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HomeMy WebLinkAboutBuilding Permit #866-13 - 212 WAVERLY ROAD 6/12/2013Permit NO: `� I Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIOf�� Date Received IMPORTANT: Applicant must complete all items on this page _ ' PR0PERTYrOWNER'�_ _._ Pring 1iJ0iYearfQId Structure,+ yes; nq, MAP' NO:: ©1 . PARCEL ZONING' QIS+ +RIOT: .H istoric.District' yes no:, machine.Shop;Village yes, no TYPE OF IMPROVEMENT PROPOSED USE Resid ial Non- Residential ❑ New Building ne family ❑ Addi ion D Two or more family ❑ Industrial ❑ Alk6ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septics❑1V1Lellt Q Floodplain ❑ Wetlands ❑ WatershedrQisttict) . El Water/Sewer. DESCRIPTION PERFORMED: Id ficationeas T pe or Print Clearly) OWNER: Name: Phone: Address: V,, -- CONTRACTOR' Name _. __ ... -_ - - - Phone:_ Lot Address:. Supervisor'siG dnstruction. License:" Exp! Date: 1 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: $ __?app - FEE: $ � `T Check No.: n /-/ -,�, Receipt No.: 26p� `% NOTE: Persons contracting with unregistered contractors do not have access o t e ra fund Sig an tureof�Agerit/Owner_. Signature�of contr Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ St ped Plans ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow z! ]Engineer: Sign LOcatea 3M us ooa careei FIRE DEPARTMENT - Temp Dum.pster on site yes no Located at'124 MainStreet Fire Depa l't-sidnatureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of fleeter 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 El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department i 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o Floor Plan Or Proposed Interior Work Li Engineering Affidavits. for .Engineered products . . NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application Li Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract o Mass check Energy Compliance Report a 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 A,J,p Location < --11 No. Date Check # 2 6 %5 0 9 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee s—K.—W Foundation Permit Fee Other Permit Fee TOTAL Burl—ding Inspector -04 r L ui LL Q cc m , y o LL E TO N a N o H Z 0 J m fY6 z LL 3 CC v U LL 0 N Z Z m J : m LL 0 y z Q W LU L bo 0 C' U > N � LL O aW z Q ago W � LL- z oc W W U. ` E ca zaj v {% �+ D o N n �o W .. 'CL : a � z iE o o 'COL m U) • �v i � u 0' � G1 • �j (��%..%.. o Jt < �: E � , F' Q ss V c A P 0— mi ~ «+ � � O v 10 �' 00 H U °' > r w to m `° co W •� M -a O O ~ 4� a, O > J yea c aZ c LU z CLcmED U)4� N0O 0) U) .N = cm L1J cn> o = W —j V c o F- a z � I Q CL = o v �• = O V ft=:o o = c = O Q L L lC 0 N N0 V m N = 'C +_•• O O W PUJ00 : C = O .v 5 O W CL N J N m m p "" = OFE O II , .� � Q. O 0 > E � o o z N O 0 w' v) d O CD v O � O � CLQ Q O a cc V J -0 •r.L O 4) U)z a 0 CL V i uj U) U) W W 19 W U) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnlicant Information _ y Please Print LeEibl Name (Business/Organization/Individual):! Address: City/State/Zip: tM'��'� Phone.#: Are you an employer? Check the appropriates b-1 L ❑ I am a employer with 4. j I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2: ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have . working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] ' 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised. their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Ro9f repairs *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. ZContractors 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. ` f Insurance Company Name: r � r Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declarati n 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 a violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oft IA for hisurance coverage verification. I do hereby cert under t e p ins a penayies of perjury that the information provided above i tru and correct. Signature: Date: Phone #: Officidl 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--S.-Plumbing Inspector 6. Other Contact Person: Phone M DATE (MWDD/YYY17 CERTIFICATE OF LIAEILITv( INSURANCE 0212712013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CETICIES BELOICATHIS CERTIFICATE FOF INSURANCE DOES NVELY OR IOT CONSTITUTE A CONTRACT VELY AMEND, EXTEND OR TBETWEEN ER THE ®VERAGE AFFORDED BY THE ISSUING INSURER(S), HE WRIIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, 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). CONTACT PRODUCER NAME: MARSH USA, INC. PHONE TWO ALLIANCE CENTER A1C No Exti, MARSH No 3560 LENOX ROAD, SUITE 2400 E-MAIL ADDRESS: ATLANTA, GA 30326 mgURER(SI AFFORDING COVERAGE NAIC q 100492-HomeD-GAW-13-14 INSURED THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD, NW INSURER A : Steadfast Insurance Company INSURER B: Zurich American Insurance Co INSURER C New Hampshire Ins Co INSURER D: Illinois National Ins Co INSURER E BUILDING C-20 ATLANTA, GA 30339 ovvrC rnhl 1,1111URFR• 7 COVERAGE5 UtKI1rl%,A1n NUIVIOMM- �•� v r T — — — 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE GENERAL' LIABILITY X COMMERCIAL GENERAL LIABILITY l CLAIMS -MADE OCCUR I i POLICY NUMBER GLO4887714-03 10310112013 LIMITS OF POLICY XS OF SIR: $1 M PER OCC POLICY EFF MM10D POLICY EXP MWDD/YYYY 0310112014 LIMITS EACH OCCURRENCE S 9'0�' 000 A DAMAGE TO R— ENT S 1,000,000 PREMISES Ea occurrence MED EXP (Anyone person) S EXCLUDED 9000000 PERSONAL & ADV INJURY S GENERAL AGGREGATE S 9'000' I i B BAP 2939863-10 SELF INSURED AUTO PHY DMG I 0310112013 0310112014 9,000,000 -COMP/OPAGG SPOLICY NGE'N'L. AGGREGATE LIMIT APPLIES PER:PRODUCTS PRO- LOC LAUTOMOBILE LIABILITY X ANY AUTO - ALL OWNED SCHEDULED AUTOS AUTOS NON -OWN, ED HIRED AUTOS AUTOS S COMBINED SINGLE LIMIT 1,000,000 , Ea accident S BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE 5 Per accident S UMBRELLA LIAROCCUR EXCESS UABH CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S S TAT X' WC LIMT- OTH- C C D NIA WG033575314 (AOS) WC033575315 (AK; A2) WC033575316 FL ( ) 0310112013 0310112013 03101/2013 0310112014 03/0112014 03/0112014 ' DED RETENTIONS WORKERS COMPENSATION I AND EMPLOYERS' LIABILITY YIN1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N (Mandatory In NH) If ye s, describe under t DESCRIPTION OF OPERATIONS below E.L. EACH ACCIDENT 5 1,000,000 E.L. DISEASE - EA EMPLOYE S E.L. DISEASE - POLICY LIMIT $ 1'000'000 C WORKERS COMPENSATION WC033575317 (KY, NC, NH, VT) 0310112013 0310112014 (EL) LIMIT 1,000,000 C WC033575318(NJ) 0310112013 03(01/2014 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) EVIDENCE OF COVERAGE t ` THE HOME DEPOT INC. HOME DEPOT USA, INC. 2455 PACES FERRY ROAD, NW BUILDING G20 ATLANTA, GA 30339 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee - V<.CLu0-0" -A • * ...50. nnmd W I.IVVV. v..,v... .... ..3..�.� ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1U/ JU! LUlG L1. J UUJJ I ULGUJ MUIV'IC UG-lJ� LI_J1 VI♦ F-I'L_ Ul/ Cil t : Massachusetts -Department of Public Safety Board of Building Regulations and Standards .Cnnstruction Supervisor Speciuity License: CSSL-100696 i i c ALAN S PAIN7CElt-` 11 16TH AVENUE HAVERITi UNA 01 I J,.�. • . '� "� Expiration Commissioner 08/21/2016 2013-06-03 03:47 3405EX Branch Name: Boston ��.II Brunch Number: 31 Installation ,Address: 6034643417 6039643417 >> Home Depot AHS P 1/7 Date- 1110 At -Home aervrces, Inc. Purchascr(s): Home Address: (If different from Installation Address) d/b/a The Iiome Depot At-IIome Services 908 )3osttrn Turnpike, Unit i, Shrewsbury, MA 01545 Toll Free (8(()) 657-5182;1 Fax (508) 845-6017 Federal 11) it 75-269840: ME Lie # C 02439; RI Cont. lJO 164 27 CT Lie # HIC.0565522; MA dame improvement Contractor 1(cg. # 126893 kal wep AM,-_ 0 t SYS" City State lip Phone: city l`178 -J - State Lip E-m-021il Address (to receive project communications and IIome Depot updates): )/itrjZo+�l 01 O NOT wish to receive any marketing emails from The Home Depot P sect Information: Undersigned ("Customer'), the owners of the. property located at the above installation address, agrees to buy, ,and THD A1.-Homc Services, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for -the installation ("Installation") of all materials de wribed on the below and on the referenced Spec Shect(s), all of which are incorporates( into this Contract by this reference:., along wi7h any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): Job #: imi«mt trcr¢w. * Pru else []Roofing ❑Siding Vindaws ❑ Insolation ❑GuUrrs ! ('Durex ❑1 nay Uoars ❑ Spec :sheets #: l I (j :! Project Amount { Or �'� WT ❑Roofing ❑Siding indaws ❑ insulation ❑( cutters i (:overs Mritry Dours ❑ QRoofing ElSiding ❑ Windows 0 Insulation � 1 (} I I I I i l ❑(ivaer:e / (:overs ❑Entry lNors ❑ ❑&Kling []Siding ❑ Windows ❑ Insulation / (avrrs Entry Mors ❑ l I $❑(intters I bfrnimum I5 % Dapnsit of Cntrtract Anwunt due upon ra ew4ion or this carrttnct. Total Contract Amount Maine Purchasers rorty not Acpasit more tttan rte -third of the (GtwtratriArnuunt. Customer agrees that, immediately upon conipletion of the work for each Product, Customer will execute a Completion Certificate (one lin- each Product as defined by an individual Spee Sheet) and pay any balance due, As applicable. each Customer under 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 diseTution, if The HomeDepot. or its authorized service provider determines that it cannot perform its obligations due to a structural problern with the home, environmental ha-rArds such as mold, asbestos or lead paint, other safety concerns, pricing ern)rs or because work required to complete the Job was not included in the Contract. Payment_Summarv: The Payment Summary #_745 +►� l � , included as Part of this l:ontracl., sets lorth the total Contract amount and paymenIs required lbr 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 r C'omplelion cerlincate (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 bate of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOMF DFPO. T MAY WITHHOLD AMOUNTS ()Wi:D TO TIIE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING TIIE HOME DFI10T'S OTHER, REMEDIES FOR RECOVERY OF SUCH AMOUNTS. AcceDtance and Authorization: Customer agrees and understands that this Agreement is the entire agreetncnt lx:tween C.ustorner and The Home Dcpot with regard to the Products and installation services and super.cdes all prior discussions and agreements, either oral or written, relating to said Products and Installation. This Abm-entent cannot be assigned or amended except by a writing signed by Customer and The Hone; Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms of and has received veil a copy of this Agreement_ Accept y: a � Sob tedby: laz 5/3' (3 Com Si nature Dail Sales Cotsn 's Si nat"�V Date