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HomeMy WebLinkAboutBuilding Permit #676 - 365 BLUE RIDGE ROAD 6/9/2009Permit NO: (;4 (0 Date Issued: (i - 'I• 0 BUILDING PERMIT TOWN OF NORTH. ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received p tttec <bs'NC PROPOSED USE " - . 9_ <xw< 1• I IMPORTANT: Applicant must complete all items on this paize I LOCA m MAP NO:&_PARCEL: ZONING DISTRICT: Historic District Machine Shop Vi TYPE OF IMPROVEMENT PROPOSED USE R Non- Residential New Building One famil Addition Two or more family Industrial No. of units: Commercial Repair, re la en Assessory Bldg Others: emolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer OWNER: Name: Address: CONTR/ Address: DESCRIPTION BE PREFORME a Type or Print Clearly) Phone: Supervisor's Construction License:Exp. Date: Home Improvement License ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ o,p FEE: $ 39 - Check No.: o�f40�;-nI Receipt No.: 22091 NOTE: Persons contracting with unregistered contractors do not have access guaranty fund Signature of Agent/Owner Signature of contracto S- Location 36�7s— No. Date ! v TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � / 2L�.Jif 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 Packagingta • 4 • 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 CONSERVATION COMMENTS Reviewed on Signature HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPAj=' -.q Temp Dumpster on site Located at 1241Mai Streetx i► Fire Department signature/date COMMENTS Locateo ;t54 yes no street 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 2008 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 2.2008 COMMENTS — - m m m m X m v m v y CA CD d 'v O 0 z y CD O 'v CL � � o CZ y 0 CD CD o CLQ ME CD CCD O CCD wco a. CD a. v y _■ O CD I C2 H O CD z o CD C CD O ' �.lid cn cn n � 0 cn . cn �f O O o� z c e.+.cn cn Oq � o. z• to gO Q to CL m CO) od o c- mCM c0n� m ,,. n c C. N o"ofa o 2 CD y v o i m � � a > > 0 : m IC �� O •-► O ((( O O LA. C2 O O C �_ •��►: a coo � :1 C m m 'om cCL-11. E y •�' o fay: CD y amt � Iwo NO fOaIr ti CD 0 CA 0 m .* ; m ms s' it I' M CD ri to cn P or cn M D -� -r- %U 00 ■�� '37 w SCD: r"LJ o88 m 7r1 w sofa: CL -R: to '?7 w n � ,"d C •rl G Cn b cp 5o H CD � M O 7d 0 om v cn P or cn M D Irl w %U 00 '37 w r"LJ o88 m 7r1 w 7d ook to '?7 w n � ,"d C •rl G Cn b cp In p x H � M O 7d 0 n U a 0 c The Commonwealth of?llassachusetts i Department of Industrial Accidents Office of In vestigations 600 Washington Street Boston, M4 02111 - www.tttass.gomwa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print i.P&M, Name (Businessi0rganizatioll individual): Address: City/State/Zip: - --i� I-1�� 2� 71 Phone - Are yon an employer? Check the appropriate box: . 1 • l am a employer with __IjnD 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ l am a homeowner doing all work myself. [No workers' comp. insurance required:] t workers' comp. insurance. 5. ❑ 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.] Any applicant that checks box i!1 t must also fill out the section below showing their workers' Type of project (required): 6. ❑ New construction 7. El Remodeling 8 El Demolition 9. ❑ Building addition 10-E]Electricalrepairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof repairs Homeovoiers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ainjormation. new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is provtdu#g workers' compensation Insurance for my employees. information. Below is the policy and job site Insurance Company Policy # or Self -ins. Lic. #: �j�/� i Expiration Date: Job Site Address: 0& City/State/Zip: Attach a copy of the workers' compensation policy decl ation 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 1 v penalties of perjury drat the information prorided above is true'and correct Official use only. Do not write in this area, to be completed btu cl& 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 nr......, u. ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM 02/20/DD 09109NYYY) PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 A Atlanta, GA 30305 GENERAL LIABILITY Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED tNSURERA:Steadfaat Ins Co 26387 THD At -Home Services, Inc. INSURER B: Zurich American Ins Co 16535 2690 Cumberland Parkway Suite 300 INSURER C: NATIONAL UNION FIRE INS CO OF PITTS 19445 - INSURERD:New Hampshire Ins Co 23841 Atlanta , GA 30339 INSURER E: Illinois Nati Ins Co 23817 MEOEXP(Anyoneperson) $EXCLUDED COVERAGES 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L N R POLICY NUMBER POLICYEFFECTIVE DATE MM DD POLICY EXPIRATION DATE (MMtQDfYYI LIMITS A GENERAL LIABILITY IPR 3757 608-02 .03/01/09 03/01/10 EACHOCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE aOCCUR LIMITS OF POLICY ARE EXCESS "OF SIR: $1,000,000 PER CC" DAMAGE 0 REN PREMISES Eaoccurence $ 1,000,000 MEOEXP(Anyoneperson) $EXCLUDED PERSONAL BADV INJURY $4,000,000 _ GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE UMITAPPLIES PER: PRODUCTS-COMP/OPAGG $4,000,000 POLICY IRI- POLICYJECT LOC B AUTOMOBILE X LIABILITY ANYAUTO BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULEDAUTOS BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) X SELF INSURED AUTO PHYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY:. EA ACCIDENT $ OTHERTHAN ' EA ACC $ ANYAUTO AUTO ONLY: AGG $ A EXCESS/UMBRELtALIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 X OCCUR M CLAIMS MADE AGGREGATE $5,000,000 $ $ DEDUCTIBLE E RETENTION E C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 WGSTATU- OTH- X TOC IMIT R D EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 3566915(AOS) 03/01/09 03/01 /10 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E OFFICER/MEMBER,EXCLUDEO? 3566917 (FL) 03/01/09 03/01/10 It yes, describe under SPECIAL PROVISIONS below - E.L. DISEASE -POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, WV) 03/01/09 03/01/10 F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES, INC. 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA, GA 30339 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ckomraus hd © ACORD CORPORATION 1988 11172180 3-AS DS{ Vin L I ,Ci;IlLo SiZC ,^,...i:.2'.{•ul•j I �i:::`lf l '�2 uCCL2 ?•�: _.... ,. Nadoral=ereffticn 3.,'3Z' :L1� 3 I C . 33 nn V: y :o Ra4r�wwr4r ?Jo Lani11_ad CL1�9 ) 4in vLSsLo Llx natio ® >ao CzLy 19Ln r¢JLLLa9 . ENERGY PERFORMANCE RATINGS eY/j A=N OE ReXlwe4M @rEAw= ... . U-Factor Solar Heat Gain Coefficient CoendV=G&rwda d. Emrgia sour %Q 32 1.6 C�.29 ADDITIONAL PERFORMANCE RATINGS COLUAC10N SUPLPAWAP A Op- REN0Me4TO Ylsible Transmittance Ttulsrnblon de lutVl�k - 0.52 no1nW �, ysr„ee,ed tar roma of nvtrezvnerttt► rd Md-d *'.)C d".rot n=mrw�4 .art 7014 rd &a rot werrvet Ce arND1RY d try D 'or an'o° ud D= tnarn KU In fnnn V avec M&d Pir(amano _d NMC pn dWmFm d refdirtefer>oo ftdd . Esat ,%t0= t. A101 4A +m vtbn+ aanden an b pros eta VkOW Rod,m lra Vw" ea "Dor tRc ne d�temetud>t P� to �A+eb . �.. ema l arDl 0, M y vi -f= C r P� . "q�eelAea Rc ro nmmhrdl moue Orodxz Y ro WNIM"d �'� en deaaeb para un un Cur em d _. Ma dd wx kwti Pn ra can WRQ dr uhf pro0t10L rrw�ankCatp Unit quaLifits foc PERCY -STIR cagion(a): 17octh¢cn, T•loctn . Cant.al, 9o.Er1 CaAtral, So.tha.A_ c Nf R6 f STM LA uAldld al1Lfi" .pa.a Cal Len (a.,) QNORaY, �TAlt: Nocts, Nocta Cantcal, 9,kc cantral, 9uc. IND. RATA a(3/Cla9f 3/32"/H-Et13- T¢itcd9ls¢: ' IND: Rafu¢czo ad/VLdcLo 2.31 xn/H-RA3 _ DP -4J1.-4� TanaAo pcobado. 91.4 cn x 160—c�► 10773. H9 Hoff"ft 2931124. C�np Iobd (or pombh ENERGf SGR' mbaha. To 6ocn mon'M r wino rstmr. Guards am elk)udo pato pa9bks n�mba6ns [061 SOJr Fora arrrocu n.6 anon do 00, &N VWkInlVatpa'c '. ..,..._.. �'-_ _� �ie Vo7rvrreaizusea� a�'✓j/I`,a�aacizuaelta Board of Building Regulations and Standards 3 HOME IMPROVEMENT CONTRACTOR t Registration: 126893 Expiration•8/3/2010 Type: Supplement Card The Home Depot At-Home Service RICHARD FALLONE 2690 CUMBERLAND PARKWAY S �•� ATL'AMA, GA 30339 Administrator 05-12-2009 13:49 FR011-THD AT HOME SERVICES +508 756 8823 T-577 P.001/004 F-841 _ _... PLEASE READ THIS Sold, furnisbed and Installed by: Date: F7171 f)45A TIID At Home Services, Inc.Branch Name: Boston d/b/a The Home Depot At -Hoene Services Branch Number- Greenwood Street, Unit 7. Worcester, MA 01607 Toll Free (800) 657-5182; Fax (508) 756-8823 QNarth 33 OSouth 31 Federal iD # 75-2698460; ME Lie # C 02439; RI ConL Lir,416427 CT Lic # 565522; MA Horrp Improvement Contractor Reg. # t� 3 Installation Address: rJ r 1 ► iState Zip Cty & 5e(,C._ Home Address: City State Zip (if different from Installation Address) .� C_maii Address (to receive project communications and Home Depot updates): [] I DO NOT wish to receive any marketing emails from The dome Depot located at the above installation address, agrees to buy, Pro'ect Information: Undersigned �(("�Customer"),fie owners of the property and arrange for the installation ("tnstallatioa'l of and THD At Services, Inc. ('°i he Homc De t'� agrees to futrttsh, this Conmct all materials described on State n the Supplementd Spec and Payment 5umsm�ary attached oil of heretare o ed nytChang Orders (collectively, rercrence, aloe with any applicable "Contractl: Job #: (lotc,o„1 R&—) orprotlLLCM '" ---"" Roofing Siding ME,flows lnsufation QGuners / Covers OEntrY Dors [] (b ( p( Roofing ❑Siding Windows lnsularion $ OGutters I Covers []Entry Doors [jGuners / Covers []frnry Doors [I,_ ❑Roofing Siding Windows Insulation $ E3Gutters / Covers DEmry Doors Minimum 25% Deposit of CootractAmount due upon enceeudon orthis conuum Total Contract Amount $ Maine 1'mshwm may not deposit more than one -thine of the ContractAmorme 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 tinder 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 ontract. Payment Summary: The Payment Summary #_11'774 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 frRed-in copy of the Contract at the time you sigh. '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 9s complete. to pay The Home Depot the costs of materials, labor, In the event of termination of this Contract, Customer agrees 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 FOIR 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 writtcm, relating to said Products and installation. This Agreement cannot be assigned or amended except by a writing sighed 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 Agt'c ement. Z 7 9 : et- /--?, ��- Customer's Signature Date X Customer's Signature Date CANCELLATiON, CUSTOMER MAY CANCEL TFIS 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 l6 ONE IS SPECIFICALLY PRESCRIBED BY LAW IN i CUSTOMER'S STATE.• _ No97CE: ADDITIONAL TERMS AND CONDITIONS ARE STAT :ub by: -7 . S onsul 's Signatu ate .•- T hone No. Sales -Consultant License o. luablc) (as 3PP 'ED ON TIU.. REVERSESIDE AND Anti PART OF TIttS CONTRACT 10-1-08 rev 6i05 -0a CSC • . Whiter- drench File Yellow- Customer. .f4nk - Sales Consultant �u ti it �f tiuil[liu_ K�_ulannn. ,tntl �[:tn[Iartl� tion .Supervisor .Specialty License License: CS SL 99364 Z.Stricred to: WS AF -RTE TORRES j to FELTOM STREET ,4AFRLBOROUGH, MA 01752 Expiration: 3/6/2012 Tr#: 99364 Restricted to: WS 1A- Masonry only RF Roof Covering WS - Windows and Skiing SF - Solid Fuel. Burning Devices DM - Demolition only Failure to possess a current edition of the Massachusetts State Building Code is cause fog revocation of this license. Refer to: WWW.Mass.Gov/DPS �� 7.6 %P -c,