HomeMy WebLinkAboutBuilding Permit #968-2016 - 40 MARTIN AVENUE 3/15/2016TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Pennit NO:q
Date Issued:
IMPORTANT:
LOCATION
PROPERTY OWNER
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
Date Received
must complete all items on this
ZONING DISTRICT:
HISTORIC DISTRICT YES D
z
TYPE OF IMPROVEMENT
PROPOSED USE
Re:siKntial
Non- Residential
0 New Building
[I Addition
0 eration
Lkne family
[I Two or more family
No. of units:
0 Industrial
,Aepair, replacement
0 Demolition
El Assessory Bldg
11 Commercial
0 Moving (relocation)
0 Other
11 Others:
[I Foundation only
111
OWNER
Address:
TO
CONTRACTOR Name:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:— wlx� -Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
No.
FEE SCHEDULE: BULDINGPE"IT. S120O PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost:$--. xl2.00=FEE:$ ei�z�
Check No.: Receipt No.: 30
Page I of 4
44
0
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued: IMPORTANT: Applicant must complete all items on this p_age
LOCATION ME,
Print,
PROPERTY OWNER
��p7ii !6M�rStrTctTre yes no
nt
yes noi
ZONING. [DISTRICT: Historic Oistrict.
MAP PARCEL
Machine Shop-Vill'age yes no
TYPE OF IMPROVEMENT
El New Building
El Addition
0 Alteration
o Repair, replacement
El Demolition
o Septic 0 Well:
[I Water/Sewer - -
PROPOSED USE
Residential
El One family
El Two or more family
No. of units:_
11 Assessory Bldg
0 Other
D RbQoplain 0 Wetlands
Non- Residential
El Industrial
Ei Commercial
[I Others'.
El Watershed District�
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name:
Email: ---
A-- - d— -- —11--- . M n�' - - --�
d ress:
Supervisor's ConstructionLicense: T ----.Exp. Date:
E ate.:
Home Improvement License D
ARCHITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT.- $1z00 PER $1000.00 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 guarantyfund
S- �ig, & (Ag t/C.- - -Fa _�j�igLature of -coht actor- -
�_atureof, A, vvtier,---- . - --l- — -1 L
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
ci Photo Copy Of H. 1. C. And/Or C. S. L. Licenses
• Copy of Contract
• Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Ej Building Permit Application
ci Certified Surveyed Plot Plan
ci 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
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
Doe: Building Permit Revised 2014
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans El
TYPE OF SEWERAGE DlS-P-0SAL
Public Sewer Tanning/1\4assage/Body Art Swiling Pool'
well Tobacco Sales Food Packaging/Sales [I
Private (septic tank, etc. El Pennanent Dumpster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comme
Comments
W, ater & Sewer Con nectionis.ignature & Date Driveway Permit
DPW Town Engineer: Signature:
ni Wr Located 384 Osgood Street
-
F, 1 R, C:: P —Q - RKPOP I . I
AT Te' 042XV0,
0.:St—e'rNd,$q e q
e,
�paft
Dimension
Number of Sto I ries: 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.$100-$l 000 fine
Doc.Building Permit Revised 2014
Location 4 C2
No. Date
Check # I
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Build ing/Frame,,Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $--
Bu'llding Inspector
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'I
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS AD
Branch Name: New England Date:�i2? Sold, Fur-nished and Installed by:
THD At -Home Services, Inc.
Branch Number: 31 d/b/a The Home Depot At -Home Services
908 Boston Turnpike, Unit 1, Shrewsbury, MA 0 1545
Tofl Free 877-903-3768
Federal ID # 75-269WO; ME Lic # C 02439: RI Cont. Lic# 16427
CT Lic # HIC.0565522-,MA Home Improvement Contractor Reg. # 126893
Installation Address: yo t#(#2 /V.
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
.6t_11 �V�M 117P18&-84:?9-9 I[ I If I
Home Address:
(If different from Installation Address)
City
E-mail Address (to receive project communications and Home Depot updates):
Ell DO NOT wish to receive any marketing emails from The 14n- n t
State Zip
E Pr
L%ect -InfOrmation: Undersigned ("Customer"). the owners of the property located at the above installation address, agrees to buy.
and THD At -Home Service%, The. ("The Home Depot") agrees to furnish, deliver and arrange for the installation ("Installation") or
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 (col!ectively,
"Contract"):
Job #: (internal Reference) P—A—f-
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 Linder this
Contract agreas to be jointly and severally obligated and liable hereundet.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included hercin, at
-tl t;1
its discretion, if The Home Depot or its authorized service provider determines thatit 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 hot included in (lie Contract.
Payment Summary: The Payment Summary # included as part of this Contract, sets forth the total
Contract amount and payments required for the depTosits and fina 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 AMOUN`TS
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.
AccgytagSe an4 Authorization: Customer aggrees and understands that this Apreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and a-
greernents, 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 (hat Customer has read. understands. voluntariJv accepts the
terms of and has received a copy of is Agreement.
Accep Submitted by:
A i V-YZ/-- - — ,- '. I
-------
El Rool'i 7ng_US_i di ng �Windows Insulation
apec 3neeits) ff:
F�Oject Amount
06 75-&3
o"e 00's 0
0Gutters / Covers ntryiDoors Ej-
1367V
$ 2% 4117
EIRoffing ElSiding LJ Windows 0 Insulation
,
OGutters / Covers El Entry Doors 0_
$
DRoofing USiding U Windows El li��u_lation
EIGutters / Covers ElEntry Doors F1
DRoAng OSiding E] Win lows 0 Insulation
EIGutters / Covers ElEntry Doors E3_
Minimum 25% Deposit of Contract Amount due upon execution of this contract.
Maine Purchasers may not deposit more than one-third of the Contract Amount
Total Contract Amount
$ I-
- I /,
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 Linder this
Contract agreas to be jointly and severally obligated and liable hereundet.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included hercin, at
-tl t;1
its discretion, if The Home Depot or its authorized service provider determines thatit 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 hot included in (lie Contract.
Payment Summary: The Payment Summary # included as part of this Contract, sets forth the total
Contract amount and payments required for the depTosits and fina 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 AMOUN`TS
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.
AccgytagSe an4 Authorization: Customer aggrees and understands that this Apreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and a-
greernents, 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 (hat Customer has read. understands. voluntariJv accepts the
terms of and has received a copy of is Agreement.
Accep Submitted by:
A i V-YZ/-- - — ,- '. I
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The Commonwealth ofMassachusetts
Departin en t of In dustrial A eciden ts
I Congress Street, Suite 100
Boston, AL4 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Iiidividual):
Address:
City/State/Zip:
Phone #:
Areyoua employer? Check the appropriate box:
7'
1.01 am a employer with ;��) -.-.employees (full and/or part-time).*
2. r_� I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
30 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. F� I am a homeowner and will be hiring contractors to conduct all work on my property. I will
. . I
ensure that all contractors either have workers' compensation insurance or are sotc
proprietors with no employees.
5.r7 1 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. insuranceJ
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):
T E] New construction
8. E] Remodeling
9. F1 Demolition
10 E] Building addition
I I.[] Electrical repairs or additions
12. E] Plumbing repairs or additions
13.[]R f
1
14. �Zbe
*Any applicant that checks box fil 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.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities bavc;
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
. - 1-n
Policy # or Self -ins. Lic. #: n,2 Expiration Date:
Job Site Address: 1-4-F 1 ri,41 11)q n!K= City/State/Zip:
Attach a copy of the workers' c66—pensaWn 'policy declaration page (showing the pojicy nui�bir ��d"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
0
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 for -warded to the Office of Investigations of the DIA for insurance
coverage ve
I do hereby
the Rains andpenalties ofpeijury that the information provided 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. Buflding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
0211812016
D AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THIS CERTIFICATE IS ISSUE R NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
CERTIFICATE DOES NOT AFFIRMATIVELY 0
TH CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
B CERTIFICATE HOLDER.
R:LORWE�ENTAISTIVE OR PRODUCER, AND THE
if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION. IS WAIVED, subject to
IMPORTANT, does not confer lights to the
ZnJ�s�ate e,
rb Se M
certificate hol A
ca 8 Nau� 0 P
c 0 �'ies M or
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate
io �em qs)_
certificate holder in lieu of such endorsement(s). CONTACT
P Duc NAME: ---I _FAX__�
RODUCER PHONE I fair N.I.
MARSH USA, INC. C o. Elst),
6
TWO ALLIANCE CENTER E-MAIL S
3560 LENOX ROAD, SUITE 2400 ADDRESS- NAIC #
'k I su ER
FATLANTA, GA 30326 INSURER(S) AFFORDING COVERAGE
INSU
100492-HorneD-GAW*-1&17 RER A: Steadfast Insurance CompanY
INSURER a Zuricti American Insurance Go
INSURED
THD AT-HOME SERVICES, INC. INSURER C New Hampshire Ins CO
DBA THE HOME DEPOT AT-HOME SERVICES
2690 CUMBERLAND PARKWAY. SUITE 300 INSURER 0 Ilrinois Nafional insurance Con
ATLANTA, GA 30339 1
INSURER E:
I INSURER F :
COVERAGES CERTIFICATE NUMBER: ATL -003746646-14 REVISION NUMBER:$ E POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH
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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EFF TP9111�t LIMITS
jK TYPE OF INSURANCE
R I
TCOMMERCIAL GENERAL LIABILfry
F-7-1
c CLA M:�:
DE
LAIMS-MADE I A I OCCUR
��GEN'L AGGREGATE LIMIT APPLIES PER:
PRO -
X POLICY [:] JECT 0 LOC
OTHER:
B AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED CHEDULED
AU1 OS P AUTOS
NON -OWNED
HIRED OS
HUMBRELLA LIAB OCCUR
EXCESS UAB CLAIMS4
ITS OF POLICY XS
SIR: $1M PER OCC
SELF INSURED AuT 0 PHY DMG
E,
Exp, (Anyone person) I S
PERSONAL & ADV INJURY�S
GENERAL AGGREGATE I S
PRODUCTS - COMPIOP AGG S
S
;COMBINED SINGLE LIMIT S
(Ea a:mcident).. I
BODILY INJURY (Par person) S
BODILY INJURY (Par almident) S
PROPERTY DAMAGE $
IParaccidenn
EACH
1,000,000
EXCLUDED
9,000,000
S'000'mo
I --- I WC015519215(AOS) STATUIh rK
C WORKERS COMPENSATION 017 1,000,000
AND EMPLOYERSLiABILITY Y/N WC0155192`17 (AK.KY,NH,NJ,VT) 03/01/2016 03101/2 7 E.L. EACH ACCIDENT S
P 'P To 1,000,000
Co' 5"' 2"'AOS) u"'u
C" 5'1 ""AKKY N H NJVT) 1311112" 6 03
STATU Ih I -K
10112'17 S
C ANY PROPRIETORIPARTNER/EXECUTIVE N NIA 9 ( L) 0310IJ2016 0310112017 E.L. DISEASE - EA EMPLOYE S
I
OFFICER/MEMSER EXCLUDED? ' VVC01 5519216 (FL)
'y in S M S
7 ifi I P
D (Mandatory in NH) S 1,000,000
u ona age
Il yes, describe un , der Conitnued on Addifional Page E.L. DISEASE -POLICY LIMIT
DESCRIPTI 3N OF OPERATIONS below
(ACORD 10i, Additional Remarks schedule, may be attached if more space is required)
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES
EVIDENCE OF INSURANCE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THD AT-HOME SERVICES, INC. SHOULD ANY 0 THE ABOVE DE NOTICE WILL BE DELIVERED IN I
I
THE EXPIRATION DATE THEREOF,
DBA THE BOME DEPOT AT-HOME SERVICES POUCI
2455 PACES FERRY ROAD tACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA, GA 30339
AUTHORIZED LREPRESENTATn[VE
of Marsh USA Inr_
Manashi Mukherjee
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs �dlusi-ness Regulation
10 Park Plaza - Suite 5170
Boston, Mas,s.aChusetts 02116
Home Improvernqt .,Contractor Registration
THD AT HOME SERVICES, INC.
RICHARD FALLONE
2690 CUMBERLAND PARKWAYS
ATLANTA, GA 30339
;CA11 C 20NI-09-1111
of Consumer- Affairs & Business Regulation
�—Mgg��IVIE IMPROVEMENT CONTRACTOR
Type:
egistration-zLIZ$qg��=_-��
Supplement Card
THD AT HOME SERVIQI
THE HOME DEPOT AT -.,i
RICHARD FALLONE'--,
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