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HomeMy WebLinkAboutBuilding Permit #914-15 - 125 CROSSBOW LANE 5/13/2015 Lip BUILDING PERMIT oRrh 6 { N w- ` TOWN OF NORTH ANDOVER � - - APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �q TEo SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER j' Print 100 Year Structure yes no MAP PARCEL:nT_ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no 1 TYPE OF IMPROVEMENT PROPOSED USE Resiogntial Non- Residential 1 ❑ New Building One family a ❑Addition ❑ Two or more family ❑ Industrial ❑AXeration No. of units: ❑ Commercial N4Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other RION Emu dp.lain ® Wetland 2 „ RIS fON F WORKTOBE PERFORMED: Identificat' - lease Type or Print Clearly OWNER: Name: / Phone: Address: f2�tP 1 AP 4 Contractor Name: � ��� Phone: `Tt�� Email: Address: F— Supervisor's Construction License: 03Z 0g23 Exp. Date: Home Improvement License: / Exp. Date: .. IIS ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.I00�PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ q /� ° FEE: $ Check No.: 1 ��vl� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to r fund G. - Location JC,? No. Date �d Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $lf ` Foundation Permit Fee $ i Other Permit Fee $ TOTAL $ Check# 1 f 28 / 6 f r Building Inspector ' f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimuing Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING cis 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 f, , 19anning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connecti on/slgnagure& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osgood Street FIRE bEPARaTMENT Temp Dumpste�onsy � ''` no IlLocatedat 1.24 Main Street �; � lie IN ` eft 1' 4``i'.�•' ..`w. ;.rtI .-fi; '' TfFire Department signatureclam /date t ` 3C®MMENTfS ., Rr .: ,�' �f �_ c, a Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, mast or service drop requires approval of Electrical Inspector Yes No i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department apse) 1 04 El Notified for pickup Call Email Date Time Contact Name ....................__..._..__._.__. Doc.Building Permit Revised 2014 J i 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 4. Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: 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 4. Workers Comp Affidavit 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 II 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 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 f 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:Building Permit Revised 2014 d r ., r10RT1-� . : .. . . S E ver W. 0 � - No. �� �� Mass42b 1!5 AT. h ver, COCHIC tICK y1. A°RATED ►'Pp '(I S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System 61&A&A C BUILDING INSPECTOR THISCERTIFIES THAT ..................... .......... ................................................................................. �zC5, �� Foundation has permission to erect .......................... buildings on ... ... .\ .•••••••••••••••••••••••�•••••••••• A ••.••• Rough to be occupied as �.4�4�4t+�i . Chimney ..... ...... ............. .............. ...6 .!`i.... .. . 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA7S Rough Service ............................. Final IL ING SPECTOR 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 PLEASE READ THIS Sold,Furnished and.Installed by: Branch Name:Boston North&South Date*]/ THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit J.Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal iD#75-2698460;ME Lic#C 02439;RI Cont.Lic#16427 CT Lic#HIC.0565522;MA Home Improvement Contractor Reg.#126893 Installation Address: �s iJ � City State Zip Pur aser(s): Work Phone: Home Phone: Cell hone: c ff�l�1 z33—537 7 [ [ l 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#: nnrernar Reference) P oducts. Sec Sheet(s)#: Project Amount Roofing Siding W lVindows 0 Insulation ❑Gutters/Covers EfEntry Doors ❑ �VWo&Z q Z 1 5— Roofing ElSiding Windows U Insulation ❑Gutters/Covers ❑Envy Doors ❑ Roofing Siding WindowsLJ insulation ❑Gutters/Covers ❑Entry Doors❑ $ Roofing Siding VV:ir3dows Insulation []Gutters/Covers ❑Entry Doors ❑ $ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Maine Purchasers may not deposit more than one-third of the Contract Amount. Total Contract Amount $ 2 Customer agrees that, immediately upon cornpletion of the work for each Product, Customer will execute a Completion Certificate (one for cacti Product as defined.by an individual Spec Sheet) and pay any balance due. As applicable, each. Customer under this I', I Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Orderor 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 int Contract. Payment Summary: The Payment Summar # y 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 filled-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. 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 AN16UNTS OWED TO THE 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:urd 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 Agree e \ cued b)� ' ///,I Submitted by: qw// ,a/:'-1f- ■ Work area will be contained = , Pre-Renovation Form Date: I �y j NAT-19276-1 rE ; This form is used to document compliance with the requirements of the Federal 3 Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. Customer Address Job Number(s) ■ Dust will be minimized OCCUPANT CONFIRMATION Pamphlet Receipt 4 1 I have received a copy of the lead hazard information pamphlet informing hie nfor i n me of the potential risk of the lead hazard exposure from re g p novation activity to be il performed in my dwelling unit. I received this pamphlet before work began. Home Year guilt Enter the year my home was built. l 0 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 c5a-t- 4a'rC4'� Printed Name of Owner-occupant gnalme of Owner-occupant SignatureVEE rson C ifyi ead Pamphlet Delivery STATE SPECIFIC FORMS ON REVERSE SIDE ' � enelgyslar.nn;an—rncan.gc.ca • 4 k. r• i •r . Fes• .. a} c IN G. Remove label.atier I"Enal inspection; SAVE lar tulurc reference weather Shleld CFD 050-A-172 p orating c 108 Double Hung P NFR Model8 Alum clad Thermal Frame ch Glazing .... .. 31A In . l-t�: fdF'nt rw+ ZO—E .022 Low— Argon Fill Grille in Air Space ENERGY PERFORMANCE RA-TINGS an rrlpLnl solar H", U-Fecler 0.30 1 �0 SII-P tfklnrl5l ADDITIONAL PERFORMANGEoRtA T•ItN1GS 1'1s161e lrutsmtilaca O f 0.40 tart b wglleshls HFRC pm hit b� eryemu ct HFM1C psn z r )(FRC does 9*1Urrec°n'^'s"d Y reulrcUnt stpultht htl C+tn nsngs the drtstmlotnq.hdt ptfldtcl afsr9T p s�qp�pc Prodrel d.,l ccftc us. Lz1 P1Ddu�'!'d'deec nit•tn+l tnt cutlslttgq a Prodoct rn7 sp Szsd at of rurlre-mmkil cvtdiso+tt and etbnrunet Inbrenreon. Ik mduct p tonsuItmtnuuttamf'tA1+nUnlat°t'WtWw.nlrti.c dt a utnmrnls I.E.C.C. l.lr Udtltntbn R e 11.EC•. C.E.C.. eM1d trxwDt ttvts.z—f7 ' Mr.ls or eseeeicdcdte ticslruu�t H -Lcri r<aa Il S uu lesut.2 torn s1tA"o-qs - H-LCIS 111tTT2e�luZ9A1 U.1 ti�.l.9ryabrd c.drrw.n.h�):S'lu ESc o,ezn ' sto�scot�l�ksto • - . \ The Commonwealth of Massachusetts Department of Industrial Accidents 0 1 Congress Street,Suite 100 _ Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip: ��� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.F�I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q 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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions p netors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� of repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are 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 required.] q` *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. tContractors 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 the policy and job site information. Insurance Company Name: ) // Policy#or Self-ins.Lie.#: �/ Q `� Expiration Date: : ^6 ^!(� Job Site Address:. ( e^'� �Ga%e�%�J9/� 2A,1° City/State/Zip Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).V/.531_U> 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. I do hereby certi&jM�9�—#:Mi�f—andp6nalti'es ofperjury that the information provided above is true and correct. SiLrna 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#: ,aco CERTIFICATE OF LIABILITY INSURANCE °o�4rzo 5°r`""' 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(les)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: MARSH USA,INC. PHONE FA TWO ALLIANCE CENTER AIc No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC A 100492-HomeD-GAW-15-16 INSURER A.Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co 16535 .THD AT-HOME SERVICES,INC. 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Cc 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685-09 REVISION NUMBER:7 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 CONTRACTOR 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 VE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR VrVD POLICY NUMBER MMIDD MM/DD A GENERAL LIABILITY GLO4887714-05 03/01/2015 0310112016 EACH OCCURRENCE $ 9.000,0011 DAMAGE TO RENTFD X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence 5 1,000,000 CLAIMS-MADE M OCCUR LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED . OF SIR:$1M PER OCC PERSONAL 8 ADV INJURY S 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COMP/OP AGG S 9,000,000 X POLICY PRO- 71 LOC S B AUTOMOBILE LIABILITY BAP 293686312 03/01/2015 03/0112016 COMBINED SINGLE LIMIT 1000 000 Ee rodent S X ANY AUTO BODILY INJURY(Per person) s ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Peraccldent) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (per accident 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE S JEXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS $ C WORKERS COMPENSATION WC017731493 (AOS) 03/01/2015 0310112016 X I wesTArTORY I IMIT OTH- AND EMPLOYERS'LIABILITY I ER 1.000.000 C' ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC017731495(AK,KY,NH,NJ,VI) 03/01/2015 03/01/2016 E.L.EACH ACCIDENT $ D OFFICER/MEMBER EXCLUDED? a N/A WC017731494 FL 03/01/2015 03/01/2016 1,000,000 (Mandatory In NH) ( ) E.L DISEASE-EA EMPLOYE $ If yes,describe under Conitnued on Additional Page E.L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS belmv L- I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,A more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi'Mukheoee -MAuoow ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD F,ermtt JArvICBS -/ 4V1 L40 L&$00 p.1 ILN GNe V'260'99� ' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement"Contractor'Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8/312018 RICHARD TROIA --------- 2690 CUMBERLAND PARKWAY SUITE 300 . --- ATLANTA, GA 30339 __ _.....__.. ..... .._.___ Update Address and return card.Mark reason for change. SCA t �� zowto,ii - Address J Renewal ::;mplog"e:cr t J vst C"aru � ___b1-�Office orCunsumcr Affairs&Business Regulation License or registration valid for individul use only 19.RR. 40ME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: `+ Office of Consumer Affairs and Business Regulation 4.s Registration: .126993 TYPe^ 10 Park Plaza-Suite 5170 Ex 'ration:.813!2016 - Supplement Card W PPI Boston,MA 02116 THD AT HOME SERVICES,INC. " THE HOME DEPOT AT HOME SERVICES RICHARD TROIA 2690 CUMBERLAND PARKWAYS A`0k139'A,GA 30339 Undersccrenry Not valid w' out signature 1 �3 Massachusetts - Department of Public Safety "j Board of Building Regulations and Standards Coomr;+nuon Sr+(,rn+.;:r License. CSSL-099823 DZMITRV BROVIN 70 NORTON AVE Manchester NH 03109, ,d Expiration Comm+ss�c+ner 0612612016