HomeMy WebLinkAboutBuilding Permit #431-13 - 59 HUCKLEBERRY LANE 11/29/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: GDate Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION
Prin
PROPERTY OWNER EWM
. - -
int 100 Year Old Structure yes no
MAP NO:U& PARCEL:02 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSEp USE
Reside al Non- Residential
❑ New Building D,6ne family
❑Addition ❑Two or more family ❑ Industrial
❑AI tion No. of units: ❑ Commercial
L?Kepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
El Water/Sewer
DESCRIPTION OF�AI�RK TO B RFO MED:
1
Identificat' n P ease Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: _Exp. Date: z
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: $ OQ� FEE: $
Check No.: =6 � 1_�f� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to a ara fund
� � _
Signatu�e_uf Agerit�Owner .� f�'j G,j Signature,of contra
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ St ped Plans ❑
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
o Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o 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
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
❑ 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)
o 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
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o 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: Doc.Building Permit Revised 2012
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.$10041000 fine
NOTES and DATA— (For department use
0 Notified for pickup - Date
E
Doc.Building Permit Revised 2010
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
i
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
HEA&H 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:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 MainStreet
Fire IJepartment signatdre/date `
COMMENTS
Location tl Lrj.
No. 1 I — Date
• ' TOWN OF NORTH ANDOVkR
• c�ti,`�r.i,fr�X64 �
5
Certificate of Occupancy $
� Building/Frame Permit Fee $ .�
Foundation Permit Fee $
Other Permit Fee $ ,
TOTAL $
Check# Q
25992 Building Inspector
OORTH
own o ndover
0%
o - �
ice' y
130
2612m
oh
ver, Mass
ISLW
2 COCMIC MtWKIc y1.
A�RATE0
S V
BOARD OF HEALTH
PER Food/Kitchen
Septic System
- T T LD
THIS CERTIFIES THAT BUILDING INSPECTOR
............... .. ...... y.... ....................... ............. ... ..... ................... ......
Am
••••.• •. • Foundation
has permission to erect .......................... buildings on .. ... ........ ...........
Rough
to be occupied as .�1� �� � •• •.. •••••• Chimney
..... ......... ' .................
provided that the person acce ting this permit shall in every respect conform to the terms o 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO R 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 andApprovedby the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
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Atlanta, GA3032o ItJSURES(5):a=ORDL'+1GCr)VBit?G'r_ N?Ji.;ias (212) 948--0902 R A: StaadfaS% Ins Co -- 25367 __.._.-
!NSURED INSURERS: 1 .c'r.. �raerica s Ir.;� Cc 16535
The Home Depot: Inc. P7�,:r Fi:mpshire Ins Co 23841
?-Some Depot U.S.A., 1n.c, iIiSURERC_ I
2455 Paces Ferry Rear. PPhi INSUREP.D: Illingia Nat1 Ina Co 23$17
Building C-20 INSURER E: NATIONAL UNION FIRE INS CO 0V PITTS -_ 19445
Atlanta, GA 30339
INSURER F: Illinois UnionInsCo _ _.•• 97960 -
•COVERAC'ECERTIFICATE NUMBER: 25776028 --RE IJISION NI6IVIDFR: _
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD l
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 TERP4S,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
11TR
ADDL SUER POLICY EFF POLICY EXP LIMITS —I
j
TYPE OF INSURANCE . D POLICY NUMBER MMIDDIYYYY MM!( DDIYYYY�, ,— _.,_._..._.,_..._.._._
LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE M $ 9,000,000_
DAMAGE TOR RENTED 1,000,000
MERCIAL GENERAL LIABILITY PREMISES Ea occurrence $CLAIMS-MADE �OCCUR MED EXP(Any one person) $EXCLUDED
MITS OF POLICY XS PERSONAL&ADV INJURY $ 9,000,000
SIR: $1M.PER OCC GENERAL AGGREGATE $ 9,000,000
GEN•LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000
_K]POLICY PEC0LOC $
B AUTOMOBILE LIABILITY BAP 2938863-09 03 O1 03/01/13 COMBINED SINGLE LIMIT 1,000,000_
Ea accident
X ANY AUTO BODILY.INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS —
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
X SELF INSUR D PHY DMG $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $ _
DED RETENTION$ $
C WORKERSCOMPENSATION WC015736915 (AOS) - 03/01/1 03/01/13 X WT RYI jZ OTH- - _----—
ANDEMPLOYERS'LIABILITYYIN WC019736917 (FL) 03/0 /103/01/13 _EACH ACCIDENT __ $ 1,00_0,000
D ANY PRO PRIETORIPARTNEWEXECUTIVE E.L.
_—
OFFICERIMEMBER EXCLUDED? N INIA
E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE $ 1,000,000_
It yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
E Workers Compensation WC1192494 (QSI) 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 TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE
BUILDING C-20 / �---
ATLANTA, GA 30339
USA 111 Gam•
1198j;'20`10 ACQRD CORPORATION. All rights reserved.
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2012-11-05 02:40 3401-EXPDTR/PHN SLS 6034374224 >> Home Depot AHS P 1/6
HOME IMPROVEMENT CONTRACT
PLEASE READ TiHS
Sold,Furnished rind Installed by:
Branch Name: Boston Date: '1'HI)At-Home Services,Inc,
—� d/b/a The Home ik:pot At-Home Services
908 Bosion'l'umpikc,Unit 1,Shrewsbury,MA 01545
'Poll lits;(800)657-5182;Fax(508)845-6017
Branch Number:31 Federal In#75-2698460;ME Lie H C 02439;It Cont.l•ic#16427
CT Lie#HIC.0565522:MA I Ionte IrnpKrvemcm Contractor keg.it 126893
Installation Addrem: / 'VaL
City State Rip
Purchsscr(s):) ,/ Work Phone: Itommee Phone:
,p Cell Phone:
AA.jt.�C i 1
L l L
Home Address:_
(if different from Installation Address) City State "Gip
E-mail Address(to receive project communications and Iiome 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 adtimss,agrees to buy,
and TI1D At-Home Services,inc.("Fite 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(%),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 1F: tmrenarRrfem eey Products: Sec Sheet($)#: Project Amount
/ 9 ❑Rnofing[I ng Windows ❑Insulation -
647 ❑Gutless/Covers ❑Entry Druirs ❑_ $ ZPO eS�
❑Roofmg❑Siding Windows ❑Insulation
C]Guttei s/C:ove s ❑Entry,Doors ❑
❑Rooting ❑Siding El Windows ❑Insulation
❑Gutters;I Covcrs []Entry Doors❑ I $
I ❑Roofing[]Siding Windows ❑]mulation
❑Gaffers I C:ovtrs ❑E? Uy Doors C] I $ I
Minhunin 25%Dqmilt of Conb-.Kt Amount due apart exacuition of this contract. Total contract Amount $ �(��►'r
Maine Purettown may not depo*more than one-thinl of the ComtudAmount.
Customer agrees that,immediately upon completion of the work for each Product,Cusmmer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. A%applicable,each(customer under this
Contract agrees to be jointly and severally obligated and liable hereunder,
I;
The IIome Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included hcrcin,at
its discretion,il'The Home Depot or its authorized service provider determines that it cannot perlbrm its obligations duc to a snUctural
problem with the home,environmental hartrds such as mold,asbestos or lead paint,other safety concerts,pricing error's or because
work required to complete the job ww;not included in die Contract.
Payment Summary: The Payment Summary# included as part of this Contract, act% firth 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 IIOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOi.JT
LIMITING THE HOME DEPOT"S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understinds that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supcncdes all prior discussions and agreements,either
oral or written,relating to said Products and Installation. flits Agreement cannot he 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
lens of and has received a copy of this Agreement.
Accepted b
cp Y- r S mitred by:
X. _ E/_3 Y l
Customer's Signature Da i 'alts Consultant's Signature Date
X I Telephone No-
Cu:lomer'N
u_Cu:lomer'N Signature Date
SaICs Consultant License No.
CANCELLATION. CUM'OMFR MAY CANCEL THiS I ixs"pplimhie)
AGREEMENT YM*HOU'1'PF.NAI.TY OR OBLIGATION j
BY DELIVERING WRI'1-1'EN NOTICE TO THE HOME I
DF.P01' BY MIDNIGHT ON THE 'THIRD BUSINESS �
DAY AFTER SIGNING THIS AGREEMiEN'1'. THE
STATE SUPPLF,MENT ATTACIIED HERETO
CONTAINS A FORM TO USE 1F ONE 1S
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S ST'AT'E,.
NOTICE:ADDITIONAL.TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ANL+PAR IOF THIS CON-1"RAC'I
05.10-12 White—Branch File Yellow Customer
Hie Coinnionivealth of Mrzssachuselts
,-;
r lei;cartrtent of IndustrialAccidents
'�
Office of Investigations
600 Mashington Street
F- Boston,MA 02111
www.nmss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name, siness/organization/individual):
Addre: s:
City/S ::'e/ 'p: ne#:
Are yo -n employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. n I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
shi and have no employees These sub-contractors have
P � 8. n Demolition
working for me in any capacity. employees and have workers'
insurance.x 9. E]Building addition
comp.[No workers'comp.insurance p•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions
myself..[No workers'comp. right of exemption per MGL 12.❑Ro repairs
insurance required.]t c. 152,§1(4),and we have no 13. Other
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.
xContractors 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 andjob site
information. r �
Insurance Company Name:
Policy#or Self-ins.Lic.#: �j � Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration pa a(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 penaltiesin 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^erage verification.
I do hereby certify under the pains a en ties perjury that the information provided ab o a is tr and correct
S i ature: Date:
Phone#: '
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
6. Other
Contact Person: Phone#:
Department of Public Safety
joard Of Building Regulations and Standards
.ffin,�truction Sopervisor Speci21ty
License: CSSL-100696
IRA VERH .L.NA ®pZ9 r' /
f •`'b
I
J,,�... . 'I "►� Expiration
Commissioner 00/21/2014
�tA ,