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Home My WebLink AboutBuilding Permit #478 - 162 HAY MEADOW ROAD 12/26/2006 L TOWN OF NORTH ANDOVER OORT#t APPLICATION FOR PLAN EXAMINATION ot,t�■� ? o 10- 9 Permit NO: Date Received � M.� Date Issued: �1Sc1H4u5 IMPORTANT:Applicant must complete all items on this page LOCATION Re?, Afy I,&) &do i Print PROPERTY OWNER D 1�77ILE2 Print MAP NO.:�u PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ne family ❑ Addition ❑Two or more'family El Industrial [k'A*'1_teration No. of units: J ❑ Repair, replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED F/N1Sr� fia ,ter resr�N�7 le as l��n,Y 4t6?7&T F-rn7ls6A S ski, Z83 S:2�Yl— rA-ro aA 6F o1%)L Identification Please Type or Print Clearly) OWNER: Name: '(,� �'17�t Ez�1 � SL= Phone: qN69'7-41Z46— Address: //&V 9 7'NZ46— Address: �/&V �' 1 2 [-ftow) CONTRACTOR Name: dl ;Dn, Phone: ' - "-1a0k) Address: (?lpQ 7�iy?)&r Q- rjJ&1r7A� Supervisor's Construction License: -7 043 Exp. Date: ��" `07 Home Improvement License: /371 Exp. Date: & ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.S12.0VER$1000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ f 762" FEE:$ Check No.: 3 Receipt No.: f qO Page 1 of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ ❑ Tanning/Massage/Body Art ❑ g Public Sewer Well F1Tobacco Sales ❑ Food Packaging/Sales '❑ Permanent Dumpster on Site El Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the uarant fu d III Signature of Agent/OSignature of contra to Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans laps ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DA PPROVED HEALTH El COMMENTS r FIRM. DEPARTMENT - Temp Dumpster on site yes no z Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit Buildin Setback Front Yard Side Yard Rear Yard Required Provided Re uired Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use r Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created IMC.Jan.2006 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 1, ❑ Copy of Contract j ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 Location/A / P/ No. T Date MORTq TOWN OF NORTH ANDOVER 3�o't•``o,•,ham°c to * ; ; Certificate of Occupancy $ sAna^ c Building/Frame Permit Fee $CHUS Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ Check # 19896 u 'bdilding Inspector NORTH Town of Andover 0 No. y �8 z ,�G• a� 1PL -L- .... ..- 0 over, Mass., 0 A 4 '�OCHICHEWICK 0"�ATED'o % BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...--ed........e Foundation has permission to are ........................................ buildings on..1,:e#2... W..AZ Rough to be occupied as... ... ......... . Chimney i*1W1*W0.....r........RA-0vt provided that the person accepting this permit shall in everyorespect.-conform...to....t.-hr.-teArm.-isrof#tohlejrlicaii.o.n#opn..IJ- Final 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 op PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR UNLESS CONSTRU jll�� Rough T ....... ... Service BUILDING INSPECTOR Final ' Occupancy Permit Required to Ocmpy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a binding commitment unless and until it has been signed by the Contractor and the Customer. Contractor: Owens Corning Basement Finishing Systems a division of Bay State Basement Systems,LLC. 60 Shawmut Road,Canton,MA 02021 Telephone If(781)821-0060 Facsimile#(781)821-8552 Federal Tax ID#14-1855297 Mass.Home Improvement Contractor Reg.#137943 Date a lryc� Customer: � ] Customer Name o;/I'J'v"v& / I-0 At er Street Address 147-2- 472— n i-y /w & / City,State,Zip /v /✓L7'V L-7L /lip- Telephone( 1 �?O / q,7' � This is a contract between the Contractor and the above named Customer to sell and install the Owens Coming Basement Wall Finishing System and related items specified herein at the Customer's residential premises identified below: Installation Premises: Street Address City,State,Zip Scope of Work: Are Sketches and/or specification sheets attached? es' ❑No 'All attachments are incorporated into and become a pan of irys contract J Description of Work/Specifications:��( /S 0g0*6(,i2) �✓/ �y A&� ,✓moi'`-� � L� G � h�tf I , Work Schedule": Approximate Commencement Date: / Approximate Completion Date: "The proposed work schedule is approximate and subject to change Contract Price: Total Contract Price: $ �7 d'>; t � I 12 3 Deposit with order: $ ❑ Cash 6!Check# Balance Due: $ Terms: ❑Cashmance (Cash terms are 10%deposit,50commencement,40%on completion) $ Due on Commencement l $ Due on Completion I DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ I AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT. YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION. Witness our hand(s)and seal(s)below on this O3 day of��1/ 1�C1 Bay State s JSy.t,e s LLC./Authorized Representative: Sign ur nd ftle 6— -t u j Print Name DO NOT!IPN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Customer/. C tomer'Slgnature'.J 4;0 Prim Nam b /'1� CONTRACTCustomer Name L � gnature \�1 I. Customer Si L SKETCH Contract Date �t Sales Representative Signat1_1ur `f^ ATTACHMENT Customer phone _ Contract Price 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1] IS 19 20 21 22t 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 46 47 48 19 M 51 52 53 5< 55 56 57 0 59 60 2 6 l 1( 9toe 10 � j - 2 3 A r 1 9- 5 - — } •tee 8 " d 1 n � 18 �3 19 20 21 zz z3 , 24 25 26 27 28 29 30 31 32 3J 34 35 NOTES: -Each box equals one foot unless otherwise noted.This sketch is a good faith representation of the work to be done,it is understood that all d'mensions derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,jacks and/or switches are subject to change if necessary. M Commonweal" of Massachusds Department of Industrial Accidents Oriee of Investigations 600 Washington Street Boston,MA 02111 www.mas&gov/din Wo ers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluuabers A lie t Information Please Print Le ib) Name ess/Organizatiow7ndividual): (/ RII/11 �ill1�-S�YSr Address: 7u40,gK6 Si ------------ _ City/StaZip:_ _ AW-4 (J / Phone#: Are you ai Temployer?Check the appropriate box: Type of project(required): I.Qd I am employer with 4. ❑ I am a general contractor and I 6 ❑ New construe empl rt tu ees(full and/or pane)." have hired the sub-contractors tion 2. I am sole proprietor or partner- listed on the attached t 7• ❑ P P P ched sheet. Rlemadclin g ship andd have no employees These sub-contractors have 8. Demol' ❑ mon wor ' g for me in any capacity. workers comp, insurance. 9. Buil [No rkers comp. insurance 5. ❑ We are a corporation and its dmg addldon requ' ] officers have exercised their 1d-❑ Electrical repairs or additions 3.❑ I am meowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions mysel [No workers' comp. c. 152,§1(4),and we have no l 2.❑ f# f its ins a required.) t employees. [No workers' - cvmp, insurance required.] 13•11 Gii4_ - 'Any applicant t at checks box X11 must also fill out the section below showing their woken,cotnpennpon Po1 ,jnfatmati4n t Homeowners o submit this affidavit indicating they are doing all work and then hire outside contractors must submit n new e#lidavit indicating suet: 'Contractors that k this box must attached an additional sheet showing the nine of the su t>cmtractors and their workers' !am an em pl yer that is providing workers'compensation insurance or m ein CDrW-policy infbrn-wtion. infwmWion• Y ployeet Below is the polley and job site Insurance Coin ipany Name: b6697y InurriAl Policy#or Se -ins. Lic. #: (,(1[L- 31S -' f ;1 Expiration Date: -�') Job Site Addr s: Awd&",141 City/StatelZip:,(.), � �t�l�— Attach acopy f the worker's'compensation policy declaration page(showing the policy number and expiration date).`1 Failure to se a coverage as required under Section 25A of MGL C. 152 can lead to the fisc up to$1,5 .00 and/or one-Year imprisonment,as well as civil penalties in the form off ao TOP WORKRDER and os't'OD Of criminal Penalties f fine of up to$250. a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations f the DIA for insurance coverage verification Idotrei,fy uncle the of perjury,that t&e in ormf ation provided above is true and corrctSi -------------- Phone#: 7L4ZL- oo6o -- O/jtcial use My. Do not write in this area,to be completed by city or town Ofj?cial City or To Permit/I,icxnse# Issuing Au rity(circle one): 1.Board of P ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspec 6.Other tor S.Plumbing inspe or Contact Per n• Phone#: 06/08/2006 15:05 FAX 1 781 659 4725 Andrew G Gordon Inc 1 001 l V WCIP Liberty ISS ING OFFICE 354 10�MutiuAL Workers Compensation and ORMATION PAGE Employers Liability Policy ACCO NO. SUB ACCT NO. Liberty Mutual Insurance Group/Boston 1-544359 0000 LIBERTY MUTUAL FIRE INSURANCE Co. PO ICY NO. TD, `CD SALES OFFICE CODE SALES CODE N/R IST WC2-31 344359-016 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR. ASSIGNED 2003 Iteti 1 1.Name of BAY STATE BASEMENTS LLC Insured DBA OVVENS CORNING FINISHED BASEMENT SYST FEIN 14-1885527 Address 960 TURNPIKE STREET RISK ID 000IA2837 CANTON,MA 02021 Status 46 LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4 Mo.Day Year Mo.Daq Year -- Item 2. Policy Period: From 05-24-06 to 05-24-07 12:01 AM standard time at the address of the insured as stated herein. .__ Ite 3.Coverage A. Workers Contpensation Insurance: Part One of the policy applies to the Workers Compensati5n Law of the states listed here: MA ' B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.The limits of our liability uxder Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000cY li limit. lm . Bodily Injury by Disease 500,000 each employee C. Other States Insurance:Part Three of the polity applies to the states,if any,listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4 Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and hating Plans 11 information required below is subject to verification and than e b audit. Premium Basis Rates LINE 110 Estimated Per$too FWmated Classifications Code TOW Annual of RE- Annual iVo. Pretninms SEE 0 TENSION OF INFORMATION PAGE maneralion Premiums Minima n Premium $ Soo ( MA ) Total Estimated Annual Premium Interim adjustment of pren-tium shall be made. ANNUAL This po ry,including all endorsements issued therewith,is hereby countersigned by Anehur4zed Re sentalive Clale es- _ "- RECEIVED. �___ Lx-Code I Term open. ANOR t c Payment R:Mlag naris Poi.riG. Rome scale niv&tend RENEV1ffr=O ----__--- ` 05-22- NR MA WC2-310-344359-015 GM 4030 R1 Copyright 1987 National Council on Canpematton insurance WC000001A BROKER copy JUN 08,2006 01:31P 1 781 659 4725 page 2 ( i A�JfiL .' CERTIFICATE.OF LIABILITY INSURANCE OP ID E DA (T+9AlDDIYYYY) PRODUCER BAYST-1 4/10/06 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER11FICA Kaplansky Insurance Brookline HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXT£N OR 114 Harvard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES B LOW. Brookline MA 02446 Phone: 617-738-5400 Fax:617-738-8214 INSURERS AFFORDING COVERAGE NPJC 9 INSURED INSURER A Norfolk & Dedham Group L3943 yy tate Basement System I.LC INSURER 8: D B�A. Owens Corning Finishing INSURER C: 960 Turnpikke St INSURER 0: Canton M& INSURER E: 21 COVERAGES 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 OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MM/DD" DATE(MMIDDIYY) Lem GENERALLU18IfTY EACH OCCURRENCE $ 1 00000 COMMERCIAL GENERAL LIABILITY PREMISES tea KCN�cureCLJnce) $10)000 CLAIMS MADE OCCUR MED EXP(Any one pew) $ 5000 A X Business Owners R0309626 02/06/06 02/06/07 PERSONAL a ADVINJURY $10)0000 GENERAL AGGREGATE $ 2 00000 GENL AGGREGATE LIMIT PRO- APPLIES PER: PRODUCTS-COMP/0P AGG S Ex 1 uded POLICYF11JECT El LOC AUTOMOBILE LMS L" COMBINED SINGLE LIMIT ANY AUTO (Ee acolderd) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA Acamar $ ANY AUTO EAACC $_— OTHER THAN _ AUTO ONLY: AGG $ EXCESSAIMBREU A LIABILITY EACH OCCURRENCE $ OCCUR M CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILRY ANY PROPRIETOR/PARTNER/EXECLMVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? If yes,desttibe under E.L.DISEASE-F.4 EMPLOYEE $ SPECIAL.PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TE EXPIRATION t� DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 AYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 0 SO SHALL 114POSE NO OBLIGATION OR LIABILfTY OF ANY KIND UPON THE INSURER,ITS A ENTS OR REPRESENTATIVES. AIZE TIVE ACORD 25(2001/08) 0 ACORD CORPO IATION 1988 Board of Building Regu crus and Standards One Ashburton Place-.Room 1301. Boston. Massachusetts 02108 Home Improvement Contactor Registration WENS CORNING BASEMENT FINISHING NIEL WALSH TURNPIKE ST. ANTON, MA 02021 Update Addrm and return cera.Mark rtmmson for Chang _ OPSGE d 101216 0 Addrtss 0 Ytemewat 0 Ewpto}wentU Lou Card � BK•t�>iau..ds�ts.ahr+dt E Mit!ttOVEMEM @ONT'RACM License or retist� before tie a pi fi"i wlo IN t $-_ RWtst oaf 137M Board of B"#64 e t ar _ 7 One A*bttte. Cam I go TURNPOW I T. CMtT011.MA 0212 - Adrai.$aa1.r - -- - IWt r sitieat i sa _ � bre ,y mwwr 40, 44 Kv * Y riG, x#$1.0 1