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HomeMy WebLinkAboutBuilding Permit #056-13 - 1084 JOHNSON STREET 7/24/2012 BUILDING PERMIT tA O Rr" TOWN OF NORTH ANDOVER �� h ,`. -•.•6 °� APPLICATION FOR PLAN EXAMINATION _ * 0 Permit NO: /3 Date ReceivedCH �� SACHUS� Date Issued: IMPORTANT,:Applicant must complete all items on this page ' LO£C'/ATI®N . R �f PF3®PE �TtY�OWNERi.w _ �. c C t�pi� MAMN© ct' dyes no� - - _ _Maclilne�Shop�Villag`e, :yes :no , TYPE OF IMPROVEMENT PROP ED USE ResilAntial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Altefintion No. of units: ❑ Commercial pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ���Septic. '0}Well _ ° ` �©'Floodplain? �=Wetlands ' ` q�lNatersfietl�D tnc��" �.illl/afer%Sewert . ,- _..�� --___� �_.. _. __ _ . . _-: _ ►. _ . 4 DESCRIP W O BE PREFORME Identific Please Type Pr'nt Clearly) OWNER: Name: Phone: cf?r4 5&2 Address: P tCONTRAC-TOR Name . 7 . Supervisor'stConstructionILcense£ _ ExpoDatea F �HomeImprovementLicense `Expo SDate _ 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: $ 1-90010 FEE: $ �30 -- Check No.: 34- � Receipt No.: Q �J � � NOTE: Persons contracting with unregistere contractors do not have access to the guaranty fund Slgnafure ;S'ignature of,contractor _. ._;_. ._. _.... . .:...:..' i I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well - ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Sionature 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: • Located 384 Osgood Street ,. FIRE DEPARTMENT, `TemphDumpsfer,on site y s. - tLocatedzat�,124.�Ma1nStreet' , iretDepartment 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.$10041000 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 VOTE: All dumpster permits require sign off from Fire Department prior to issuanceof 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 thea get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location/0 ! 1 A"j Jn s r No. — Date �� • ' TOWN OF NORTH ANDOVER • ��jS'LGl7 t�,y� • • Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2 25535 Building Inspector s" '�, 9 u[ gap t i_FL 0 Ell n2-< ilKCa YC ULs es _ _ . tL _! IkF ,. 1Y fa ' .�—.....e_.—....,_�_..._._—......�_(- pi�.s."u- rt°'t Name �usiless/Organizal-ion/IEidividua,): UIty/s2 LGIzIr, '_ R�t / T--- Z�IiCt'c' A7eyi�an ennppoyer? Checl the apprapl Tate°rso : .T,ape of p.ra�ect(r.eq-mrm;i)4. [' I am a general contractor and I � tn ,_ {�1.. a.r_��a emptayer v✓zth_ t� V. ��drri cc;is�.lch„1, eirployees(hilt anllar part-tiirje).'T have homed the sub-contractors 7, F1 Reniodelfiap, 2.[] I am is sole proprietor orpai-tiie?•• listed on the attached sheet. ship and have no employees These sub-contractors have g. Demolition and have workers working for ire in any capacity. employees9. Building addition [No workers' comp.insurance comp.insurance.I 10•[j Electrical repairs required.] 5. [] VVe are-a corporation and its or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.C1 Plumbing iepairs®r additions myself. [No workers'comp. right Of exemption per MGL 12.❑Roo pairs insurance required.] t c. 152,§1(4),and we have no employees.[No workers' 1 thee_ comp:insurance required.] *Any applicant that checks box#1 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 Delow,is the policy and job site. information. Insurance Company Name: Policy#or Self-ins. Lic.M tt ������ � Expiration Date: Job Site Address: L N � � —3City/State/Zip:_ r 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 fire of up to$250.00 a day a t e violator. Be advised that a copy of this statement may be forwarded to the Office of _investi adons of the DIA for indurance cov ra e verification. .1do hereby certify.u der the air nd enaltiesof perjury that the information provided above is true nd correct. Sign re, 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: +� YS Ai I CEIRTINGATE 7H,_:E THIS CERTIMCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 0 RIGH75 UPOIN T)'F- OLDER, !- CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CtYVERAGE AFFORDE'D I3 _-q14E POL*CIE.--� N BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A C0N7'R_N-CT BE-711JEE'B TLIg ISSUIpjG NSURER(9), AU -40,, B' REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. iuS11Fkia IMPORTANT- if the carlificate holder is an ADDITIONAL INSURED,the poljcy(,ems)m1st bs andiDrsed. IT' UBROGATY-11M 5 IKA" % quire an andorsament. A Statramey,,-on do'-s rkillu-S lo.) nO i *e terms and randitions of the PollcY,certain policies may re -ertificate holder In lieu of suchandcrasment(s). 'CONTACT PRODUCER NAME: xarsh USA Inc. PHONE '11; Mol: ,No, MIC E:(I): E-MAIL homedepot.certrequest@marsh.com _ADDRESS:— Two Alliance Center, 3560 Lenox Road, suite 2400 INSURER(S)AFFORDING COVERAGE NAIC Atlanta, GA 30326 INSURER A: Steadfast ins Co 26387 Fax (212) 948-0902 INSURED INSURER 8: Zurich American Ins CO 16535 The Rome Depot, Inc. INSURERC:'N— Hampshire Ins Co 23841 Rome Depot U.S.A., Inc. INSURERD: illi .is'Natl ins Co 23817 2455 Paces Ferry Road NW Building C-20 INSURERE. NATIONAL UNION FIRE INS CO OF PITTS 1944S Atlanta, GA 30339 IINSURERF: Illinois Union ins Co 27960 COVERAGES CERTIFICATE NUMBER: 25776028 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. SR S_UN rMPOLICY FF LIMITS LTR TYPE OF INSURANCE MJGDY�Yr POLICY EXP __Iwmlwvo POLICY NUMBER IMM1DO1YYyyl A GENERAL LIABILITY DAMAGE 1-0 RENTED :202020:�0200 GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $i COMMERCIAL GENERAL LIABILITY PREMISES(Fa occurrence, CLAIMS-MADE Fil OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL&ADV INJURY $9,000io0o X OF SIR: $lM PER OCC GENERAL AGGREGATE $9,000,000 _ERODUCTS-COMPIOP AGG $9,000,000 GENL AGGREGATE LIMIT APPLIES PER: $ X PRO- PO ICY JFCT LOC BAP 29 3-09 03/01/1 03,/01/13 COMBINEDSINGLE LIMIT B AUTOMOBILE LIABILITY (Eaacci ent) . S1,000,000 BODILY INJURY(Per person) $ N I P(My one S EXCLUDED NAL8 ADV INJURY $ 9,000,000 RAL AGGREGATE $9,000,000 ,UCTS COMPIOP AGG $9,000,000 L X ANY AUTO ALL OWNED SCHEDULED RY(Peraccident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED War accident) HIRED AUTOS AUTOS X SELF INS wl PRY DMG $ UMBRELLA UAB EACH OCCURRENCE $ EXCESS LIXB HCLAIMS-MADE [AGGREGATE $ DED RE=mT1nK1 C WC STATU- 'OTH- WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 TOCR I FR OU'LY I �R PROPERTY�O UMBRELLAL' 3886 _,d EXCESS UAB y F WORKERS COMPENSATION � : �7 C AND EMPLOYERS!LIABILITY YIN WC019736917 (FL) 03/01/ 03/01/13 E.L.EACH ACCIDENT $1,000,000 JEXECUTIVE Lo NIA, * ANY PROPRIETOFVPARTNEP CU N NIA 1 OFFICERWEMBER EXCLUDED? _j WC019736916 (CA) 03/01/ 03/01/13_E.L DISEASE-EAEMPLOYEE $1,000,000 * (Mandatory In NHI) 11 E.L.DISEASE-POLICY LIMIT $1,000,000 'D'rS'dRj'P'n0'N'01d`OPERA-n0,jNSb.I0w 4 (4SI) 50000 03/01/1 R (AOS)/SIR H Workers Compensation C1192494 C workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TMSC46566397 (TX) 03/01/1 1 03/01/13 Occurrence/SIR 30M/1M DESDESCRIPTIONa LOCATIONS is ON OF OPERATIONS I LOCAONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE ROME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA 1984-2010 ACORD CORPORATION.'All rights reserved.. ACORD 25(2010105) The ACORD name and logo are registered markilef ACO1!l0V,:," Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration:126893 TYPE" Expiration 8/3!2012 Supplement I 7/ The Home DeP 0 AC1 f6 e Services rj Pi :. RICHARD. FALLC)NE ' 2690 CUMBERLAND P/14i<WAY S � �— A'I'�cAN` ,GA 30339`-:;=" . Undersecretary JUN-29-2012 14:59 From:KEN SANDE11 RSW 603 782 8726 To:Home Depot AHS P.1/8 HOME IMPROVEMENTCONTRACT PLEASE READ THIS Sold.Furnished and installed by: Branch Name: Boston Datc: THD At-Home Services:Inc. b /.?/12 d/b/a 1'he II0me Depot At-Horne Services 908 Briton Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5192;Fax(508)845-6017 Branch Number:31 Federal Ip#75-26984(A),,MF.T,ic 4 C(V1439;RI Cant Licit 16427 CT Tic#H1C.0565522;MA Home Improvement Carnractor Reg.#126893 inglallatlon Address: 1 AiSy �o�,n,S3n1 49T. MWIt., ,AAjPbOY1zC l�A Q1R4, City State Zip 1'urchaser(s): Work Phone: Hume Mum: Cell Phone: [ 1 [ ] I ] Home Address; (If dil)irent frrmr Installation Address) City �A Std Zip Kt i1 Address(to reissue project rwnmunicaliums and home DCpCrI uiasates):S'w""NON t}�tggn/ p�s,r a,t;� DO NO wish to receive any marketing emails from The Home Depot J Protect infurnmtiun: Undersigned("Clxstotner ),the owners of tie pruperty located at the above installation address,agrees to buy, and THD At-Home Services,inc_("The Rome Depot")agrees to furnish,deliver and arrange for the installation("Installation',)of all materials described on the below and an the ref'erenced Spec Shm-t(s), all of which arc incorporated into this Contract by this rcl'crcnm,along with any applicable State Supplement and Payment Summary attached hereto and aoty Change Orders(collectively, "Contract"): Job*: (1�x so.. ) roduLtr Spee Shuet(s)#: Projoort Arrogant L7 K�rj+G Rooting Sidon endows LJInulalitm �,J GjV� ❑Oluiters/Covers ❑Fancy Diva,, ❑ RuaCmg ElSiding 0 Windows U ht+mlaann ❑Comers r Covers❑limy Doers ❑ —! Roofing Siding❑VAndaws LJ Insulation 06uilets I Cetera❑Entry Doors I> $ Rw&r- LJSidiag 0 Windows ❑Insulation $ ❑(;utters/Coven: ❑rn,ry doors E] Mhthmm�2596lp{optM(7rrpraetArluwmtdnetrpanexm�ondlhpuwttn,d Total Contract Arnaud $ t71`1D Maine.Purdu s any not deposit nom that ate[Mrd oitbc CaRrad Ammnt 4 Customer agrees that.immediately upon completion of the work lir each product,Customet will execute a Complotioti Certirlcatc (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customet under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the tight to issue a Change Order or terminate this Contract or any individual Prrxtuct(s)includes herein,at its discretion-if The Home Depot or its authorized saviec provider determines that it catmot pc-Mrm its obligations due to a structural problem with the home,environmental hazards such aN mold,asbestos or lead paint.other safety concerns.pricing etrors or hm-ruse. work rcyuirod to complete the job was not included in the Contract. Payrrlent Summary: The Payment Summary# 9 — included as pan of this Contract,sets forth tie total Contract amount and payments required for the deposit¢and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you align. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spee Sheets)before weak on[lint Product is complete. In the event of termination of this Contract.Customer agrees to pay The.Ilorne Depot the costa of materlalc,labor,expenses and wrviees provided by The Home Repot or Authorized Service Provider through the date of termination,plus ally other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHIIOI,D AMOUNT~ OWED TO THE HOME DEPOT FROM TIIF DF"IT PAYMENT OR OTHER PAYMENTS MADE WiTIIOUT LIMITING THH HOME:DEPOTS OTIIER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance agg Authorization: Customer ngreec and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and lnstallatiolt set'vices and supersedes all prior discussions and agreements,eitur oral or written,relating to said Products and Installation.This Agreement cannot be.assigned tr amended except by a writing signed by Customer curd the Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily wwpts the terms of and has received a copy of this Agreement. Acce hy: �abtnlned hy: c c� 6 z.7) Cush er's Signature Da Sales Consultant's Signature Date X TeleplttntcNo_ Cuslorner'N Signgture llale - Sa1PS COASultamt 1_le:ense No. CANCELLATION: CUSTOMER MAY CANCY1, TIIIS (as uppBcntdc) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRl'1'CEN NOTICE TO T'lll:HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SU'vNiNG TRiS ACILEk:MKN`J'. THE STATE. SUPPLEMENT ATTACHED HERE'T'O CONTAINS A FORM TO USE IF ONE 1S SPECM, CALLY PRE.SCRDBRD BY LAW IN CI18TOMF.R'S STATE. NOT1tT:ADDITIONAL TEBMS AND CONDITIONS AKN:St'AILDON THE RKNOME SIDE.AND ARE PAi r OF TBIs vonrrRACI 03.30.12 C-SC white-Rranch FIe Yellow-Customer HP Officejet J3600 series J3680 Personal Printer/Fax/Copier/Scanner Fax Log for Richard Fallone 4014531357 Jun 21 2012 2: 53p Last Transaction Date Time T11pe Station ID Duration Pages Result Jun 21 02: 51p Fax Sent 19783742337 1 : 36 2 OK a '.�� } �h i i v I , MA `FQRSUVAS - 4 � ; 1,' 4 {Q, z. :: .+`F 'lt, ..SFr t w : .:r-. i . x ] t :x :. xat { cgs} r 6 a A t 4 m" ,k c� G f �., to I ': i _-e_.q y -. d I . s at '; l c i SaS: 5 \l T s r; S" .t Mk i 6"''E: . i �` !` 1 L ,} f x w i5 ,�"' c f../ > .'z I r. w.: '' T �- '� `1 Ati; LYS 9.: -� G v 3� a: e 11 :3 ` `� r ': x 7�� `' . ' 4€ �: . "-. _y33 , r F J, t '-"-�+ I'd W ', s t 1 1- 9 �; '.'-3. r 9 it l{,�Y his c , gv y � NORTN Town ofAndover _ 0 ' . �" 0 No. t : - h ver, Mass, Lao COCHIC.IWICK A04ATED 011V �y - S U BOARD OF HEALTH Food/Kitchen --1-T T LD PER Septic System THIS CERTIFIES THAT ... .. . .,r!!.$V�......... . . .ia O... ,,,,,,,,,,,,, BUILDING INSPECTOR ............ .... ... .................. . Foundation has permission to erect................. ........ buildings on . 0.. .. .......�, .. .....h!!5 .... .......a...... Rough tobe occupied as .. . ....... ........ ............ ........... .11�44. ........................................... Chimney provided that the pe n ccepting 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 PermitRough. Final PERMIT EXPIRES IN 6 ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S TS Rough Service .............. ........................................................ Final BUILDING INSPECTOR 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