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HomeMy WebLinkAboutBuilding Permit #404-2016 - 21 MAY STREET 9/30/2015 i NORTFr 9 BUILDING PERMIT0.o . TOWN OF NORTH ANDOVER 4t�4- Z�1 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ,. Date Issued: � wcHuse�� IMPORTANT:Applicant must complete all items on this page LOCATION A4 1, PROPERTY OWNER Print k Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yeno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer 619F Identification Please Type or Print Clearly) t OWNER: Name: ..cff> — Phone: Address: slljy�q -(I &6C tL CONTRACTOR Name: Phone: T Address: q - �— idi� 4A Supervisor's Construction Licen e: D Exp. ate: Home Improvement License: Exp. Date: r ARCHITECT/ENGINEER Phone: 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: $ '��o--- Check No.: Receipt No.: 2-0433 NOTE: Persons contracting with unregistered contractors do not have access a owar my fund Signature of Agent/Owner T _ ignature of contra �] nature - ORTH BUILDING PERMIT o� 1yx TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION h y'� 0 C .,--. Permit No#: Date Received gSsArED 5 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION i Print PROPERTY OWNER Print lob Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑1/Vell ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: t • Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: _ Phone: Email: _ Address: Supervisor's Construction License: 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.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent!Lvvnor Signature of contractor J t 4� 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 ❑ 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_ I COMMENTS i i 1 CONSERVATION Reviewed on Signature COMMENTS I j HEALTH Reviewed on _ Si nature COMMENTS I 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTiMENT - Temp Dum_,ster on site es p y no, �� u - Located at 12.4 Main Street --. — Fire Department signature/date _ COMMENTS _ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 S — _ N Section 21A F and G min.�100 X1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 r 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 Li 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 1 ❑ 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 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:Building Permit Revised 2014 Location No. `r '" � Date `1 J-->201 15 . • TOWN OF NORTH ANDOVER . LEI)lq . Certificate of Occupancy $ Building/Frame.Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector c10RTFi Town of Q No. 40q , p(� h h ver, Mass, ir CoCNICMIWICK .Ot. I S V BOARD OF HEALTH Food/Kitchen PERLD Septic System THIS CERTIFIES THAT �� Ct �A�� BUILDING INSPECTOR ........................... ...................................... ......... ........ ...... ,.. ... Foundation has permission to erect buildings on .. Rough 6 to be occupied as ...............I......�M*•-.AS.-a-11 .... ......................... Chimney provided that the person accepting this permit 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 CONSTRUCTIONA 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. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston North&South Dater/Pq_/_L5_ THD At-Home Services, Inc. d/b/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lic# 16427 Hell (' A CT Lic#HIC.0565522;MA Horne Improvement Contractor Reg.#126893 t Installation Address: rJ�` /V ' 0 �t City tate Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: AJ 0-00Lu 11 is 131q - �, E � ILI I Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails fi-om The Home Depot Proieet Information: Undersigned ("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services, Inc. ("The Home Depot")agrees to furnish, deliver and arrange for the installation ("Installation")of all materials described on the below and on the referenced Spec Sheet(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"): .lob#: (internal Reference) Products: Sec Sheet(s)#: Project Amount Roofing ElSiding Windows Ll Insulation (4p El Gutters/Covers ntry Doors ❑ l O �j ' $ � Roofing Siding 0 Windows F1 Insulation (� ❑Gutters/Covers []Entry Doors ❑ $ ]7 Roofing ElSiding El Windows Insulation $ t ❑Gutters/Covers ❑Entry Doors Fl Roofing ElSiding El Windows El Insulation $ []Gutters/Covers ❑Entry Doors ❑ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Total Contract Amount $ Maine Purchasers may not deposit more than one-third of the Contract Amount L 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 provider determines that it cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold. asbestos or lead paint, other safety concerns,pricing errors or because work required to complete the job was not included in the Contract. Pa-ment 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 through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT 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 Horne 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. 4 Submitted by: f� i m Work area will be contained Pre-Renovation Form Date: NAT-19276 g'q ` a This form is used to document compliance with the requirements of the Federal ��- Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. +( Customer Address Job Number(s) + OCCUPANT CONFIRMATION Dust will be minimized Pamphlet Receipt i , 4 1 have received a copy of the lead hazard information pamphlet informing me of -,° `*w �j the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began i VAP", ' Home Year Built $'4 Enter the year my home was built. 1, If my Home Year Built is Pre-1978,my home requires lead paint testing to determine �+ whether Lead-Safe Work Practices are necessary per EPA or State regulations. irk area will be cleaned u� If my Home Year Built is 1978 or after, Lead-Safe Work Practices are not required, thoroughly r P.� �hGrAj4 �` Cre hof x? w APrintedVwner-occupant occupant �; ray,�6 AV ! Signator of Person Certifying Lead Pamphlet Delivery On �, SEE STATE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massacc uses Department of Industrial Accidents . office of Investigations I Congress Stree4 Suite 100 Boston,MA 02114-2019 ww w mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contract ors/Electricians/Plumbers � Please Print Legibly Mame (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are an employer?Check the appropriate box: 'Type of project(required): 1. 1 am a employer with 4. [] I am a general contractor and I 6 New construction employees(frill and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have gDemolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance? required.] 5..C] We are a corporation and its IU.❑Electrical repairs or additions re 3.❑ 1 qu a homeowner doing all work officers have exercised their I IU Plumbing repairs or additions myself. [No workers' comp. right of exemption-per MGL 12.[�R repairs ins• Uired4 t c. 152;§1(4),and we have no emp oyees. o wor ers comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their worker:'compensation policy information. t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 andjob site information. �---- Insurance Company Name: — Policy#or Self-ins.Lic,.#: Expiration Date: tX 1)6 YLmln)ee Job Site Address: NA, City/State/Zip: Attach a copy of the workers'compensation policy 6eclaration 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 DIA for' urance coverage verification. I do hereby certify under h ai a. pens ies of perjury that the information provided abov is true and correct. _ 4 Signature: Date: r Phone#: O� Official use only. Do not write in this area,to be completed by city or town official. 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#: CERTIFICATE OF LIABILITY INSURANCE 07/15/2015 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(ies)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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE PAX 3560 LENOX ROAD,SUITE 2400 No.F40: A1C No: E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC k 100492-HomeD GAW'-1516 INSURED INSURER A:Steadfast Insurance Company 26387 THD AT-HOME SERVICES,INC. INSURER B:Zurich American Insurance Co 16535 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 23841 2690 CUMBERLAND PARKWAY,SUITE 300 ATLANTA,GA 30339 INSURER D:Illinois National Insurance Company 23817 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-13 REVISION NUMBER:8 THIS IS TO CERTIFY THAT 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iLTR DDE TYPE OF INSURANCE A POLICY EFF POLICY EXP POLICY NUMBER MM/DDIYYYY MMIDD LIMITS _ A X COMMERCIAL GENERAL LIABILITY GL04887714-05 03/01/2015 03101/2016 EACH OCCURRENCE S 9,000,000 CLAIMS-MADE U OCCUR DAMAGE TO RENTED PREMISES Ea occurrence)_- $ 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED OF SIR:SIM PER OCC PERSONAL&ADV INJURY $ 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,00'000 X POLICY, j JECTLOC 1 OTHER: 17 PRODUCTS-COMPIOPAGG S 9,000,000 � B (AUTOMOBILE UABIUTY IBAP 2938863-12 0310112015 03/01/2016 COMBINED SINGLE LIMIT $ � Ea accident $ 1,000,000 ANY AUTO BODILY INJURY(Pere person)ALL OWNED `-1 SCHEDULED S i AUTOS i AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY'"nr axidenq S HIRED AUTOS NON-OWNED — ! AUTOS I ( PROPERTY DAMAGE S Per acr dent UMBRELLA UAB I I OCCUR EXCESS UAB EACH OCCURRENCE— ED S CLAIMS-MADE I ` AGGREGATE $DEO I RETENTIONS C WORKERS COMPENSATION WCOIT731493(AOS) 03/0112015 0310112016 PER 0TH- $ AND EMPLOYERS'LIABILITY X C STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE WC017731495(AK,KY,NH,NJ,VT) 03101/2015 03/01/2016 D OFFICER/MEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) WC01M1494(FL) 03/01/2015 03/01/2016 If yes,describe under E.L.DISEASE-EA EMPLOYEE 1,00'000 DESCRIPTION OF OPERATIONS below Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) EVIDENCE OF INSURANCE 4 CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATNE of Marsh USA Inc. Manashi Mukherjee © 14 CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marksrks of of ACORDRD _ .04-61 TMI r7l TIC s DAM]16 THD A !'Y.1&.I'SI'S t X GkS63.8 __• up&ta Addr=slid ren yard.bRr� elt:a;ige. .Addr.r � r-��'dt `�'f•�r7111.d71!Ytl��/1 Cf�•.''��r"J�I/i'�1�:+Y�- � .� . ASE at Con :ncs uai S u in���i� u3a o� LI;,a� br r gradon va3i�fDr WIViN Igo Or7� r-_ fipP�i�BG��i;•R3j1 {dI_t�`!Cfi�� 3� �`�Yw _ mora �te Oft oT ?W ieis"av A 's FIA 5sia� Fte�rla�ara .,� �: rE�MI4taiTarv; 'FS .. Tca: lat 'fr :a� tois ;' '�`slr''; icpRcat�pro:�8t 1 0 Sup©Dmant-Cavil Kph S�E"GtA tisHAFt a�JOtjmb&w 'p'hRliUVAY S A 3MQ;nrxtretiSay plus' sigaa _ i a r C tFes ;a �� ar � 3 n . BENJAMIN PARKER JR. 43 ('P'RLENOUGI-I ROAD PlaistoiN Nil 03865 k, 8 J