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HomeMy WebLinkAboutBuilding Permit #82 - 58 MEADOWOOD ROAD 7/28/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 4�> L.- Date Received Date Issued:2�� IMPORTANT: Applicant must complete all items,on this page LOCATION �Ot�oej Pj _Print PROPERTY OWNER(- _ Print MAP NO: �PARCEL:-,�'E 'ZONING DISTRICT: Historic District 11 'VO0 cr Resid Non- Residential New BuildingOne yes C.no yes no TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New BuildingOne family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement x Assessory Bldg Others: Demolition Other Septic Well Floodplain; Wetlands Watershed District Water/Sewer OWNER: Name: Address: DESCRIPTION OF—WIRK TO B ,Identification Please Type or Print Clearly) CONTRACTOR Name: rnone: It Supervisor's Construction License: Exp. Exp, Date: Home I ARCHITECT/ENGINEER, Date: 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.: Z NOTE: Persons contracting with unregistered contractors do not have access tote >gran3fu>gd 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 DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Commen Comments Zoning Decision/receipt submitted yes Water $ Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories:. Total land area, sq. ft.:_ Total square feet of floor area, based on Exterior dimensions. 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 — ❑ Notified for pickup - Date Doc.Building Permit Revised 2009 ent use 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: Building Permit Revised 2008 Location J ��yt�t% (i(%od - No. SZ„' Date�� MaRTN TOWN OF NORTH ANDOVER O:t�n �•,hC L 9 M.. Certificate of Occupancy $ �SSA�M�SE<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22259 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations -= 600 Washiy1gdon street - Boston, MA 02111 �vttw.l7-ass.gov/dia Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Lef!iltly Name (Business/Organization/Individual): Address: ► uh1 Y �' Vtl,c�l/ City/State/Zip:,. r -}-, �fl�� Phone.#: Are yo an employer? Check the appropriate bog: 1. I am a employer with Ino4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required)-,. 6. 0 New construction 7. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ f repairs 13. Other 'Any applicant that checks box #I 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 anew affidavit indicating such. tContractors 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. 1 r t Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 tip to $1,5.00.00 and/or one-year imprisonment, 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. I do hereby certiMun penalties of perjury that the information provided above is true and correct. 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 6. Other Contact Person: Phone #: O • rA W V.; w A o� as xV) a w° u s cn ° w W z z a L�1 a ro -o w° v C U w ° O a x z w x o 1a U w ,. 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HOME IMPROVEMENT CONTRACTOR Regi strati o n t :. 1268 93 Expiration S':' 8%3/2010 Type; Supplement Card The Home Depot 'At Home Service ' RICHARD FALLONE 2690 CUMBERLAND PARKWAY S A( ®QRQM CERTIFICATE OF LIABILITY INSURANCE MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DATE20 /DD,YYYY, INSR LT DO'L N RC TYPE OF INSURANCE- 02/20/09 PRODUCER 1-504-99S-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION *sa:sh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAIF .03/01/09 03/01/10 HOLDIER. 1I -11S CER11FICATE DOES NIIOT ANIE:.NO, c ;TEND Ort I. o.:iedenoC.certrzgnest�marsh.con MERCIALGENERALLIABILITY 4C-10MCLAIMS MADE OCCUR AL -TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. -:75 Piedmont I'd NE, Suite 1200 Atlanta, GA 30305 A A ORENTED PREMISES Eaoccurence f 1,000,000 MEDEXP(Anyoneperson) $EXCLUDED ^`------_ — Fay� (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED TI© At -Horne Services, Inc. -- INSURERA:steadfast Ins Co 2.6387 ------- INSURER B:Zurich American Ins Co16535 GEN'LAGGREGATE tIMLTAPPLIESPER: PRODUCTS - COMP/OPAGG s4,000,:000 2690 Cumberland Parkway Suite 300 Atlanta GA 30339 INSURER C: NATIONAL UNION FIRE INS CO - OF PITTS 19445 INSURERO:New Hampshire Ins Co 123841 , IINSURER E:Illinois Natl Ins Co 23817 [4101TIII:L[9IX01 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LT DO'L N RC TYPE OF INSURANCE- POLICYNUMBER POLICYEFFECTIVE DATE (MMIDDNYIDATE POLICY EXPIRATION MM 0 LIMITS A GENERAL LIABILITY IPR 3757 608-02 .03/01/09 03/01/10 EACH OCCURRENCE $4,000,000 MERCIALGENERALLIABILITY 4C-10MCLAIMS MADE OCCUR LIMITS OF POLICY ARE EXC "OF SIR: $1,000,000 PER SS CC" A A ORENTED PREMISES Eaoccurence f 1,000,000 MEDEXP(Anyoneperson) $EXCLUDED PERSONAL dADV INJURY $4,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'LAGGREGATE tIMLTAPPLIESPER: PRODUCTS - COMP/OPAGG s4,000,:000 POLICY PRO - X - _ LOC - B AUTOMOBILE X LIABILITY ANYAUTO BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT (Ea accident)' $1,000,000 BODILY INJURY $ (Per person) ALLOWNEDAUTOS SCHEDULED AUTOS BODILY INJURY (Peraccident) $ HIRED AUTOS NON -OWNED AUTOS X SELF INSURED AUTO PROPERTY DAMAGE $ (Peraccident) PHYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY.: EAACC(OENT $ ' -' EA ACC S OTHER THAN ANY AUTO AUTOONLY: AGG $ A EXCESSIUMBRELLA LIABILITY X OCCUR EICLAIMS MADE IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ $ DEDUCTIBLE - - $ RETENTION S C D WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPNETOR/PARTNEWEXECUTIVE 3566916 (CA) 3566915 (AOS) 03 01/09 / 03/01/09E.L.-EACH 03/01/10 03/01/10 X WC STATU- O7H- RY IMIT ER f 1;000,000 E.L. DISEASE - EA EMPLOYEEI $1,000,000' E OFFICER/MEMBEREXCLUDED? 35.66917: (FL) 03/01/09 03/01/10 Ifyes, describe under SPECIAL PROVISIONS below .. E.L. DISEASE -POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY,M0, NY, WI, ) 03/01/09 03/01/10 F TX Employers Excess TNSC4S694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE �w /rA ' - USA • J�'� ACORD 25 (2001/08) ckomraus hd ACORD CORPORATION 1988 11172180 :Massachusetts - Department of Public Safetti Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 99124 t Restricted to: WS JOHN AMERO 12 CARRIAGE CHACE LANE ATKINSON$ NH 03,811 i s Expiration: 7/16/2012 G mniissigpile I. Tr#: 99214 07-16-2009 11:05AM FROM -THE HOME DEPOT +6038940425 T-701 P.001/004 F-945 .� r rvrrar; a ura a a.v r v.arauar a r..vir a _tsl_ ll ` PLEASE READ THIS Branch Name: Boston Branch Number: 31. Installation Address: 1 ! Sold, Furnished and Installed Inc. v—t. THA At -Home Services, Inc. Date d/b/a The Home Depot At-l-iome Services 345A Greenwood Street, Unit 2, Worcester, MA 01607 Toll Free (800) 657-5182; Fax (508) 756-8823 Federal ID # 75-2698460; ME Lie # C 02439; RI Cont. Lie# 16427 ` G1' Lic # 565522;.MA Home hnprovemem Contractor Reg. # 126893 City State Purchaser(s): Work Phone: Home Phone: Cell Phone: ML ^[ Nome Address: (If different from Installation Address) City E-mail Address (to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails from The Home Depot State Zip Project Information: Undersigned ("Customer"), the owners of the property located at Elie above installation address, agrees to buy, and THD At -Home Services, Inc. ("The 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 (collectively, "Contract"); Job t am—i Rer._) P-11irtc Snm Sheet(s) #: Proiect 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 Contract agrees to be jointly and severally obligated arid liable hereunder. The Home Depot reserve, 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 die joh was not included in the Contract. Payment Summary: The Payment Summary #�N Lt I[ , 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 Certiricate (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 tbrougb the date of termination, plus any other amount% set forth in this Agreement or allowed under applicable law. THF. HOME DEPOT MAY WITHHOLD AMOUNTS OWE 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 Authorization: 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 agreement.;, either oral or written, relating to said Products and Insudhdion. This Agreement cannot be assigned or amended except by a writing signet) 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 7//: 10 Customer's Signature Date Customer's Signature Date CANCELLATION: CUSTOMER MAY CANCEL THIS 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: ADDIT10NAi_ TERMS AND CONDITIONS ARE STA9 Su by: Sales Consultant's Signature �{ Date Telephone No. Sales Consultant License No. (ac applicnblc) FD ON THE REVtRSE SIDE AND ARE PART OF THIS CONTRACT nn %AFF;+a—RmnrhFIIA Va11nes,t:1410m9r Pink—Sales consultant ❑Roofing ❑Siding indows ❑ Insulation `"� /� l ,..,� ❑Guuen / Covers ❑Entry Doors ❑ L ❑Rooting ❑Siding ❑ Windows ❑ Insulation $ ❑Gutters / Covers ❑Entry Doors ❑ Cj Roofing Siding Windows Insululion $ ❑Gutters / Covers ❑Entry Doors ❑ ❑Roofing []Siding ❑ Windows ❑ Insulation $ ❑Gutters / Covtrc ❑Enlry Doors ❑ Minima n 2S% Deposit of Contract Amount due upon execution of this contract Total Contract Amount $1 L � �{ -3 Maim: Purchasers may not deposit mote than omtithird of the Contract Amount t/F t�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 under this Contract agrees to be jointly and severally obligated arid liable hereunder. The Home Depot reserve, 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 die joh was not included in the Contract. Payment Summary: The Payment Summary #�N Lt I[ , 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 Certiricate (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 tbrougb the date of termination, plus any other amount% set forth in this Agreement or allowed under applicable law. THF. HOME DEPOT MAY WITHHOLD AMOUNTS OWE 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 Authorization: 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 agreement.;, either oral or written, relating to said Products and Insudhdion. This Agreement cannot be assigned or amended except by a writing signet) 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 7//: 10 Customer's Signature Date Customer's Signature Date CANCELLATION: CUSTOMER MAY CANCEL THIS 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: ADDIT10NAi_ TERMS AND CONDITIONS ARE STA9 Su by: Sales Consultant's Signature �{ Date Telephone No. Sales Consultant License No. (ac applicnblc) FD ON THE REVtRSE SIDE AND ARE PART OF THIS CONTRACT nn %AFF;+a—RmnrhFIIA Va11nes,t:1410m9r Pink—Sales consultant