HomeMy WebLinkAboutBuilding Permit #405-2016 - 42 NADINE LANE 9/30/2015 SC,-;z1214A 19
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BUILDING PERMIT 3?�`tt16D •b r6�O�
TOWN OF NORTH ANDOVER z
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Permit N0: APPLICATION FOR PLAN EXAMINATION +
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Date Received
Date Issued:G� 1�115 gc►+us���
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print
MAP-NO: � ' PARCELI.6 -'�? ZONING DISTRICT: Historic District yes ',no
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic 0 Well 0 Floodplain Q Wetlands ❑ Watershed District
Water/Sewer
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S
�I
Identification Please Type or Print Clearly)
OWNER: Name: Phone: a'75 X11
Address: `
CONTRACTOR Name: Phone: -� 3
Address:
itle
Supervisor's,Construction License: Exp, Date. r'
Home Improvement License: Exp. Date: .
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: $_ ,� FEE: $ r6_
Check No.: 17-1 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acces t thgu an fund
ignature of AgenVOwner Signature of contra
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NORrh
BUILDING PERMIT '".006'6
".0 06'6 -
6 U�
j TOWN OF NORTH ANDOVER 0 .
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received gssgcHus����
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION -
Print
PROPERTY OWNER..
Paint 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 ❑Well, Q Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
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:
R
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have accesTlo the guarantyfund
of Age.ntXOvvner_.._ Signature of contractor,
d �Y
L rt
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming P001s ❑
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
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:
IFLRE+DEa.PA - onsite 'yes._ _ tom_
Located .�3noo sg�oo�n
Streetsreet
MT TRTEempurnperps
�Locatedat 124MamrStet —
$ Fire�Department signature/d.'ate
C_OMMENTS�,
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
I�
NOTES and DATA— (For department use)
I
I
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
r
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
u Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Li Copy of Contract
o 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
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
u 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)
Li Building Permit Application j
o Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
a Mass check Energy Compliance Report
o 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 204
Location �2-
Date
`7
TOWN OF NORTH ANDOVERK
Certificate of Occupancy $
Building/Frame Permit Fee $ }
Foundation Permit Fee $
Other Permit Fee $
�I
' a TOTAL $
i
12�
Check#
'-e6ilding Inspector
29434
NORTH
own of 2 E ItAndover
h ver, Mass,.'�7.j
A- COCH1CAWICK y1.
7,4 A�RgTE
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT • BUILDING INSPECTOR
......................................................................... ....:... ....................... ..............
Foundation
has permission to erect .......................... buildings on ..... ?........ ....._. ........... ... .. ..... . .
0.!.-Wo
Rough
.to be occupied as ........10...... .111; .. CPA4N's................................ Chimney
provided that the person accepting this 15ermit 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 CONSTRUCTI RTS Rough
Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Sep 10 15 11:49p Rick Odonnell 6033780151 p. l
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:_// THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal ID#75-2698460;ME Lic It C 02439;RI Cont.Lic#16427
CT Uc#HIC.056555222;MSA Home Improvement Contractor Reg.#126893
Installation Address: !Z2_ 4" �� A' �7r2Fs�v�r I L/T 0/S Y3r
City State Zip
Purchaser(s)- Work Phone: Home Phone: Cell Phone:
ve; 3« [ ] E ] Ind qz--1811
[ ] [ l [ ]
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
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc.("Phe 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(collegtJ ely, ��
"Contract"): O
Job#: tintemw itd�) products: Spec Sheet(s)#: Project Amount
Roofing Siding iodows U Insulation ^
�
?'570 33 D ❑GuttetslCovers [:]EntryDoors C1 879 <
OY7 $ 7 D jA
Roofing Siding U%Vindows LjInsulation
❑Gutters/Covers ❑Entry Doom,❑ .
Roofing Siding EJ Windows Insulation
S
❑Gutters/Covers Entry Doors❑
Roofing LISiding El Windows Insulation
❑Gutters/Covers []Entry Doors El
Minimum 25%Deposit of Contract Amount due upon execution of this conte ac t � -77
7
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
Contruct agrees to bejointly 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# //Vyq�zi 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.
Acceotance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to die 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.
Accepted by: Submitted by:
Customer's Signature Date Sales Consultant's Signature Date
X Telephone No. 6G'3-- Y7S— Y6d'I
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable)
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 STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
03-17-15 White—Branch File Yellow—Customer
The (Commonwealth of Massac��sews.
Department of Industrial Accidents
Ofce of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017 -
www.mass.gov1dia
Workers'Compensation Insurance Affidavit:Builders/Contract i>rs/Electricians/Plumbers j
T p.�n.,��.�R�a��.,�.� �� Please Print L; ibl
- -- - �'I�y.�'g�j$yy'R]IY-iIIYQiSY�111
Name (Business/Organization/Individual):
Address: 41*do
city/ ateCI Phone#:
Are an employer?Check the appropriate boxi FDon
(required):
1. 1 am a employer with 4. I am a general contractor and I struction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. ing
ship and have no employees These sub-contractors have ion
working for me in any capacity. employees and have workers' addition
[No workers' comp.insurance comp.insurance.$
required.]
5..❑ We are a corporation and its 1 . eccal repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11:n Plumbing repairs or additions
myself. [No workers' comp. right of exemption.per MGL 12.Qof repairs
uranse r�gaire
t c. 152;§1(4),and we have rio 13
emp oyees. o wo ers
9 Other
comp.insurance required.]
"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.
tContractors 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. 1----
Insurance Company Name:
Policy#or Self-ins.Lic.#: �� � -1�n ' Expiration Date:
Job Site Address: �St��i - ( 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 nsurance coverage verification.
I do hereby certify and r t p ns a (dpe aloes of perjury that the information provided abov is true and correct
Si tore: Date:
: . ��h
Phone#: a
Official use only. Do not write in this area,to be completed by city or town off aciat.
City or Town: 'Permit/License#
Issuing Authority,(circle one):
1.Board of health 2.Building(Department 3.City/Town Clerk 4:(Electrical Inspector S.Plumbing Inspector
6.Other '
Contact Person: Phone#:
CERTIFICATE
OF LIABILITY INSURANCE07,1
t oA,�:�WDcrrr>rj
iHiS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGH i S UPON THE CERTIFICATE HOLDO15
E;t THIS
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE
ORDED BY
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE INSURER(S),THE
HORIZIED 1
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the tic Les must be endorsed. if SUBROGATION IS y+JA1VED,subject to _
the terms and conditions of the policy,certain policies may require an e d endorsement A statement on this certificate does not confer rights a the
certificate holder in lieu of such endorsement{s).
PRODUCER
MARSH USA,INC. NTACT
TWO ALLIANCE CENSER NA E:
3560 LENOX ROAD,SUITE 2400 PHONE FAX
ATLANTA,CA 30326 AIC No
ADDRESS
tRFSS:
100492-HorneD-GAW'45-16 INSURERS AFFORDING COVERAGE NAIC N
INSURED INSURER A:Steadfast insurance Company N23817
TND AT-HOME SERVICES,INC. INSURER 0:Zurich American insurance Co
DBA THE HOME DEPOT AT+IOME SERVICES
2690 CUMBERLAND PARKWAY,SUITE 300 INSURER C:New Hampshire Ins Co ATLANTA,GA 30339 irlsuRFR D:Illinois Nacional insurance Company
INSURER E:
COVERAGES CERTIFICATE NUMBER: INSURER F.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED'TO THE INSUREDEN WIED ABO6-3 RVISION V
INDICATED. E FOR THE POLICY PERIOD
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 TEP HIS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS.
INSR• AD 7GLIO)486
LTR I TYPE OF INSURANCE POLICY EFF POLICY F�(P
A X COMMERCIAL GENERAL LIABILITYPOLICY NUMBER (M DON
MMlOD
T7.i LIMITS
03/01!2015 03/01/2016EACFiOccURRENCE g1 CLAIMS-MADE OCCUR 9,000000
DAMA E RENTED
F POLICY XS PREMISES Ea occurrence $ 1,000000OFSIR:$1 M PER OCC MED EXP(An one person) 5 EXCLUDED
�GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY S 9,0U'Dw
POLICY IPRO- GENERAL AGGREGATE
`J Jc'CT LOC $ 9,000,000
!OTHER: PR
DUCTS-COM S 9,000,000
B �AU MOBILE LIABILITY I
1 BAP 2938863-12 s
X 03/01/2015 03/0112016 CO a_*dent) LIMIT s
ANY AUTO __ 1,000,000
ALL OWNED —l SCHEDULED BODILY INJURY(Per person) S
AUTO$ AUTOS SELF INSURED AUTO PHY DMG
HIRED AUTOS NOR-OAUTOS MED BODILY INJURY
AUTOS ,'o�raccident),S
1 I PROPERTY OAMA-6E'—
i Peretti enc S
UMBRELLA LIAB I OCCUR S
EXCESS UAB r CLAIMS MgDE EACH OCCURRENCE S
DEO RETENTION g AGGREGATE S
C WORKERS COMPENSATION
C AND EMPLOYERS' 0017737493 5
UABIUTY Y r N (AOS) 03/01/2015 03/01/2016 X PER DTH-
ANY PROPRIETOWPARTNER/EXECUTIVE WC017731495(AK KY,NH,NJ, STATUTE E
D OFFICER/MEMBER EXCLUDED? NN NIA � 03/012015 03/01/2016 —----(Mandatory
in NH) WC017731494 E.L.E.LEACH ACCIDENT S 1,pO0,pOQ
uyes,de T'r) FL under ( ) 03/012015 03/01!2016 S 10001000000
DESCRIPTIONF O
OPERATIONS.below Conitntled on Addl6onai pageE.L DISEASE-EA EMPLOYE
E.LDISEASE-POLICY LIMIT 5 1,OGO,�Ju
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required)
EVIDENCE OF INSURANCE
to
CERTIFICATE HOLDER
CANCELLATION
7DBA
HOME SERVICES,INC.
HOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRI13ED POLICIES BE CANCELLED BEFORE
ES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL
ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. BE DELIVERED IN
AUTHOR ZED REPRESENTATNE
of Marsh USA Inc.
Manashi Mukherjee �MytiU oe�a: .
AGORD 25(2014/01) The ACORD name and logo are registered marks of ACORDO�CORPORATION. All rights reserved.
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