HomeMy WebLinkAboutBuilding Permit #369 - 23 ANDREW CIRCLE 11/8/2007 NORTH
BUILDING PERMIT o�tt,�° tio
TOWN OF NORTH ANDOVER
02 4' ° Om
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received �4p°AATt°
'�/j _ �SSACN�15��
Date Issued: �' ,//�
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER 1:70
Print
MAP NO: LA I PARCEL: 19A 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 Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
�e91ar.Q, 5 w►r-�1��
Identificatio Please Type or Print Clearly)
OWNER: Name: r1(J 2 Phone:
Address: �j q,n8r2w C t r, a-100 - C(
CONTRACTOR Name: �A(>T ry, Phone:
-
Address: ��1`=- Cj-1U x-)\&) bA
Supervisor's Construction License: Exp. Date:
Home Improvement License: Q 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: $ �ol� FEE: $ �
1)
Check No.: � 3� Receipt No.: a o
NOTE: Persons contracting nw unregistered contractors do not have access t t e aranty fund
Signature of Agent/Owner Signature of contractor
Location o)3 Abt,�,d cld G
No. ?Zq- Date /
NORTH TOWN OF NORTH ANDOVER
►. .. 9
` Certificate of Occupancy $
Building/Frame Permit Fee I
ACNus
Foundation Permit Fee $
Other Permit Fee •$
TOTAL $
Check # 0 �39 .
2 0 7 �
V Building Inspector
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
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
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
Located at 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 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.:
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
Doc.Building Permit Revised 2007
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
❑ 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 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:BPFORM07
Revised 2.2007
I
•" FMM : KIMBLY FAX NO. : 6033629679 Nov. 05 2007 11:37PM P3
HOME IMPRI)VF:i4F.NT C:ONTRA(."I'
r SOK furnished and lusUilled by:
! _�(J Dille, - THD spot At-1At,Home mw SLr.mC-
Itraech Name: •_ '%l7.— d/h/a the Home Depot At-lions +txvicce
345A(rreenwood StrC95t,Wt MO'tter,MA 016011
�j —Job lf: L,� I-oil pvcz(W))657-5182; Fax:$013-756.28517
Branch Nuntbuf:_ Pedual 111 N 7s x.61&4Mt ML•t.ktl C'lrJR19 Rl Cont.1.10 16427
(.t Lic ff 5nMti/:/2. MA 1•tnete Im�tK�m/cm�cN�i`uiAMCtnr,,k/ug.li�t3p4f 3 fS
" �p �q /! _!LALP.•r ffl�. tial✓ t/'✓
laatagation Address: Or !.l.'.=1[tl .. - f =
cityStarr- Zip
Inst♦Digits of PrNW% Pha
IParskaect(s I.;t_*&tiYp.MdYr. vVortc,Footle �. Homs mm
- vim/
Holme Address:_._. —- —- �1
.•.—...-.—._._ •--. stem zlr
(If difforrit from IAStZIWion Addteaa)
E-mail Addy (to rtxcive trpt4ltes and pr fmm The Nottta Depot):—.-----.---..—_. --- "��•
Project Infortnntion: I/WdYrnr(,,ptu4itasa"1.the owners of the property located at the above installation Idtkxss,otTi:r to 4A �• 1
cotdract with THD At-Hoo Scrviccs,kT-(`bottle Donut".)to fu►msh,deliver and arrnnt a for the iw 210tion a u11 rt��f
u deserihcxl tat the attached Spot Shut tf �—,incot7xxatexl herein b)'stfet'encc artd trade:a pan
ptse re-ins a a1 the oh.Rom Depot tletcrm es that it 1 � �
Home Deptst titiseroeK tM t to eaucel thic.vtatract ii*.u peefio j
cannot perform its obligations due to a structural.problem with dw home.pricing errors or because work required to �cjr1 1(�j i.�complete job was eM meluded iD the Spec$hcet or ConUxt- L�J'I I o�o
DFPOSYf PAv3 uN'1'OPTIONS
.-._•• � (Subject a fund vlaPextian aDtlloraretlit nlgmrval.l 1`^- � �,y '
7
CONTRACT AMOUNT $_ �.S 1.
/ , rlCMtmtrudlia�1"E.'4cayT,db•l•e mtoi'CV1)cu1+ce acHltLa�rrmKrVUSSlYrnxemj
DZPpal sDnraea-CMIorepMes(cDaee trtetow "�.}"
r
RAI.&NCE 009 � vi:ja MurtmCrrd Dircawer As
ON t OMPI ETON S +- The dome t�puc HOW tr0rovammt ihtt{eme DcpotC�ditC,rd\J
}hYnlmuae 25%of Caalrm A,aotmt doe upon 6w�5'nt l S► t,r8 Account n Ven•Y }1
extend"otUScuntracL Avadakik(t:&tSS tgadtitDCCOSVL7
tadteats
—ft ymentMethod ftr ...—
BAI,ANC:'E 0000E ON C()iNPi MON:
] [ n --Hy my/our eignattuti below.IIWC u9ea to allow Htmte Depot to
` card for fire it
indicated-information fiom Your Cho*tD umb-a ace-timt d4irmic lder x Sii7�ma .
.bmd tromfir fmm yoof aceuartr of to P the pxyroart
tat;traaeeaion-W ecu we are inkz++�+tiae trona yoCheckto N07:_
C:AltthOl F�GOD Credos
electeonie fold uaasfa'tlmds may be witt4mwu fivinot
yrna ecewmt ss nom ax the lWflnmr is weived,»il ymc will nat .,tec6ve your check beck. # 61
purtilimer ttgrees lhar~immediawly upon Wltip]ofiou of the Worts. baser wt7l execute a t uaiplction Certit"icate and pay qtly i.
balance chic. Nachamr also agseol 10 bo jointly and.severally obligated mid liable hercondcr.
utire et: p:This agFemnent and iffi aEracFaut nor indoding any fmttm iter$agreement,c4jmAin the complt:fe agreement
between the ptutiCs And can not be amended or mr�Pred t 104 in writing m a separate agrommit signed by both Parties.
NOTICE TO PURCHASER r
1)tr not sign this cnafrdet bcfbre You read it Yoe arc eatitiltd to a eoinplealy fllle�i�t:op� ttlR eoatrACt at the time
ytm tlgrt Keep it to protect sunt rfgLts Da not sign a Complciitln Certdleate before this project is cnmplet� I.aw
py»hit►its borne repair Contretters frolLl rtagacating or
tltepptitag a Completion Cert+ficttte shred by trio owner prior is
the actual cn!elirrn let rite work hr be ptuiurmtxl+miler the contract
Ytlu -ye"
y cancel this Iraaetioa gay bate prior turn
ut lite third bnsiecss d:y alter the dale of this cttalnct See
Notice f f:atoa:llat'oe Eur as espI""Aation of titin right llterc will be a nervine charge+awed to 14%of the coAtraet
amonot if jnh bi f:Ullcei►ed by Perdlassr A'I'l'ETt the third be'sincgs day,bat 13El 0RX matet'txis are ordered.Them will
L
a wx vftt slime egeal to?.5.of the d,atract aml6Unt if job is tanCelted by Purchaser AFPER materials art ordered.
fIY MYtOItR$KiNATURF BELOW,UWE UNDERSTANIP TIIAT THE AGREEMENT MAY BE SUBIi7C:T TO REVIEW
OF MY/OUR CREDIT HISTOICY AND iAVE AI)TIIORME IjemE T)F.POT TO VERIFY ANT) REVIEW MYIOUR
AGENCY AND RELEASE_'1'1IEM FROM AI,I.,
CRisDFf Rb.CORI7 W1714 AN iNDF,I"F.N.DENT t RIrDiT'REp()KT1NC;
L.IABIHTY INCURRED FROM 11qAT)VFR•i'ENT 4L)M]SSI0NS OR ERRORS.
By MYIOI.IR SIG?4ATURE BELOW,VWE AGRGG TO BE BOUND BY TfIF TERMS Dr Tlit3.CONTRACT, I/WL
PI1 5'OF l21I?NOTICE
A-'KN0WLSDGF.RECEIPT()I A CUNY OF TItHS()ONTRACF AND TWO COMPL I'M CO
Cs'FCANCULATIO N. ^?
SUF2MffTfl7
AC:GIiPTRD BY _
_ �.� �_... - Datz.
NOI'ICr:ADDITIONAL TERM$AND I:ONDI'i'IONS ARE STATED ON THE REVIMOV SiDTs.
T
E' ti
Aa
AT-HOME installed
;SR'VES Siding and Windows
V Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 126893
Type: Supplement Card
Expiration: 8/3/2008
THE Home Depot At-Home Services
BUNROEUN CHHOUY
3200 COBB GALLERIA PKWY#200
AVANTA, GA 30339
Update Address and return card.Mark reason for change.
;-CA1 0 5oM-05/06-PC8490 � Address Cj Renewal 0 Employment Lost Card
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 126893 Board of Building Regulations and Standards
Expiration: 8/3/2008 One Ashburton Place Rm 1301
Type: Supplement Card Boston,Ma.02108
THE Home Depot At-Home Servic
6TJNROEUN CHHOUY
3200 COBB GALLERIA PKWY#20 �
AtIANTA,GA 30339
Administrator Not valid without signature
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
MARSHIrF�/►TG1��T{lRCIJ��j� CERTIFICATE NUMBER
.;�., ATL-001234410-01
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
homedepot.certrequest(dmarsh.com POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
FAX(212)948-0902 AFFORDED BY THE POLICIES DESCRIBED HEREIN.
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 COMPANIES AFFORDING COVERAGE
COMPANY
00492-THD-IPUSA-07-08 IPUSA A STEADFAST INSURANCE COMPANY
INSURED COMPANY
HOME DEPOT USA,INC. B ZURICH AMERICAN INSURANCE COMPANY
2455 PACES FERRY ROAD NW
BUILDING C-8 COMPANY
ATLANTA,GA 30339 C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D NEW HAMPSHIRE INS COMPANY
,COVERAGES ';.
`' ThfS ceitlticate supersedes.arldreplaces 2ny;prWously issued;ceitificafe;forthe.paticy?pe�iod Hated below. 2
:.r_. „3Ja _e.
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS
A GENERAL LIABILITY IPR 3757 608-02 03/01/07 03/01/08 GENERAL AGGREGATE $ 4,000,000
X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' PRODUCTS-COMP/OP AGG $ 4,000,000
CLAIMS MADE a OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL BADV INJURY $ 4,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
FIRE DAMAGE(Any one fire) $ 1,000,000
MED EXP An one erson $ EXCLUDED
B AUTOMOBILE LIABILITY BAP 2938863-04 03/01/07 03/01/08
X COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
X ELF-INSURED AUTO —
HYSICAL DAMAGE --
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ _
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
A EXCESS LIABILITY IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000
X UMBRELLA FORM AGGREGATE $ 5,000,000
OTHER THAN UMBRELLA FORM $
C WORKERS COMPENSATION AND 2921209(CA) Q3/O1/07 03/01/06 X W AT - H-`
EMPLOYERS'LIABILITY TORY LIMITS ER
E 2921210(FL) 03/01/07 03/01/08 EL EACH ACCIDENT $ 1,000,000
F THE PROPRIETOR/ X INCL 2921211 (AZ,ID,MD,VA) 03/01/07 03/01/08 EL DISEASE-POLICY LIMIT $ 1,000,000
D PARTNERS/EXECUTIVE 2921208 AOS
OFFICERS ARE: EXCL ( ) 03/01/07 03/01/08 EL DISEASE-EACH EMPLOYEE $ 1,000,000
C OTHER 2921213(QSI) 03/01/07 03/01/08
E WORKERS'COMPENSATION 2921212(KY,MO,NY,WQ 03/01/07 03/01/08
G TEXAS EMPLOYERS TNS-C44642086(TX) 03/01/07 03/01/08 EACH OCCURENCE 25,000,000
EXCESS LIABILITY I SIR 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER CANCEL"LATIQN`
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 10.DAYS WRITTEN NOTICE TO THE
FOR EVIDENCE ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE.ITS AGENTS OR REPRESENTATIVES,OR THE
ISSUER OF THIS CERTIFICATE.
MARSH USA INC.
BY: MaryRadaszewski "" )�.Id.it13 ����QlwU , n_1
` a MMt(3102j'" a' VALID AS OF: 02/28/07
NORTH
0" Of Andover
0 '.
No. !D �0 -
0
dover, Ma tL- LA 0 SS.
COC
HICHEWICK
IT Of?ATED BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
k BUILDING INSPECTOR
r.—I................ ..............9 L MWa............................................................................................
THIS CERTIFIES THAT........ Foundation
has permission to(rect. ........... .... buildings on....Z-1.......... 0-4-c........... Rough
Chimney
-AtmA................................
to be occupied as .... ...... ........... wivV4
provided that the on opting this perm s6ii-in.every-respect--conform to the terms of the application on file in Final
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
_S PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONSTRUP TS... Rough
............ft
...... ................................ .......................... Service
BUILD Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
i ne t,ommonwealth of/llassachusetts
r
Department.of Industria!Accidents
OJfice oflnvestigations
600 Washington Street
Boston,MA 02111 -
Workers' Compensation Insurance Af davit Builders
Tobin of riingtnn
Applicant information /Contractors/Electricians/PilI — s
Please Print Le ibl
Name (Business/organization/Individual): N
Address: PLA _ at(A U0 00 t S�
City/State/Zip:
Phone
Are you an employer?Check the appropriate box:
l.9 I am a employer with.__ _ 4. Type of project (required):
emiloyees (full and/or part-time).* ❑have bn� �Contractor and I
2.❑ I am a sole proprietor or partner- listed on the attached sheectto1rs 7. [E.p CO coon
ship and have no employees These sub-contractors have u F�'deling
working for me in any capacity. workers co 8. 0 Demolition
[No workers'co . insurance
mp• insurance
mp ance 5.
W 9.
❑ e are a co Building r ration ❑ addition
required.] � and its g
3.0 I am a homeowner doing all work fficers have exercised their 10.0 Electrical repairs or additions
myself. right of exemption per MGL 11.
[No workers comp. c.152,§1(4),and we have no 0 Plumbmg repairs or additions
insurance required.] t. e 2:0 Roof repairs
r employees. [No workers' 1
'Any applicant that checks box kl must also fill out the section below owmg hnn worce kgers�d] 13.0 O��
t Ilnmeowners who submit this affidavit indicating they are doing all work and then hire outside contract
tContractors that check this box must attached rnpensanon policy infomration
an additional sheet showin the name °'s must subrr>it a new affidavit indicating g of the sub-contractors and their workers' g such
I am an employer that is providing workers'compensation corrv'Policy mfam ration.
in ormarion P cation insura
.� nce for my employees. Below is theoli and
Insurance Company Nares: ` Policy .lob site
Policy#or Self-ins.Lic. #:
Expiration D
Job Site Address: ate: — —O
t r
Attach a copy of the workers' compensation policy declaration page(showinCity/State/Zip:g the policy
Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to
number and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP W
Of up to$250.00 a day against the violator. Be advised that a co the nnPosition of criminal penalties of a
Investigations of the DIA for insurance coverage verification. WORK ORDER and a fine
copy of this statement may be forwarded to the Office of
I do hereby certify under the pains and penalties orP l er u ry that the information provided above is true and correct
Si azure:
Phone#: _ '—,
Date:
Oficial use ori/j,. Do not write in this area,to be completed by city ty or town official
City or Town:
Issuing Authorit Permit/License#
y(circle one):
1. Board of Health 2.Building g
wldin
6. Other Department 3.City/Town Clerk 4. Electrical Inspector 5. PlumbingInspector pector
Contact Person:
Phone#: