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HomeMy WebLinkAboutBuilding Permit #874-15 - 240 FARNUM STREET 5/4/2015cbWt< BUILDING PERMIT TOWN OF NORTH ANDOVER �f APPLICATION FOR PLAN EXAMINATION Permit No#: / Date Received v' �tLeo '6�•N�\ otv rep Date Issued: U 7 IMPORTANT: Applicant must complete all items on this page j LOCATION - I ^ JZ� nn PROPERTY OWNER Print 10o Year Structure _ yesno -MAPPARCEL: 0/0ZONING DISTRICT -Historic District y s no Machine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Meration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer IrP/T�10� � 0 BE PE FO ED: f� 44 R / IVO Identification - Please Type or rant Clearly OWNER: Name: �%� �dW/�� Phone: � Address:&� `7� �il�C� �/ `/�'%���y� /�/r ✓ ° G%� Contractor Nam rhone:, Address: � 6 p! Supervisor's Construction License: :Exp. Date:�f� Home ImprovementLicense: _ . _ Exp. Date: _ _ _ -. _ ARCHITECT/ENGINEER Phone: ' Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ *0 FEE: $ Check No.: u �'�I0 Receipt No.:�'�1'� NOTE: Persons contracting with unregistered contractors do not have accessatohe ara ty uSignature of Agent/OwnerSiqnature of contractor ./�1� Location r 13 4,144 No. Date V 41 6p�- o )- Check f 6; TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $- Other Permit Fee TOTAL e,77�X 14 —Buildir�g 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Sianature COMMENTS HEALTH COMMENTS Reviewed on Signature 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 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 NU i t5 and UA I A — (For department use ❑ Notified for pickup Call Email Date Time Contact Name 3 Doc.Building Permit Revised 2014 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 Li 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 o 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 that the appeal period is over. The applicant must then get this rl must be submitted with the building application office must stamp the decision from the Board of Appeals at the Registry of Deeds. One copy and proof of recording Doc: Building Permit Revised 2014 1 j a CD 0 z CD O Cr >cQ• O 00 CL r.r� CCD O CD O' O S• co CD .F 10 CD rrt O AWA n Cn n� 0 CD U) v z CD O CCD in- -- z c nMO X z 0 Cl) 55 �m c Cl) iz < O 3 � O _ in = < m -0 y O cD. CD �. � n Q m z c. O O N '-. M m o o .tea m .h S N MWA N W CD mO - CD 2 � n (� coCL 0 dommo N O O c7 W n �D C CD CL O < to co . �,' • o oCD . Z U D m �'•� � < 0o 0 <= cn � cn 2 CD rCD L -(n *� cn 0CD 0 N� Ln cn W T ;;oT N :7 T S T () m T N T 3 p rD (D ;-' (D K c m o D -ZIO j N O C S G) H H m -� DJ (D N O C S m m n D Z m 0 j N O C S C W G) m m 0 Dl S 7 O CC S O a- p' > W C o z C) N (D '6 0 3 O O - n S (D ca O > O T 2 m D x Branch Name: Boston North & South Branch Number: 31 and 33 Installation Address: Purchaser(s): HOME IMPROVEMENT CONTRACT PLEASE READ THIS cv�0_11 Sold, Furnished and Installed by: Date: & t s_ THD At -Home Services I ­ d/b/a The Home Depot At -Home Services 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 CT Lic # HIC.0565522; MA Home Improvement Contractor Reg. # 126893 State Zip Work Phone: Home Phone: Cell Phone: SCA OW t [ I J LI'....... AAA _ 1 (If different from installation Address) City State Zip mail Address (to receive project communications and Home Depot updates):� �A AJ q ,� ( CCS 1"1 DO NOT wish to receive any marketing emails from The Home Depot Proiect 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'): ± Job #: (tnternelRefenmce) Prodalrte- ii I3 Roofing Siding indows Insulation []Gutters/ Covers ❑Entry Doors ❑ , a cc 0nee[ s ff: rro eet Amount 3RD Q fo L� �g Roofing Siding indows Insulation ❑Gutters/ Covers ❑Entry Doors�y'' I $ 3 - Roofing OSidin— g Windows Insulation ❑Gutters / Covers []Entry Doors ❑ $ Roofing Siding Windows El Insulation ❑Gutters/Covers []Entry Doors [] $ Minimum 25% Deposit of Contract'Amount due upon execution of this contract. Maine Purchasers may not deposit more than one-third of the ContractAmount. Total Contract Amount $,� 443 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 CConntrtra�Q Payment 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 Home 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. Accto P Sub it d by:V A / / A 0 v 4 31Miami -1 IIdiom 113Ismael all-anNONEARM nmill I11211112 MillN112221881313So 1 18SHES as Big=ME 1- 2-3133 I Type(F.S,GRG) e MEN uNumom�MENNENMOMME 3 C C mmmmmm I I oil I 7 IS M--- as imomm Boom= IMMEMEMEMEMEME I ONE MENNENMillm ii ISO M MEnEMEMEMEMMEME im ME \ The Commonwealth of Massachusetts twi.Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): ' :1] 19 Address: City/State/Zip:/f f,/ �e Phone #: Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole pnetors with no employees. 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance: 6. ❑ 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): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbi g repairs or additions 13. ❑ of repairs 14. Other *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. 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 isproviding workers' compensation insurance for my employees. Below is thheepolicy and job site information. /� 2 / �/ Insurance Company Name: — Policy # or Self -ins. Lic. M wl�_ ' 7 Expiration Date: Job Site Address: 11 �l' V V City/State/Zip: U ►✓`' 1 Attach a copy of the workers' compensation policy declaration page (showing the policy um er and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this stat may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi and naltie erjury that the information provided above is true and correct. Cion afitt ante- ^� r 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 #: ee�cat;Y�iAA , - t. i tntC lD iKSV1 Au171�M W DA i WLS-2—S7 M—LCIS l{Y:lo Ic9ef �� LLU1m Du LIE 91 10tH s2�iup—ps N-LCJS 111tYRFpluY9D1 pet Yrrir 9rt ibrd G.d�r*�uu hr /.SIV I]L 016tH stia�scm�>>Kst� ' Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcni%orSpccialts License: CSSL-099823 �f3 DZMITRY BROWN 70 NORTON AVL 109 I Manc6cstcr NH 0109') �n Expiration Commissioner 06/26/2016 -- -------- I-lermit bervices 4U1 '140"Z?5100 p. -2 j 9 Office of Consumer AffaiWand Business Regulation 10 Park Plaza -Suite 5170 Boston, Massachusetts 02116 Home Improvement'Contractor'Registration THD AT HOME SERVICES, INC. RICHARD TROIA 2690 CUMBERLAND PARKWAY SUITE 300.. ATLANTA, GA 30339 SCA I C, 2044-0-5111 o. -Office of Cuinsuratr Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR Registration: .12603 Type: Expiratiow. 8r312016 . Supplement Card THD AT HOME SERVICES. INC. THE HOME DEPOT AT HOME SERVICES RICHARD TROIA 2690 CUMBERLAND PARKWAY S X'UM GA 30339 Undersccrtury Registration: 125893 Type: Supplement Card Expiration: 8512016 Update Address and return card. mark reason for change. Address Renewal —inpicyricrit J :.,vstuatu License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park F12Z2 - Suite SI70 Boston, MA 02116 Not t vaIid wVAout s iig�nsitre A�C� O CERTIFICATE OF LIABILITY INSURANCE 0212420DATETM0NDD/YYY1D 15 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(fes) 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 endomement(s). PRODUCER MARSH USA, INC. TWO ALLIANCE CENTER CONTACT NAME"FAX PHONE A/C No: ADDRESS: 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 INSURER(S) AFFORDING COVERAGE NAIC # 100492-HomeD-GAW-15-16 INSURER A: Steadfast Insurance Company 26387 INSURED THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER B: Zurich American Insurance Co 16535 INSURER C: New Hampshire Ins Co 23841 INSURER D: Illinois National Insurance Company 23817 2690 CUMBERLAND PARKWAY, SUITE 300 ATLANTA, GA 30339 GEN'L AGGREGATE LIMIT APPUES PER: X POLICY PRO- El LOC PRODUCTS - COMP/OP AGG S 9,000,000 INSURER E: INSURER F: AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS Cr1VFRAr.FB CFRTIFICATF Nl1MRFR- ATI -0032496P&09 REVISION NUMBER:? 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 CONTRACTOR 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. INSR I LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF MOMLDD/ EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABIUTY F-71 CLAIMS-MADE OCCUR of Marsh USA Inc. GLO4887714-05 LIMITS OF POLICY XS OF SIR: $1 M PER OCC 03/0112015 0310112016 EACH OCCURRENCE $ 9,000,000 PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ EXCLUDED PERSONAL & ADV INJURY s 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPUES PER: X POLICY PRO- El LOC PRODUCTS - COMP/OP AGG S 9,000,000 S B AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS BAP 2938863.12 SELF INSURED AUTO PHY DMG 03/0112015 03101/2016 EeMBBIINEEDI INGLE UMIT $ 1,000,000 BODILY INJURY (Perperson) s BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ fPer accident S UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ C C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDE[ (Mandatory in NH) If yes, descr be under DESCRIPTION OF OPERATIONS below N / A WC017731493 (AOS) WC017731495 (AK, KY, NH, NJ, V17 WCOIT731494 FL ( ) Conitnued on Additional Pae 9 03/01/2015 03101/2015 03/0112015 03/01/2016 03/01/2016 03/01/2016,000,000 X 1 VvCSTATUL.T- OTI I ER E.L EACH ACCIDENT $ 1'000'000 E.L.EDISEASE-EA EMPLOYE S E.L DISEASE -POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) EVIDENCE OF INSURANCE CFRTIFICATF Nrll r1FR CANCFI 1 AT10N THD AT-HOME SERVICES, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �l oLuoo �i ^cru -a cr' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD