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Home My WebLink AboutBuilding Permit #259-14 - 194 GRAY STREET 9/19/2013 TOWN OF NORTH ANDOVER A PLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued. P RTANT:Applicant must complete all items on this page LOCATION rA Print PROPERTY OWNERA - rint 100 Year Old Structure yes no MAP NO: PARCEZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resideal Non- Residential ❑ New Building ne family ❑Addition ❑ Two or more family ❑ Industrial ❑A ation No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identi icat' n P1 aS T pe or Print Clearly) OWNER: Name: 0 Phone: Address: .� G At t I lt\�"W/, CONTRACTOR Name: Phone: Address: Supervisor's Construction License: b Relf Exp. Date: r Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: 4 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.. c 7 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access he uar my fund Signature of Agent/Qwner S�goature of contract .„ ._� Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ S roped Plans ❑ TOWN OF NORTH ANDOVER A PLICATION FOR PLAN EXAMINATION Permit N0: I Date Received Date Issued: —qj loi-be-z P RTANT: Applicant must complete all items on this page LOCATION rA .Print PROPERTY OWNER Ig Print 100 Year Old Structure yes no MAP NO: rftf PARCE�ZONING DISTRICT: Historic District yes no 1W ! Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside 'al Non- Residential ❑ New Building ne family ❑Addition ❑ Two or more family ❑ Industrial ❑A ation No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identi scat' n P1 as T pe or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: 4)L10E]afS4,tPhone: Address: IL Supervisor's Construction License: �bD 'fit Exp. Date: ql:�lu Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: 4 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 � he uar my fund r Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S mped Plans ❑ LocationL No. ( Date 3 • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#t.- L) L j iD-f� �( — Building Inspector i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -TYPE-OF'';SEWERAGE:DiSPOSAL ` Public Sewer ❑ Tanning/Massage/Body Art ❑... ..Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ i Private(septic tank,etc- ❑ - Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM j DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_.. Planning'Board Decision: Comments A Conservation Decision: Comments tr Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE DE PA - Temp Dumpster on site yes no . Located-at'l24Main Street Fire Departmeitsignature/date-' ,K COMMENTS r; -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 f Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate.permit to be obtained. RoofirAg, 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 . l Building Department The foEswing 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 apnaal 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 Town ; NORTH # Andover 0 . to Z o h , ver, Mass, 3 S U BOARD OF HEALTH LD Food/Kitchen PERMIT T Septic System • ... . THIS CERTIFIES THAT ................. �,�.. I. BUILDING INSPECTOR lillhas permission to erect ......... buildings on t !.`i.... .................. Foundation � Rough p' �NA.)0\146. ny t0 be OCCU led aS ........................................ 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 MONLTH§ ELECTRICAL INSPECTOR UNLESS CONSTRUC I S 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 1 Department of Industrial Accidents Office of Investigations ' 600 Washington Street l Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): .--- Address: '' City/Sta /Zip: Phone #: �Kaemployer n employer?Check the appropriate boll,". Type. of project(required); L 4. I am a eneral contractor and IYP P J with g employees(full and/or part-time). have hired the sub-contractors 6. E]New construction 2.El I am a sole proprietor-,or partner-. listed on the attached sheet. 7. E]Remodeling ship and have no employees * These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' _ _ __ J 9. ❑Building addition _ . o workers coin msurance _ __ ---..comp.-insurance: P 10.❑Electrical repairs or additions required.] 5. We are a corporation and its 3.❑ []I am a homeowner-doing all work officers have exercised their 11. Plumbing repairs or additions g ❑ dt ions g P myself o workers' right of exemption per MGL y [N comp. P ❑ P 12. Ro re airs insurance required.)t c. 152, §1(4),and we have no r" employees..[No workers 134?'Other4h:Z:� 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. #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-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. Insurance Company Name: Policy#or Self-ins.Lic.#: `% �'�,�� Expiration Date:O _ Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy decl ration page(showing the policy number and expiration date). Failure to secure covera a as required g q d under Section 25A of MGL a 152 can lead to the im osition of criminal enalties f p p of 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 Do insurance coverage verification. 'I I do hereby certify nder t e 'ns a penal ' of perjury that the information provided above ' tru .and correct Si Mature: Date: 11-le-101) Phone#: Official use only. Do not write in this area,to be completed by city or town offrciat 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#: i i _..- � 0212717013 A�D CERTIFICATE Of LIABILITY INSURANCE ! 'I CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE AF CERTIFICATE HOLDER. POLICIES THIS THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder Is ar:ADDITIONAL itISURED,the poficy(iEl must be endorsed. If SUBROGATION 1S WANED,subject to ms and conditions of the policy,certain policies may require an endorsement. A statement on this cettlflcate does not confer rights to the the ter P Y certittcate holder in Lieu of such endorsement(s). NTA T PRODUCER NAME: MARSH USA,INC. PHONE AIC No TWO ALLIANCE CENTER a MAIL 3560 LENOX ROAD,SUITE 2400 ATLANTA,GA 30326i INSURER p INSURER S AFFORDING COVERAGE 26397 100492-HomeD•GAW-13.14 INSURER A.Steadfast Insurance Company Zurich American Inswanw Co 16535 INSUuRED INSURER B: 23841 THE HOME DEPOT,INC. INsuRER c:New Hampstiue ins Co HOME DEPOT U.SA,INC. Illinois National Ins Co 23817 2455 PACES FERRY ROAD,NW INSURER D BUILDING C•20 INSURER E ATLANTA,GA 30339 - INSURERf: ' COVERAGES CERTIFICATE NUMBER: ATL*3159545(A REVISION NUMBER:.? THIS IS TO CERTIFY THAT THE PANIYIREOUIREMENTNTERM OR CONDCE LISTED ITION OF ANHAVE BEEN ISSUED T Y CONTRACT OR OTHER DOOUMENT WITH RESPECT TO WHICHTHIS INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM , EXCLUSIONS AND,CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INR NUMBER MMtODY EF MMID POLICY TR TYPE OF INSURANCE 9,000,000 A GENERALUABiLm GL04887714-03 03ro1f2013 0310112014 EACIjOccttRRENCE s 1,000,000 X S COMMERCIAL GENERAL LIABILITY ETO R EXCLUDED CLAIMS•MADE a OCCUR LIMITS OF POLICY XS MED EXP ono ►son S 9,000,000 OF SIR=1M PER GCC PERSONAL i ADV INJURY S GENERAL AGGREGATE S 9'= 01111 PRODUCTS•COMPIOP AGG GEN'.AGGREGATE LIMIT APPLIES PEL• S B - LCBAP 2°9@86310 EaaxenIX POLICYPRO03100013 30 AUTOMOBE LIABILITY 1,000,000 BODILY INJURY(Por Parson) S X ANY AUTO ' BODILY INJURY(Por saideM) 5 ALL OWNED SCHEDULED SELF INSURED AUTO PHY OMG ---; AUTOS AUTOS a ENON-OWNED 4 DAMAGE S HIRED AUTOS AUTOS S EACH OCCURRENCE S UMBRELLA WB OCCUR EXCESS UAB AGGREGATE S CLAIMS-MADE S DED RETENTIONS D$ 112013 031011201 X WC STATU 0TH- C WORKERS COMPENSATION W335714(AOS) 1000000 C AND EMPLOYERS'LIABILITY YIN WC033575315(AK,AZ) 0310112013 03(0112014 E.L.EACH ACCIDENT S OFFICERMEANY Me R EXC UDECUTNE NIA 03!0112013 0310112014 ,009,000 D WC033575316(FL) E.L.DISEASE•EA EMPLOYE S (Mandatory In NH) 1,000,000 IIt yes.describe under E.L DISEASE•POLICY LIMIT s DESCRIPTION OF OPERATIONS below 10Mwo C WORKERS COMPENSATION WC03357531T(KY,NC,W.V9 0310112013 03MIM14 (EL)LIMIT C WC033575318(NJ) 03!0112013 03(Ot/2014 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addit(ona{Remarks Schedule,It more space is required) EVIDENCE OF COVERAGE i CANCELLATION CERTIFICATE HOLDER THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B CWILL AN CELLED B EO RN HOME OEPOTUSA.INC. THE EXPIRATION DATE EFOE THEREOF, NOTICE 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING C-20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE _ or Marsh USA Inc. ManasN Mukherjes 01968-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of'ACORD • ;: rj :n i. 1 a,�IIE KQQ7P/YJ•r �YY "YY.V•" UGtW�'3+.✓" ' •• ' ;QfCice of�pnstcmerA Clan,jN 15uzmess Regula on -Lie Pr reg,s�rai�oi�•��t��=ei in�ir��a}�,,°'flrily ...... ian dlte IF o=�ndreturn ta: . :_ ONiE Ii4 PR y�EN1E"'T CO TRACTOR = ' Uffice of Consizru�, Afia�rS aiid Iaa�sinessegultifln Regtsafion893 �:° TYPE; 10 'arrfe5 �0 Explra ' �upplarlent; aid �,��#on,l�IA 0211 ;'y 'Fhe Home Depe RtD�a _ ya t ICHAR4 Fr1LL Y te' g. +ZE90 CUMBEP.tA ��f Si r t;i; w ;`�7,N`t ,GA;3033 ' �Uo�ersccretaryy 1. oE:vaIid thoutsigrafure .I Ii k101ML1MPROVEWINT CONTRACY TPD At-!Ionic Services,JR,% Branch Numberi 31 and 3-1 p18 Boston Tuinpikc.L'ait 1.Slijewslitiry,3WA 01545 1,011 FTC—,877-90.3-37(36 u 4 i.5 63,312 2 IN i'A 11 i 111 i v I. A14-6 w,sauna." 4, 1 a lvurI 11 f— -V;—!� '7 • %— 711�vate- L.jp VV!ak 1,hunt: "tmtt�iw-ut; L C;H V E-IE K,t: nLj ni 7> r I 'if'HIT, rn' 11%�nlflnm ir,17 - lir. AA t,,,p f57J all. (ii'.i„ri Vr III I 1jrL-I VCMI 1IM-111-M. DO NCiT wish to jeccive any tnarkcim g.emaik from The I forile Depot TiCT1,11'MI I"- Ll� ovjixic,.�,mw;o it!I);Y, " till muterialm described on the 1�low and the v*,P—d-S.npCShpstkl. n1l of which are incor-mv2ted Into this Contract by this retercrice,along with any jjpplici:)je Staid'S,.,prlcmcl)i and Pavi-nent SurnmitTv etatch-ed and inv Cbm-e -1P, Z: f--) a-w ;-4 Let r-i... Win iovLj Wilt. WiffiWiaLcly Upui,'AWaincilidi 0i rill's Work ilii r'joLA(LL.s,.u%WiiitL will tA�jjjC.4.1 -1......... ------- ------ g� 7- %7'r!-.; Mfe amounts set forth in this Agreement ir alloweo,undf«s. OWED TO THE HOME DEPOT VqnM rift,, 2—z il (hifl it,;, A.. .........I i,Ilp, vIrPoInipm liviwcon Customer -4,iixurd to the Prodiiets andt installation services and supersedes all prior(rim;uNiiiinis and agreements,either U1 84(N written,rulating to said Products and Installation. Ihis Agreement cannot be assigned or amended excel)l by u wi ifing signed hv Cuglmm I and nPnr.! AT111 a+=rrP.if Al CkiSiQ0 i-r hak rrnd-tinflerAnrid,4,voluntarily accepts the .'t nva* AcceP y Siffizzitt d=h y x i ature Sale:Commitant7s Signature Tbic Wephone No & Signature Dair I,Vg. Sales Consultant License No. CANCLLLATION: (11,45TOMER MAY CANCEL 'IRLS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDMC-14T ON THE THIRD BUSINESS DAY AFTER SIGNIN(; THIS AGREEMENT. THE STATE , ';UPPI.FMFNT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRK4;CRIBKI) HY LAW IN cus-roMER'S STATE. MY!I(W!ADDI'lFIONAL.TERMS AND('014DITTONS ARP STATT.D ON RMILSE SIDE AND ARE.PARI M I HIS CON I RACT 06-04-13 White Branch He Yellow-Customer t7/T'd sFpd jodaa awOH.01 92)L8 28L £09 msa -nEICHUS N3)1:wOJ-i 62:Jl ET02-20-c3S I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialt} License: CSSL 10018 9 THEODOREJPLO) 18 THAVWAYER .L 3 AUBURN MA 01301 Expiration 091j3I2014 Commissioner I r �'ta