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HomeMy WebLinkAboutBuilding Permit # 1/7/2016 BUILDING PERMIT �ORTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#,. Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page .................. 1. J1,%Z 0 N I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 11 One family [I Addition [I Two or more family 11 Industrial [I Alteration No. of units: 11 Commercial [I Repair, replacement [I Assessory Bldg A Others: El Demolition El Other rp 'd n �p legro W' ' I g� e m gpm'�"�pgpa ey,p g'!�rar 11,111,1111 111111MI"'pris 11'4 P/e/'i 4,N-I "I'Sp/gp, I�// 1/121 DESCRIPTION OF WORK TO BE PERFORMED: f EAfU10101A 7-0 Ae Identification- Please Type or Print Clearly OWNER: Name: tfGee-,-q Wi't e 5 Phone: Address: -57- 211 71', >Y17 P bo,n ContractorName "I"g r, r .ter liaviii/--'Owl rr ON 11 Jr r "I....................I.I I I I I I I I I I I I........... ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3 � 00-0 0 FEE: Check No.: Receipt No.: NOTE: Persons contracting kz unregistered contractors do not have access to the guarantyfund 40 hySignature of,cghtropt ,t., � NORTt� 2 E • .•r. Andover ® _ #q T'qi $ _ ��SS yy�. ass �O LAKE ver, ASS, - •, COCNICNE WICK �� ArE t) iV U - BOARD OF HEALTH PERMI T L Food/Kitchen Septic System THIS CERTIFIES THAT ....................... BUILDING INSPECTOR ............ .. ....... ....... .... .............. .................... . .... . . ... .... has permission to erect .......................... buildings on ....1'. .......� Foundation . .. ....... .. .......................... Rough tobe occupied as ....................... ...:....... .. ... ... ....... .... . ............................................ 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final I T S ELECTRICAL INSPECTOR UNLESS CONSTRUC,,' I N T Rough Service .......... .. ............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to 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. -7 Federal ID it 05-0405629 RISE Engineei-hig Rl Contractor Registration No 8106 MA Contractor Registration No 120979 R ISE k division ofThicisch Engineering ENGINEERING* 61)Shawnitul Unit 112,Onnon.NIA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page I PROGRAM I I`RSCOUIRACT 13 ENTERED INTO BETWEEN RISE CMA-HES E?GINEETURG AND THE CUSTOMER FOR WORK AS .......... 5j, DESCRIDEOSELOW CUSTOMER ............... PHONE DATE CUERT 0 WORKORDER Rebecca Wildes (978)258-1998 10/30/2015 424670 00002 SERVICE STREET CALLING STREET 11 Camden Street I I Camden Street SERVICE CITY,STATE,7JP CALLING CITY,STATE,ZIP North Andover,MA 0 184 c'D a North Andover, MA 01845 ail JOB DESCRIPTION BARRIER:A Blower rioor'rcslILyiot bye 9,ndUc1Vxv1qour home,due to the presense orastiestos. $0.00 BARIUER:We have identified a moisture issue in your hurne that needs to hu addressed.I lonicowner is responsible for correctiru,this moisture concern,prior to the installation of any weatherization work. $0.00 BARMER:We have discovered what appears to be mold/inildew-like substance in your horne.This is being brought((I your attention to identify itasu pre-existing condition to the insulation and air scaling work planned for your home.Your signature is your acknowledgement of these conditions an(]agreement to proceed. $0,00 AIR SEALING:Provide labor and inincrials to seal areas oryour home against wasteful,excess air leakage. This work will be performed in concert with the use orspecial tools and diagnostic tests to assure that your honic will be left with healthful level Of air exchange and indoor air quality.Materials to be used to seal your home can include caulk,;,foanis and other products. Primary at"for scaling include air leaka-t:to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) This will require(6)Working hours.A reduction in cubic feet per minute(efin)or air infiltration will occur,but the actual number of cfin is not guaranteed. At the completion of the weatheri7jition work,and at no additional cost to the homeowner,a final blower door and/or combustion salcty analysis will be conducted by(lie sub-contractor to ensure the safety ortlic indoor air quality. 5510.00 ATTIC FLA*r:Provide labor and materials to install,I 10"layer Of R-35 Class I Cellulose added to(288)square feet of open attic space. $423.36 NITIC FLAT:Provide Tabor and materials to install at 14"layer of R-49 Class I Cellulose added to(144)square fiect of open attic space. $2,13.36 ATHC ACCESS:Provide labor and niaterials to insulate the back of(2)attic hatch with 2"rigid,rhernixx board.Weatherstrip the perimeter. S120MO VENTILATION:Provide labor and materials to install(2)12"X 12"alurninuin gable end attic vent. $229.00 VENTH.KnCIN:Provide labor and materials to install(3)8"diameter roof vent(s)to increase ventilation in attic areas. The vent can be supplied in(circle color)black,brown,gray or RIM finish. $256.50 VEN,rILATION:Provide labor and materials to install ventilation Chutes in(24)rafter bays to maintain air flow. $48.00 BASENIENTCEILING:Provide labor and materials to instatl()H)linear feet Of R-19 Unraced fiberglass insulation to the perinicter ortlic basement ceiling at the house sill. 5171.50 'l 71.50 Federal IQ#05.0405629 RISE Engineering Rl Contractor Registration No 8186 RISE MA Contractor Registration No 120979 A division ofThlelsch Engineering ENGINEERING 60 Shawmut Unit#2,Canton,MA 02021 CONTRACT 339-502-6335 FAX 339-502-6345 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RAH! CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENTO WORK ORDER Rebecca Wildes (978)258-1998 10/30/2015 424670 00002 SERVICE sTRETT --- BILUNG STREET ---�—� I l Camden Street l I Camden Street SERVICE CITY,STATE.ZIP Bn.UNG CITY,STATE.ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION CRAWLSPACE:Provide labor and materials to install(144)square feet of R-19 unlaced fiberglass insulation to the crawlspace ceiling to be in contact with the subfloor and completely filling the joist cavity to be[lush with the joist bottoms. Then install I" polyismyanurate foam board insulation. Seal all searns with FSK tape. $554.40 CRAWLSPACE:Provide labor and materials to install(428)square feet of 6 ml polyethylene over open ground in designated crawlspace/earthen basement areas. $329.56 CRAWLSPACE:Provide labor and materials to install (90)square feet of R-10 rigid Thermax insulation to the crawlspace perimeter wall up to the sill and against the band joist. $333.00 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 of 100'Yo for the Air Scaling measures up to the first$680 and an additional$340 if savings arejustified by the auditor. For the safety and health of your 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 full assessment of the combustion safety of your 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 Total: $3,307.68 Program Incentive: $2,600.00 Customer Total: $707.68 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS FOR THE SUM OF ***Seven Hundred Seven&I 68/100 Dollars $707.68 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.q4OMER AGREES TO REmrrmo NT our IN FULL.INTEREST OF i A WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE OPWR 30 DAYS.SEE REVERSE FOR WO!IAMORMATION ON GUARANTEES.RIGHTS OF RECISION.SCREDULINO,AND CONTRACTOR REGISTRATION. 00 SIGN THIS CONTRACT IF THERE LANK SPA S —46 816NATURE-RISE — OM - E NOTE.THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE 30 SATMACTORY TO US AND ARE HERESY ACCEPTED.YOU ARE AUTHORMW TO 00 THE WORK DAM AS SPECIFIED.PAYMENT WILL BE MADE AS ounMW ABOVE OWNER AUTHORIZATION FORM ( er'sName) .� owner of the property located at (Property 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 Date The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:But3ders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. APPHcant Information _j Please Print Leelbly Name (Business/Organization/Individual): 1/b 1,A -e rt Il` Il� 5 1114 )-/'0 M Address: City/State/Zip: ? l t If M 5 Phone#: Are you an employer?cheep the appropriate boa: Type of project(required): Larl am a employer with � _emplayees(full nod/or part-time).® 7. ❑New construction 2.01 am a sole pmprictor or-partnership and have no employees working for me in 8. O Remodeling 3.0 any capacity.[No workers'comp.in-- required.) I am a bomaramcr doing all work myself:(No workers'comp.insurance required.)t 9. 1:1 Demolition 4.[]]am a homeowner and will be hiring conctors trato conduct all work on my property- I will 1 Building addition ensure that all contractors©cher have workers'compensation insurance or are sole 1 I.E]Electrical repairs or additions proprietors with no employees 12.[:]Plumbing repairs or additions 5�1 am a general contractor and 1 have hired the sub-contractors listed on the attached shad These sub-contractus have employees and have workers comp.insuraDct 13-Roof repairs 6.E]We we 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 mquire&] *Any applicant that checks box#1 must also fill out the section blow showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such_ tContractors that check this box must attached an add'uional sheet showing the name of the sub-contracwrs.and state wbcthv or not those entities have employees. If the sub-contractors have employccs,they must provide tbeir workers'comp.policy numbs. I am an employer that as providing workers'corapensadon insurance for my employees. Below is thepo/icy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Z, Job Site Address: ( � /V�- % City/State/Zip: n- 9 r 6/4 t/-(JJ.. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 tnd/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 Jay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct ziQrtature: C ►-41 • . ,�r-_ - _ -- Date. / 7 'hone Official use only. Do not write in this area,to be completed by city or town offtciaL City or Town: Permit/License# Issuing Authority(circle one): 1_Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.- Plumbing Inspector 6-Other Contact Person: Phone#: POLABEA-01 JONEILL DATE(MM/DD/YYYY) CERTIFICATE F LIABILITY INSURANCE 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(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). CONTACT PRODUCER NAME:- -._- -- Durso&Jankowski Insurance Agency PHONE 978 688-700 ac,No 978 688-7001 11 Saunders Street ac No EXt); ) ____- — (- `� -- - - E-MAIL North Andover,MA 01845 ADDRESS;_ INSURERS)AFFORD_ING 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 INSURER D_: P 0 Box 958 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_ ADDL SUB POLICY EFF POLICY EXP LIMITS LTR I TYPE OF INSURANCE I SD D I POLICY NUMBER MM/DD MM/DD/Y I A X COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED ! CLAIMS MADE OCCUR NN538691 03/24/2015 03/24/2016 I PREMISES(Ea occurrence) $ 50000 --- MED EXP(Any one person) $ _5,000 PERSONAL&ADV INJURY i $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE !$ 2,000,000 I : � IPRO- r I GG $ LOC X-1 JECT 1,000,000 OTHER: COMBINED—SINGLE LIMIT i$ 1,000,000 AUTOMOBILE LIABILITY I (Ea accidence__- 2100926 01/04/2016 01/04/2017 _ B �;ANY AUTO BODILY INJURY(Per person) {$ -- -- ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS I PROPERTY DAMAGE $ NON-OWNED I Per accident —_ _ - - X HIRED AUTOS AUTOS $ UMBRELLA LIAB 1X I EACH OCCURRENCE $ 1,000,000 EXCESS LIAB 1 CLAIMS-MADE �AN019284 ! 03/24/2015 03/24/2016 AGGREGATE $ OCCUR iii A - DED I RETENTION$ �$ WORKERS COMPENSATION ( PER I OTH- AND EMPLOYERS'LIABILITY STATUTE ER_ _- Y/N E. ANY PROPRIETOR/PARTNER/EXECUTIVE L.EACH ACCIDENT $ ---- --- OFFICER/MEMBER EXCLUDED? N/A El (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L. ISEASE-POLICY LIMIT $ D I 1 ' 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 Thleisch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE Lll, l' ........ (rI-1000 gfliA A/lAOr1/+A00Ar2A TIAhi All r,.Mtr.r •nd 1/4/2016 Preview:Certificates of Insurance ACORO® DATE(rAMiDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 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 NA)AE: Automatic Data Processing Insurance Agency,Inc. PHONE A A1C.No.Ext): (AIC.No): M 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC p INSURER A: NorGUARD Insurance Company 31470 INSURED INSURERS: 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 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. NSRPO ICFOLICY P I LTR TYPE OF INSURANCE INSb WVD POLICY NUMBER (rA&VD0 EFNYYY) INVAIDDfYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCUfiRENCE S CLAILIS MADE ❑OCCUR , 10-riFT+TE PREF.IIBES'IEa n:.wren[^I S ANEO EXP,A--one p_s-1 PERSONAL S ADV INJURY S GENL AGGREGA l E LIM11 APPLIES PER: GENERALAGGREGATE S PL'LIL'Y IRC? LOC PRODUCIS-CCMP�CP AGG S JEGI OTHER: S AUTOMOBILE LIABILITY G'.I'IN USI CL 11:111 tE sutic li Ar:YAll IU BODILY INJURY 41, S ALLG;NEO SCHEOLLED BCDILY INJURY'Pc'a.ciCeN) S AUTOS AUIOS EC)I:"O-NED PRUPERI'I DAMAUE S HIREUAUTOS HAUICS IP-va-udrml; - S UMBRELLALIAB OCGUI EACH OCCURRENCE EXCESS LIAR CLAI.IS-IAADE AGGREGATE S DED I RETENTIONS S WORKERS COMPENSATION X < V H AND EMPLOYERS'LIABILIrY SDIIU)E ER NtY MOPRIEICF,I'ART I:EHEXECUTIlk YIN EL EACH ACCIUHIT S 1,000,000 A CFFICERI.M.IBEREXCLUUED? NIA N POWC772258 01/01/2016 01101/2017 (Mandatory in NH) EL.DISEASE EAEUPLOYEE S 1,000,000 It yes.d—be�ctl uESCRI'ncracFCPtrnnotas EL.DISEASE-FODCYUrAT S 1,000,000 LL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remsks ScMdulomay be wu0W 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 AO 1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD r wva Regdafioll er Affairs and Office of Co�asum plaza-Suite 5170 101' 02116 ®s` ou9- sacbusetls wcrat%n omrovemeut Cont�e1or Reg e Re9is"all" gd272B TYPe_ DBA 'Cr# 25 pImuon_ 7.10' XT,ON c® BEAR INSUL- POLAR _ Vincent LeBlanc ---� work P.O.BOX 95$ = reason for cilangge. At4pQVER, MA 01810 _ ` 'Upaate Address and retura� m loYM �Lost Cgrd —� Address Renewal DP�Ai is SUM�'1 01216 rd S nons al sem_CSSLAW17 ?F.TER A LEBLANC � '�LaIU�'SMET _ Plaistow I+TR 03865 _ 042812818