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HomeMy WebLinkAboutBuilding Permit #121-12 - 68 BELMONT STREET 8/10/2012 TOWN OF NORTH ANDOVER l APPLICATION FOR PLAN EXAMINATION Permit NO: � Date Received Date Issued: DRORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER II4,q, Print •�, PARCEL. ZONING DISTRICT: Historic District e MAP NO: yes no Shop Village es no (f' p Villg Y 'nit TYPE OF IMPROVEMENT PROPOSED USE Reside al Non- Residential ❑ New Building .2-6ne family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial WfZepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other j t®Septici`w ll' " In oodplaui� ; etlands ® Water he LQistrlct ❑W r/Sewers _ DES Cs �t 10�ORIC T i --TLilF RMED: i pit (Ade?�tification lease Type or Print Clearly) W ONER: Name: _I 14le t- � Phone: o Address: CONTRACTOR Name: p t'1 Phone: s Address: 1e7 Supervisor's Construction License: J bQ(R4 Exp. Date: _ Home Improvement License: f� �=l= Exp. Date: _ ARCHITECT/ENGINEER Phone: I ,lit 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 Coat: $ FEE: $ � . ._ Check No.: �7�5 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acces to the gu my fund • S gnature of'Agent/Ovuner .�-�: -_ T�Signature ofcont� .�-� �= ;a� • �` ' Location (ea on T No. d�/ " /- - Date MORT� TOWN OF NORTH ANDOVER O Certificate of Occupancy $ - ;�, MSS�� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ��� 24464 Building Inspector II Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools O Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY ` 4 INTERDEPARTMENTAL SIGN OFF - U FORM I DATE REJECTED DATE APPROVED i PLANNING & DEVELOPMENT' ❑ ❑ r I ^f i COMMENTS CONSERVATION Reviewed on Signature i COMMENTS HEALTH Reviewed on Signature COMMENTS k, 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 Main Street Fire Department signature/date CONIMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. it.: 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 m1n.$100-$1000 fine NOTES and DATA— For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi Building Department f' 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 I M ® Building Permit Application a `Norkers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract a Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pen 4 s Addition Or Decks ❑ Building Permit Application a Certified Surveyed Plot Plan j ❑ Workers Comp Affidavit P o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy 01' C0111. 112 i o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (if Applicable) a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pern r 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 o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) L, Copy of Contract L3 Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 4 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perr 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 recordin ' must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi 1 i NORTH own ® ovendr .. No. / -*0 Ao j;- 1 .. = AK o , dover, Mass., COC HI CHEWICK ADRATED P' CJ S U ` BOARD OF HEALTH PE� MIT Food/Kitchen Septic System 1`1 r � BUILDING INSPECTOR THISCERTIFIES THAT.........................................................G. ..............................S................................................. ........... Foundation GGhas permission to erect...... buildings on .....p �Ir.`.�iA!4�.!b ... Rough .... ............ ............... Wooft t0 be occupied as............... -1 :.. L ...'T I�Ri� ' ........................................... .... Chimney ................................................... provided that the person accep mg this permit shall in every respect conform to the terms of the application on file in Final 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 UNLESS CONSTRUC ST TS ELECTRICAL INSPECTOR Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. DATC(MMIDDIYYYY) I A'_" CERT'IFICAT'E, OF LIABILITY INSURANCE 02/21/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HULDER.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(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). coNTACT PRODUCER 1-404-995-3000 NAME: FFAT - - Marsh USA, Inc. PHONE'"` "" E-MAIL homedepot.certrequest@marsh.com '" - - ADDRESS_ - ---'- -' '- - Two Alliance Center, 3560 Lenox Road, Suite,2400 INSURERS AFFORDING COVERAGE Atlanta, GA 30326 Steadfast Ins Co 26387_ - Fax (212) 948-0902fINSURERB' URERA: __--• - -- -- Zurich American Ins Co 16535 INSURED '----"-'- The Home Depot, Inc. URERC: NewHampshire Ins Co23841 Home Depot V.S.A., Inc. Illinois Natl Ins Co 238172455 Paces Ferry Road NWURERO Building C-20 URER E: NATIONAL UNION FIRE INSCO OF PITTS 19445 Atlanta, GA 30339 Illinois Union Ins Co27960 URER F: COVERAGES CERTIFICATE NUMBER: 19834682 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. -- AOUL SUER -- POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER MMIODIYYY MMIDDIYYYY 00 000 LT 03/01/1A 03/01/12 EACH OCCURRENCE S 9.0 A GENERAL LIABILITY GL04887714-01 _DAMAGE FO RENTED 5-1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence/ _ MED EXP((My one person)- E EXCLUDED CLAIMS MAGE X OCCUR _'—PERSONAL 6 ADV INJURY 9,000,000 _ X LIMITS OF POLICYXS S —______"-•-_ GENERALAGGREGATE S 9,000,000 X OF SIR: $114 PER-OCC — PRODUCTS•COMP/OP AGG S 9.000,000 - - GEWL AGGREGATE LIMIT APPLIES PER. $ X POLICY PRO- LOC HAY 2938863-08 03 01 1 03 Ol 1 COMBINED SINGLE LIMIT 1,000,000- _ B AUTOMOBILE LIABILITY E a ant BODILY INJURY(Per person) $ X ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) S - AUTOS AUTOS _ PROPERTY DAMAGE S NON-OWNED (Per a cident HIRED AUTOS AUTOS X SIR AUTO P Y UMBRELLA LWB OCCUR EACH OCCURRENCE S -•--_..,,_._.____...._ EXCESS LIAO CLAIMS-MAGE AGGREGATE $ S DED RETENTIONS WC STATU• OTH- WORKERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 X C AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNEIVEXECUTIVE YIN WC061967354 (FL) 03/01/1 03/01/12 E.L.EACH ACCIDENT $1,000,000 - OFFICERIMEMBEREXCLUDED7 a NIA 03/01/12 E.L.OISEASE•EAEMPLOYE S 1,000,000 E (Mandatory in NH) WC061967353 (CA) 03/01/1 If yes,describe under E.L.DISEASE-POLICY LIMIT E 1,000,000 DESCRIPTION OF OPERATIONS below 67355(RY,MO,NY,WI, p3/O1/1 03/01/12 C Workers Compensation WC0619 . F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/lM E Workers Compensation WC1192378 (OSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORO 101,Additional Remarks Schedule,if 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jfiero_hd 19834682 U•r3C.C( �,s ,�Bbdl:.rsrv:Lill - 10,..32. ' aDDMONALPERFuRMA1�iCE RATINGS - •. , . • I�LWtGbpN SUpID.tETn7tAlA Cd E1E'r0A'¢Q:(i9 . nce 16indclnr soD dist hd Chet r�P�'^ onldr t rd t ��>tu?ISL d"'�^ lecanst>rd np laid • n ao�rnkad kir c koQ rt d rxkmr� tbraR �61 dr} cQ�P Pa !r 4 nd>ttirrlr+t Qv'> it D kr s7>qs 'a .; pm ICY Uhims fid► rd<a rarr,e ais+pletd� ar�krOle Y Eirt>.r�a d Radtn padWt istat ver Dar tl�C sn 6sert !�a� ,�1 pl�iia ei.oadq pn r up-Pada; Inc m rao Mbr dit�DRia°t•°p�� -j,�,• j'. • .;:. 't7nLt T. c;.Illflii Yo_c ,PERCY lLLR �,�•• etglen(i)= UaetNeed, Noetl►•' - I s. Canteal,•!o.tR C,AtvaL, %*o then. 1!,'4 A9 r ST kR ajLLiloa,pa.i IA LAI -' cs+LOnl��} '�HROY,l21l1: Uoctm. '; + • ,f'* �, :;• lioctt Cant:eal• J•w,c •_ � • `+' .._ I>aD:—' A'CO%ClAafSA 3f32'!k-Rt3 .-- • , •'. '. - � • ' •INO: arif�tcao OtlJYldclo ].3C >�a/N'R13 • ISP -'-45. ct 1.. .: • 1 - •xs. Y•alfaln : ' :a131124. • dG713 ' E�9 SC;9 mw.��Dim .�vrnili�����,�a,�,t�t�:+� ` &,ade iia tl +da pa9?��mbahas ljl(SV 1w mnow n's=m i b:N#;t t Kill"In I :.OlreeoCConsumerA[[aRgulatio en irs&Busioess J. o E iMpikoVEMENT CONTRACTOR Registmtion i26893 TYp� - •.. gtippiemenl�. The tt�llfineS +=®s RICHARDFALLONE I 2690 CUMBERLAND PARKWAY 5 � . The C'omnionwealtn of Massachusetts :w Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston MA 02114-2017 � s www.mass.00v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - Applicant Information Please Print Legibly Name(Business/Organization/lndividual): It tl Cl tom= Address: 1, l.0 r 00 661 Ciry/St to/Zip: c 1 Phone #: s Are u an employer? Check the appropriate box: Type of project(required): 1, I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partfier- ship and have no employees These sub-contractors have g• E:]Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition o workers.comp. insurance comp. insurance.: P Electrical repairs or additions CN 10.❑Ele p ns required.] 5. ❑ We are a corporation and its 3.❑ I required.] a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.[]R 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 k1 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. tCoatractors 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. r--► Insurance Company Name: r Policy#or Self-ins.Lica M Expiration Date: Job Site Address: �CJ� � ` 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$250.00 qday against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un er the ppins qAd penalties of per'ury that the information provided above is truef nd correct Signature: _ Date- Ph ne ate'Phone#-. Oficial use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 07/12/2011 17:09 15087568823 THD AT HOME SERVICES PAGE 01/07 FROM :3482 FRX NO. '6036283415 Jul. 11 2011 06:26PM P1 NOME IMPROVEMI=NT CONTRACT K EAtIF READ THIS Sato,Raraiatrod and installed by,' Braomb Alamer Ooeton I>stG THD opoitAf-Hthe Services,SCsv Loo. dl'bht Tlte<liurme Dent At-Home Scryitxs MSA Otteetttwx d Suets.I10it$W0raxlm.MA 01607 Toll pre.(900)657-5182:F'aa(5ft)756-811x� Branch Nestler:31 Padani 1D#7S-WOS46P.ME Lic R C 02434 Ri Ox a.L&*16427 4T Lte#19C.050122:NtA home]rrslnrpvemmaCtirwogns Ra%.a 126593 rnihlllataa wddraasr. ��- tfi � . t cure bariart-+.t-. Flamm w:t 1�a.•nn G � IV ts5� 1foato Addyewt3tarc rAP (If diffareril fmmn ltudalla4011 Addrem) cty ii Addmo(to receive prujcat cumm lilc:Kiotts mrd llm=Daput galales): N07'wIa M f 90Givo soy madtalina Dlnaib 1TON ilm 14orrrc Depot • 17t►detxigatotl("t' "),the uwaerr.of the property loaned at the shove installation addreasa,agrrta to troy. and Tt1i�Ai-haat Services.irtc (-M,Haaw Depon agrees to ftmtiah-deriver and ar>•nP for the ingW11aHtm E"lt tiatr of all otawrirda dowAbod on tote below and ua the rritaratced Spa Shom(s),nil of stfiicb ere iAcu"Fiureted iota ihes t'onttact bX tlia tttcrcmce,nkfag veldt any appricoft State Supplement and Paytnant Sluamary atmctmd lrraoto and any Change ChdM(e0lriuhvely, -t:nntrstx"k lobJh nw.natam.rnen s y- --..__. AtrmotRtt ' t -aoafrai dinit ilana inrulmiimAi ilk &�1 J. l wlntcam 1Q.,.aza try (} 1< Rpttfp�g tdl iasurn laealatian' j $ [�t ua tour I Qin cwmy tm*.*[1 �Reafing Siding WNrdnttro btmlatioa _ $ �(Gdtcnitbrens�R�tryDaorrf 1 _ _... . Raefitrt Mgidtiig iaddws bpolaim $ ❑tea/Coven[]-mvi3am L3---- i- i ToWCmrtraetArnount $ WWM"hrhwwrsmgBOA"yoa,airm lamone4hWardw0-tr"Arnewat- C _ L-uslomee apyeea that,immcdntely upon CM picit"M of dW work for each Product,Custnmta•will ex=ta a Convkdan Certificate \V�` (one for each i'aalr ct.m defend by an inrbvhleia Spec Sheet)and pay may balance dice. As appliMUM.each Cutdttmar under tins CaMtr=agmcs to be jolmly std scvcrally obllpttM and linbte hcrcunrkx. The Hent Depot»ta tiro tight to itrsuc a Change Order or terminate dda Cnonect or any individual Prudtrot(a)inchrdcd berms,at its 4ist'ir:8on.if Tote Horne Depot or its aothridwil mr fte ptovkler detow irca that it camta perf"m tis obligations due to it SMM- hal problern with the haat,cavironrozoW hazer s Such its mold.aeM:atoa or kad paint anter safety concerns.pricing ewers w because work rctptired towntpitebe oho job was not includod VI the'Contract. pavmaat Summer The rayplem Summary(1 E incloMd na part of this Cgttt M sax forth the tonal C.0 nract amonnl and payments rggvired for lire deposits and finnt paygtertts by Pmduot{aa npplirntble) NOU(ZTO CW1rOM ER nCw`ttlleatP.(ntdra Van are entitlydto a fined-in copy nP the Ctintraet et the effne you Jo oat ai®t a[am�ntiun awro Is etre Cotnplstion�xr kciitte Tor each 16d6d P Pito as d"PO i by hririA d*1 Spre Stteetta)Ire►nre work on first t Is 4*mplete. In dee evclrt of terndrattioa of Aiis Contract,Caatartter agrees to paty the 71ooa+ hire eat�s.of mpierials,tabor,errpamen and aervtaw pptr+rrnvfded byThe Hamm Drartt ar Actow faod Service F'ravlder tta�Ara dittse oP terminatiM4 ppd,s.hay oRter amounts act fords In this Agre�tmt f wed malerFP�� ic"law. THE HOMti:uic'P(7T 1v1AY W OLU AIVIOUN Pti iOwFM TO.fMl PINC.l HRE ROME DF'MT FROM "M P IIOME DBP(Ws 0TRIM REMEDZS R R Y VERY OPSU H AMOUN M- MADTi, W%TSOTJ 1' Aa rax ander t t}satentter agrrxs and nitdet-stands ibat lhits Agmu cut is the cntite agreernerd betwc ae Curttemai and The ii�nti.Data,with regard to alis yfto n and lumlintion wrviocs and m. qw ndax all prior disetasetow and ngrcamarnta,eilitr'r oat or writiarr,relating to said Pgad"M gad lnsiallafitm.This Agrmntmst cannot be w4IfVwd or amtttrdod MOW by A waking xngrred by CumD n s and 1,he Holme Depot.Cnanomer aetmawladges ami agrees that Customer hss mad,understan&.volunlerity acem s the terms rtrand it0.s received a co"of this Apre=01. Srbariutd by: 4iw,Surc Date Sahat CoasaitRrn'a Siptaeurc Date T&P{rhone Nu._�{ti3� t,vslumer'b Signetune Date Sala!CoR4nitant License No. CANCBI.1tQU(&- CUNW)MIRR MAY CANCEL- TtM (as appltaehlot AGREEMRNT WrrHOlTT b'rWAff TV OR OOLIGATZON BY utst.iV6RiHiC.WRt9's7mm Ntri7CE TO THE NOME REPOT DY ta•iIpPl GUT Off '"W. THIRD BlINIP1K9.R DAY ArMll SIGNING 'PILIN AGREEMENT. TfM STATE SUPPUMUNT AT'TACREn IIFBTiM CONTAINS A YOitM To USE IF ONE IS 9YkA:IKi(ALI.V PRESCM14FM RV LAW IN CUMM1IR1 STA I'E ntyrKV:A0VrM)"Ar.1mRR"Arm cxm*V fl0N5 ARES1'ATan tart TWRRYKRYC SM AND ARK PAar OF'47rL`1[7UNiRACr 0417-tt CSC isnr7c-.amnch FM YwWav—fls.sr.he.