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Home My WebLink AboutBuilding Permit #18 - 30 LACY STREET 7/9/2007 TOWN OF NORTH ANDOVER MORTM APPLICATION FOR PLAN EXAMINATION 0114,1,,.•° 010 Permit NO: Date ReceivedOL �+► �.� i Date Issued: �1ss OranC14 IMPORTANT:Applicant must complete all items on this page LOCATION �O L.m,f S—, Prin PROPERTY OWNER Ak�,MS&A V nt 1<tv�t.l�S Print MAP NO.: Ib 1 PARCEL: a; ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building YSIOne family ❑ Addition ❑Two or more'family ❑ Industrial ❑ Alteration No.of units: XRepai replacement ❑Assessory Bldg ❑Commercial 0 Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED V,zn� 22D Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: �11 iy�E (r,t-7- C-751 �- CONTRACTOR Name: Phone: �`r+�nr Phone: Address: �J4`� =,QEEtv�a �' �o+2CG��Ivt2 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: r6-3-018 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$11.00 PER$1000.00 OF THE TOTAL ESTIMATED C ST BASED ON$125.00 PERF. Total Total Project Cost :$ 1 FEE:$ Check No.:14�� X**- Receipt No.: p2c7 3 Page i of 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan. ❑ Starnped Plans ❑ 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 FIRE DEPARTMENT - Temp Dumpster on site yes 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/Si¢nature& Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required--j Required--jProvided 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 DEPARTMENT:BPFORM05 Created IMC.Jan.2006 J 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:BPFORMOS Page 4 of 4 Location Sy Lc(e� , 5r- No. r-No. t _ Date (' y MORTq TOWN OF NORTH ANDOVER � 9 Certificate of Occupancy $ '��s'•^° tt�' Building/Frame Permit Fee $ ncMus Foundation Permit Fee $ Other Permit Fee $ // TOTAL $ Check #116 2G5ij Building Inspector r10RTH TO" Of : over C,o over, Mass. LAK COCMICMEWICK ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT.....!. LhdAh.w....... . �+.e.. .I�.r.� ........................................................................... Foundation has permission to erect........................................ buildings on3a....../.. 7......Jr"................................ Rough to be occupied as .......til�� 1. .. Chimney ....6a............ ........ ............ .. ........................................................ provided that the person accepting this ermit shall 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 Final I PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU S TS Rough .......... Service BUILDING INSPECTOR 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. Sunday,July 01,2007 10:57 PM Craig Smith 603-594-5973 P.05 r. a HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: C7 Date. THD AtServices,Inc. Branch Name:� � dub/a The Home Depotot At-Home Services �2p 345A Greenwood Street,Worcester,MA 01607 Branch Number:_ C?� _Job#: ?z LOLL"l� Toll Free(800)657-5182;Fax:Cont Lic#508-756-2859 Federal ID#75-2698460 ME Lw#CO2439 Rl or Reg.#126427 Cr Lic#565522; MA Home ImPrOve"'Ort �36893 U iLCi to Installation Address: 'I city State Zip Last 4 Digits of Driver's Purchaser(s): Lia#&Erp.Mo/Yr: 'Work Phone: (Home Phone:M r, 8 b C. �0l$1 t7 )e Home Address: S(a� Zip (If different from Installation Address) City E-mail Address(to receive updates and promotions from The Home Depot): Project Information: UWdYou C Purchaser"),the owners of the property located at the above installation address,offer to contract with THD At-Home Services,Inc.("Dome Depot")to finntS^deliver and arrange anby or thinstallation i�monde Of all Materials as described on the attached Spec Sheet# � —,incorporated eof W art- 4;l'0J Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that It cannot perforin its ohligations due to a structural problem with the home,pricing errors or because work required to complete the job was not included in the Spec Sheet or Contract DEPOSIT PAYMENT OPTIONS ,lam — (Subject to fund verification and/or credit approval.) CONTRACT AMOUNT $13 ' 1. Ch cashiers Check or US Postal Service Money Order (Made payable to the Home Depot). tLESS DEPOSIT S �i" 2. (,yet =•and/or other payment options-Circle Below BALANCE DUE .y Ysa erCard Discover Amen Wcss ON COMPLETION $ U Tire Homc Depot H Improvement loan Home Depot Credit Card tMinimmn Wle of Contract Amount due upon ❑New Account ❑E 'g Account &BDCC ONLY) execution of this contract Available Credit:S (HIL&HDCC ONLY) Indicate Payment Method For Acct#: Exp.Date: BALANCE DUE ON COMPLETION: Name as a appearson card: ..By mylour Signa a below,VW to allow Home Depot to charge the abov erenced credit for the deposit indicated. 'When you provide a check as payment,you authorize us either Date to use informahou from yon,check to make a one-time elechonic Cacrlltol Signature fund transfer from your account or to process the payment as a check transaction.When we use infonnagm from your check to HIL or HDCC Authorization Codes make an ciecbonic fund transfer,funds may be withdrawn from De it F'mal Pa e your account as soon as the payment is received,and you will not receive your check bark. # # Purchaser agrees that,immediately upon completion of the worl5 Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Agreement This agreement and its attachments,including any financing agreement,contain the complete agreement between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely Filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction any time prior to midnight of the third business day alter the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10%of the contract amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered. BY MWOUR SIGNATURE BELOW,I/WE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW OF MY/OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS_ BY MY/OUR SIGNATURE BELOW, 11WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE ACKNOWLEDGE RECEIPT OF A CP07A OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. SUBMITTED BY: Date. ACCEPTED BY: Date: P er Date: Purchaser NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 6-1-07 rev 4-2-07' CSC White—Branch File Yellow—Customer Pink—Sales consultant AT-HOME installed SERVICES Siding and Windows 14 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 � �MARSH CERTIFICATE OF INSURANCE CERTIFICATE NUMBER 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@marsh.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 COMPANIES AFFORDING COVERAGE ATLANTA,GA 30305 COMPANY 100492-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 COMPANY BUILDING C-8 C AMERICAN HOME ASSURANCE COMPANY ATLANTA,GA 30339 COMPANY D NEW HAMPSHIRE INS COMPANY COVERAGES This certificate supersedes and replaces any previously issued..certificate for the policy period noted below. 2 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 POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYY) DATE(MMIDDIYY) 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&ADV INJURY $ 4,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000 FIRE DAMAGE(Any one fire) $ 1,000,000 MED EXP(Any oneperson) $ EXCLUDED B AUTOMOBILE LIABILITY BAP 2938863-04 03/01/07 03/01/08 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY I $ (Per accident) NON-OWNED AUTOS X ELF-INSURED AUTO PROPERTY DAMAGE $ HYSICAL 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) 03/01/07 03/01/08 X TO LIMITS ER EMPLOYERS'LIABILITY 03/01/08 EL EACH ACCIDENT $ 1,000,000 E 2921210(FL) 03/01/07 _ � —_—_—.. F THE PROPRIETORI X INCL 2921211 (AZ,ID,MD,VA) 03/01/07 03/01/08 EL DISEASE-POLICY LIMIT I Is 1,000,000 PARTNERS/EXECUTIVE 2921208(AOS) 03/01/07 03/01/08 1,000,000 D OFFICERS ARE: EXCL EL DISEASE-EACH EMPLOYEE $ C OTHER 2921213(QSI) 03/01/07 03/01/08 E WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 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 I ISIR 2,000,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL_'In 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: Mary Radaszewski f'l'ip* 1 �1 c :.:J)��...•< k= MM1(3102) VALID AS OF: 02/28/07 .� i tie (,ommonwealth of Massachusetts —' Departmenpof Industrial Accidents Officc of-Investigations 600 Washington Street Boston,MA 02111- www.mass.gov/dia Tabin Of _Arlington Workers' Compensation Insurance Affidavit: Builders/Contractors/E)ectricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/individual): Address: 5-A" City/State/Zip: �,� `) p Phone#:_ F2.0 an employer? Check the appropriate box: a employer with 4. ❑ 1 am a general contractor and I Type of project (required):loyees (full and/or part-time).* have hired the sub-contractors 6 ❑New construction a sole proprietor or partner- listed on the attached sheet 1 2• 2 Remodeling ship and have no employees These sub-contractors have working forme in any capacity. workers' comp. insurance. 8. EJ Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑ Building addition 3.❑ required.] officers have exercised their 10.F-1 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C-1 52,§1(4),and we have no insurance Pequired.] t. em ]o employees. 12>❑ Roof repairs P Y [No workers' ❑ comp- insurance required.] 13' Other 'Any applicant that checks boa t/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 must workers' comp.policy inforrnation. I ane an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site it formation Insurance Company Name: \�� 0 Policy#or Self-ins.Lic. #:_g., Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct S igp alure: _ Date: Phone#: --1 Oficial 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#•