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HomeMy WebLinkAboutBuilding Permit #512-13 - 100 GREAT POND ROAD 1/15/2013 AORTFI , ♦ p`t��ao �a'q.{rp BUILDN P9R' MIT TOWN OF NORTH ANDOVER o /� APPLICATION FOR PLAN EXAMINAT IO Permit NO: / Date Received 1I 1 117 / I q�AAToD— Date Issued: I 7 �SSA`""5�s IMPORTANT:Applicant must complete all items on this pae LOCATION 1610 arra/-Af d woad Pont PROPERTY OWNER ✓�� .fir Aro Print MAPNO:0qkP PARCEL ZONING DISTRICT: Historic District yes no M h Vil achene S op i lage ye 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 iii Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer 1 Identification Please Type or Print Clearly) / �or OWNER: Name: ✓��O � �« � Phone: 9-7B &b-7-0,5-60 Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction Licensee,O�►Si9 Exp. Date: Home Improvement License: 1 ,?^? Exp. Date: 70 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: $ -�/00 FEE: $ 3& Check No.: lo 230- Receipt No.: 2iop� NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund ignature of Agent/Owner Signature of contractor //3 �,�/ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tob ❑ acco Sales Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW'Than Engineer: Signature: Located 384 Os ood Street FIRE DEPARTfil ENT %Temp Dumpster on siteyes_ ..,no .Located at'124{Mai Street Fire. Department signatureldate 1 COMMENTS , . i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$10041000 fine I NOTES and DATA—(For department use B Notified for pickup - Date it Doc.Building Permit Revised 2010 t Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i i Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ti ❑ Mass check Energy Compliance Report (If Applicable) ' ❑ Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) { o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign offrom Fire Department prior to issuance of Bldg Permit � In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Location Ito No. Date o • - TOWN OF NORTH ANDOVER e Certificate of Occupancy $ Building/Frame Permit Fee $ r Foundation Permit Fee $ {` 4, Other Permit Fee TOTAL $ Check �I 26088 Building Inspector NORTH T* oven o E : �, 6 ndover O - 0 No. h ver, Mass G� . O �} p I COC"ICMJWICK y�• A�R�TE o S V BOARD OF HEALTH Food/Kitchen PERM ..IT T D Septic System • THIS CERTIFIES THAT BUILDING INSPECTOR 1 � � .Tm Foundation has permission to ereAahxi�w .......... ..... buildings on .. ..... ... ..... .... ............ • Rough • YS SPA. I.rj AWL..to be occupied as ...... .......3^s...... .. . .... .. ..... . . ... .............. 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 CONSTRUCTIO ARTS Rough Service .................�s....: ......... ........... .................... Final BUILDING INSPECTOR r GAS INSPECTOR Occupancy Permit Required 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. SEE REVERSE SIDE �+� ® DATE(MM/DD/YYYY) A�oRO CERTIFICATE OF LIABILITY INSURANCE 03/30/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 0 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 w certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: . m � Aon Risk Services Central, Inc. PHONE (g66) 283-7122 FAX (847) 953-5390 `y Chicago IL office (AIC.No.Ext): ac.No.: .o 200 East Randolph E-MAIL 0 Chicago IL 60601 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Zurich American Ins CO 16535 TruGreen Limited Partnership INSURERB: American Zurich Ins CO 40142 860 Ridge Lake Boulevard Memphis TN 38120-9434 USA INSURER C: INSURER D: INSURER E: INSURER F: - COVERAGES CERTIFICATE NUMBER:570045720663 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIPOLICY EFF DDIYYYY CY EXIP LIMBS A GENERAL LIABILITY G LO EACH OCCURRENCE $3,000,006' X COMMERCIAL GENERAL LIABILITY DAMAGE $1,000,000 PREMISES Ea occunence CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) $10,000 X Pesticide or Herbicide Applicator Cov PERSONAL&ADV INJURY $3,000,000 X Contractual Liability GENERAL AGGREGATE $5,000,000 N GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG Included Lo X POLICY PRO LOC A AUTOMOBILE LIABILITY BAP 2938657-05 011011701-2 01/01/2015 COMBINED SINGLE LIMIT u) Ea accident) $5,000,000 X ANY AUTO BODILY INJURY(Per person) 2 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) tV X HIRED AUTOSX NON-OWNED PROPERTY DAMAGE V AUTOS Per accident t d UMBRELLA LIAB OCCUR EACH OCCURRENCE L) EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND WC293865405 01/01/2012 01/01/2015 X WCSTATU- OTH- EMPLOYERS'LUIBILITY YIN AOS TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMB EXCLUDED? NIA WC293865505 01/01/2012 01/01/2015 (Mandatory in NH) WI E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) - Additional Information *The named insured includes (but is not limited to): TruGreen Limited Partnership dba Barefoot Grass FEIN #36-3734669 AN TruGreen Limited Partnership dba EPM Lawn Care FEIN #36-3734669 -5:4 TruGreen Limited Partnership dba AgroLawn FEIN #36-3734669 TruGreen Limited Partnership dba Bay Country FEIN #36-3734669 �J R5 L� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TruGreen Limited Partnership AUTHORIZED REPRESENTATIVE 860 Ridge Lake Boulevard Memphis TN 38120 USA ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD n-:nris ~,: ;c:go are registered marks of ACORD r AGENCY CUSTOMER ID: 570000023893 LOC#: ACORD ADDITIONAL REMARKS SCHEDULE Page 1 of 1 //''�� AGENCY NAMEDINSURED OAon Risk services central, Inc. TruGreen Limited Partnership POLICY NUMBER See Certificate Number: 570045720663 CARRIER NAIC CODE See certificate Number: 570045720663 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Additional Description of Operations/Locations/Vehicles: TruGreen Limited Partnership dba safeguard Pest Control FEIN #36-3734669 TruGreen Limited Partnership dba TruGreen Chemlawn FEIN #36-3734669 TruGreen Limited Partnership dba Heritage Lawns FEIN #36-3734669 Additional Insured applies to the General Liability and Automobile Liability policies if required by written contract. waiver of Subrogation applies to the General Liability, Automobile Liability and workers Compensation policies if required by written contract. Any party with which the named insured is contractually required to include as additional insured, loss payee or mortgagee, is automatically granted such status; mortgagees of property leased by the named insured are also automatically granted such status where required. However, coverage under the policy only applies to the extent of the coverage required by such contractual requirement and for the limits of liability specified in such contractual requirement, but in no event for insurance not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the policy. ACORD 101 (2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: =173270 Type: Expiration: 9%20[2014 LLP iTIRREEN LIMITED-PARTNERSHIPIP ERIC MARINO 32 BRIARWOOD DW.' SALEM,NH 03079 Undersecretary r 7 �t . r F k Mr— A ri,,,J0, �,i;t "ll, E, 71�k sa s U, �Ilil J, NU M Yh. ' '°? RU, 40, zy t &..e: f' I'n --A4 Zo».. - — ,yr- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip:&0 II OV , OlF,VTPhone#: 97 ��� —7. . Are you an employer?Check the appropriate box: Type of project(required): I.R9 I am a employer with�� 4. ❑ I am a general contractor and I 6. ❑New construction employees(full andlor part-time).* have hired the sub-contractors 2.[] m I aa sole proprietor or partner- listed on the attached sheet.t E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, 9. ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its 10.❑Electrical repairs or additions required] officers have exercised their 3.❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other C!/t�J� �® comp.insurance required.] "Any applicant that checks box til must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: `'� � ��®z 93 RD-&05 Expiration Date: Policy#or Self-ins.Lic.#: xp Job Site Address: I00 6/W1_An7Qt A0101 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.152 can lead to the imposition of criminal penalties of a fine up to$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$250.00 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 under the pains and penalties of perjury that the information provided abov is true and correct Si nature: Date: Phone#: ° Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: o TISI EEAr. Insulation Service Agreement INSULATION SERVICE TruGreen.com 1-855-207-5223 Customer Name: ll�U >. (j j:( [' _ E-mail: klb ) ——e Address: eftT City: t State: 1 a County: ZIP Code: o ns Billing Address: City: State: County: ZIP Code: Home Phone: ` O CJk.7ork Phone: Cell Phone: O YES; I am interested in your insulation service but not ready to purchase today.You have my permission to call me at any of the above numbers at a later date to discuss further. Customer's Signature Date TruGreen Rep's Name Date TruGreen Insulation Service: Date of Installation: v( (or as otherwise agreed) TruGreen will install insulation in accessible open/uncovered desi nated spaces(Service Areas)of Property as described below. Total Sq. Existing Insulation Avg.Depth R-Value Current R-Value Final Cellulose TOTAL Footage (Inches) Inch R-Value Added R-Value Inches Applied Sm Fiberglass Loose-Fill 2.5 Fiberglass Batts 3.2 R-Value Goal Cellulose Loose-Fill 3.5 � , ? Rockwool 2.8 C"'%TOMER AGREES TO SUPPLY TRUGREEN WITH ACCESS TO GROUNDED OUTLET(S) AND POWER AND TO SHUT DOWN THE 6US14ERTY'S HEATING/COOLING SYSTEM(S).CUSTOMER UNDERSTANDS THAT INSTALLATION OF INSULATION MAY GENERATE DUST AND OTHER AIRBORNE IRRITANTS IN THE SERVICE AREA AND THROUGHOUT THE PROPERTY.TRUGREEN RECOMMENDS CLOSING ALL WINDOWS AND INTERIOR DOORS DURING INSTALLATION. CUSTOMER MAY WISH TO COVER OR REMOVE PERSONAL PROPERTY AND TAKE OTHER PRECAUTIONS CUSTOMER DEEMS NECESSARY TO AVOID DUST/IRRITANT EXPOSURE. SUMMARY OF CHARGES AND PAYMENT OPTIONS SUMMARY OF CHARGES AND PAYMENTS O Financing Option: See TruGreen Retail Installment Agreement INSULATION SERVICES Xpown Payment Option: Initial 20% down-payment of Total Investment(#1) INSTALLATION. . . . . . . . . . . .. . . . . . . . . . . . . . . .. . b check or credit card due upon execution of Agreement. Remaining Balance Y p 9 g (#3) due upon completion of installation. ATTIC TENT INVESTMENT. . . . . . . . . . . . . . . . . . . . ."NOUC OPre-Payment Option: Payment in full of Total Investment (41) by check or credit card due upon execution of Agreement. OTHER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . O Payment On Completion:A one-time check or credit card payment of Total TAX.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . _ Investment(#1)due upon completion of installation. b, If paying by credit card, Customer authorizes TruGreen to Process credit card 1.TOTAL INVESTMENT.. . . . . . . . . . . . . . . . . . . . _ payments in accordance with the above payment option selected by Customer without further signature or authorization. 2. 2. LESS$ °J DOWN PAYMENT. . . . _ Customer Signature: 3. REMAINING BALANCE . . .. . . . . . . . . .. . . . . . - ` Best Number to Reach Customer to Obtain Credit Card Number: 91YES, I would like to purchase the services set forth in the Total Investment W).My agreement is subject to the terms and conditions on the reverse � 0 side Cu9fo gnatureZDate C {-'TruGreen Rep's Name r6ITH � 1,16 6 Sales Rep# Ci ' hi.;THE BUYER,MAY CAN&L THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE %dwHIS TRANSACTION. PLEASE SEE NOTICE OF CANCELLATION PROVIDED FOR MORE EXPLANATION OF THIS RIGHT. The Terms and Conditions on the reverse side,including the mandatory arbitration provision,are part of this agreement. Key#10248 New 6/12 O 2012 TruGreen Limited Partnership.All rights reserved. fr TN Charter#448,#439,#185,4422,#443,#3883. See Reverse for Additional Terms and Conditions License# c _ CGJ In CT,B-0153,B-1380,B-0127,B-0200,B-0151 PA-#HIC.092436 CT-#HIC.0544505 MI-#2101202938 BRANC I COPY