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HomeMy WebLinkAboutBuilding Permit #255-2017 - 28 BERKELEY ROAD 9/8/2016' ��,•��`'�, � � � NORTH .q 0 BUILDING PERMIT cr e�,;,. •, °o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0:2:q_— ! Date Received '� ° SSSS(a'( Date Issu ACHU IMPORTANT: Applicant must complete all items on this page LOCATIONY� - Print PROPERTY OWNER X &an n Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resio6ntial Non- Residential ❑ New Building EYbne family ❑Ad ' ion ❑ Two or more family ❑ Industrial ❑PXeration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well Floodplain ❑Wetlands Watershed District 0. Water/Sewer W6 K�� �. Identification Please Type or Print Clearly) OWNER: Name: -no Phone. Address: Lid& CONTRACTOR Name: Phone: Address: r Supervisor's Construction Lic se: 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: $ 5 -2 ' _ FEE: $_ Check No.: Receipt No.: 3M,�6 NOTE: Persons contracting with unregistered contractors do not have access ihe guaranty fund ignature of Agent/Owner Signature of contractor_ ; BUILDING PERMIT o� NORT!( q SZLED /6 TOWN OF NORTH ANDOVER p APPLICATION FOR PLAN EXAMINATION � Z i Permit No#: Date Received 7 ORATED�4a c5 9SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 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 D 1N"e_]lElf F-40-0 in i]rU1/elands 1]. 1Natershed Distract DESCRIPTION OF WORK TO BE PERFORMED: 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.$92.00 PER$9000.00 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 liana �r of Aunt/Ow►ZeL�. -.Sianat�rP.of contractor - Location �*[ Y� O V 7lDate No. x • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $- Foundation Permit Fee $ Other Permit Fee $ lsi' TOTAL $ A i Check# 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r• 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- DEPAR<TMENK -,Tempster on site yes., Located af�124iMaintStreet . � � ' FiigiiDepartmentsignatiatold ate .,� 4. i I� 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 Call Email Date Time Contact Name Doc.Buildiug 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 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 OTE: 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/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 ISIOTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doe:Building Permit Revised 2014 NORTH own of ndover O : - 0 No. - C, h y ver, Mass, A_ COCHIGN2WICK �'t 7�A�R�TED PPp,�'�5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT:..... ... . .. ...... ... .� . ..................................... ... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ...Z0400...... ,. .. Rough tobe occupied as ........ ....... ... ... ........ . .. . .. .....I ............................ Chimney provided that the person accepting this permit shall 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 CONST.. TION S Rough Service .. .. . . ............ *BU61iMiN�G�IVCPTOR. Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. i t ROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: New England Date: / lr THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Uc#C 02439;RI Cont Lic#16427 CT is#HIC.0565522;MA Home Improvernent Contractor Reg.#1,26893 Installation Address: w � City State Zip Purchaser(s): Work Phone: Home Phone: Celt Phone: 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 from The Home Depot Protect 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#: anierrmt Reference) roducts- Sec Sheet(s)#: Project Amount 1�� � [-)Gutters Siding Windows Insulation a R & Gutters/Covers ntry Doors [1 /� !9 S3 iJ Roofing USiding ❑Windows ❑Insulation ❑Gutters/Covers []Entry Doors ❑ Roofing LJSidi.ng LJ Windows Insulation $ ❑Gutters/Covers ❑Enny Doors❑ Roofing Siding Windows Insulation $ ❑Gutters/Covers ❑Entry Doors Minimum 25%Deport of Contract Amount due upon execution of this contract. Total Contract Amount $ -67 f 1 Maine Purchasers may not deposit more than one-third of the ContractAmount `J 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 Horne 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. Payment Summary: The Payment Summary #_ 7&) 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 Comptetion 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 Horne Depot. Customer acknowledges and agrees that Customer has read,understands, voluntarily accepts the terms of and has received a copy of this Agreement. Accapi; oy: n n ,. )r Submitted by: /C Werk area will be contained . rt - Pre-Renovation Form Dater�`� NAT-19276 4 1 This form is used to document compliance with the requirements of the E If Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010. y3 E Customer Address Job Number(s) 28 erq .S7Gv 5 Dust will be minimized V . Aaella '"L 1 1 OCCUPANT CONFIRMATION t t Pamphlet Receipt t ►, r. have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead E hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet f a before work began. t' V - i Home Year Built h, " M .C11 Enter the year my home was built. If the ypar your home was built is Pre-1978,all work will be done following lead safe work practices. Work area will be cleaned up pdntedNameofOw - cupant thoroughly Signature of Owner-occupant Signature of rsort Certifyi gV. . lel Delivery r , SEE STATE SPECIFIC FORMS ON REVERSE SIDE I tie (:ommonwealth 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 Applicant Information Please Print Legibly Name(Business/Organization/Individual): "•A:dd're-ss . . . . . .��� [tel.. .. .. ��� ... . .. ..... __._..... . ... . City/State/Zip: hone#: Are you an employer?Check the appropriateb . Type of project(required): 1.ElI am a employer with 4. a general contractor and I 6. ❑New.construction employees (full and/or part time).* have hired the sub-contractors 2.EJ I am a sole proprietor or partner- listed on the attached sheet.# 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§ (4 1 ,and we have no ) 12.El Ro epairs insurance required.]t employees. [No workers' 13 Other comp.insurance required.] 44&) 'Lny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing•all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infonnation. trm an employer that is providing workers'compensation insurance for my employees Below is the policy and job site formation. - surance Company Name: dicy#or Self-ins.Lic.#: Expiration Date: r chiptb Site Address: City/State/Zip: :tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a .e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of iestigations of the DIA for insurance coverage verification. o hereby ce i nd r th pains and penalties of perjury that the information provided above is true and correct. nature: Date: ane#• Official use only. Do not write in this area, to be completed by city or town officlaL City or Town: Permit/License# Issuing Authority(circle one): t.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i. Other ::ontact Person: Phone#: ' A�R®® CERTIFICATE OF LIABILITY INSURANCE FDATE(/2016 YYYY) 02242016 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 CN o EM• aC No: 3560 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 9 100492-HomeD-GAW A13-17 INSURER A:Steadfast Insurance Company 26387 INSURED THE HOME DEPOT,INC. INSURER B:Zuadt American Insurance Co 16535 HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW BUILDING G20 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003741310-08 REVISION NUMBER:O 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR LTR TYPE OF INSURANCE POLICY NUMBER MMDD EFF MPOLICY DDIDI� LIMITS A. X COMMERCIAL GENERAL LIABILITY GL04887714-06 03012016 03/012017 EACH OCCURRENCE 5 9,000,000 dADEaCURCLAIMSPREMSES Ea DAMAGE TO Mrrence 5 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:SIM PER OCC PERSONAL&ADV INJURY 5 9,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000 X POLICY❑JEC7 LOC PRODUCTS-COMPIOPAGG S 9,000,000 OTHER: I S B AUTOMOBILE LIABILITY BAP 2938863-13 03/012016 03/012017 COMBINED SINGLE LIMIT 5 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident S S UMBRELLA LIAR[4OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE S _ DED I I RETENTIONS I 1 5 C WORKERS COMPENSATION W0015619215(AOS) 03/012016 03/012017 X C AND EMPLOYERS'LIABILITY YIN ST AND LITETE ERs„ ANY PROPRIETORIPARTNEWlEXECUTNE W0015519217(AK,KY,NH,NJ,VT) 03/01/2016 03/012017 D OFFICER/MEMBER EXCLUDED? N❑NIA E.L.EACH ACCIDENT S 1,000,000 (Mandatory In NH) WC015519216(FL) 03/01/2016 031012017 E.L.DISEASE-EA EMPLOYEE S 1,000,000 It Dyes,describe under DContinued on Adchonal Pa 1,000,000 DESCRIPTION OF OPERATIONS below 9e EL DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16000SGOODST. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhedee _.TYLoL%A_a w_ Eche e.L ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD r Office ice of Consumer Affairs and Business Regulation b —5 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveontractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC RICHARD FALLONE 2455 PACES FERRY ROAD, HSC1Y€ q ATLANTA, GA 30339 Update Address and return card.Mark reason for change. — Address Renewal Employment Lost Card SCA' 20M-05/'! / J�W TI:YYi,�r.�igii�n�f3�✓f��,l��i'�f/,!'ry�iio�. ffice of Consumer Affairs&Business Regulation License or registration valid for individual use only � _.. before the expiration date. U found return to: - #TOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ., `j Registratr� 3 Type 10 Park Plaza-Suite 5170 EIRE - &< Supplement.Card--- - Bosten,hL10?i Xr THD AT HOME SERV# -S-Cly THE HOME DEPOTA ERVICES RICHARD FALLONE._ - 2455 PACES FERRY R6aE�-'HSC - --- AAl WA,GA 30339 Undersecretary 4otlid with t si ture f J f J s I c, L 's CSSL-099699 p. .nristrwc ROBERT poczoSUT 112 WHALERS LANE SALEM MA 0197D b L 02108/2018 (70 r7;ry P-r