HomeMy WebLinkAboutBuilding Permit #793 - 1520 Forest Street 5/2/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued: �' Z
Date Received
L IMPORTANT: Applicant must complete all items on this base
LOCATION Q.ffic":AqIsT
Print
Print
MAP NO/V. � PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes no
100 year-old structure yes o
TYPE OF IMPROVEMENT
PROPOSE SE
Reside al
Non- Residential
❑ New Building
WIne family
❑dition
El Two or more family
❑ Industrial
❑ Iteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
,>
®We lands ' W w
NO®Floodplain
�rshedDistact
DESCRIPTION
OF WORK TI - )'RF. PRRFORMPT). f� ...
or Print Clearly)
CONTRACTOR Name: /�- Phone:��
Address:
Supervisor's Construction License: 1 �Q _ ( _Exp. Date: 'Ply/1,9
Home Improvement License: Exp. Date:
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: $' , FEE: $ �,—
Check No.: ��t1 _ Receipt No.: , e
MOTE: Persons contracting with unregistered contractors do not have access toAi gAari ity fund
ICS
A; -
Location
No. 7WS3 Date_
Check # cl7 v
25258
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Feed
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑Swimming
Art ❑
Pools El
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS,
HEALTH
COMMENTS
DATE REJECTED
n
DATE APPROVED
Reviewed on Siqnature
Reviewed on Siqnature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wafer & Sewer Connection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signa
FIRE DEPARTMENT - Temp Dumpster on site yes.
Located at 124 Main Street
Fire Department signature/date
Located 384 Osgood Street
no
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
I _
Doc:.Building Permit Revised 2011 June/mi
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 .
Doc: Doc.Building Permit Revised 2008mi
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston, MA 02111
• www mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information � Please Print Lea1b11
Name (Business/Organization/Individual):
Address:�
City/State/Zip: aA: �
Are you an employer? Check the ppro
1.9 I am a employer with
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.)
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
5t��
- 3p33q Phone#: 921-6.5 — 57/9
nate box:
4. ❑ I am a general contractor and I
have Hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.
5. ® We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
coma. insurance reouired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. [] Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.[] Plumbing repairs or additions
12.of repairs
13. Other
*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 nameof 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. - - A
Insurance Company Name:
So (. ,
_D...
Policy # or Self -ins. Lrc. #: u1C o 0 7 3 6r I / Expiration Date:
Job Site Address: i t''j(-M4 1e,51 L21 LK, I City/State/Zip:,f pa MLk /
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^3 A for insurance coverage verification.
I do hereby
Official use only. Do not
City or Town:
of perjury that the information provided above is time and correct.
this area, to be completed by city or town official
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 #: '�
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0
A4C"R " CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
02/27/2012
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).
PRODUCER 1-866-966-4654
Marsh USA Inc.
homedepot.certrequest@marsh.com
Two Alliance Center, 3560 Lenox Road, Suite 2400
CONTACT
NAME:
PHONE FAX
AIC No Ext); AIC No
E-MAIL
ADDRESS:
INSURERS AFFORDING COVERAGE NAIC#
INSURER A: Steadfast Ins Co 26387
Atlanta, GA 30326
Fax (212) 948-0902
INSURED
The Home Depot, Inc.
INSURER B: Zurich American Ins. CO 16535
INSURER C. New Hampshire Ins Co 23841
Rome Depot U.S.A., Inc.
2455 Paces Ferry Road NW
Building C-20
Atlanta, GA 30339
-
INSURERD: Illinois Natl Ins Co 23817
INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
INSURERF: Union Ins Co 27960
DAMAGE TOR NTED 1,000,000
PREMISES Ea occurrence)$
COVERAGES
LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS..
INSR
TYPE OF INSURANCE
DL
INSR I
S R
wvn
POLICY NUMBER
POLICY EFF 1
MM/DD
POUCY EXP
MMIDD
LIMITS
LTR
A
.I
GENERALLU►BILITY
GGA A 3
ATLANTA, 30339
GL04887714-02
03/01/1
03/01/13
EACH OCCURRENCE $ 9,000,000
DAMAGE TOR NTED 1,000,000
PREMISES Ea occurrence)$
X COMMERCIAL GENERAL LIABILITY
MED EXP (Any one Person) $ EXCLUDED
CLAIMS MADE � OCCUR
X LIMITS OF POLICY XS
PERSONAL BADV INJURY $ 9,000,000
GENERAL AGGREGATE $ 9,000,000
X OF SIR: $1M PER OCC
PRODUCTS -COMP/OPAGG $ 9,000,000
GEN'LAGGREGATE LIMIT APP LIES PER,
$
LIMIT
1,000,000
COMBINEDSINGLELLE
Ea
RO-
x POUCY PLOC
BAP 2938863-09
03/01/1
03/01/13
LIABILITYacccident)E
BODILY INJURY (Per person) $
x ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
Nx
PROPERTY DAMAGE $
Per accident
HIREDAUTOS AUTOS
$
SELF INSUR3 M PRY DMG
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAR
CLAIMS -MADE
FD
DEO I I RETENTION $
WORKERS COMPENSATION
WC019736915 (AOS)
03/01/1
03/01/13
STAT$
x wRYLIMI - OTH-
AND EMPLOYERS!
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
WC019736917 (FL)
03/01/1
03/01/13
E.L. EACH ACCIDENT $ 1,000,000 0
E.L. DISEASE - EA EMPLOYE $ 1,000,000
OFFICER/MEMBER EXCLUDED?
N / A
WC019736916 (CA)
03/01/1
03/01/13
E
(Mandatory in NH)
E.L. DISEASE -POLICY LIMIT $ 1,000,000
Ifyes, describe under
DESCRIPTION OF OPERATIONS below
E
Workers Compensation
WC1192494 (QSI)
03/01/1
03/01/13
SIR (AOS)/SIR (GA) 1M/750,000
C
Workers Compensation
WC019736918 (WI)
03/01/1
03/01/13
F
Tx Employers BS Indemnity
TNSC46566397 (Tx)
03/01/1
03/01/13
Occurrence/SIR 30M/lM
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
RE: EVIDENCE OF COVERAGE
GEKTIHL;A It: nULUr-K
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
THE HOME DEPOT, INC..
ACCORDANCE WITH THE POLICY PROVISIONS.
HOME DEPOT U.S.A., INC.
2455 PACES FERRY ROAD NW
AUTHORIZED REPRESENTATIVE
BUILDING
GGA A 3
ATLANTA, 30339
USA
�,1wT1Aw1 A11�w1.1e. nrl
Yi.
ACORD 25 (2010/05) The ACORD name and logo are registered markt V ACORD.
Jthornton_hd
25776028
Uflicc of(`uusumcr:lfGiirx S Rus/incss Itr„u ,�tiui�
I7'
sir ''HOME IMPROVEMENT CONTRACTOR
t q = Registration: 126893
TYP'
Expiration:
8/3/2012 SUpplement
The Home Depot IAt-Home Services
RICHARD FALLONE
2690 CUMBERLAND PARKWAYS
GA 30339
1 �nder'sccrctary
Al
�la,•achu•rtt:; - Dchurtmcnt 'ifPUI11ic S::i'et%
Board of 6uiltlia�, Relrulution.:ut�[ Sruttlurth
+ Construction Supervisor Specialty License
License: CS SL 1OC696
Restricted to: WS
ALAN PAINTEN
11 16TH AVENUE _
HAVERHILL. MA OIGSO
Expiration: '8/2112012
('nunaisviunrr r Tr:`: 100696
y
Apr 03 12 08:12p p.1
HOME IMPROVEMENT CONTRACT
PLEASE, READ THIS
Sold, Furnished and Installed by:
>3ttan Nazme:�Boston Date: THD At-HomeofAt-Services, Inc,
�Ai–�'� /��� d/bla The Home Depot At -Horne Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657-5182; Fax (508) 756-8823
Branch Number: 31 Federat M # 75-2698460; ME Lie # C 02439; RI Cont- Lic# 16427
t CT Lic # HIC.0565522: MA Home Improvve/ment Contractor Reg. # 126893
Installs ' n Address: t SZ �U( ST /V,�Pf�
(L ( !td (� SZa Szu V?y rk A. ace at'/ � p
Purcha-s(s): Work Phone: Home Phone: Cell Phone:
� � O C23�- co4(35-0
Home Address:
(If different from Installation Address) City State t� n,rTrp ,(
E-mail Address (to receive project communications and Hoe Depot updates):
b0 ulNOT wish to receive any marketing emaib; from The Horne Depot
Mdinformation: Undersigned ("Customer'), dee owners of the property located at the above installation address, agrees to buy,
RHAD At -Home Services, Inc. C 71he Home Depot") agrees to furnish, deliver and arrange for the installation ("Installation") of
all materials described on tele below and on the referenced Spec Shect(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!'): o�,fr e-.0
-L 7 -7
JVU m: l.mp,ui ne,mvee,
!ltoc:fing
Ip 66
rrVO•lC6-
Siding aQmrudows ❑ Insulation
❑ersGur/ Covers ❑Entry Dooxs ❑j
___- _
S
I
Roc-fmg USiding Windows LJ Insulation
$
❑Csutters / Covers []Entry Doors ❑
Roc-fmg L3Siding ❑ Windows ❑ Insulation
$
❑Gutters /Covers ❑Fr ry Dors ❑
Rot.fing Siding Arwdours Insulation
$
❑Gutten / Covers ❑Entry Doors I3
Wmimom 25% Deposit of CaitraciAmourd dote upon enctnion of this centrad.Total
Contract Amount
Maim Purdtasats may not deposit more thanaaethixd of the ContradAmoont
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 prodder determines that it cannot perform its obligations due to a structural
problem with the home, em iroamental hazards such as mold asbestos or lead paint, other safety concerns, pricing errors or because
work required to complete dee job was not included in a Contract.
Payment Summary: The Payment Summary * , 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 througb the date of termination, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE ROME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOMY. DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WIT19OUT
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 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.
Aceep 3 a–
Ctrs mer' Si a Date
Customer's Signature Late
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE. ,
NOT X: ADDITIONAL TERW AND CONDITIONS ARE STAT
Submittl_w_�>
2
X
Sales Consultant's 5ignaFure O Date
�`�t + f" F
TelephoneNo. � t--C>a
Sales Consultant License No.
(as applicable)
ED ON TILE REVERSE SIDE AND ARE PART OF THM CONTRACT
10-18-10 CSC White—Branch File Yellow—Customer
HP Officeiet J3600 series 33630
Personal Printer/Fax/Copier/Scanner
Fax Log for
Richard Fallone
4014531367
Feb 07 2012 5:32p
NOTE: Blocked calls are
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this report.
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Last Transaction
Date Time Type
Station ID
Duration Pages Result
Caller ID
Feb 07 05:31p Received
15032780709
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Feb 12 2012 8:32p
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4014531367
Feb 12 2012 8:30p
(Last Transaction
Date Time TtIpe Station ID Duration Pages Result
Feb 12 08:30p Fax Sent 14012462868 0:36 0 Error 387*
a A communication error occurred during the transaction. Tru again.
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