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HomeMy WebLinkAboutBuilding Permit #1118-15 - 1600 GREAT POND ROAD 6/29/2015 � NORT{N q BUILDING P ERMIT 2o�t,Eo �b16tio TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received 7,4 A�RtieD�fp�(�J SgACHUSb Date Issued:---w-M IMPORTANT:Applicant must complete all items on this page LOCATION y� Print PROPERTY OWNER Pel' Print 100 Year Structure4yeno MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Villa TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑ teration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �>Septic ❑1Ne1h T' ❑,Floodplai.n 1 Wetlands - ❑ Watersf ed District. D.Wates/Sewe:r S J D SCRIPTION 0F.00 T S E ERFORMED: >� �5W&71))ZAZ Identific on- Please Ty a or Print Clearly OWNER: Name: gex �-fl/li �Z� Phone: Address: (2A /V AAA h*mL, ®� P — Contractor Name: �` r Phone: / Email: Address: Supervisor's Construction License: �f Exp. Date: Home Improvement License: �/ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �" �� FEE: $ Check No.: �4- l�,Receipt No.:�= 9 NOTE: Persons contracting with unregistered contractors do not have acres o t -Aruaran f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION Reviewed on Siqnature 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 ConnectioniSignature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREDEPAR M IVT` Tern` um"sten rir �4.-� ie, �� _. �..�. .43-x. -76,1a. 90- ,"7 .:F ttp F ,.w ti''yey, �t.� i:..,. +..m. ��..,.., Vii'• tiLcad(at` 1�2MaiStr.e" ,c i35,ire�,t+�De artmeM s nature/.date° p. �9... g .=g -- y .,rF- 1�_-., r' ��rt '`-- - +try- �a .Yo-d.-•— - ,tg. •P..} P..-f-.d_'t. F - ` - . y; 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 DAGGER 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 Call Email Date Time Contact Name Doc.Building Permit 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 4� Building Permit Application 4. Workers Comp Affidavit 4, 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4, 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/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 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 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:Building Permit Revised 2014 Location No. { U t Date . • TOWN OF NORTH ANDOVER . Certificate of Occupancy $ E Building/Frame Permit Fee $: Foundation Permit Fee $ Other Permit Fee $ `� TOTAL $ Check# 2b9: Builydcd g Inspector NORTH Town of 2 E 1, Andover O R+ No. h ver, Mass, , Vt '(L �► A- COCNICMIWICM �1• 7�A�aAT E D S U - BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System A vA ZZ a THIS CERTIFIES THAT ............ .........,� ..l.!� � BUILDING INSPECTOR .... ............................... .. ................... 1"14 Foundation has permission to erect ..... ................... bui dings n .j. .... ... ................. ... ......... Rough tobe occupied as ........ ..... ........�L.................................................................................................. 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 CONSTRUCTION ST TS Rough Service ..................... ..... ... .. . . Z�d6NING ..................... Final 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. HONME,IMPROVEMENT CONTRACT PLE'ASF.READ THIS Sold.Furnished and Installed hr. Brunch Name:floslon North R South i)ate: 5^/jQ/ THD At-Home Scr- ice:.Inc d/h/a The Horne Depot At-t•lome Ser-,icey Branch Number:31 and 33 908 Boston Turnpike,Unit 1.ShreusNwry.MA 0154; Toll Fre'.577-1h').1-:765 Federal ID#7;269SA60'.ME 1_ic#C 0=11 9:RI Com.Lic-1642-7 n Cf lie#1,1IC.0$65522;SIA Home InilmiNenieut Contrtetor Reg_#1''-6891 Installation Address: J C�_ re�,°� j Q��qs� City' State Zip Porrhsicer(. ): Work 1'htme• Home Phone: Cell Phone: - [gt�16 -13�9 [97b-]3P7-1vao ' [ 3 I°fame Address: -----_------- 01"different from Installation Address) City State Zip 11-"Jalf Addrec%tto receive project coinnunications and Home Depot updates): 1 DO NOT wish to receive any marketing entails from The Home Depot !Information: Undersigned("Customer").the owners of the property located at the above instatlntion address.agree?to buy. anti ID r\t,t•lonu:Services.Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation(-*Installation")of all materials de<crrhed on the below and on the referenced Spec Sheci(s), all of which are incorporated into this Contract by ihi refcrcnce.aloin with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively. "Contract"):- Job#: Products: Spec Sheet(s)#: ProjectArrurunt Q Q 7 r _tatfine Siding Wnutrnvs Insulation i S i V X0 ) �t /�t76 ❑Guuen/Covers Entry Door. ❑ 3`033,F" i Roofing OSidinv 0 1Vuidrnvs C1 insuL•nitm j S ! � DGuuen/Coven ❑&i y Dtmin ElI Rimifing OSidingO Wnrdo%vs 0 Insulation j S j DGuitem/Covers DEnuy Doors D 1) Rtu'ring osidilig Windows insulation i 5 DGuttt:n/Coveys DGnn)Dtmirs Q t l h1irrimuni 25%Mrisit of Contract Amoual due upon c'Nectition orthis etmrract. Total Contract Amount $ l Maine 11un'lutset's nray not delurvt nuin than cuimltird of the Contract lnumint. Ctistonicr agrees that, inmtediaiely upon completion ol'thc work for each Product. Customer will execute a Completion Certificate (pile for each 13rocltict as defined by an individual Spec Sheet)and pay any balance due. As applicable.each Customer tinder this Contract agrees to he 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 aervice provider determines that it cannot perform its obligations due to a strti Lural problem will%the home.environmental haiards such as meld.asbestos or lead paint.other sarety concems.pricing error,or becauae- work required to complete the jot?was not included in the Contract. Pavinent Numniarv; The Payment Sotnmary M,_,/��Q?�_�_ . included a., part of this Contract. sets ft-+th the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE.TO CUSTOMER You ore entitled tog completely filled-in copy of the Contract at the utile you sign. Do not sign a Completion Certificate i note: there is one Completion Certietcrte for each listed Product as defined by indiiidual Spec Sheets)before iAork on that Product is complete. In the event of termination of this Contract.Customer agrees to pay The Home Depot the coals of materials.labor,expen.cs and services provided by]'he Home Depot or Authorized Service Prouder through the date of termination, phis ani other amciunts set forth in till%Agreement or allowed under applicable law. THE HOX DFPOT MAY lV 1THHOLD ANIOUN-r,% Otl'E;D TO THE HOME I)EP(.)r FRON4 THE DEPOSIT P:\YNIENf OR OTHFR PAYMENTS JIADE, WITHOUT LIMITING]'Ill-HOME DEPOT-'S OTHER REMEDIES FOR RECOYERA•OF Sl'C H AmOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire nyreemem betiwcen Customer and The Home Depur with regard to the Prixlucts and Installation services and supersedes all prior diwwu mon,and asreemem:.,either ural or wrii'cn.refulin,!10 said Producls and installation.fibs Agreement cannot tk,as,igned or amended ewcept by a"bang i_aed hi Cu �r:ot 77he Home Di,pol.Customer acknowledges and agrees that Customer has read.understands.ioluntarilw accepts the tc sof and t eceivel a copy of this Agreement. 5uhnutled Customer$CulgnalUTC D:+te Sates Consultant's Simi- e I ate Telephone:Vii.�/ ,= 2 q,_2 Sales Consultant License No. CANCELLATION: CUSTOMER CUSTOMER MAY CANCEL THiS AGRE:I'::'1iENT WITHOUT PENALTY OR OBLIGATION •' BY DELIVERING WRITUN NOTICE TO THE HOME DVPOT BY (MIDNIGHT ON THE THIRD BUSINESS DAY AF`PE.R SIGNING THIS AGREEMENT. THE STATE. SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS :,Yt.t iFff.Ai I.Y PR<rSCRIBE:D BY LAW IN t t S I"1 A Il R S STATE. a.r)til:.AnonTioNh).IVAMS AM)CQNDM014S ARF.STATF.t)trN TtIF:REt't:RSE ti1Dk ARID ARE PAR'f f)F THIS(Y)\T1tACT 1 ',s.glis white-Branch File Yellow-Cuslomttr ----- 11 c. -\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 _ www.mass.gov/dia Workers' Compensation Insurance Affidavit:Buil der s/C o ntr acto rs/Electric ians/P lumbers. TO BE FILED WITH THE PERMT=G AUTHORITY. A licant Information Please Print Le 'blv Name(Business/Organization/Individual): Address: City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.7 1 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.Q 1 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. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ lee cal repairs or additions p n tors with no employees. 12.Q P mbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.*-. 14.E]Other 6.Q 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'comp.insurance required.] `Any applicant that checks box nl 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 contactors 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-contactors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. /t/ Insurance Company Name: Policy T or Self-ins.Lic.n: 155:0?2 Expiration Date: 6 �/ Job Site Address: City/State/Zip z �i Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiration date). 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 and naNg erjury that the information provided above is true and�cL Sierta Date: I Phone n: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitUcense# .i 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 tt: 4 Fermat JBrvices / 4U1 Z40'006 p.L r, 1 -, &Xe �/V{/L�i'�C/tf Z"�V-C/��/ ti �'i./taw-0 (/LV.j'V(/V.i• Office of Consumer Affairs and Business Regulation A 10 Park Plaza - Suite 5170 Boston Massachusetts 02116 Home Improvement Contractor'Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 6/312016 RICHARD TROIA -------- 2690 CUMBERLAND PARKWAY SUITE 300 -- ATLANTA, GA 30339 _.....__. ......._.___ Update Address and return card.hiark.rtason for change. Address �J Renewalnplo}t::r:; J cmLatc - " Office of Cunsurutr Art'airs&Business RegulationLiceast or red stration valid for individul use only ��5b®WOBtE IMPROVEMENT CONTRACTOR before the expiration date. [f found return to: Office of Consumer Affairs and Business Regulation Rcgistration: .126593 Typc: 10 Park Y1aza-Suite 5170 Ex 'ration . &32016 Supplement Card Boston,MA 02E16 • THD AT HOME SERVICES,INC. THE HOME DEPOT AT P0ME SERVICES RICHARD ERLA ROIX 2690 CUMBERLAND PARKWAYS �-c---�6•��— ,/� A°IL�t�`A GA 30339 Undersecretary Notvalidwi outsignature it `. ---...._-..._..__....---•---....-------•----------------..._... .. ...- ---- --- ...f - - - - r ' ucwu, nup:�i�ucense.cns.�talG.illil.tlJ/Vr'll"ntIULUV abps:a6®uuy_nx... The Official website of the Executive Office of public Safety and Security(EOPSS) Mass.Gav Home State Agencies Licensee Details Demographic Information Full Name: RICKY SOUTHERS Gender. caner Name: License Address Information ddress: Address 2: City: Salisbury State: MA ipcode: 01952 Country: United States License Information License No: CSSL-105993 License Type: CSSL-RF-Roofing Profession: Building Licenses Date of Last Renewal: Issue Date: Expiration Date: 3/14/2017 License Status: Active Today's Date: 9/15/2014 Secondary License: Doing Business As: Status Change: License Issuance i Prerequisite Information Licensee: SOUTHERS, RICKY Relationship: Attribute Of License No: CSSL-105993 Discipline p� No Disci line Information Documentum Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us lofl 9/15/2014 8:57 AM Permit Services 401 246 2868 P.1 AC�R ® CERTIFICATE OF LIABILITY INSURANCE j o0ATE 2252:+15 JMMMDVYYY) 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 13Y 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain pclicfes may require an endorsement A statemont an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .PRODUCER CONTACT MARSH EISA,!.NC. NAME: _. -.___�-. - TWr,AIIASCC CENTER PHONE 3560 LENOX RCA D.SUITE 24CO IL AtcCigL_,_—_---.. ATLANTA,GA 30326 goagESS;----__ _--- IN$URERISIAFFORCNNGCOVERAGE I NAIC t� 10045"j_HomDC•w+'b`•1�-16 INSURERA:S:ea:1'asl ln,mice Corr -y ---._..._._...'2633'^--- ". INSJRED THEROVEDEPOT NC. 'NsuRERB:Zur'chAlro::tac! surlr•,ceCo ;t6:55 HO'AEDEPOTL'.S.A,INC. INSURER C; '.'S CO 23S4i 2455 PACES FERRY ROAD,N;VINSURER o:C6ros Nm cna!o suranco Ccrp ry BUf,-GING C-20 - -- ATLANTA.1'A 30:39 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003155301•oi REVISION NUMBER:0 THIS!S TO CERTI%Y THAT THE POLICIES CF INSJRANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL'CY PERIOD INDICATED- NOT.^ATHSTANDING ANY RECU!REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESaECT TO IMHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE -ER1/S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LWITS SHOM MAY HAVE BEEN REDUCED BY PAID CLAIE.!S. POLICY'YUMBER MMIDDIYv NMrODIYYYY :IMITS WSRR TYPE OF INSURANCE (AODLs TFOLICY EPOLICY EXP-i -11, GENERALLIAMUrY I IGi.C4M77.4-05 'n1S(1C75 C3.0117C10SGGOC-0D EACH OCCURRENCE J S X ?COJIAERCIAL GENERA I 7 V:.M--E' R_ _._. .X. C I FR _M(S-Slraptrsrrence :CLAIMS-.MADE (_I OCCUR ! LWIT„OF POIJCl XS C "r_XCL'J D U_OEXP;A:p,eperccr) 5 ' IFR CCC'OF SIR:51M I - °ERSONAlBAOV Ifti WRY i s S.CGL•COD 1 GENERALA�_.GRE-GATE I S ..- .030•C+03 GEN'L AGGREGATE UNT APPUE5 PER: i `.___-__-- �; II°R00VCTS-C07APj0P AGO 5 -----_- C.OW.00O x POLICY 1 rsR� I LOG B AUTONOBILEUAWLM I 'BAP2938663.12 iolo=15 ar,I;rJ16 cOMBIN-0SINGLE_:MIT Ea atd]cr..+ g 1 v7J ICG IX I „1'--'---- - ..-------------- ... ! ANY l.'JTO � I UV.ILYINJURY 1VEr DErsom 5 ALLOWNED SCIECU:EO ` ' .-•. _.__...,.._ AUTOS — Aures SELF INSURED AUTO FHY DUu ! BOC_Y Ir:1JRY(peva caul; s 'HIREDALR05 AUTOS NON-OPMED ! I rP Ga RTv,krAaGE I I aE..denl S _F S UMBRELLA L:ABOCCUR I , I I EACH CCCL MENCE !EKCESSLIAB .---_-..—.._.._.. .-- _ C:J+It15->,!aDEj i I i G3EGATE I� DED RETennoms C :WORKERSCOMPENSAnoN I N'C017731693(AOS; :0101!201 OK112016 X WCrs TLV. HH-. +ANC EMPLAYERS•UABILRY I Fa C' ANY PROPRIETOAPPARTNER&XECUTIVE YIN I ' IWC01773t485(AY. 'T1 i0?(OIr2D15 IGYM2016 11laU3•!. i S ----- . D OFF:CERME4ABSR DfCLUDEO1 { :V IIN/A � I __EAG.ACCIDE N7 --`.. 1,000,Cl3 (Mandatory in NH) l� 1^7Cul773TAS4(FL? E,L.DISEASE.61 EEAPLQYEE'S 1.000.000 It yEs.Cesvft w4er I ....._. 0-SCRtPTOH OF CPE ONS DeEw f j��^'-ro!n6Cd On AS�il Tal Page _.L.DISEASE•POUCY LIMIT IS 1.DOG•�CO i - I I OESCMPnCN OF OPERATIOVSI LOCATIONS 1 VEHICLES(AUaeh ACORD 101,AdGlNanal Romaft Schedule,it more spate is mquiraol CERTIFICATE HOLDER CANCELLATION "OWN OF NORTH ANDOVER i60005S00D SI. SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER.VA 0184= ACCORDANCE'NITH THE POLICY PROVISICNS. AUTHORIZED REPRESENTATIVE of Marsh USA Ina M1M7Shi UIu;cIM�CO �]'`AVILpLu .-11Q,�a.{�_aµijgy ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD