HomeMy WebLinkAboutBuilding Permit #816 - 164 MILL ROAD 6/20/2016 OtµORTH
° p TOWN OF NORTH ANDOVER
w,o APPLICATION FOR PLAN EXAMINATION
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Date Received:
Permit NO: b
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION L4 <<t
Print
PROPERTY OWNER
9-7Print
MAP NO.: 10-7-C- PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DIS'T'RICT YES ❑
PEI
E OF IMPROVEMENT PROPOSED USE
Resi ential Non- Residential
New Building One family
Addition ❑ Two or more family ❑ Industrial
❑ Iteratio ---- No. of units:
G Repair, lacement 11Assessory Bldg ❑ Commercial
❑ Demolition
❑ Moving(relocation) ❑ Other ❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
`l7 t A C, l�J�r� � w ex�.5 Jr 0 04sE n
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Identification Please Type or Print Clearly)
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OWNER: Name: l"tC�C'�Gn�n P �— � Ste' Phone:
Address: S ave -18
CONTRACTOR Name: I �7 � ''t"I Phone: - -
Address: ��S G(Urx t.)0 S 3er- c,-7 t- �4 -�76
Supervisor's Construction License: Exp. Date:
L 2 to 8 g� Ex Date: S-3��
Home Improvement License: p
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost :$ L4,D CSU x10.00=FEE:$ (4()
Check No.: L 3a'o L( Receipt No.: \, I
Page Iof4
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
Addition Or Decks
o 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
w proof of recording must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTNIENT:RPFORI105
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Page 4 of
TYPE OF SEWARGE DISPOSAL
❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Public Sewer
Tobacco Sales 11Well El Food Packaging/Sales ❑
F7 Permanent Dumpster on Site ❑
Private(septic tank,etc. u Electric Meter location to
project
NOTE: Persons contracting with unregistered cog actors do not have access to the guarantyfund
Signature of Agent/Owner Signature of Contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM - , -
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ < ❑
COMMENTS
i
DATE REJECTED DATE APPROVED
F
! HEALTH
❑- - ❑-
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
I
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer connection signature&&date
Temp Dempster on site yes_no✓ Fire Department signature/date
Building Permit Approved and Issued by: WY ev\
Page 2 of 4
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
I
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)
I
1 ,
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:I3PFORM05
Created 1MC.Jan-2006
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Location 1 tG t VIA,t ��
No. l Date D
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„oRT„ TOWN OF NORTH ANDOVER
0 9
Certificate of Occupancy $ �—
;�s�CMUs Building/Frame Permit Fee $
Foundation Permit Fee $ >
Other Permit Fee $
4
TOTAL $
tu U
Check # 2-d
Y
19 440
�' Building Inspector
AT-HOME installed
`�5 5,11V MACES Siding and Windows
it
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✓1ce �a�r»ranuica�c o�✓�iiQoud�uaelld
Board of Building Regulations and Standards
HOME IMt?ROVEMENT CONTRACTOR
RegistratiOn.'.vt26893
;�ExPj ti92-=:x/3/2006
Supplement Card
THE Home Depot-: -'- a
8TJNROEUN CF1Hf�lJ _ .
3200 COBB GALLE20w �
ALTANTA,GA 30339 Administrator
Proudly sold,furnished and installed by RMA Home Services,Inc.,a Home Depot authorized contractor.
345 Greenwood St.Unit 2•Worcester,MA 01607•508-756-6686•Fax 508-756-2859•Toll Free 800-657-5182
I i
FROM : KIMBLY / �1 l� 8-7 FAX NO. : 6033629679 Sun. 14 2006 11:31PM P4
1101VIC iMPROVEMEN'T CONTRACT'
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Branch Name: Sold,Furnished and Installed by:
Date: TI-Tll At-Home Services,Inc. U
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Worcester,MA 01607
Branch Number: Job#: l{ {6 -� Toll Free(800)657-5182; Falx:508-756-2850
Federal 11)#75-2698460 MF r,lc P C 02479 RI Cont.Lic#16427
/ CT Lic#565522; MA Idome lulpruvontent Contr:lelur Rep•.#12(1893
Installation Address:
Citc State Gip
Ihlrchase 9: Last,lDi is of Driver's Lic.#&Ex Mo/Yr: r 'Ph
oPe: Lome Phone:
r Laic—
Home
x Home Address:
(If different from Installation Address) City Stine 7.,ip
E-mail Address(to receive updates and promotions from The Home Depot):
Proicct
contract Information: I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to
with glome Depot U.S.A.,Inc.("Home Depot"}to furnish,deliver and arrange for the installation of all trial as
described on rile attached Spec Sheet#: incorporated herein,by reference and made a pen hereof.
Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,some Depot determines that it
cannot nerforni its obligations due to a structural problem with the home,pricing errors or becruse work required to
complete the job was'not included in the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
(Sulrjoct to find vcClficalion ancl/or ewdit upproval.)
CONTRACT AMOUNT S I. 'hook.Cashiers Check or US Postal Seviw Money Order
(Made payable to The Home Depot).
ALESS DEPOSIT S 2. CrrditCarrl' ymcntoptions-C•SrdcOneFiolvw
Vis,1 stucinl iscover American L•rpmss
BALANCE DUE
ON COMPLETION S r1'_:319 S The Dome Impmvamcnl Loan The Home Depot Cradit Card
/ -
U New Account 0 F.ristinE Aeconnt (Hn.&ADCC.'ONLY)
Minimum 2.5%of Contract Amount due upon execution Availxbl'c Credit:S
f this contract. _1 (IiIL&HDC(
�.lcJ 3l
neclu:,..: 4.,.-:.. qy 3�.3 .. P:Paw: t o D 7
7.
Indicate Payment Method For Name as it appears on
BALANCE DUE ON COMPLETION: 'By my/our slgllatu n below,T/We agree to allow Home Depot to uhar2a the above
rcfeCence{T credit card to•lite deposit inri raed.
aRnitc
HIL or ADCC Authorization Codes
Deposit Final Payment
# #
Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate
and pay any balance due. Purchaser.-also agrees to be jointly and severally obligated and liable hereunder.
Entire Agreement:This agreement and its attachments,including any Financing. eemeM contain the complete agreement
etweeb n tele parties and*can not be amended or modified unless in writing m a separate agreement signed by both panies-
NOTICE TO PURCHASER
Do not siva this contruct before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep
it to protect your rights. Do not sign a a Completion Certificate before this project is complete. Law prohibits home ceptor,
contractors.from requesting or accep g Cumpletion Certificate signed by the owner prior to the actual completion or the work to
be performed under the.contract.'
You may cancel this transaction at any time prior to midnight of the third business day atter the date of this contract Sec Notice of
Cancellation for an explanation of this right. There will Ule u service charge equal to 25%of the contract amount if the job is
cancelled,by Purchaser AFTER the third business day.
BY MY/OUR SIGNATURE BELOW,iIWE AGREB'1.O Lilt BOUND BY THE TERMS OF THIS CONTRACT. UWE ACKNOWLEDGI:
RECEIPT OF A COPY OF THIS CONTRA(:C AND TWO COMPLI;'r1-sD COPIES OP TIIF NOTICE OF CANCELLATION.
BY MYYUUR SIGNATURE RF,LOW, IIWE UNDERSTAND TITAT THE AGREE•MANT IS SUBJiECT TO REV117W OF MY/OUR
CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN
INDEPENDENT CREDIT R•pO ' G' A L Y AND RELEASE THEM FROM ALL LIA131LITY INCURRED FROM
INADVERTENT OMIS ON: R' RR RS. NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
SUBMITTED BY: Date:
al an nt
ACCEPTED BY: Date: 6 '
Hnrrleown �� ,
Date:
Homeowner
NOTICE:ADDITIONA I,TERMS,CONDITIONS AND WARRANYl'I BS ARE ST.1TEn uN I'ttE REV ERISIC SIDE AND ARIL PART OF'1*1[IS CONT1tACT
Wld,,-I) xh Pile WHO- 04e1omce PhN<-ado Ocns�lm.n
12-5-05 C-SC
,&Stam\
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual):
Address:_ f2 0712 zFeM000 j S`
City/State/Zip: ('t )QFZ ti57L ER, Phone#: 4 7S�o`�—5 7
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with I— 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6• El New construction
ZED I am a sole proprietor or partner-.. listed on the attached sheet t ® Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. Q Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical airs or additions
required.] officers have exercised their rep
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12. Roof repairs
insurance required.]t employees. [No workers' ❑
13.Q Other
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
tConb actors that check this box must attached an additional sheet showing the name of the sub-contnictors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information. n
Insurance Company Name: ! Y l7 l J ]5 i 420
Policy#or Self-ins.Lic. #: to [!�j D Cf 4 Expiration Date: 51 7
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Facture 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
Jf 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 DIA for insurance coverage verification.
l do hereby certify under th ains and penalties ofperjury that the information provided above is true and correct
ii ature: Dater
?hone#: 7S-- 5'&-97
Orwial use only. Do not write in this area,to be completed by city or town gfj'wW
City or Town:
Per
mit/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 M
WINDOW SPECIRCATION SHEET - Spec. Sheet •W 3.23091 Sheet: a
Customer: _ /�1� #:IL6�°�.rConsuitant:_ � C _ Date:
Existing Window New Window
Measurements Grids Pattern' Pattern72 Pattern' Window Hinge Locations'
.-4 C c V a &Glass Misc. Csmt,CPC,Bay.Bow,
—1 � � Rough Opening o �. � o � o `o m o
Location Style Metal Style Series C m o ;� N Options Items Patio 4 Garden Doors
ILI r (Room I Floor) "Code" YIN "Code" "Code" U width Height t)I C� 1 > i J > J z "Code" "Code" (from outside,U to Rt)
2 l I 6
h
n
3
{
d191 AS!N 3 S
e 36 Y�
7
CT
lN0 B
M
tD �
l0
.. 10
O 15
X
cc 12
LL
Grid Pattern and Location MUST be indicated. Color Of
: If a<-_ngle•::indow or mulled windows require multiple grid patterns,indicate location and pattern in the additional spaces provided_ Window I Door Wraps [_
' Forvsrits.CPC.Bay or Bow,use 1","R•'or••S"(Stationary). For Paso&Garden Doors,use"S"(Stationary)or"X(Operating).
BAY l BOW WINDOW GARDEN WINDOWS
Projection Angle: [Bay:30°or 45() Top of Window to Soffit(inches) WALL THICKNESS 4 (inches)
Bay Window Rankers-DH I Csmt. Width of Overhang(inches) SEATBOARD MATERIAL
Sea lboard Material-Birch or Oak If tied to Soffit,color of Soffit material Specify Birch or Oak Veneer or White Pionite
New Interior Casing(BaylBowlGardenlPatio Doors) Construct Roof 3(Yes I No) 'Addition-Al charge for wall thickness of 6'or more.
Clamshell(CL)or Colonial(CO) s There is no guarantee that neer shingles will match existing color.
I hive reviewed and agree with all the job specifications above and the
f
J SPECIAL CONSIDERATIONS: ? / Special Terms and Conditionson-theback of the yellow(Customer)copy.
06
I as Cer Si nature ate
o ' S V g
ley f 11.23-C•s CI FC-1h. M. // / While-the Home Cepot Yeliov;-Customer Rm-Sales Corsultant
6 c lir lG n ( (CO7