HomeMy WebLinkAboutBuilding Permit #615-2016 - 320 BOXFORD STREET 11/18/2015Permit
Date Issued: <
LOCATION
OWNER:
Address:
BUILDING PERMIT 0 �,4LED.1Fb* Ha
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION ,0e
I� Date Received
ORTA.NT: Applicant must complete all items on this
1'4 istrict
100 Year Structure
Print
ARCEL: ZONING DISTRICT:_ Ma hivorice Shop Village
Contractor Name:
Email:
Identification - please Type or
1%
Address: `"I ' `
Supervisor's Construction License: Exp. Date:
4,0#,--(-:2—
Home Improvement License: Exp. Date:
Phone:
ARCH ITECT/ENGI NEE
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ FEE: $
Receipt No.: 2ACheck No.: 1�
NOTE: Persons contracting w unregisteretd contractors do not have access the/ aranty fa�nd
Location
No.���i1
7—GI � Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $—"
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
6 Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Flan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swnnming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dmnpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature,
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
ling Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/signature � ®ate Driveway Permit
)DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE�DEP,41, iML-SIT .-:Ternp;Dumps e --yes
fir on site.
4 •
Locatetl at 124 Main Street 1 J ;uri`} �,;�` a} Y 0�
z sur f _ y
Fire+Delvartrn�rit+�i nature/dale
. .. - {', . t. ... / , : M R `.'.'C'r }i'w-7}T w3-�K��•.f h ��„ f .+
COMMENTS_��,,,.�rt,;riw
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Motor location, mast or service drop requires approval of
Electrical Inspector Yes M®
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.$'(0o-$1000 fine
NOTES and DATA —(For department ruse)
El Notified for pickup Call Email
} Date Time Contact Name
Doc.Building Permit Revised 2014.
No
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 Y
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 durnpster 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®e Department prior to issuance of Bldg Permit
ducts
TOTE: All dumpster permits require sign off from F p P
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
46 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
TOTE: 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: Building Permit Revised 2014
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Nov 04 15 02:49p Rick Odonnell 6033780151
"VIV111 liVll'1(V v it 1v1L' 1N 1 %,VIN I lr&m%l I
PLEASE READ THIS
p.1
Sold, Furnished and Installed by
Branch Name: New England Date: _/ / 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 Lie # C 02439; RI Cont. Lie# 16427
32-o x CT Lie # HIC.0565522; MA Home Improvement Contractor Reg. # 126893
Installation Address: LZ cS / L-r'/11r7� . /-( ✓7 0 19 r/
City State Zip
rurcnasegs): Work Phone: Home Phone: Cell Phone:
Home Address:
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
❑ 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 instal lation address, agrees to buy,
and THD At -Home Services, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for the installation ("Installation") of
at] 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 #: (W.—I Rd Products: Spec Sheet(s) #: Proiect Amount
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 Contract.
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.
Accep ed by:
xZojs
Cu st er' ignature Date
V
Customer's Signature Date
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STAT
Submitted b
X ----
Sales Consultant's Signature Date
Telephone No. 1<O3 - 4"7S"- / 6� i
Sales Consultant License No.
(as applicable)
ED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
08-03-15 White - Branch File Yellow - Customer
Roofing LJSiding,,NWindows LJ Insulation
❑Gutters / Covers ❑Entry Doors ❑
70 d 9 G
$
Roofing LJSiding El Windows D Insulation
❑Gutters/ Covers C1 Entry Doors ElS
Roofing USiding El Windows EJ Insulation
❑Gutters I Covers ❑Entry Doors El$
Roofing ElSiding EJ Windows El Insulation
❑Gutters / Covers ❑Entry Doors Fl$
Minimum 25% Deposit of Contract Amount due upon execution of this contract.
Total Contract Amount
$
Maine Purchasers may not deposit more than one-third of the Contract Amount.
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 Contract.
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.
Accep ed by:
xZojs
Cu st er' ignature Date
V
Customer's Signature Date
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STAT
Submitted b
X ----
Sales Consultant's Signature Date
Telephone No. 1<O3 - 4"7S"- / 6� i
Sales Consultant License No.
(as applicable)
ED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
08-03-15 White - Branch File Yellow - Customer
�f-3.q rJ -CERTIFICATE OF L
4 IS ISSUED AS A MATTER OF INFORMA-nLIN C
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. 'decate hoIdiar '3 Is in 7t0Cl FI61+iAL )Npuw,
the s termapi
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20e_�rI N?Icferin 1166 of such, end&serndnj:(s),
PRODUCER
TWO ALLONLC CbTFR
3-0-60 LFNOX ROAD SUITE 2400
ATLANTA,. GA�.�6� -
=42-Homel)-Gw,45-iB
INSURED
THD A'F{IOME INC,
DBA 11JE kIM9 00-6t- - SERVICES, _'
_A.
T HOM8 SERVICES
2696 CUMPKMMAOMY, SUITE 300
ATLANTA, GA 30339.
COVERAGES CERTIFICATE NUMBER:
THIS Is TO CERTIFY THAT THE I I l; _II g 1 11 ll� CE LISTED AELo
W
I N DI'CATED-`,NOl' T*H s*TA9bJNG_ ANlf RE coli
CERTIFICATE MAY-dE IS�Lj.. .8 Y. SUAW _. .
IN . IRQE A�FC
AND CONWI IES
EXCLUSION. AND 6 FkCH. L MS SHOWN III H/
INSP. TS S
LTR TYPE 0FINsURAI4tff AOL)
A
COMMERCIAL GENERAL LIA131UTY GL04887714-'05
CLAIMS -MADE OCCUR
LIMITS OF POLICY XS
OFSIR: $jMPER 000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOG
OTHER:
13 AUTOMOBILE LIABILITY BAP —2M63-12.
ANY AUTO
ALCOVYINED --I o
AUTOS AnUTOS
. SELF INSOREDAUTOPHYDMG
HIRED AUTOS NON-0WNED
AUTOS
UMBRELLA LIABOCCUR
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JABILITY INSURANCE
EXP.
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14LY AND CONFERS RG RIGHTS UPON THE CERTIFICATE HOLDEP, rH13
ND, Eftk4D- OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
TUTS A CONTRACT aE`PjVr-_Ejq THE ISSUING INSLIRI=R(S), AUTriORIZED
h9- pil'olicy(jes) must be endorsed. If SUBROGATION ISWA - IVED, suLl to
n Sildorserpent A statement on this certificate. does not confer rights to the
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PERSCiNAL, V119AIRY S
PHONE
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..INSURER A4.lewfaitlitiuilee canpwy 87
------------------
00"" -INJURY (Pa ;51 $
mideril
PROPERTY DAMAGE
Per accident
Irvslni� a': LI.r(eh.arljenc�-Ifisurance Co 16535
'INSURER C--- eW a-1 SR.e-,hfs.& - - 23841
EACHOCCURRENCE
INSURER D`: .06 7 -
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AGGREGATE
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ANY'P R 0 FiR i9fUA!VA_9NbkA_
D OFFICE.%[EM.13% EXCLUDEE
(Mandatoryln'fW) .
If yes, describe Wider
OESCRIPT CIN OFOPERAi
DESCRIPTION OPOPERATIONS
EVIDENCE OF INSURANCE -
Wi 493 (AOS} 13101120-15 63-10,71,
NIA WC017731495 (AK KY, NH, NJ, VT) 0 -ii 031010
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ISURW 14AMER A BQ kft THE
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TO WHICH THIS
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EXP.
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PREMISES Ea.occlfrcencel $
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mideril
PROPERTY DAMAGE
Per accident
EACHOCCURRENCE
AGGREGATE
x'1 PER 10- is
1 VEHICLES (AGORD 101,.AddiDonal Rerharks Schedule, may bepttachadirmore "eels required)
CERTIFI ktE HOLDER
CANGLLATIOk
THD AT-ROME8f�MtEs jKr
DBA THE HOME bkt Wi�OME SERVICES sHc)u*Llj ANY OF THE. ABOVE DESCRIBED POLICIES BE (:A'I II
qE
2455kCESR*RQ'AD THE EkPlR1lTI0N DACE THEIiEOF. NOTICE WILL E 0 B ELIV
tpfD IN
ATLANTA, GA 30339 ACCORDANCE WITH THE PoLicy pjjovjSlOh§.
AU7HDRIZE11 0PRESENTATP/E
The Commonwealth of Massachusetts
w Department of IndustrialAccidents
d 1 Congress Street, Suite 100
Boston, MA 02114-2017
°�M SVB"W www mass.gov/dia
N orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNUTTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:
.93
Are you an employer? Check the appropriate box:
1.0 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.[J 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
proprietors 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
1 LE] Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13.❑Roof airs
14. them
*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 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self ins. Lie. #:(�� (� �� ► =� Expiration Date:f:F3//
Job Site Address: +���NA&I`7 J City/State/Zip: f /
Attach a copy of the workers' compensation policy declaration page (showing the policy number 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 statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification/-\
Ido hereby certify nd r t p ns a dpenalties of perjury that the informationprovided above is true and correct.
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 #:
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