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HomeMy WebLinkAboutBuilding Permit #681-16 - 1084 JOHNSON STREET 12/3/2015 SCAN104-0 IA -2-147 �osaYy BUILDING PERMIT oF�tLED ,b�% TOWN OF NORTH ANDOVER o ; '~ APPLICATION FOR PLAN EXAMINATION _y D, 0H Date Received TED Permit No#: A Date Issued: � '' IMpORTAl�i:Applic�a-nt must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes o MAP PARCEL: ZONING DISTRICT:_Historic District yes o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residial Non- Residential e t ❑ New Building ne family ❑Addition ❑Two or more family 11 Industrial ❑Alt tion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ate'�shed ®� strit� fSeptic ❑ yvelll ppp ❑ FI©`©d Iain ,)IVetlands Water/Sewers_ �- -- e � DESCRIPTION OF R TO PERFORMED: r I tificat'on- PI e T Pe or Print Clearly OWNER: Name: �l� " �-- Phone: Address ��mnaxd: Phone' s 90 Contractor Name: � Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date:.:6�_ ARCHITECT/ENGINEER Phone: s Address: Reg. No. , x FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. � . � Total Project Cost: $ 0'22 FEE: $ ' Check No.:—. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ace the aranty fund r 4 . -_._. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped flans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Sody Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales El Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR. OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 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 Connectio91/Sr�c nagure s&Bute Driveway Permit x DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR-4;M8N;T k- Ternp3Dumpster an site. es no..4 Locafe_ d;af,1243Main ` r Fi�e�De ... , partrnenf 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.$1oo-$1000 fine NOTES and DATA-- (For department use) IJ Notified for pickup Call Email Date Time Contact Name Doa.Building Pennit Revised 2014 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 a. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks jL Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit 4: Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/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 OTE: 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 26 2012 IECC Energy code � Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit Ian 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:Building Permit Revised 2014 Location 1dw No. Date3 �S • - TOWN OF NORTH ANDOVER DI . . Certificate of Occupancy $ Building/Frame Permit Fee l Foundation Permit Fee Other Permit Fee $ r TOTAL $ ` t Check# 2 r 7 u 5 Building Inspector � NORTF•r � Town of ., ndover o : : - No. kh ( — 261 - - � * • M h ver, Mass COCMICN[WICMPy1 �7S RATED PP ,`'�5 V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System • THIS CERTIFIES THAT ... OWE~ BUILDING INSPECTOR has permission to erect . ..... uildings on 10.1%... . .. . . aef— Foundation ..... .. . .. 6 ` ........................ Rough .. S to be occupied as Rep • • �W•� 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 CONSTRUC S Rough • Service ........... ... ........... ..................... BUILDING INSPECTOR Final 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. HOME IMPROVEMENT CONTRACT t '� PLEASE READ THISj� � Branch Name: New England Date: 15-��/ tS Sold,Furnished and Installed by: THD At-Home Services, Inc. Branch Number:31 d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal.ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 CT Lie#HIC.0565522;MA Home Improvement Contractor Reg.#126893 Installation Address: �b�y V y f 6Y) Si. A) d wQl bib City State Zip Purebaser(s): Work Phone: Home Phone: Cell Phone: 4c [X31 J%a_9323 E 3 [ 3 Home Address: (.If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails 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 State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: (Internal Referencc) �di : Sec Sheet(s)#: Project Amount ��^'C� [ r� ws Insulation /�J (''7 ❑ rs ❑ `tel l ?�7 $ Z S� Roofing Siding Windows ❑ Insulation []Gutters/Covers ❑Entry Doors ❑ $ Roofing LjSiding Windows Insulation ❑Gutters/Covers ❑Entry Doors❑ $ Roofing ElSiding Windows LJ insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Minimum 25%Deposit of Contract Amount due upon execution of this contract Total Contract Amount Maine nurhasers may not deposit more than one-third of the Contract Amount $ 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 Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, environmental 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 # 117 S-TZ-9 , included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely tilled-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 indiAdual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract, 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 date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law, THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOTS 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 Products 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 terms of and has received a copy of this Agreement. Aced bv-,, (—)/ .' ./ I Submitted by: A�� Work area will be contained . Pre-Renovation Form Date: NAT-19276 This form is used to document compliance with the requirements of the Federal Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. Customer Andress Job Number(s) 4 q. X75 j,5W 2- . OCCUPANT CONFIRMATION ® Dust will be minimized Pamphlet Receipt Y J 5 ' 1 have received a copy of the lead hazard information pamphlet informing me of �1 f , ' -' _ � , the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began. F Home Year Built ti, Enter the year my home was built.Av If my Home Year Built is Pre-1978,my home requires lead paint testing to determine whether Lead-Safe Work Practices are necessary per EPA or State regulations, Work area will be cleaned up if my Home Year Built is 1978 or after,Lead-Safe Work Practices are not required. thoroughly t ,•> Printed Name of Owner-occupant 64AL*- f L Signature of Owner-occupant R Sign t re of Pefscfh Certifying Lead Pamphlet Delivery f; SEE STATE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,AVIA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip: Are you an employer?Check the appropriate box: Type Of project(required): 1. I am a employer with _employees(full and/or part-time)_* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.) 9. ❑Demolition 3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole i l_❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑rther pairs These sub-contractors have employees and have workers'comp.insumnce.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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'comp sation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: t� Policy#or Self-ins.Lic.#: �������'� Expiration Date: Job Site Address: C J ASI n6o,l City/State/Zip: Wx0l 5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dal Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify u der t pa' s a penalties of perjury that the information provided above i 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: HP Officejet Pro 8610 Series Fax Log for 4014531367 Nov 17 2015 7:47AM Last Transaction Date Time Type Station ID Duration Pages Result Digital Fax Nov 17 7:47AM Fax Sent 18663181070 0:00 0 Busy N/A CERTIFICATE OF LIABILITY INSURANCE- =OM4215 yYrl � "THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE BOB 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 BOLDER IMPORTANT: tt the certificate holder is an ADDITIONAL INSURED,the PDIICy(tes)must be endorsed. If SUBROGATION 13 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endolsemant A statement on this certificate does not confer rights to the certificate holder In Lieu of such endorsement(s)_ PRODUCER MARSH USA,INC. CONTA TWO ALLUWCE CFMER PHONE FAX 3560 LEVOX ROAD,SUITE 240D 6 MAIL No): ATLANTA,GA 3032& 100492-HoumD-GAW15-16 ►NSU S AFFORDING CpVERAGE IHaUNA1C 9 INSURED RER A:Stefast Insurance Company 26387 THD AT-HOME SERVICES,INC. INSURER s:ZudM Ameffm Mona CD 16535 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C!New HapAim h Co 23841 ATL NTA.CUMG RL 0 PARINVAY,SUITE 304 i@mois National Insurance Company 23817 ATLANTA,GA 30339 INsuRER O R E RER E, INSURERF: COVERAGES CERTIFICATE NUMBER: ATL4M24268509 REVISION NUMBER-7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 8F10W HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVATHSTANDING 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 BYTHE POLICIES DESCRIBED H EXCLUSIONS AIND CONDITIONS OF SUCH EREIN IS SUBJECT TO ALL THE?FRMS, TIPOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDEPOO BY PAID CLAIM& LSR TYPE OFRNSUWWCEADDL POLICY NUMBER POLiCYEFF SLID EXP LIMITS A GENERALLiAsu TY U-48 '1"5 03/012015 03IM12016 X EACH OCCURRENCE S 9,000,000 EACH GENERAL LIABILITY rORENT CL AIMSUADE M OCCUR UMiTS OF POLICY XS EMESES Ea oonlrrence S 1,000,000 OF SIR:$IM PER OCC MED EXP(Any one person) g EXCLUDED PERSONAL 8 ADV INJURY 5 9,000,000 GENEIRALAGGREGATE 5 9,000,000 GENE AGGREGATE LIMiTAPPUES PER: X POUCY PRO-% LOC PRODUCTS-COMPIOPAGG 5 9.00D,000 B AUTOMOBILE UA131L—/ BAP 2438086312 031Dt/2015 03/D42016 COMBINED 31NGU5 LIMIT S X ANY AUTO acdrna/ S 11 00 S AUTOS BODILY INJURY(Perperson) S AUTO SELF INSURED AUTO PHY DMO BODILY INJURYS(Peracdtlen) HIREDAUTOS pUroONOS INED PRaOPERTY E s UMBRELLA LIAR S OCCUR . EXCESS(ITIS CLAIMS4dADE EACH OCCURRENCE S DED RETENr10NS AGGREGATE g C ate , wC017791 93(ADS) o3t012015 D3fOt201s wcSiATtt- oTH- S C ANY PROPRtET0RPARTMqMDMMffIVE YIN WCMM1495(AK.KY.NH.NJ.VT) 03@1DD15 03/012016 .000 D (Mand ftrIryfaNN CWDED7 a NIA WC017731494 E1,0 L EACH ACCIDENT g It deseflha Inner �) 03!01/2015 001016 EL DISEASE-EA EMPLOYEE s 1.000.000 DESCRIPTION OFOPERATIONS below Combued on AdcWoW Page 1,000 000 ELDISEASE-POLICY LIMIT S , DESCRIPTION OF OPERATIONS ILOCATMNSIVEHICLES(Aftch EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. DBA THE HOME Di fOTAT-HOME SERVICES SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRYROAD THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ATLANTA,GA 34339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESEENTATM of Marsh USA Inm ManashAMukhegee ACORD 26(ZOtO/pis) Tice ACORD name and logo are registered marks of CORPORATION. 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