HomeMy WebLinkAboutBuilding Permit #260-14 - 14 PARK WAY 9/19/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �`r b Date Received
Date Issued:
14PORTANT: Applicant must complete all items on this page
LOCATION _
- -- 4n
PROPERTY OWNER
D4
Print' 100 Year Old Structure yes
MAP NO: PARCEL ZONING DISTRICT: Historic District y no
Machine Shop Village.. ye_ no
TYPE OF IMPROVEMENT PROPqgD USE
Res' ential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑A;/ration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain o Wetlands ❑ Watershed District
El Water/Sewer
DESCRIPTION OF WOR BE PE ORMED:
- lde i tion ase T pe or Print Clearly)
OWNER: Name: Phone:
Address:
.A DW16, klw �Y,=
I KI-7
CONTRACTOR Name: 4Phone:
Address: ae
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to e aray y fund
Signature of Agent/Owner Siggature of contrasty
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sta ped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF-SEWERAGEDiSPOSAL
Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑
Well ❑ Tobacco 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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
4
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
PlanningBoard Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Tow;! Engineer: Signature:
Located 384 Osgood Street
(FIRE DEPARTMENT - Temp Dumpster on site yes no .
Located at 124 Mair Street -
Fire Department signatu-re/date t
}
COMMENTS
f
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
I
Doc.Building Permit Revised 2010
Building Department
The folbDwing 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm-tted with the building application
Doc: Doc.Building Permit Revised 2012 .
3'- �� :i Public
♦y VY .�.+3:+ 'a.'i� w.iSa�" * pr� t�+ L� bi T 5.�3i 1 �1 `y
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11 16- AVET
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IEX pi ration
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E
� NORTF�
Town of E ,, Andover
o T
14
*� h ver, Mass,
A- COC NIC Ml wKK �
7S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ............ .. . ......... . . .. ...... .........................................................
BUILDING INSPECTOR
has permission to erect ....... buildings on Foundation
�� Rough
to be occupied as ....(.a).. pdo*oa................................................................................ 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 CONSTRUCTe
RTS 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
_ ;:__
The Commonwealth of Massachusetts
! r
Department of Industrial Accidents
Iw Office of Investigations
600 Washington.Street
1 Boston,MA 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: 26,q.GLC X,
=JJ M", , - I W
City/Sta /Zip: Phone#:
A4yon employer?Check the appropriate bo . Iype_of project(required):
a employer with 4. I am a general contractor and I
employees(full and/or part-time)"-* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner-: listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, E]Demolition
working for me in any capacity. employees and have workers'
• # __ - 9._❑Building addition
_. -. - [No workers'comp:insurance__ --------.._-------.:_ .
required.] 5. E] We are a corporation and its 1Q.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11:[]Plumbing repairs or additions
myself.m se ' . right of exemption per MGL
Y �o workerscomp. 12.E]Ro epaus
insurance required.]t c. 152, §1(4),and we have no 13. Other
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.
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 far my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 ag ',akst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D f insurance coverage verification.
I do hereby certify nder a ins d e aloes of perjury that the information provided above ' tru and correct
Si ature: Date:
IVPhone#: - tz
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#:
oa
CERTIFICATE OFLIABILI INSURANCE 02,27013
THISTif1GATJ:IS ISSUED AS A MATTER Of INFORMATIONONLY 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 pclicy(Ies) must be endorsed. if SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may requlre an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
C NTA T
PRODUCER NAME:
F
MARSH USA,INC. PHONE C No:
TWO ALLIANCE CENTER
3500 LENOX ROAD,SUITE 24W a MAIL
ATLANTA,GA 30326 INSURERS i AFFORDING COVERAGE NAIL 0
Steadfast Insurance Company 26381
100492-HomeD-GAW-13.14 INSURER A: 16535 ..
INSURED INSURER I:Zurkh Amelfcan insurance CO
THE HOME DEPOT,INC. New Hampshire Ins Co 23841
INSURER C
HOME DEPOT U.SA,INC. 116no's National Ins Co 23817
2455 PACES FERRY ROAD,NW INSURER D
BUILDING C•20 INSURER E
ATLANTA,GA 30339
INSURER f: •
COVERAGES CERTIFICATE NUMBER: ATL-00315954504 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 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 OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTH TYPE OF INSURANCE POUCYNUMBER MM10D MMID LIMITS
GLO488T714-03 01'01/2013 . 0310112014 EACHOCCVRRENCE s 9,000,000
A GENERAL LIABILITY !' 1,C00,000
X c 6
COMMERCIALGENERALLIABILITY R E EXCLUDED
CLAIMS-MADE a OCCUR LIMITS OF POLICY XS MED EXP I orw arson S
OF SIR:SIM PER OCC PERSONAL 6 ADV INJURY S 9'�'�
GENERAL AGGREGATE
PRODUCTS-COMPIOPAGG S 9'�'�
GEN'L AGGREGATE LIMIT APPLIES PER: 6
X POLICY PRO LCC I 10 03/012013 0/0112014XEMNd0 SIN 1 1,000,00
8 AUTOMOBILE LIABILITY 8AP2° 863 '
BODILY INJURY(Per persoh) S
X ANY AUTO ---
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per wdderd) 6
AUTOS NON-0WIED _ R nOAMAGE 6 !
HIREDAUTOS AUTOS S
UMBRELLA LIAe OCCUR EACH OCCURRENCE S
EXCESS UABAGGREGATE S
CLAIMS-MADE
S
OED RETENTION SWC STATU• 0TH'
C WORKERS COMPENSATION W 33575 14(AOS) 03!0112013 031011201 X
AND EMPLOYERS'UABILITY YIN WCOWS315 AK. 0310112013 0310112014 1,000,000
C ANY PROPRIETORIPARTNER/EXECUTtVE ( E.L.EACH A(xIOENT 5 _�
OFFICERIMEMBER EXCLUDED? Q NIA WC033575316(FL) 0310112013 031018014 EL DISEASE-EA EMPLOYE S 1' '�
D (Mandatory In NMN 1,000,000
Ues,desaibe under EL DISIT 5
EASE-POLICY LIM
DESCRIPTION OF OPERATIONS below 1,000000
C WORKERS COMPENSATION WC03357531T(KY,NC,NH,VT) 0310112013 0310112014 (EL)LIMIT
C WC03351M18(NJ) 03101/2013 0310112014
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addltlonal Remarks Schedule,If mon space is required)
EVIDENCE OF COVERAGE "
CERTIFICATE HOLDER CANCELLATION
THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
'BUILDING C20
ATLANTA,GA 30339 AUTHORD:ED REPRESENTATIVE
or Marsh USA Inc.
Manastd Mukherjee
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD
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_ ,QfCice ui�anstcme-A rtatr,lis witness RzgUlat+on ,fC2ri5'Gr re5is#ri� to11 aii�,a .ind���
befo,ebeatir3titan date irzo=�n�retuinto .'•.'.
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068E 1ivillk EMENT 7P� CTORof Consum�i Affa�rr�iid 's�?ecut. tion
" Type XOPartPiaza=5urte'571�''
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,`'f AN9�r,GA;303. ^�Uodecscceetary .. �
SEP-10-2013 09:39 From:KEN SANDELL RSW 603 782 8726 To:Home Depot AHS P.1/7
ot �. Lr ..w. .+ .• .:r t
NOME IMPROVaWNT CONTRACT
PLEASE READ THIS
44 {3 Sad.rwrnfdmd and Installed hy:
$rnaGb N1 Dmix 17aaim North do Swath 1?aiea � THE?At-How SwAces.hie.
dmra The HaatC Depot AWbu,a Services
Mauch Nonhber.X Rad 33 908 6o9 w Mp rnpikc-Unit 1.Sbrowabaty.MA 01545
TOA Floe 877903.3768
Fbdwd 1D#754V0$4ft MEUc*CMM FdCkm Uco16427
i W f} Cr1ac•H,CA5403zZ:ilei►Eiarc lo>pmwnent t7aapmtxae ikF a 143
,aslallauaaAddrem: �..,�'Ae� �' :'� ._Pl+v�fbV@1� lY1/� Or$t(S
� Sim* ZIP
PattEaasris)s WeekPtaowt itemphaae: CeQE'hanr
hbrj 4-Kcft"TeT- -- [ ] C 7� T3�FH�r T103 19130
Home Address; .. ...� •-
(if dilrerent from Installation Adderm)� City S S�tatpe Zi
)�Saali Addattas(to raoaiva project conttnuaimdons and Home WPot RpdAte3Y P=♦ p
[[JJ I DO NOT wish to receive any markWng comic,from The Haste Depot
Pio t faIlan: Oaatiasigned t CusfOattT°'?.the olrutrs of the property lw�ted at the above Irtslailadoo addr..,now to bay.
and 11tD At Hams Sswites,100-t"771C Hume lkpat')agree to fimnW dollvar ad arrwpa fat the installation("Inswint en of
EM mataislf 00CIlbed an the below and an the ta:jrr Qed Spec Sttoet(s),all of Which are in ted into this Contract by this
W g with any applicable State Soppltamt and Payment Summa-noodled herM mod any(Stange Oadem(collectively.
jobtk tusa,hner.w+w orfs StaeeSFteeust YrgtecaAttrnhaal
`�• DRuotlaS�Stdiag tedaaa d Ltautattaa
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'•00wimtCb9as OFAtryDmft p_._ 5
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10GOWIC&M OGWyDoas 0—
ToW ContraetAmomrt $
btdaePuirat�may sot deprtsa rose uw,aoettdr,t erten t3anarad t.00ad.
Customer ogees den.hnniedimdy upon completion or the work for each PMdW:I,CtuaomW will ettixtile it CmIpWiou Ckfxll="
(arc fi:ezb Product as defined by an individual Spee Sheet)and pay any bola,tm due. As applicable.each Cesium tender our
Montreal Agnes to be jointly and WvmIly ubligraed curd liable hermader.
The Home Dcpot reserves the right en issno a Change Ordcf or tcrmiaate Utas Centrad army individual Product(s)included hcf,dn,of
its disc cn.if The Herne depot ar is asnimmimA savim provider detamiurx that it cannot park"its obligations due m a struetwnl
problem v&h the home,emkomnettal hazards soh as mokf,asltlftaS at had paint.oma safety cone ms,pricing mars or because
work rcgttited to complete the job ares not included in the Cm=*,�$ a
Pa�mcmt.,hanmarv: The Payment Sumurrn Nincluded as part of this Contract,sC4a'Ibrdt the total
Chaotic[amarart and payments fegmrW for the deposits smd Finat payments by Product(as opptimbicL
NOTICE T O CUMMER
Yea are cnutk'd to acampfet*Gtleddn copy of fire CAatrad at the tante yyowustj;ta. Do nal saga a Coaaplett®Ccrititentc(motet
chart is one Cbmplcdm cerillieate for each listed Prodact m dellen-d by IrAwhltaal Spec Sbeets)before work an am Product
to Complete.
Ea the event or terminnu m or this Cm rad,Cummer agrees to M The Haase Depot the costs or am1trials,labori a wean
and lmrvkvs piqvided by The Rom Depot or Authorlmd Sordes PmvldW thttuxl;the date of terWoodom,PW any albar
amounts set forth In this Agreeumbt or allowed under applicable taw. THE HOME DEPOT 51AY WITHHOLD Al►IOU.N FS
OWED TO 7ilE HOME DEPOT T.1tfINT THF DEPOSSiT PAYMENT OR OTHER PAYMENTS MADE,NVMIOtr1'
LlhI1TWG THE HOME D1t MMS OTHER RF-%I DMS FOR RECOVn11Y OF SUCH AMOUNTS.
and AtrtMw3 tihaa: Customer agrees and understands that this Agrcanant is the cadre agro m m bemeen Customer
ant a roan Depot wo regxd to the Pmduttf mad 1=11mim services and supersoft all ar discussions amt agreements.either
ora!or written,telating to and FmdoW and tact ddiadar.'rids Agia���naI canna be oss=a omaadad except by a writing signed
by Cumomer,and The Hans Depot_Cuatarner acknowledges and agrees that 0womer has read.undumands vnluntprily aceept_t aha
teat w of aro!has mu ived s copy of INS Agzheetttam.
by: _ I&ttandilttl
xl 0%1411
�hstama s Sigaatute Ome / I Saha Consultant's Stvmum Wee
s7 i- SN V
Custahnces SFjoatare Date Saki Coastttaat>ritxtuic No.
gANCF.I, T1QN: CU$1"IER hLAY CANCF,1. THIS
AREEOITENT Wi11fOL7 PENALTV OR OBUGATION
nv DE.LIVERING WRITTEN NOTICE TO THE HOW&
DEPOT BY MiDNICHT ON THS 'TMM BMN1•SS
DAY AMR 61CP9 G T#W ACPRR MgKT. TOE
STATE SUPPLFAIW r A t l ACHM HERETO
CONTAINS A FORM TO USE IF ONE IS .
SPWIFICALLY MFSCR1 ZD By WV IN!
CUST'OMER'S STATE. I
Ne>YtMAbbMDNALTMtiANDCONMTIOkttARSSTATEDONTalcI99V R lggUCAltDAUPARTOFTt1ISCONTRACT
ta6orts wxQo-�oncn>�, ret+..- � .
Location LbU
No.
Date
�
• - TOWN OF NORTH ANDOVER j
'W Certificate of Occupancy $
Building/Frame Permit Fee $
�] - Foundation Permit Fee
Other Permit Fee $
kATED, TOTAL $
Check#
26 .4 Building Inspector