HomeMy WebLinkAboutBuilding Permit #670 - 2211 TURNPIKE STREET 4/19/2007TOWN OF NORTH ANDOVER NORTH
APPLICATION FOR PLAN EXAMINATION c16
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Permit NO: Date Received
7 �yss ,T. D .S��qy
Date Issued: / ACHU
IMPORTANT: Applicant must complete all items on this page
LOCATION a 2 ) 7u r rn- � I S+� � e
Print
PROPERTY OWNER e C Q r D A. � e 1 e S l l S
Print
MAP NO.: 2/(7 PARCEL: /0?: C ZONING DISTRICT:
T�7TT A l�Tn iTcu i-% -D inr, ninmr,
MQ.TORIC nlv%TRICT VF.S F1
TYPE OF IMPROVEMENTya v
PROPOSED USE
Residential
Non- Residential
❑ New Building
F1 Addition
❑ Alteration
One family
0 Two or more family
No. of units:
❑Industrial
repair, replacement
❑ Demolition
❑ Assessory Bldg
0 Commercial
0 Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION�F WORK S B I,'REFORMla �,1
IYI�
Identification Please Type or Print Clearly)6�,,
OWNER: Name: Rcca rJ 0 � I J ��5 t . S Phone: Fell;'??4 •'76'6'•g7o3
Address: o� 9 � r' 1 Gt r n ► . Ali
An r MA , 01845
CONTRACTOR Name: gears 3Yige_ vv1✓J ryy e WI P Ylf Phone: Oe // :8(;o • 753.0452
Address: $ 9'7 _7_� oI-ki rJ 5 C/r) W Z7� a yn 42 5 y" , C 7-, 0 6 07 '%
Supervisor's Construction License:- +-� Exp. Date:
Home Improvement License: 14 S G U ( Exp. Date: / U l 1 00
ARCHITECT/ENGINEER ------— Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT�• $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.0,0 PER S.F.
Total Project Cost :$ �'�t,, l FEE:$
Check No.: 3 Receipt No.:
Page I of 4
TYPE OF SEWERAGE DISPOSAL
Art E]g
Swimming Pools 1111Tanning/Massage/Body
Public Sewer
Well •- ❑ �.
Tobacco Sales ❑
,
Food Packaging/Sales ❑
❑
Permanent Dumpster on Site ❑
4-
Private (septic tank, etc.
Electric Meter location to
project
iNU I r:: Persons contracting with unregistered contractors do not have access to the guarantyfund
(ke-lf
rSignature AgentOwner ) 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
PLANNING & DEVELOPMENT ❑11
COMMENTS
CONSERVATION
COMMENTS
HEALTH
DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED DATE APPROVED
❑ ❑ F.
,
COMMENTS
Alt
FIRE DEPARTMENT- --Temp Dumpster ori site .yes ti : no ()•
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
Building Setback (ft.)
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
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTM ENT: BPFORM05
Created JMC. 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
❑ Copy of Contract
❑ 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
Locaflon,Z2
No. -7 6 Date -�5/
TOWN OF NORTH ANDOVER
UP Mr
Certificate of Occupancy $
Fee $
CHU Building/Frame Permit
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
20125
Building Inspector
IIIl�a�n s-
seat>s Home ImprovementSears Products, Inc.Ino. Job No.:
1024 Florida Central Parkway ♦ Longwood, FL 327506d m ( gy m Phone
FEIN 25.1688591 /I
License Numbers. AL 54811, FL C000125W: LA 84194' Location:
MA 14tiW7; MS 50222 NC 47330RI 27281' SC
TN 231 W, CONMIT, orf (31767; CT HIGn. 07� Siding _ �',�%
Name ��! £c��A J t[.a'.�tiS Phone %J �`�- Bus.,/� ���_
Address: -0 •� // !—Vh deet City: / Z&O q r - St.: ALP' zip: U/�
YA
IANe, the owners of the premises ribed below, hereinafter referred to as "Purchaser" offer to oontract with Sears Home Improvement
Products hereinafter referred to as "Comrect0l', to furnish, deliver, and arrange for installation of all materials necessary to improve the
premises located at:
(Street) (may) (am) (zip)
According to the following specifications:
NOT
INCLUDED INCLUDED SPECIRCATIONS
PREPARATION: I. ® ❑ Obtain all necessary permits and insurances.
2x❑ ❑ inspect surfaces in work area . mind Well, wood, replace rotten surface wood where necessary In work
SIDING:
PORCH
SYSTEMS:
CLEAN UP
WARRANTIE
SPECIAL ITEMS:
Work not to be
3. ❑
4. ❑
5. ® ❑❑
7.
8.
8. ,®
to. ® ❑
11. ❑ ,®
12. ElA
13.
14. ❑ Z
15. f ❑
18. Cl
17. ❑99
is. ® ❑
19. ❑
20. B D
21. ❑
22 ❑
23. ❑
24. ❑
25. 0 Cl
26. a ❑
area excluding roof, decking or taflers, and structural members.
Remove Existing aiding: Type:
Fir out wells on brick, block, metal or slucoo areae: Location:
Caulk and seal around all windows 6 doom In work
Insiol approved norHxmmsive starter ship.
Instar Insulation on IlshveQ meas to be aided with " exMdN of
,*we inauletion. ( one)
Custom Vyna-Klad aluminturn fascia system: Color: Q2
Remove and reattedVdispose of existing guttering.
Cover Soffa areas of home with vby soft system, simapt thous areas rated �#
Weatherbeater 0 Mau 5r7Pius ❑ Weetherbeater ❑ Other (check one) Colo Pattern: Cb
Custom Vyne-Kied alurnkxrm maze boards:
Location: Color: Size:
u trt Butt window irtm: Location: 3E-- Color
Custom wrap wlndows(s11Islmul1s/headem with Vyna-taad aluminum:
Remove and reinstall feinting storm windowslawnktgslshuttem.
Custom wrap door facings with Vyna-Klad aluminum: 1 `4A°t r
Lofretl 1gAu n: or:
Custom wrap garage door lacings single/dotdte with Vyna load al uCo�
Remove and reinstall stem doors � •/L N 4
Deluxe comer posts: Color:
Clip looking system: Location:
InstallWealpad ter [I Max 9plus
TYPE=, 1 Vertical
Porch callings:
Portal posts:
Porch beams:
4, �
❑ Weatherbeater ❑ other Solid vi idin (check one)
COLOR:
Location: Color:
Color:
_ Color.
Clean up and removal of all job related debris:
Each job Is over shipped to avoid delays. Remove excess materials and rock,
Mamtacture's warranty sent upon completion.
Aa A
Ali of the above cheek boxes and the work not to be done" section have been reviewed and explained to me.
TIME FOR COMPLETION OF WORK. Contractor shall commence work within approximately twenty (20) days from the date shown herein and ll be
substantially completed within forty-five (4S) days thereaffer unless a differed estimated completion date ls shown herein.
Aoono 1mats slartind date is: /� y a`� – a�� .� —Approximate completion date is: U = V 1 2.Jy2
II ADD
ADDITIONAL PPROVVISE: THE �IONSRANISIONS AS D WARRANTIES STATED ON
STAHE TED ED ON REVERSE AND ARE HAVE BEEN E PART THIS CONTRACT. � I
Please read the following hold type and Initial corresponding line.
Verbal understandings and agreements with representative shall not be binding. All understandings and agreenneiritamu a el forth In
writing In this Contract.�C�/y�� Purchaser Inlaele:
The TOTAL PRICE for ail Labor & Materials (including any applicable discount) is $ l– Contract Price S
Down Payment s
Balance Payable $ State Sales Tax (,_%) $
(If applicable) (�
Terms: Credit X (Subject to the .approval of the Credit Department) Tate) Contras Price $
Cash ❑ (Find payment payable to Installer upon completion) Funded by: Bank:
City St.
Acs A
10% Preferred Customer Discount (PCD) awarded for any future Saar Home Improvement Products purchases. Current pricing evalleble for one (1) year.
11 this is a credit trensactlon, the agreement for credit Is contained in a separate document which Is Incorporated herein by reference and made a part
hereof. IANe the undersigned are hereby authorizing Sear Home Irtgrovement Products to verily and review mytour credit record with an independent
credit reporting agency and release them from all neDllity Incurred from inadverteept "lesions or
IN WITNESS WHEREOF Purchaser(s) have hereunto signed their name(s) this `� day of � 2o _ and acknowledge receipt
of a true copy of this Contras � at t and unless otherwise specified. it is understoowner is rellidly for this work to beg n.
THIS MESSAGE APPLIES TO DOOR-TO-DOOR SALES ONLY. You the Punchaser(s) may cancel this transaction
any time prior to midnight of the third day after the date of this transaction. See accompanying notice of
cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Srgrtature affixed below acts as feosipt stat Pura,eser(s) rewnaa separate cancelimm roans.
9VBMITT pr mea Date /� j� Dei
Sign tor Sema Milne IrrenxAnwre Pro0i6, In< Dai Pxrxinw Delo
D2 -SO . Rev. 02106
The Commonwealth of Massachusetts
Department of Industrial Accidents
9_3 Office of Investigations
C, 600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Print Legibly
Name (Business/Organization/Individual): t)M r-$ NOY" P _Lm O rnV16
Address: 1094 F1or i jo, C0r) Ora p k vj
City/State/Zip:
90A�-7e.: S60 ' 7 Ci a• 8 t O,c
Phone #: e e / / : 2 6 0 • 753 ' 04 579 -
Are
9 -
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. El am a sole proprietor or partner- listed on the attached sheet. I
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
5. ;<We are a corporation and its
officers have exercised their
right of exemption per MGL
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. El Electrical repairs or additions
11. El Plumbing repairs or additions
12.❑ Roof repairs ll
13O�V7n Edi
*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 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.
Insurance Company Name: �C men'
car) 27nS u r a n C e CoYY1pctny
Policy # or Self -ins. Lie. M U/ I- R C 444 Co 0 79 OExpiration Date: a'q- O / U0
ZZ "1 ( 1 tArn i k e. IS�
Job Site Address: I'J 1'e E City/State/Zip: f�� � ny� r. M A , U 12 S
Attach a copy of the workers' compensation policy declaration 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 insurance coverage verification.
I do hereby ce%& wider the tins andpenalties ofperjury that the informal{on providedjabove is true and correct
y� Y
Board of Building Regulatibns and Standards
Orae Ashburton place Roon-i 1.301
Boston. Massachusetts 02108
1-lonie Improvement Contractor Rei stration
Registration: 148607
Type: Supplement d`art!
Expiration: 10/,11/2007
SEARS HOME IMPROVEMENT PRODUCT
LuaOS SVEC
I 1024 FLORIDA CENTRAL PKWY
L.ONGWOOD, FI_ 32750
Update Address •nit! return card. Kirk rc;tsmj fur chmit e.
I Address i I iteiie-wal Emplayment Lest Card
"Ale �f'. !Ia 411Y;11jr'If
hoard of Building Regulatiiomi :tnd Standards
a
HOME IMPROVEMENT CONTRACTOR
Registration: 148607
Expiration: 10111/2007
Type: Supplement Cart)
SEARS HOME IMPROVEMENT PR
License or registration valid for iudh'idul use 0114€
before the expiration date.. Iffound rrttn-n ta:
Board of Building negulations and : tm3oards
One Ashburton Place Rin hill 1
Boston, Ma. 021(18
1_01303 s7vrc
1024 FLORIDA CENTRAL. PKWY rr-�2��-°
I-ONGNNOOD, PL 32750Not i id v► ittco tt sign cfu''� i�
Ackucinslt-ator'
r~'G@ I
//Qm +°9 C)--/!t� )' X109.
5
G,--sa 2idl Rastr 8 E yrs NONE
4 r int Hgi & tl ? r ra- i• AZ 60XK, 113.16-211113
SVEC
LUBOS
,-
821 THOMPSON-RIT - �•• _
wiY •" ._
THOMPSON CT 116277
//Qm +°9 C)--/!t� )' X109.
;I
Board of Bui Iding Regulations and Standardl
HOME IMPROVEMENT CONTRACTOR
Registration:
LONGWOOD, Fl- 32750
07—SS I c, S7 -40a
1.48607
10/111/2007
22=
Administrator
41
04/02/2007 11:20 407-767-8536 LICENCE PERMITS SUBS PAGE, 01
ACORD�. CERTIFICATE OF LIABILITY INSURANCE 08/01.12007
03110/2006
TYPE QF INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER
LOCKfON COMPANIES,LLC-K CHICAGO
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
525 W. Monroe, Suite 600
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
CHICAGO IL 60681
U_AFF-O}RDW YjHf: POU�1Ujl3E1L.
(312) 66U9M
INSURERS AFFORDING COVERAGE
INSURED
Sears Holdings Corporation
INSURER A; ACC American S Ari
1062183
d/b/a Sears Home Improvement Products, Inc.
ins.
INsuREO a�T��y .. Co. of North Amen ,
Attn: Risk Management 85-1778o
llkr$C
08/01/2007
3333 Beverly Rd.
INSURER I-
u tar A PfSUTDAPT Mr-TW91FA1 TWE ISSUING
Hgffman Estates, IL 60179
rnvFReGEs SFAT4004 C7
INSURERISI. AUT}f0131bED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE dgLDER.
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.
INSR
L
TYPE QF INSURANCE
PDI ICY NUMBER
POLICYEFFECTNE
G T
POLLL:YEXPIRA710N
DATE M
LIMBS
GENERAL LIABILITY
EACH OCCURRENCE S 5.000.000
FIRE DAMAGES IM nre s Excluded
ME4 EXP Amr-e kp- $ EXC1UdCd
A
X CO MERCIAL GENERAL LIABILITY
CLAIMS MADE El OCCUR
MDO 621729383
0410)/2007
08/01/2007
PERSONAL & ADV INJURY ,P 5.0 0 000
GENERAL AGGREGATE $ 5.000 000
GEWL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $ 5.000,000
POLICY LOC
JECT
A
AUTOMOBILE LIABILITY
X ANY AUTO
T.SAH08219953
04/01/2007
08/01/2007
COMBINED SINGLE LIMIT
(ER eccldent) 5,000,000
BODILY INJIJRY $ XXX7C7CXX
(ParParsan))
ALL OWNED AUT05
SCHEDULED AUTOS
n
BODILY INJURY $ XX
(Per accident)
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE S XXxXXXX
(Par =kfmk)
OARAGELIABRJTY
AUTO ONLY -EAACCIDENT S X}t7CKIXX
OTHER THAN EA ACC $ XXXXXXX
AUTO ONLY: AGG S XXXXXXX
A.
ANY AUTO
S.1. R. $5,000,000
0410112007
08/01/2007
EXCESS LIABL(TY
EACH OCCURRENCE $ 10,000,000
A
X MCUR ❑ CLAIMS MADE
XOO G23573830
04101/2007
08/01/2007
AGGREGATE $ 10,000,000
xxxc
DEDUCTIBLE FORM
xxxxXXX
RETENTION $
$ xxxxXXX^-
A
WORKERS aoMPeNsATION AND
WT,RC44460737(C:A) (DED)
04/01/2007
04/01/7008
X we sTATu- orl+
E.L. EACH ACCIDENT $ 1,000.000
EMPLOYERS' UABUJTY
SCFC44460749(RETRO)
04/0112007
04/01/2008
E,L, DISEASE - FA EMPLOYEE $ 1000 000
B
WLRC44460798
04/01/2007
04/01/2008
E.L. DISEASE - POLICY LIMIT $ 1000 000
B
ALL OTHER STATES
A
affl R
S.T.R. $5,000.000
04/01/2007
09/01/2007
'MA, $5,M0,00
O:a 96cepers Liability
DESCRIPTION OF OPERATION"OCATiONSIVENICLESIEXCLUSONS ADOEO BY ENDORSEMENTISPECUIL PROVISIONS
Alfred W, Nyman, Jr.. License #CGCG) 2538 Ineated @1024 Florida Central Parkway, Longwood, FI, 32750 and Alfred W. Nyman, Jr., License NCMC124951.0
Incatcd @ 1024 Florida Central Parkway, Longwood, FL 32750
2268062 SHOULD ANY OF TME ABOVE 01EVAIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Sears Home Improvement Products DATE THEREOF. THE ISSUING INSURERWILL ENDEAVOR TO MAR. 30 DAYS wRrrTEN
1024 Florida Central Parkway
Longwood FL 32750 NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL,
IMPOU NO OBLIGATION OR UABLLJTY OF ANY WND UPON THE INSURER, ITS AGENT$ OR,
REPRESENTATIM.
AUTHORLMO REPRESENTATBM
ACORD 255.8 (7197) eor aaectton¢ talpmma this awMmaw. aamMOOe m1mbor axaa M me'wouuea' ""len AbbaA a,nd sPeaty the easnt aoerA •sE—W. " 69 ACORD CORPORATION 9988
Received on 4/2/2007 9:22:20 AM
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