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HomeMy WebLinkAboutBuilding Permit #281-2017 - 44 COBBLESTONE CIRCLE 9/15/2016 BUILDING PERMIT o� N". q �tyE° 6 H TOWN OF NORTH ANDOVER y `,,. Y::1.1 �.,, o APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �QA°RATE° Date Issued: IMP RTANT: Applicant must complete all items on this page yy &Lble4o e CteZ LOCATION 4 x P t 11 PROPERTY OWNER N -7 Print 100 Year Structure yes no MAP - PARCEL:' l 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 epair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other0— a eptic UVell az � fl Flogodplain7`1l�letlands k aters4,N- _*, f ied Distract DESCRIPTION OF WORK TO BE PERFORMED: WON gPut ay eg (VIndowl IdentificatioPlease Type or Print Clearly OWNER: Name: �' Y - qn Phone: 455 - 4 Address: �� ��S'� ����• Contractor Name ( Phone: -7 Email: Address �D DSI S Supervisor's Construction License: Exp. Date:10 ad-r7 Homep Im rOvement License:. D 2q 5-7 Exp. Date: 7 3 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: $ J;z�[1 C1.7 FEE: $ f�� Check No.: Receipt No.: NOTE: Persons contractingw'th reregistered contractors do not have access to the g ranty fund Location y� � ' ry No. a G 1 ' * Date q • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ 15"- o:J Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 19& 7 7,�G � x 1&- - Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ F PE OF SEWERAGE DISPOS lic Sewer ❑ Swimmin PoolsTanning/MassageBodyArt ❑ gl ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY f INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I { CONSERVATION Reviewed on Signature � COMMENTS HEALTH ,. Reviewed ori Si nature W - , COMMENTS 1 I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIFiE MENT - - DEPA�RU' �Twp ®urn.�pster on�sit eses Loi"sated at t1r24 ain eetd �-�--�— ~-- --- — - FirLe De art enidature�%da)et �COMMENIT� _ { 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 Call Email Date _ Time Contact Name Doc.Building Penuit Revised 2014 I 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 4. Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4, Floor Plan Or Proposed Interior Work 4 Engineering Affidavits for Engineered products OTE: 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 j 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4 Building Permit-Application 4. Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit s 4- Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And L Hydraulic Calculations (If Applicable) I u^opy of Contract 21. 12 IECC Energy code Enoineering Affidavits for Engineered products (ATE; 'All dumps.ter permits require sign off from Fire Department prior to issuance of Bldg. Permit ` In all cases if a variance o;,,.a special permit was required the Town Clerks office must stamp the decision from the Board of Appeals .` that the appeal period is ovr.,. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording ��•application must be submitted with the buiiu ._ Doc;Building permit Revised 2014 ,_ 2 Andover Town of ver, Mass, COCNIC NlWKK y1. A0 ATED S V ' BOARD OF HEALTH E R T T L D Food/Kitchen Septic System ' :ERTIFIES THAT ........... . 14�...........G`..l-ABUILDING INSPECTOR ..OV.?..................................... :rmission to erect .......................... buildings on .....41if....C0.ble..S .............. Foundation Rough 3ccupiedas ................................................................................................................................... Chimney led that the person accepting this permit shall in every respect conform to the terms of the application Final in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and ruction of Buildings in the Town of North Andover. PLUMBING INSPECTOR ►TION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA TS 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. # C0U50t15 R,a -t w4w. x � r 2; ., .a LOWE'S AUTHO, REPRESEMATIVE NUME1ER r ~CUSTOMER sok) STORE NO STREET AD SS s STRE ADDR $.. 3� ,9� ,cnv�al��y v cm STATE ZIP � cITY,',-` sM Olfy� Y� /„ At.gM ova 03.6.79 m TELEPHONE Ft ; TELEPHONE os 6�i �(Z) 97b 6s yZz a ',+ DA LOWE'S HOME CEMERS,LLC'S MA HIC NO.:148688 - s. CASH BANK LCC REG y a` FEIN 56-0748358 - .�,,.{y5 CARD ��T87Pl5 anti✓: BM�'1 �. �,'�x r,s � $y"'r �,'� ni.: p �:READ'AL4 ARMS AND INSTALLATION STREET DRESS CITY _ STATE ZIP ? u4 ZSo Sc2.0 NOTICE TO CUSTOMER—PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the,lnstallation Services are performed. Are permits required for this installation?:[ es ( ]No Contract Total [� applicable tax included �.��.Sy9• NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right By signing this Contract;Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. NOTE:If rotted wood is discovered during installation additional charges will ppl Y, will be given a quote and a change order must be completed and signed by the customer for any additional charges. ustomer must initial. 'Any work or material not specified is not Included in this contract.Any changes or additions will be at an additional charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in,print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,inclu ' g,but not limited to,marketing, advertising,publicity,illustration,training and Web content.By initialing here,Customer agrees to the foregoing. [Customer to initial to the left]. Work is tgcpm ner made ce upon reasonable availability of Contractor and/or any special order Good(s)which is anticipated to be yl, �(o [fill in date].Estimated completion date Is /e s [fill in date]. Said estimated substantial Completion date is not of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: (1)Deposit $ to be paid upon signing contract.Deposit should be 1/3 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,IANe authorize Lowe's' to do one of the following(check appropriate box below): [ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c.142A.THE SIGNATURES OF TNF PARTIES RFL OW ADPL Y ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LMS.PURSUANT TO MAL_c 142A THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.if customer has a complaint which cannot be resolved informally,the home Improvement Contractor Law(M.G.L.c.142A)may provide Customer with the right to request arbitration through a private arbitration program approved by the Director of the Office of Consumer Affairs and Business Regulation,as an alternative to court action.The same right is not afforded to Lowe's unless this Notice is signed and dated by Lowe's and Customer. ims by Customer or Lowe's concerning this Contract which cannot be resolved informally,and which are.not covered by M.G.L. c142A or subject to the jurisdictiqlni ofA small clair &urt,shall be resolved by binding arbitration t e General Terms and Conditions.By: • � .Date: Lowe's ALL ed Representa' e �� By: Date: C/ / Customer DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING.BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS, CONTRACT.YOU ARE ENTITLED TO A COPY O THIS CONT CT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY OF /&.n / Lowe's H e ent rs,Lc[Com., Lowe's Autho'ed Representative Owfier Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,me cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. 0 T by.LUW9'9.e L.— 9114 618 g9W9 de9lgrl —.1 nr 1a n Vol C f`/1DV. Br9 r8nl8t8r8d tr90en1arla 01 LF I'.9rpOrBllOn. ' The Commonwealth of Massachusetts Department of Industrial Accidents . 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicant Information 4 Please Print Le 'bl Name(Business/Organization/individual): W Address: I D RA Wue City/State/Zip: d ftlf7 1n4 021$5 Phone#: IT R;-Li3D Are you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with employees(full and/or part-time).` 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp,insurance required.] 9. ❑Demolition 3.❑1 am,a homeowner doing all work myself.[No workers'comp.insurance required.] 10❑Building addition 4.0 1 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 arc sole 11.❑Electrical repairs or additions proprietors with no employees. 12.C]Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: &F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14 e[ 152,§, 1(4),and we have no employees.[No workers'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. Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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: 17I. J y!A& �ri sfan a Co. Policy#or Self-ins.Lic:#: AW C• 100 70A_ $rJ_I q"AV16!q Expiration Date; 3 Jq11W ,lob Site Address: N/ City/State/Zip:_P 6( � Attach a copy of the workers'compensation po icy 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. I do hereby c the pains and penalties of perjury that the information provided above is true and correct Si are: Date: Phone#: Ai I :*:2— t 30 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 b.Other .Contact Person: Phone#: Page 5 GREEINS-01 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 5/26/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLC PHONE (781)933-3100 aC Ne:(781)933-9048 445 Main Street AIC No Ext Woburn,MA 01801 p DRIESS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIC i INSURER A:Safety Insurance Company 39454 INSURED INSURER B:Safety Indemnity Ins.Co. 33618 Greene Installation Co.Inc. INSURERC:AIM Mutual Insurance Co. 0913 Ron Greene 10 Rita Drive INSURER D: Medford,MA 02155 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE T OCCUR X BMA0008519 05108/2016 05/08/2017 PREMISES Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ECT F—] LOC PRODUCTS-COM PIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B ANY AUTO X 6208932 01/30/2016 01/30/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ i DED I I RETENTION$ $ WORKERS COMPENSATIONP R OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE I I ER C ANY OFFICER/MEMBER/EXCLUDED ECUTIVE N/A WC-400-7025594-2016A 03/04/2016 03104/2017 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) Lowe's Companies Inc.any and all subsidiaries are named as additional insured as respects to the General Liability and Auto Liability policies per written contract or agreement. 30-Day cancellation clause e CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc.and any and all Subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IS Insurance ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 1111 North Wilkesboro,NC 28656 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD `!�~nrrrrrrnr,rrrtn/!f Off ce of consumer Aftairs&Bus" ess Regulation HOME IMPROVEMENT CONTRACTOR Registration: 102957 Type: - Expiration: 713/2018 Private Corporation GREENE INSTALLATION CO.,'INC. Ronald Greene 10 RITA DRIVE �:e= ..�• > -- MEDFORD,MA 02155 Undersecretary a Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CA Construction Supervisor I & 2 �M 4 Family .' x' ) RONALD A QRS64 10 RITA ORM MEDFORD MA C