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HomeMy WebLinkAboutBuilding Permit #889 - 479 SALEM STREET 6/13/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0-0',� Permit NO: 0 Date Issued: IMPORTANT:A Date Received must complete all items on this TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial eratio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition_ Other Septic Well F .Floodplain _ --Wetlands I _TV1latershed District` 'Water/Seweh DESCRIPTION OF WORK TO BE PREFORMED: 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: $ 6� FEE: Check No.: P Receipt No.: L�-- NOTE: Persons contracting ivA unr a ontractors do not have access to the guaranty fund Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL , Public Sewer Taming/Massage/Body Art Swimming Pools 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature 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: Locatea 6ts4 usgooa street TempDumpster on4sitel yes _ a _et , u 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 MGL Chapter 166 Section 2 1 A —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 DEPARTMENTMFORM07 Revised 2.2008 zj-, Location 71 s - No. R M. Date Check # 0 (:6- 25402 TOWN OF NORTH ANDOV ER Certificate of Occupancy $ Building/Frame Permit Fee $: Foundation Permit Fee $ Other Permit Fee $ TOTAL Building Inspector I 0 z a co Iw '� O w v c/) O U A co p w O w v ^C U G w U a p w c w W P -4A u W p c:4 cii C u. O c7 p n: G w W v � oo ° z cn Q E U) . O �U W ;A Q py CO m cm a � U O r_, CD cm C W CM P-4 0 cm C �C N I R! O CD L O O O Z C. O y � C O cm CA O O— E- m m CL H � i c 3.0 O i cc o a a cma c c c ev ca v J .0 CL cm CD C Zts 0 CL � C..7 y O C c CO) 0 W W 19 W U) E"a �m 0 c C O � C N O C dC R O O ;= 0 L �R E y: 0 ICE. m CL •:�' N Co V: ,o 00 C7 6 mcm C N m mm o m 3 N CD m M .o 't C N � go E m O :aC.,L.: LA m m O y=+ rte+ :0Q .aa ` acs :mom V y O. Ca•cc �Z C c m `-mc a pd COD EDPma ++ C cc E Oma+ mLLJ� v-ovy C.3 L. p JCD 0 C C#* CL N ; C '0 •b- y = Z a !- t saem O �U W ;A Q py CO m cm a � U O r_, CD cm C W CM P-4 0 cm C �C N I R! O CD L O O O Z C. O y � C O cm CA O O— E- m m CL H � i c 3.0 O i cc o a a cma c c c ev ca v J .0 CL cm CD C Zts 0 CL � C..7 y O C c CO) 0 W W 19 W U) Details Page 1 of 1 Licensee Details Demographic Information Full Name: LEONARD SANTOSUOSSO III Gender: Owner Name: License Address Information Address: 5 RED FERN CIRCLE Address 2: Profession: City: LONDONDERRY State: NH ipcode: 03053 Country: United States License Information License No: CS -087691 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: Issue Date: 9/21/2011 Expiration Date: 9/21/2013 License Status: Active Today's Date: 6/12/2012 Secondary License: Doing Business As: Status Chan e: Prerequisite Information No Prere uisite Information Discipline No Discipline Information http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1 &license_id=276633& 6/12/2012 ALN The Commonwealth of Massachusetts Department of .£ndustr ial Accidents Office ofinvestigations ..600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizafion/Individual):_ Address: f City/State/Zip; Phone #:__U ou an employer? Check the appropriate boa: 1 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).*' have hired the sub -contractors ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -'contractors have working for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ .I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *A.ry an. ,.�,Iicaat t at eieeks box ti must also uL out F'ye sAca hAt tet, Type of project (required):' 6. VRemoaeling w construction 7. 8..❑ Demolition 9. ❑ Building addition 10.11 Electrical repairs or additions .11 .0 Plumbing repairs or additions 12.❑ Roof repairs I3.❑ Other T Homeowners who submit this affidavit indicating they azedoing all wowal rk and then co hire outstionpoli or— lit Xiaide 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 their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my information. employees BeloNl is the policy and job site Insurance Company Policy # or Self -ins. Lie. S Expiration Date: __Q'3,1 .3 Job Site Address: 447 3 A ,c�,� . City/state/Zip: S { 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 ofMGL 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. Ido hereby ffP_�u er th p s a end dies ofperjury that the information provided above is true and correct Phone #: Official use only. Do not ws:ite in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone #: L2/2012 10:54 AM The Home Depot ZN -> 9_19786889542 Arsh E - i Tx EMPLOYERS=TNS-C46566397 01 -Mar- E 01 -Mar -2013 so,000,000 EA EXCESS LIAB- OCC/1,000,000/SIR =COMPANYF-SEE 2012 s SELO W WORKERS'=WC1192494 01 -Mar- =01 -Mar -2013 "COMPENSATION- _ _ _$750,000(GA) 5COMPANYE-SEE =CA,GA,IL,MI,NV,OH,OR,PA,UT,WAI 2012 = 1,000,000 (AOS) _WORKERS' EWC1192495 MA (QSI) 01 -Mar- = 01 -Mar -2013 -1,000,000/$500,000 COMPENSATION- _ --SIR COMPANYE-SEE _ 2012 =BELOW IThe Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any (modifications hereto are not authorized. Page 6 of 6 1,000,000 This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rights upon any viewer of this Memorandum. This Memorandum does not amend, extend or alter the coverage described below. This Memorandum may only be copied, printed and distributed within an authorized viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an entity or person which is authorized by the insured named herein to access this Memorandum via hnp://www.marsh.com/moi?client=D723. The information contained herein is as of the date referred to above. Marsh shall be under no obligation to update such information. PRODUCER t INSURED Marsh USA Inc. =Home Depot U.S.A., Inc. ("Marsh") =2455 Paces Ferry Road NW Building C-20 'Atlanta, Georgia 30339 -United States ADDITIONAL INFORMATION Additional Insurance Carriers: E- National Union Fire Ins. Co. of Pittsburgh F- llinois Union Insurance Company isured Continued: ome Depot USA, Inc. DBA The Home Depot HD At Home Services, Inc. DBA The Home Depot At -Home Services HD At -Home Services, Inc. he Home Depot, Inc. he Home Depot, Inc. Home Depot USA, Inc. our Other Warehouse, LLC Solely as respects the General Liability Policy: Limits of Policy are excess of SIR $1,000,000 per occurrence Any party with which the Named Insured is contractually required to include as an additional insured on the above General Liability and Automobile Liability policies is automatically granted such status. However, coverage under the policy only applies to the extent of the coverage required by such contractual requirements for the limits of liability specified in such contractual requirement, but in no event for insurance not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the policy. 'The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any Y (modifications hereto are not authorized. icl. Dere for a printer -friendly version of this document. tp://moi.marsh.coni/MarshPortaUPortalMain?PID=AppMoiPubhc&C=com.marsh.moi.gbl.comp.MoiPublic[5/16/2012 10:26:54 AM] L2/2012 10:54 AM The Home Depot - ZN -> 9_19786889542 Page 5 of 6 arsh IThis Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rights upon any viewer sof this Memorandum. This Memorandum does not amend, extend or alter the coverage described below. This Memorandum may only be copied, jprinted and distributed within an authorized viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an entity or person 1which is authorized by the insured named herein to access this Memorandum via http://www.marsh.com/moi?client=D723. The information contained 'herein is as of the date referred to above. Marsh shall be under no obligation to update such information. rPRODUCER COMPANIES AFFORDING COVERAGE EMarsh USA Inc. `Co.A Steadfast Insurance Company ("Marsh") !INSURED C..B Zurich American Insurance Company 1Home Depot U.S.A., Inca 92455 Paces Ferry Road NW "Co.0 New Hampshire Insurance Co. sBuilding C-20 =co.D Illinois National Insurance Company !Atlanta, Georgia 30339 'United States s =THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDTTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS =MEMORANDUM MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEDBY 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. CO TYPE OF = POLICY NUMBER = POLI CY POLI CY LIMITS LTR = INSURANCE_ EFFECTI VE EXPI RATI ON LIMITS IN USD UNLESS OTHERWISE DATE DATE INDICATED A €GENERAL GL04887714-02------------------- 01 -Mar- 101 -Mar -20131 GENERAL § USD _LIABILITY s aAGGREGATE s =_ coMMERCIAL = = 2012 1 g 9000000 GENERAL LIABILITY OCCURRENCE W AUTOMOBILE LIABILITY ANY AUTO SELF INSURED AUTO PHYSICAL DAMAGE 2938863-09 01 -Mar- 101 -Mar -2013 2012 C1lVLVl-1J - COMP/OP AGO PERSONAL AND ADV INJURY EACH OCCURRENCE -- --------------------------- FIRE DAMAGE (ANY ONE FIRE) MED EXP (ANY ONE PERSON) COMBINED SINGLE LIMIT BODILY INJURY (PER PERSON) BODILY INJURY (PER ACCIDENT) > e USD 9,000,000 USD 9,000,000 USD 9,000,000 ------------------- USD 1,000,000 EXCLUDED USD 1,000,000 tp://moi.marsh.corn/MarshPortallPortalMain?PID=AppMoiPubhc&C=com.marsh.moi.gbl.comp.MoiPublic[5/16/2012 10:26:54 AM] EXCESS LIABILITY = = e BEACH e EOCCURRENCE oAGGREGATE i GARAGE - z =AUTO ONLY (PER E s_LIABILITY NACCIDENT) e s s r = gOTHERTHAN AUTO ONLY: EACH ACCIDENT e t g s_ € AGGREGATES - 9 C r WORKERS = =WC 019736915 AOS _ 01 -Mar- 01 -Mar -20130 w°RICERS COMP _ COMPENSATION = ) DgEMPLOYERs =WC019736917 FL = 2012 01-Mar-2013LrnuTs i C eLIABILITY s THE PROPRIETOR / -WC019736918 WI 01 -Mar- ar- s O1-Mar-2013ELEwcH USD s =PARTNERS/ --EXECUTIVE =WC019736916 CA s = 2012 a ACCIDENT e = 01 -Mar -2013' 1 r 1,00o,000 s 1 s _OFFICERS ARE: = OL -Mat- € EEL DISEASE - USD e s UNCLUDED __ _ _ = 2012 _ NPOLICY LIMIT - 1,000,000 3 9 01 -Mat- 4 i 2012 S EL DISEASE - EACH € 1 E1 fDT ��� E USD tp://moi.marsh.corn/MarshPortallPortalMain?PID=AppMoiPubhc&C=com.marsh.moi.gbl.comp.MoiPublic[5/16/2012 10:26:54 AM] co co M 1 co M O Ln a) cm ^co LL a� c 0 U w U 0 z cr w 0 U Cn w U w Cn J Q U w a. 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