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HomeMy WebLinkAboutBuilding Permit #065-2017 - 64 Kingston 7/21/2016 NOr ,9 1 BUILDING PERMIT " TOWN OF NORTH ANDOVER ° - �� APPLICATION FOR PLAN EXAMINATION _ �* Permit NO: Date Received �9SSACNUS Date Issued: I PORTANT:Applicant must complete all items on this page LOCATION ,int PROPERTY OWNER ✓ Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yes ' no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Xeration No. of units: ❑ Commercial iVRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic. ❑Well ❑ Floodplain D Wetlands ❑ Watershed District ❑Water/Sewer D -q? J Identification Please Type or Print Clearly) OWNER: Name: --" Phone: Address: h •, CONTRACTOR Name. Phone: Address: Supervisor's Construction icense: xp. Date: . Home Improvement License: Exp. Date: Whim 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: $ Dom'-- FEE: $ .� Check No.: Receipt No.: 14N,2(A NOTE: Persons contracting with unre istered contractors do not have access to Me g�ty fund Signature of Agent/Owner Signature of contractor BUILDING PERMIT ;1 of No DTh qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0 1e Permit No#: Date Received �y p�RATEO SSAC14us Date Issued: IMPORTANT:Applicant must complete.all items on this page LOCATION. Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: 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 ❑ Repair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ E!Septic = .Well ❑ Floodplain, �w❑Wetlands r0.Watershed.Distnct ra « i _y-x❑,Y;Y ater�SP.wP.r�.`.o... �y�- , tK } 4 ..-L..°RJ '* .: �, ,� ,.,..• ,. .-=.0 ' DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: y 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.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;S`ianaturP of Ma i tKwvner Siariat6f of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanaing/MassageBody Art ❑ Swim,ning 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 Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Siqnature ' I COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r' Conservation Decision: Comments Dater & Sewer Connection/Signature ®afie Driveway Permifi I DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster onsite yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 arse) ® Notified for pickup Call Email Date Time Contact Name Doe.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing g� Sidin Interior Rehabilitation Permits d 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 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 j Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 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) 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 2012 IECC Energy code Engineering Affidavits for Engineered products 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:Building Permit Revised 2014 t%O R TH Town of � _ ndover 0 Y• No. 2 h . ver, Mass,0 LAKI ��I coc Nlc Kl WICK �'►• re o PPa,��(5 L) BOARD OF HEALTH Food/Kitchen IT Septic System PER T THIS CERTIFIES THAT . , BUILDING INSPECTOR .................. .. ....r'"Vjee...... ... ... ......... ......... ...................... . .... . .. .. .. ..... .. has permission to erect .. . .... buildings on . ... � ..................................... Foundation. . ,. Rough tobe occupied as ............................ . . ................>...................................... Chimney provided that the person accepting this ermit shall in every respect conform to the terms of 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST T=74i Rough Service .. .. ..... ......... Final DI INSP CTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. HOME IMPROVEMENT PLEASE READ THIS Sold,Furnished and Installed by. Branch Name:New England Date: CDI 1 THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2693460;ME Uc#C 02439,RI Cont Lic#16427 CT .ic#HIC.0565522-,MA Home Improvement Contractor Reg.#126893 Installation Address: City State Zip Purchaser(s): Work Phone: Horne Phone: Cen Phone: 481 1 1 [ ] Home Address; (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing entails from The Hoare Depot Project Information: Undersigned("Customer"),the owners of the property located at the 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#: (tmernai lteterenec) Products: Sec Sheet(s)#: Project Amount Roofing Siding Windows Insulation ❑Gutters/Covers ❑ ntry Doors ❑ .78 RoofingSiding Windows . Insulatian Gutters/Covers. []Entry Doors.❑ $ Roofing ElSiding El Windows' ❑;Insulation ❑Gutters/,Covers ❑Entry Doors❑ RoofingSiding Windows Insulation []Gutters f Covers ❑EiitryDoars ❑ 4-- Minimum 251%Deposit of Contract Amount due upon execution of this contra Total Contrast Amount $ Maine Purchasers may not deposit more than one-third of the ContractAdtount. 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 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 the job was not included in the'Contract. Pa`ment Summary: The Payment Summary included as part of this Contract; sets forth the total Contract amount and payments required for the deposits and finalpayments 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 HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT 1,M1ITING 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 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. Acceptedhi Submitted by: X The Commonwealth of Massachusetts Deparintent oflndustrialAccidents I Coag ress Street,Suite 100 Foston,AU 02114-21117 ;vm mass.gov/dia lVavkars' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbars, TO BE FILED WITH THE PEIL'MfCIT NG AUTHORM. Applicant Information Please Print Legibly Name (Bus(ness/Organizatiowlndividual):_ T�22t Address: Ci /State/Zi r tY P� Phone#• Areyou a player?Check the approprlata box: Type of project(required}; 1. I am a amployar with�employees(!fill and/or part-time).' 7. New ❑ - construction 2.❑(am a sale proprietor or partnership and have no amptoyees working for me in 3, ❑(remodeling any capacity.(No workers'comp.insurance requited.] 3.❑I am a homeowner doing all work mysefE(No workers'comp,insurance required.]t g• ❑Demolition 4, tun a homeowner an&wdl be hiring contractors t y property, I will l0 ❑Building addition ❑ g. o conduct a!t work an m ro ensure that all contractors eitherhave workers'eompem6an insurance or are sofa i l.❑Electrical repairs or additions proprietors with no-empfoyees. i2,❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the aub•conhractors listed an the attached sheat. These sub-contractors have employees and have workers'comp,insurance•! l3.❑R repairs 6.❑We are it corporation and its officers have exercised their right of exemption per MGL c. 14,F1 Other 152,j.1(4),and we have no amployees.(No workers'camp.insurance required.) Any applicant that checks box 41 must also fill out the section he[ow 3hortua thetkwoFkera-cam n.atton ori pe '. • p cy-information:• - " 'forireo+iners`:fho suTiavf this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicaling such. !Contractors that check this box must ached an additional sheet showing the name of the sub contractors and state whether or not those entities have employees.-If the sub•contraetors havicttaemplayees,they mtiit gr6i idt 1Fiei-r-arorkers'wrap.policy number. ram an employer that Is-providing workers'compensation Insurance for my employees. Below Is the policy and job site Information. �^ Insurance Company Name: Policy d or Self-ins:Lic, Expiration Date: / Job Site Address: City/State/Zip: Attach a copy of the workers'conipeingatio,oliey 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 vetiflca" Ido hereby car y to in rte pa u and penalties of pgJr1ry that the lrrformation provided above Is true and correct Signature: - D e Phon At: Ofjlclal use only. Do not write In this area,to be completed by city or town offlolat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health L Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phoned!.. ACC) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02124/2016 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 TAE-CER'TrFICATE 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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD,SUITE 2400 E-MAIL AIC No): ATLANTA,GA 30326 ADDRESS: INSURER AFFORDINGCOVER-AGE NAiC1s 100492-HomeD-GAW`-16-17 INSURER A-:Steadfasi_lnsuranoe Company 26387 INSURED THE HOME DEPOT,INC. INSURER B:Zurich American Insurance CO 16535 HOME DEPOT U.S.A.,INC. INSURER c:New Hampshire Ins Cc 23841 2455 PACES FERRY ROAD,NW BUILDING G20 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER.F: COVERAGES CERTIFICATE NUMBER: ATL-003741310-08 REVISION NUMBER:O THIS"IS TO CERTIFY THAT-THE-POLICIES OF'INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 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 ADDLSUBR LTR TYPE OF INSURANCEINSO POLICY NUMBER POLI YYYFY MMIDDYIYEYYY LIMITS A TXCOMIMERCIAL GENERAL LIABILITY GLO4887714-06 03101/2016 03101/2017 EACH OCCURRENCE S 9,000,000 CLAIMS-MADE MOCCUR DAMAGETO.RENTEPREMISES Ea occurrence) S 11000,000 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED OF S!R yS'I fA PER O0C PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000 X POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMPlOP AGG S 9,000,000 OTHER: 5 B AUTOMOBILE LIABILITY BAP 2938863.13 03101/2016 03/01/2017 COMBINED SINGLE LIMIT Ea accident s 1,000,000 X ANY AUTO BODILY INJURY{Per person) S ALL OWNEDSCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS BODILY INJURY(Per accident) S ::i11REG'ttUTos.. .AU,f 4WPIFD aS :?HOPERT DAFtAGE S P r accident 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS C WORKERS COMPENSATION WC015519215(AOS) 03101/2016 03/01/2017 X PER OTH- s C AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE YIN WC015519217(AK,KY,NH,NJ,VT) 03101/3016 03101/2017 E.L.EACH ACCIDENT s 1,000,000 OFFICER/MEMBER EXCLUDED2 N NIA _ D (Mindatoty n-NNY. WCO;+.5513296 FL. 0310112016 03/.011217 EL.OISEASE-EA.EvPLGYE S 1,On O r0It Dyes,describe under Continued on Additional Pa 1,000,000 ESCRIPTIOMOFOPERATIONSbeiow 9e E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES(ACORD 101,Addhlonal Remarks Schedule,may be attached If more.space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16000SGOODS7. THE EXPIRATION D'A'TE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherjeeLaua�t,: ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD � i i5'�R1,Y spar Act,*���b A`���� i y Ic '4 1 �i y 3 >t< s: ty g (,tin%tf kt4 441 �,lPC 1"to 3RVt,luUA ir BENJAMIN PARKER JFL,:, 43 GREENO (y�� �/�■ .. � aY. air } 0386.5 Q �Y4 021/112018 j� -64.S 14T w1 1 4!Y 5 � k n I ,� j - /F �3 t' ;�h�� '�'*•�4` a � R���� s s _e •''f: ,. �. �;,_ <.,?� ,.,��1� �- .k �:<�'-� �� _ 5"�.� ..c �s-.* _f.,4i.f:� 9, tam d .�,., ,. w.r Office of Con5urn--'r AML3 amdbt6ill�7,3 11'atl')� 10 Pu: k Plaza - Suit-, D5 170 Poston, Mq.ssac�husl---f fts 02116 Homo jmprg-, ovem� , C,-ontractor F,eogdstration Registration: 12BB93 Type: Supplement Card Expiration: 802016 THD AT HOME SERVICES, INC. -F RICHARD FALLONE 2690 CUMBERLAND PARKWAY ATLANTA, GA 30339 Mark reason for change. UydeteAddress aad return card.L -71 Address -7 Renewal ED Employment L Lost Card License or registratioft vand for individul use only . W5 of con�urner.kffalrs&B6iaess Re. flon before theax'piration date. if found return to. -1E INIFIROVEWENT COMTP070R Regulation M. L L:P Office D,-Consumer Affairs and Business Typ-3: 10 Park'Plaza-Suite 5170 suppiament Ca-i Boston.N- Lk 02 115 D AT HONIE SERVlQE5--r-*t0:— E HONE OF-POT AT-ff9KE— ,HARD FALLON- go auMBERLMD PARKII.A-Y --Not lid wi hoot signatureTA90X.GA 30339 Undersecretary i _ k E Location Ij © � Date • - TOWN OF NORTH ANDOVER ... Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ r. Other Permit Fee $ y TOTAL $ Check# ' 1 ; Building Inspector