcHus���y Date Issued: MPOR'I'ANT: Applicant must complete all items on this page LOCATION ( L - Print PROPE. TYOWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shap Village yeso 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 N Others: ❑ Demolition ❑ Other m 0 v("t.�-(C,17 tJ N w 2e "W""e"fiMN Y�A� �ra i DESCRIPTION OF WORK TO BE PERFORMED: i Identification- Please Type or Print Clearly OWNER: Name: Cm i" r`�'► - e Phone: Address: / i r (� .-- Contractor Name: -r- l Y" (e:9 vtc. Phone: Email Address: w. 5'r r�0 -e 1"7 Supervisor's Construction License: / 0 6 0 1 Exp. Date: Home Improvement License: ' 6 Exp. Date: /C ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: '' Receipt No.: 2- NOTE: Persons contracting with unregistered contractors do not have access to the Wuarantyfund !„�/% Hrt,JUJ rxadr'1�A. rmr� '�u+ins tl ii 1 • � NORT�y '� '' Town ofAndover - • Lai O •w y+ f 0 ® ® y s i AOAAM 26tto rO LAKE ver, ass COCNICNE WICK �' RATE D UBOARD OF HEALTH Food/Kitchen PERMIT T LN�Nlr� Septic System Y ®� BUILDING INSPECTOR THIS CERTIFIES THAT .............. ..... .... .. .... ............................... ........................... Foundation has permission to erect ........................ buil ings on ... . ... .. ....... .. .. .. .. ............. Rough tobe occupied as ............ .. .. ... .... ...... ..W. ... ....................................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERM-ITI S IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST; S Rough Service ...................................................... ...................... 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. 90 ae Federal 10 til 060105M RISE Engineering RContractor r Registration No 1seas>� RISE A division ofThlelseh Engineering MA ENGINEERING` 60 Shawmat Volt#1,Canton,MA 02021 CONTRACT 339-502.6335 FAX 339-502.6345 Pago 1 PROGRAM MTWUN turn CMA-HRS cr baa POR W)M AS 0133CRMED 013,001 rxarroasa PHOM OATS CUM haxoc OmaR Christine Jee (978)902-0526 12/15/2015 423608 00001 omvrea arTraar _ suywu aTnear 154E Nigh Street 1 Rig 154E High Street i Rig arsrrMACq MY,aTAM ZW an.h.erO COY,STATE,res North Andover,MA 01845 North Andover,MA 01845 JOB DESCRiM'ION AIR SEALING;Provide labor and materials to seal areas ofyour home against wasteffd,excess air leakogrr.This work will be paformed in concert with the use ofspocial toots and diagnostic tests to assure that your home will be left with a healdifirl level of air exchange and indoor air quality.Materials to be used to sea]your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,bascrntntts,attached garages and other unheated muss(windows are not generally addressed.)Ibis wit require(5)working bows.A reduction in cubic feel per minute(cftn)ofair infiltration will occur,but the actual number of cfrn is not guaranteed. At Ute complotion ofthe wratrerization 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 cusum the safely of the indoor air quality. 5425.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfuced fiberglass baits to(90)square feet for damming pub. $184.50 ATTIC FLAT:Provide labor and materials to instal a 9"layer of R-32 Class I Cellulose added to(612)square feel of open attic 1+875.16 WHOLE HOUSE FAN:Provide tabor and materials to fabricate and inctail a rigid foam insulating cover for the whole house fru$ $209.21 AITIC ACCESS:Provide labor and materials to install(1)easily moved,Insulating cover for the attic access folding star. A small flat surfacc ofptywood will be created around the opening within the attic. This will allow the oov&s integral weather-stripping to restrict air leakage. 5237.65 VENTILATION:Provide tabor and materials to install(1)insulated exhaust hose with soffit mounted flapper vent to exhaust existing bathroom fim(s). $118.75 VEN UA71ON:Provide labor and materials to install vemfletion chutes in(33)rafter bays to maintain air flow. 566.00 RISE Engincering will apply all applicable,eligible incentives to this contract You will only be billed the Not amount Currently, for eligible measures,Columbia Oss offers 73%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Aix Scaling measures up to the first 5680 and an additional$340 if savings are Justited by the auditor. For the safely and health ofyour home's 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 fidl assessment of to combustion safety of your beating system and water heater.This has a value of S90 and is at no cost to you. Total allowable wenttcrization Incentive is$3,110. $90.00 i Fadomi In a otw4oaaxT► RISE Engineering R1 Contractor ftistration No 8186 6%contractor RDghtbation No 120575 RISE A division ofTidelsch Engineering ENGINEERING' 60 Shawmat Unit#2,Canton,MA 02021 CONTRACT 339-S02-6335 FAX 339-502-6345 Page 2 PROGRAM TM IS WERM INTO BEUNM ME CMA-HES JOItMR310 AM 111H COSTOWA FOR WORM AS Memo DELGw DLgnDwR PHONE DATE CUENTB WOMORDER Christine Jee (978)902-0526 12115!1015 423608 00001 SERVICE OTREIET BALM GtRITT 154E High Street I Rig 154E High Street I Rig BETCVICE CITY,STA'ITy rU+ IPLLWO CITY.$TAM IIP '.. North Andover,MA 01845 North Andover,MA 01845 ,YOB DESCRIPTION Total: $2,208.27 Program Incentive: $1,783.45 Customer Total: $422.82 WE ACRES fURM TO nMtM#SERVICES•COMPLEW IN ACCORMANCE Wt M ADM SPEaReATION9.FOR THE Sue+OF ***Four Hundred Twenty--Two&821100 Dollars $422.82 WON FTNAL TNB APPROVAL SYAMENGMLIDUNO.CUOTONSH AORM TO REMITANNI MWEIN FULL INTERIM OP MiWRLna CtUUNIEDNONntLYONANY UNPAcd t W MOM EFOR IMPORTANT INFORMATION ON GUARANTEED.R1OIfm OFRSCSSM OCREWUN%AND CONTRACTOR RECISYRATIO& 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES NOTE:TW3 CONTRACT NAY IM WITHDRAWN TTY UO IF NOT MWZUTMNATRDI DATE OF ACCEPTANCE+ ��.,,. J....�..1.�_ ._.. _......_..�_.�.__.__....._.. ACCIMANCO OF CONTRACT.THE AOOVE PRICK SPED ICATIONB AND CONDITIONS ARE 3U CAM As ISPACrrO pAT1 Us AND ARS WW.Dal BR AS COPM.YOU ARE AMORM TO DO THE WO M i �Ir i OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at (Prooft Address) (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 Data The Commonwealth oflllassachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mas&gov/dia NYorkers'Compensation Insurance Affidavit:Bul3ders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information j { Please Print Legibly Name (Business/Organization/individual):_ [/b J�Y rt tl Address: City/State/Zip: 1,,-t I X1'1 - �d/b Phone#: Are you an employer?Check the appropriate box: Type of project(required): TI Lal am a employer with TIcmployocs(fitll and/or part-time)_• 7_ D New construction 21—]1 am a sole proprietor or partnership and have no employees working for me in g_ Remodeling 3.0 any capacity_[No workers'comp.insurance required_] t 9_ ❑Demolition I am a homeowner doing all work myselL(No workers'comp.insurance required.) 4.01 am a homeowner and will be hiring contractors to conduct all work on my property_ 1 will 1 Building addition ensure that all contractors©thcr have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprictors with no employees_ S o 1 am a genaral contractor and I have hired the sub-contractors listed on the attached shed 12.E]Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurarlcc_t 13.F]Roof repairs 6.❑We aro a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other 152,§1(4),and we have no employees.(No workers'comp.insurance rcquim&j 'Any applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information_ t Homeowners who submit this affidavit indicating they arc doing alT work and then biro outside contractors must submit a new affidavit indicating such_ lCoutractors that check this box must attached an additional sheet showing the name of the subcontractors.and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic_ Expiration Date: 62111,11 Job Site Address: 16—` / I� f�l,g,� 5 ► A/*c— city/Statemp._ � Q e Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required colder MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 ind/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 lay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. t do hereby certify under the pains and penalties of perjury that the information provided above is true and correct T� iignature: ?e C et� -- Date: 'hone#: Gr k r r)7 Official use only. Do not write in this area,to be completed by city or town o&.1al City or Town: Permit/License# Issuing Authority(circle one): I_Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector 5 Plumbing Inspector 6-Other Contact Person: Phone#: POLABEA-01 JONEI LL DATDYYYY) CERTIFICATE O ®®TICIA F LIABILITY INSURNC 1/6/2016 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). CONTACT PRODUCER NAME: _ Durso&Jankowski Insurance Agency PHONE 978 688-7000 ac,No):(978)688-7001 11 Saunders Street A/c No );� ) - �(_. _._ North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE _ NAIC# INSURER A;Nautilus Insurance Co. 17370 INSURED INSURER B.Safety Insurance Company _ 33618 Polar Bear Insulation Co.Inc. _INSURER C_: Peter Leblanc&Steven Leblanc P 0 BOX 958 INSURER D: Andover,MA 01810 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. -IN—SR IADDL SUERS POLICY EFF j POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD 1 D POLICY NUMBER MM/DD MM/DDI A I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 03/24/2015 j 03/24/2016 oAI MAGES( a occurrence)cnc 50 000 CLAIMS-MADE X OCCUR NN538691 PREMISES(Ea i-$ , MED EXP(Any one person) $ _ 5,000 PERSONAL&ADV INJURY $ 1,000,000 ---A - GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 f X POLICY! JECT �LOC PRODUCTS-COMP/OP AGG $ 1,000,000 �$ - OTHER: � � - — COMBINED SINGLE LIMIT i AUTOMOBILE LIABILITY + (Ea accidence $ 1-._-. ,000,000 B J ANY AUTO01/04/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNED y SCHEDULED BODILY INJURY(Per accident);$ AUTOS '_IAUTOS NON-OWNED �ROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident)__- I $ _- J UMBRELLA LtAB' X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR cLAIMs fvIADE] I iAN019284 ; 03/24/2015 03/24/2016,gGGREGgTE $ DED I RETENTION$ i $ OTH WORKERS COMPENSATION I PER I AND EMPLOYERS'LIABILITY STATUTE ER Y/N E.L.EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE $ OFFICERIMEMBEREXCLUDED? N/A (Mandatory In NH) E.L-DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ I i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATNE i� n-1000onanAt%f%D11An....r.a...........a 1/4/2016 Preview:Certificates of Insurance CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYYY) 01/04/2016 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: PHONE tW Automatic Data Processing Insurance Agency,Inc. Arc.No.E I: 1 Adp Boulevard ADDRESS Roseland,NJ 07068 INSURER(S)AFFORDING COVERAG '. INSURER A. NorGUARD Insurance Company 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: 429703 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 REOUIREkIENT.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 INSOAUULWVD POLICY NUMBER OLIO L ICY I LIMITS (hIM`DDfYYYY) (MUIIDD1YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAtf.is MADE ❑OCCUR PREMISES IEa o¢unL'mv) S NED EXP yAn>one;,rwnl PEIISOKAL b AU'd INJURA' S GENL AGGREATE LIMIT APPLIES PER: GENERAL AGG=REGATE S '.. POLICY JEGT LOC PRODUCIS COUP;CPAGG S PH"- CTI-ER: S '. AUTOMOBILE LIABILITY CuijetNEu SI'GL if.il (Enrcnd-1) ANY All 10 BODILY INJURY 0',Irranl S ALLC"lAtED SCHEDLLED BODILY INJURY IPrr.—d-A) S AUTOS ALTOS I:U(11S EU '[V't Y Af:.G S HllteD,wros nufOs IPv sccmn,u s UMBRELLALIABOCCUR EACH OCCURRENCE EXCESS UAB HCLAIMS UADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION X AND EMPLOYERS'L(ABILITY STA TU IE Eli ft YIN i'NY Hif'fll ETORVARTNEREXECUTp:1= E EACH ACCI UENT S 1,000,006 ''.. A CFHCER1:�IJBFJ,EXCLUDEDa NIA N POWC772258 01/01/2016 01101!2017 (M-daloryin NH) EL DISEASE-EA ELIPLOYE S 1,000,600 It y—d=be-C, 1,000,000 UESCRIP TI CN OF CPLRA I IONS bc;— El DISEASE POLICY LIMIT S LL DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES(ACORO 101.Additional Remarks Sehedu(e.may be atuched 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 Theilsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE i AQ 1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD injess eT Af fe&s ai office of COusuml s��® 10 Park -Suite octan,lassachuses©211b lion P star itoestm ljome jmpxavement Contra=_-- tion. ©27x6 Registry Type DBA 712t2a 16 T 2 ►9 ExOtmUon. Tt®N CO- = pOLAR BEAR INSULA - %lincent LeBlanc P.O. BOX 958 - Wark reason for change. ANDOVER, MA 01810 : - update Address and return�Employment ❑Lost card Address Rene►vai J - : _ . ._.. OPS-GAa i 50M dt2t6 dards sly;ons and�. oT3hir35Ct3t5rt SuPt:rsi°wr Sprudaln GsSL-106017 PETER A LRBLW 2 WTPII[M STREET _ Plaistow NK 03865 0412812018 :on�rr�iss�nnei