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Home My WebLink AboutBuilding Permit #766-14 - 70 PEMBROOK ROAD 4/29/2014Permit NO: .Date. Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 66 — ( Date Received IMPORTANT: +LOCATIONS ;� - -. §M iPROP'ER TY OWNER' ` 1MARAN IPARCEL _ icant must complete all items on this page PROPOSP USE Resid ial Non- Residential ❑ New Building One family ❑ Add' 'on ❑ Two or more family ❑ Industrial 0 01fiation Pr►nt= ' ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Print ' Wryear OIdStucture ye: �noF . ❑ Watershed,®istnct x ING ®ISTRICT �Histonc Distract y = ono Shop Village _yes ono .TYPE OF IMPROVEMENT PROPOSP USE Resid ial Non- Residential ❑ New Building One family ❑ Add' 'on ❑ Two or more family ❑ Industrial 0 01fiation No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ®Septic: V1/ell _'Floodplain _ ❑tiWetlaridss . . ❑ Watershed,®istnct x ❑Water/Sewer.. °- t _ - - - - -- Identification Please Type or Print Clearly) OWNER: Name: Phone: A AA .-�... �. . t- l - ICON; 'RACTOR"``N me �P :hone:. Address,: _Ant= - _ a -- _ r ' Construction License ° - Exp:. Date. . Supervisor s ._. _ _ _ = - - y 41i,. o-Irr;r:rnvcCnAnt'`IAranCP---ExD. Date:`'7J�7A _ — 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: $ IBJ -FEE: $� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ "Stamped Plans ❑ -PlansSubmitted ❑ Plans -Waived-❑ ;_Certified Plot Plan ❑ Stamped Plans ❑ =I`I'PE-OF:SEWERACEDISP-OSAL" Public Sewer ❑ Tanning/Massage/Body Art ❑ . Swimming Pools ❑ Well ❑, Tobacco.Sales ❑ :Food Packaging/Sales ❑ Private.:se tic tank etc:_ - p ❑. =Permanent Dumpster on:Site ❑ FOLLOWING SECTION'S 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: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: :Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Toiv A -Engineer: Signature: Located 384 Osgood Street FIRE DEPARTM.E'NT •Temp Dumps er on site yes no Located�at,1,24=MainStreet. .;•,, r-• "1 - � Fire b i'lJ me►it!signature/date COMMENTS f ..:. ,.. D.ii7-enston Number of Stories: Total square feet of floor area, based on Exterior dimensions. :_Total land area; sq. ft.: ELECTRICAL: IVdovement:of.Meter location, rr ast-or service drop requires approval of :Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes Pio MGL-.Chapter166.Section 21A -F and G min.$100-$1000...fine NU I E5 and DA I A - (tor department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol wing is'a list of;the required:forms to be filled outfor the appropriate:permit to be obtained. R.00fiig, Siding, Interior Rehabilitation Permits Rtjilding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C:S-L Licenses ❑ Copy of Contract o 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 a Building Permit Application a 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) a Copy of Contract ❑ Mass check Energy Compliance Report u 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 apw, al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc -Building Permit Revised 2012 Location "�'�'` „ Ulf k, - No. Date Y o - TOWN OF NORTH ANDOVER o Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ `•�, �` Other Permit Fee $ TOTAL $ i a Check 4t `+ r 27511 Building Inspector Eq * all rA J LU LL z Q m v E N a z z 0 C c o H z z m J D. H V 0 H z a W J W O O O: 0 LU z Q C7 N O d z LU 2. ac Q W LUc LU LL w O 0 LL Ln CL ul O :37 LL = U LL d' LL = o0 L 7 K U i In LL (D t to d' LL CO O z ++ W N o Y O (n O J I:) S O O O O •Q � CL as Q W V N E C �Q Q cC c o H V E O O O L ate. C N O d w O Q W V N E C F. O W CL CO Z 0 m M za 0 G Z CD0 U Cl) W C a. Z w0 L) U) U) LU J 5w V d Q cC J • O i O O > N o O C � t t o N O O t •y = o0 L Q. W d (D 0.5 m V i N C = L :C •a CD ate+ N O 2 m _ -0O O t/1 C :E N O m .2 E v 0 c� � c � Q O 'a N > m cc O o cL o c) F. O W CL CO Z 0 m M za 0 G Z CD0 U Cl) W C a. Z w0 L) U) U) LU J 5w HUbtt6ln'Irnvvr.nndvr ----- PLEASE READ THIS Sold, Furnished and Installed by: Date: THD At -Home Services, Inc. Branch Name: Boston Date: The Home Depot At -Horne Services 3-12VIY— g)8 Boston Turnpike. Unit I, Shrewsbury, MA 01545 Toll Free ($00) 657-5182: Fax (508) 845-6017 Branch Number: 31 Federal ID # 75-26984ho: ME Lic # C 02419: RI Cont. Lic# 1(x127 f�CT Lic # HIC.0565522; MA Home Improvement Contractor Reg. # 126893 Installation Address: 70 �° �od�C /`tld f/ City ' State Zip Purchaserts): Work Phone: Home Phone: Cell Phone: I - I Home Address: (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): ❑ 1 DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undenigned ("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"y N. Prniert 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 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. Payment Summary: The Payment Summary # 9 2 �iY 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). 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 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 Instal [at inn 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. Aicceptyd by: Custt ner's Signature ffite Customer's Signature Date CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENTWITHOUT 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. NOTtcc: ADDITIONAL TERMS AND CONDITIONS ARM: STAT 10-11-1z White — Branch File Submitted b X Sales Consultant's St nature Date Telephone No. -3 — Sales Consultant License No. (as applicable) ED ON THE REVERSE SIDE AND ARE I'ART OF THIS C0 ,%TRA(:T Yellow — Customer Roong ❑• • VSiding indotvs ❑ Insulation ❑fi s �� $ / �� 7 ❑Gutters / Coven Entn' Doors C]l/ ❑Roofing ElSiding Windows ❑ Insulation $ ❑Gutters / Coven ❑Entry Door, ❑_ Roofing ❑Siding ❑ Windows ❑ Insolation $ ❑Gutters / Covers ❑Entry Doors ❑ Roofing ❑Siding ❑ Window. p Insulation $ ❑Gutters / Coven ❑Entry Doors ❑ Mirnmum 25% Deposit of Contract Arr aunt due upon execution of this contract Total Contract Amount / $ Maine Purchasers may not deposit more than one-third of the Contract Amount. l l 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. Payment Summary: The Payment Summary # 9 2 �iY 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). 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 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 Instal [at inn 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. Aicceptyd by: Custt ner's Signature ffite Customer's Signature Date CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENTWITHOUT 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. NOTtcc: ADDITIONAL TERMS AND CONDITIONS ARM: STAT 10-11-1z White — Branch File Submitted b X Sales Consultant's St nature Date Telephone No. -3 — Sales Consultant License No. (as applicable) ED ON THE REVERSE SIDE AND ARE I'ART OF THIS C0 ,%TRA(:T Yellow — Customer rl .. L'1 �:ng;ti'.vi �;iiiCi1�.=„a,'�i'�'�}•i)�.i.t7i�� a'l� :a-'ra`('i•.''a'�?.. The Commonu ealth of Massachusetts. Department of Industrial Accidents Oce of Investigations 600 Washington Street Boston, AM 02111 411M.mass.gov/daa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers T ....51.1. Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are u an employer? Check the ppropriate box: 4. ❑ I am a contractor and I 1. I am a employer with general employees (full and/or art -time).` have hired the sub -contractors listed on the attached sheet. # 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and have no employees working forme in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner. doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4); and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. Building addition 10. ❑ Electrical repairs or additions 11. Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #f1 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer Haat isproviding workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: k�b 7Q le Job Site Address:— 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 against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify une the pains and penalties of perjury that the information provided above is t�e an d 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ACC?R" . CERTIFICATE OF LIABILITY INSURANCE `�- DATE( 02f19//20142014 YYYY) 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 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 MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 CONTACT NAME: P IC E FAIC No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Steadfast Insurance Company 26387 100492-HomeD-GAW-14-15 INSUREDZurich THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER B American Insurance Co 16535 INSURER C: New Hampshire Ins Cc 23841 INSURER D: Illinois National Insurance Company 23817 2455 PACES FERRY ROAD ATLANTA, GA 30339 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JECT PRO LOC INSURER E: INSURER F: B rnv�cer.Gc CGRTIPi( ATP MI IMRPR• ATI -(1(139496A5-01 REVISION NUMBER. -3 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. TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMDD/YPOLICY EFF YYY POLICY EXP MM DD/YYYY LIMITS rA GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR GL04887714-04 LIMITS OF POLICY XS OF SIR: $1M PER OCC 03101(2014 0310112015 EACH OCCURRENCE 1$ 9,000,000 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ EXCLUDED PERSONAL & ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JECT PRO LOC PRODUCTS - COMP/OP AGG $ 9,000,000 $ B AUTOMOBILE LIABILITY X ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BAP 2938863-11 SELF INSURED AUTO PHY DMG 0310112014 03101/2015 - COMBINED SINGLE LIMIT 1,000,000 Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $___ C C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y /N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC049101882 (AOS) ( ) WC049101884 AK, AZ, VA WC049101883 (FL) 0310112014 03/0112014 0310112014 0310112015 03/0112015 03101/2015 X I WC STATU-ORY LIMITSOTH- ER 1,000,000 E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 C C WORKERS COMPENSATION WC049101885 (KY, NC, NH, VT) WC049101886(NJ) 0310112014 03/01/2014 03/0112015 03/0112015 (EL) LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) EVIDENCE OF INSURANCE THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES 2455 PACES FERRY ROAD ATLANTA, GA 30339 ,../11`4%1 C LLN 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 of Marsh USA Inc. ManashiMukherjee�+: U 19t3S-YU1U AUUKU UUKI'UKA 1 IUN. All rignis reserveo. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 4