HomeMy WebLinkAboutBuilding Permit #489-11 - 1005 FOREST STREET 12/17/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received 1
Date Issued: — ~ (a
IMPORTANT:Applicant must complete all items on this age
LOCATION � o T�, � � �
Print
PROPERTY OWNER )r,4
Print
MAP NO: LO rPARCEL: ZONING DISTRICT: Historic District yes o
Machine Shop Village ye(
e no
TYPE OF IMPROVEMENT PROPOSED USE
Resi tial Non- Residential
❑ New BuildingOne family
❑Addi ' n ❑Two or more family ❑ Industrial
❑Aje4ation No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑Other
0 Septic ❑Well D Floodplain 0 Wetlands �0 Watershed District
D Water/Sewer
DESCRIPTION OF WORK TO ERFO D:
Identific 'o ease Type or Print Clearly)
OWNER: Name: �, Phone: &ARLI: S�`f
Address: (�lf `' ��1 �} t -Igo'
CONTRACTOR Name: +IDHG Phone: e4B1�?333
Address: I)WAi4A 01th)-7
Supervisor's Construction License: Exp. Date:
Home Improvement License: �' � Exp. Date:
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: $ 1 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access t e gua arty fund
Slgnature_of Agent/Owner z+� rc Signature of contract
.- _ __._._ — .. _ .__ 7 T T— _ --_ 9 gam-CPS
Location
No. Date �`✓ v
MaRTM TOWN OF NORTH ANDOVER
3 O
F R
9
Certificate of Occupancy $
s��M�s<� Building/Frame Permit Fee $ /00
r_
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #--�.�� o
2 3 7 Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL '
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools El
Well ElTobacco Sales ElFood 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
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
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
r ". , 0 Located 384 Osgood Street
FIRE DEPARTMENT'-`Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from 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 submitted with the building application
Doe: Doc.Building Permit Revised 2008mi
F QRTIy
ToVM of
0 W.+v, v:`.?�:• 'ifs' ,.�..,�
No. �`
LAK O dover, Mass.,
�f COCMICH
EWICK
7,95 RgrE o
BOARD OF HEALTH
Food/Kitchen
.PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT O .' !• --...................................................
...........�........... . ............. . ....... ........................ Foundation
has permission to erect........................................ buildings on ...to..D..9........... ............................. Rough
t Chimney
to be occupied as �..,,t........(�.��1.� —
............Q
. .......................................:.........................................................................
provided that the person e tin this permit shall in eve respect conform to the terms of the application on file in
P P P g P every p PP Final
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
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTI T�T ELECTRICAL INSPECTOR
Rough
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
The Commonwealth of Massachusetts
Department of In Iustri&Accidents
Office of Investigations
600 Washington Sheet
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: � q'� lJ•t { y1-�i�Cl�7 �
City/State/Zip: Phone#:
Are y an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. E] I am a general contractor and I
employees(full ndb� - ..,
* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees Thesc sub-contractors have 8. E]Demolition
working for me in any capacity. employees and have workers' 9. E]Building addition
[No workers'comp. insurance, comp. insurance.T
required.] 5. ❑ We are a corporation and its 10.E:1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 121] repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' U.-El Other
LA:2)jaji�
comp.insurance required.]
*Any applicant that checks box#I 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 sub-contractors 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 is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: 1 I fy L:2
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: F�� � City/State/Zip: p 1,
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 u d r th ains d penalties of perjury that the information provided above ' true and correct
-AdSi ature: 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.Build;ng Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
GATE(MIMA l00NYYY)
Ac'o l CERTIFICATE OF LIABILITY1 ,11SURANCE 02/19/10
1-404-993-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON T!IE CSR I!FICA
PRODUCER
5cacsh USA, Inc. LLEP.HrnTH!S CERTiFfCA.' DOES NCT A;4!'=iiC EXTEINC Or?J -
THE ter. 1•F=^Q:1
0de•Jo:.C-a:: sy:0s`.'JCna L9.1._=LR
35iLanc:c load, Sui.=_ 210'J - 1
u:\ 30325 - - -
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Cr_; 53
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Hare Degat, I::c. _=h ?-arican
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ENERGY PERFORMANCE F,AnNC-S '
U-Factor Solar Heat Gain Coeffident
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. AMDM0NAL PEAF..QFiMANCE RATINGS
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Office of consumer Affairs&Business Regulation 1
�iOME IMPROVEMENT CONTRACTOR
a
T
Registration 476893 YP�
Ezpifa on-8�3(ZETZ_� Supplement
,
The Home RoMi;Seivcces
RICHARD FAlLO6JE
—A r•I:.evcof ntiir%OVAQkWAV R � ��—
Branch Name: Boston D.tte: j] /%oleo THD At-Home Services,Inc
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Unit 2,Worcester,MA 01607
Toll Free(800)557-5182;Fax(508)756-8823
Branch Numbem 31 Federal ID#75-2648460;ME Lic#C 02439;RI Cont Lie#16427
_ {� CT Lie#HTCr.O'S65522;MA Home Improvement Contractor Reg.#126893
Installation Address: int) -- t J t-1'{�( kwMR- OI eq v-
City State zip
Pu )' Work Phone: Home Phone: Cell Phone:
[ Litt— S a
Home Address:
(If different from Installation Address's City State Zip
- E-mail Address(to receive project communications and Home Depot updaies): iJ( ur� r te,B
1KI DO NOT wish to receive any marketing ernails from The Home Depot
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference,along with any applicable:hate Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#: amemm ft&mw i Pte; SPM Sh 8 #: Prv'ect Amount t
❑Roofing ❑SidingWindows ❑insulation
63 Cf jig 6 Z, ❑Gertner/covm ❑Entry Doors ❑
❑Roofing ❑Siding ❑Windows ❑Insulation $
❑Gutters/Coven ❑Fatty Doors ❑
Roofing Siding 0 Windows C3 Insulation
❑Guunrs/Covers ❑Entry Door 171 $
❑Roofing ❑Siding ❑Windows ❑insulation $
[]Gutters/Coven []Entry Doors ❑
11 a rmrn25%DepiadorContractAnvamntdueuponemeationorthisepnnraet. Total Contract Amount $ 8
Maine Purchasers may not depoit mora than one-third of the C orttrarxAmotnnt.
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The dome Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmenurl hazards such as mold,asbestos Or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary #_ f4 11 Z. , included as part Of this Contract, sets forth the total
Contract amount and payments requin<:d for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely frllcd-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note;
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
Tn the event of termination of this 4'antract,Customer agrees to pay The home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the dale of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WTTHHOL.D AMOUNTS
OWED TO THF HOME: DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and installation services and supersedes all prior discussions and agreements,either
oral or written,relating to said Prodw:ts and Installation_This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
toots of and has received a copy of this Agreement.
Accepted by; Suburi y
.3o CD
X _14- L4A4x44U 111.4q/Lo
Customer's Signature Date Sales Consultant'si nature 1 Date r
X Telephone No. �'+;J( � Z-b `9 +�
Customer's Signature Date
Sales Consultant License No.
CANCELLATION; CUSTOMER MAY CANCEL THIS (ns applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITCEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THM BUSYNESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUYPLEN(ENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBEI) BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDITIONAL TERMS r.ND CONDITIONS ARE STATED ON THE REVHRSE Sn)E AND ARE PART OF THLS CON't'ttACr
"I-10 CSC White—Branch File Yegow—Customer
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rotaffion .
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-, '- 1iaaccacJruxcts-Drpartnecnr of Pub cSal"cl%&4i ,
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ii L al c -t4at Board of Baadia;Regsla6esY and Standard.
�:arsY:;��ion Sir;.ervisar L;tn�se '
a lmeresr GS 88756
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