HomeMy WebLinkAboutBuilding Permit #794 - 5 UNION STREET 5/2/2012. BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received-
Date Issued: r Z
IMPORTANT: Applicant must complete all items on this page
L
'Pin a
'PROPER=.
§0
TYPE OF IMPROVEMENT
PROPOSP;)-�
Resiq?lial
Non- Residential
Build' ild'
0 New xig
41"brie family
'0' Add�jl�
0 Two or more family
11 Industrial
tio
;�erafion
No. of units:
0 Commercial
XRepair, replacement
El Assessory Bldg
El Others:
El Demolition
El Other
'n" ff --i
.p-p! :Wetlands_
s firlb
0"t, 0/
1jentificat* Pease Type or Print Clearly)
OWNER: Name:
Address: lan5Z. i�tsak L
''Ph—
OhEi"
00INT, RA �Name
r8 -
I
Leffm
t
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST 8 ED ON $125.00 PER S.F.
Total Project Cost: $ 4059- FEE: $_ � le,
Check No.: -Receipt No.: re)
NOTE: Persons contracting with unregistered contractors do not have acces to th guar ty and
Signature F ,_ r_i
", Signature . C06.Fni6ib, . . . . . . . . . . . . 4L
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 Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE APPROVED
0
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
1
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connecition/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
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
VOTE: 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
N OTE: 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
Location� V�t��• S''�
No. Q " t Date
Check #—; -�– 56 C
25259
TOWN OF NORTH ANDOVER
Certificate of Occupancy $_
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofj�ice of Investigations
600 Washington Street
Boston, MA 02111
www. mass gov/dia
Workers' Compensation Insurance Affidavit: Bu lders/Contractors/Electricians/Plumbers
Aaylicant Information Please Print Leg&y
NaMe (Business/Organization/Individual):
Address: ;-q 5,�7 F &c 5
/State/Zin:
Are you an employer? Check the Appr
1. I am a employer with
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
4.
5.
WZ
r
3 03 �' � Phone #: O�D b S5_7
to bog:
❑ I 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. insurance J
❑ . 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'
comm insurance reauired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ R' s
13. Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homedvmers 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 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 isproviding workers' compensation insurance for my employees Below is thepolicy andjob site
information. n
Insurance Company
S. (,p..
Policy # or Self -ins. Lic. #: f C o i q 3 6' % �J Expiration Date: 3
Job Site Address: _—J LA U 1(x1 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 a t the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D for jnsurance coverage verification.
I do hereby
of perjury that the information provided above is #rue, 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. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: ;
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CERTIFICATE OF LIABILITY INSURANCE
FDATEYA
0al27/2012�
THIS CERTIFICATE 1S 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(les) 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 1-866-966-4664
Marsh USA Inc.
CONTACT
NAME:
PHONE FAX
AC No):
A/C No Ext); (AC.
A MAIL
DRESS:
homedepot.certrequest@marsh.com
Two Alliance Center, 3560 Lenox Road, Suite 2400
Atlanta, GA 30326
INSURERS AFFORDING COVERAGE NAIC#
INSURERA: Steadfast Ins Co 26387
Fax (212) 948-0902
INSURED
INSURER B: Zurich American Ins CO 16535
The Home Depot, Inc.
Home Depot U.S.A., Inc.
INSURER C: New Hampshire Ins Cc 23841
INSURERD: Illinois Nati Ins Co 23817
2455 Paces Ferry Road NW
INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
Building C-20
Atlanta, GA 30339
INSURERF: Illinois Union ins Co 27960
COVERAGES CERTIFICATE NUMBER: 25776028 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
LTR
TYPE OF INSURANCE
L
S
POLICY NUMBER
MUBR M DDY EFF
MM DDY EXP
LIMITS
A
GENERAL LIABILITY
GL04887714-02
03/01/1
03/01/13
EACH OCCURRENCE $ 9,000,000
X COMMERCIAL GENERAL LIABILITY
GE TO RENTED
PREMISES a occurrence $ 1,000,000
CLAIMS -MADE a OCCUR
MED EXP (Any one person) $ EXCLUDED
PERSONAL BADV INJURY $ 9,000,000
X LIMITS OF POLICY XS
X OF SIR: $1M PER OCC
GENERAL AGGREGATE $ 9,000,000
GEMLAGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 9,000,000
$
X POLICY PROECT LOC
B
AUTOMOBILE LIABILITY
BAP 2938863-09
03/01/1
03/01/13
EOaBINdEDSINGLELIMIT 1,000,000
BODILY INJURY (Per person) $
X ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
PROPERTY DAMAGE $
paraccident
NON -OWNED
HIREDAUTOS AUTOS
$
X SELF INSUFJ PHY DMG
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
C
WORKERS COMPENSATION
WC019736915 (AOS)
03/01/1
03/01/13
X WCYLIMIT OH,
ETR
D
EMPLOYERS LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNE YIN
WC019736917 (FL)
03/01/1
03/01/13
E.L. EACH ACCIDENT $ 1,000,000
E
OandatoME.NH)BEIR EXCLUDE
(Mandatory in NH)
NIA
WC019736916 (CA)
03/01/1
03/01/13
E.L. DISEASE - EA EMPLOYE $1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E
Workers Compensation
WC1192494 (OSI)
03/01/1
03/01/13
SIR (AOS)/SIR (GA) 1M/750,000
C
Workers Compensation
WC019736918 (WI)
03/01/1
03/01/13
F
TX Employers XS Indemnity
I
TNSC46566397 (TX)
03/01/1
03/01/13
Occurrence/SIR 30M/1M
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
RE: EVIDENCE OF COVERAGE
THE HOME DEPOT, INC.
HOME DEPOT U.S.A., INC.
2455 PACES FERRY ROAD NW
BUILDING C-20
ATLANTA, GA 30339
ACORD 25 (2010105)
Jthornton_hd
25776028
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
USA
W IVES -ZULU AGUKU GUKI-UKAI IUr4. All ngnis reserVea.
The ACORD name and logo are registered markitf ACOk1D
011mc of Collsumcr A I I..
&. Bloilless It(
JJ -
'`HOME IMPROVEMENT CONTRACTOR
Registration: 126893
Expiration: 8/3/2012 Suppleniklit
The Home Depot At -Home Services
RICHARD FALLONE
2690 CUMBERLAND PARKWAYS
'4y"Mn. GA 30339
L
FROM :
FAX NO. :9786857585 Apr.10 2012 07:24PM P1/8
��Ct�PQ01N�If�TCOti��ll1
PLEASE READ THIS
J Sold, Famished and Installed by:
� '
Branch Name: Boston Date: ?1 Z01 � THA At -Home Services, Inc.
� d/b/a The Home Depot At -Home Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657-5182; Fax (508) 756-8823
Branch Number: 31 Federal ID # 75-2698460: ME Lic # C 02439; RI Cont. Lic# 16427
!� CT i.ic # HiC.0565522; MA Home Improvement Contractor Reg. # 126893
installation Address: ,/ V AA O J fV.;,kxK AAJW *I— V14 -A 61 t{s—
City State lip
Purchuaer(s): Work Phone: dome Phone: Cell Phone:
Home Address;^"
(If different from Installation Address) City State Zip
iI Address (to receive project communications and Hume Depot updates): C A_1 , f°e/j � tIC-
1 DO NO 1' wish to receive any marketing entails from The Home Depot
ect information: Undersigned ("Customer"), the owners of the prnpeny located at the above installation address, agrees to buy,
and THD At -Horne Services, Inc, C The Home Dept') agrees to furnish, deliver and arrange for the installation ("Installatiod') 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 (collectively,
"Contract"):
Joh #: Products: sv v %hews) #: P -1—t Ammrnt
J
❑Roofing ❑Siding Windows Ins
NI
$
❑Gutters / Covers Entry Door+ ❑ Gy
❑Roofing Siding Windows ❑Insulation
$
❑Gutters /Covers ❑EntryDans ❑
❑Roofing Siding Wietkcws ❑ it snlaaan
$
❑Gutter / Covets []Entry Door% ❑
Roofing Siding�Windows ❑ Insulation
$
❑Gutter / Coven []Entry Doors ❑ _ .
Minimum 25% Deposit of Contract Amw»t fire upon vAcco ion or this contract.
Maine Purrha
Total Contract Amount
$
srrs mayaotdepositmaethancm�thirrloftht(.cxuractAnrmnt
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
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 Hunte; Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home, environmental hazard~ such as mold, asbestos or lead paint, other safety concerns, pricing errors or because
work required to complete the job was not included in lite Contract.
Payment Summary: The Payment Summary # �O `1 &(,n . included as pan of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICF 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 ([tote:
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, expense$
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any outer
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.
Acceptance and Authori9Afion: 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 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,
A y: i
X
is
ux/� ZalZ
Customer's Signature " Date Sales Coiesul'tant'S Signature Date
X
Customer's Signature Date
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WU13-FUN 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.
NU'110E: ADDITIONAL. TERMS AND CONDITIONS ARE MAI
Telephone Nn - en-?, rT _
Sales Consultant License No_
(as applicabtc)
RD ON THF. RFNTRSE SIDE AND ARE PART OF TRIS CONTRACr
140411 C -Sc White- Brandt File Yellow - Customer