HomeMy WebLinkAboutBuilding Permit #Exception - 73 CARLTON LANE 5/1/2018 NORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER o� rye.° t° �°�,
APPLICATION FOR PLAN EXAMINATION
Permit No#: `�^ Date Received
rEV
/n
��SSgcHus�t�y
Date Issued: Tq 14
IM OR ANT:Applicant must complete all items on this page
LOCATION _ _ 6% For7) ,
' PROPERTY OWNER
J Print _ 100 Year Structure yes (no
o
MAP/&6t - PARCEL: D ZONING DISTRICT: Historic District yesno
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building a O' ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic 0 Well p Floodplain ❑Wetlands ❑ Watershed i tri
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
QVD -��eT z G &�5
Identification- Please Type or Print Clearly j _l��
OWNER: Name: 0,91vL'5 W)1.,LLAR22� Phone:`�` y� lam'
Address: C`a'l �� L),pV9 �V�I�`/ f/ 1� �'/ ���7�✓
-;Contractor Name . _I. P
Address.-_ ?,p _ -5T�` f�}'��-• Q 1
Supervisor's Construction License: --Exp. Date:_
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 O` $125.00 PER S.F.
Total Project Cost: $ ° �� FEE: $ �7
Check No.: �,�.( Receipt No.: Loa2_
NOTE: Persons contracting with unregistered contractors do not have access to a ar d
SiSi ature of Agent/owner _�__� Signature of contractor
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
❑ Workers Comp Affidavit
o 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
❑ Building pp Permit Application
u Certified Surveyed Plot Plan
a Workers Comp Affidavit
o 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)
o 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
o Certified Proposed Plot Plan
❑ Photo of'H.I.C. And C.S.L. Licenses
a 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
❑ 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 2014
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
0
CONSERVATION Reviewed on Signature
COMMENTS
\Tk
HEALTH 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 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 use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
/ f I
LocationNo. Date vJ/
v ' !
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
- Building/Frame Permit Fee
Foundation Permit Fee $�
Other Permit Fee $ �.
TOTAL $
Check#
28076
Building Inspector
r 1 NORTH .
: ve"
No.
CIO Vh ver, Mass,
LAKE zo
COCNIc"awl N 1.
�l.9S gwreo �e����5
U BOARD OF HEALTH
Food/Kitchen
P. ERMIT T D Septic System
THIS CERTIFIES THAT .......6.r.0.�,, a (,.#A �!K„ ,,, ,,, ,., BUILDING INSPECTOR
.................. ................... .. Foundationhas permission to erect .......................... buil i gs on ... %.................... ... .�..........,
Rough
to be occupied as ......... .......Atmew.. • . . �� .... .......................... Chimney
provided that the person accepting this permit 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
30• UNLESS CONSTRUCT SiS 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 and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
ulamm 11VU111 Cl—.at ant 30 t yVa tsoston tumpnce,unit 1,mnrewsoury,MA Ulo4o
`s•/ Toil Free 877-903-3768
Federal ID#75-.2698460;ME Lie#C 02439;RI Cont.Uc#16427
Cr Lie#IiIC.0565522;MA home Improvement Contractor Reg,.#126893
Installation Address: —7 3 CO LrW LOF N"H o
f City eo State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
Home Address: 4
(if different from Installation Address) City State,f Zip
E-mail Address(to receive project communications and Horne Depot updates): 8 D V 1aCSJ . )v
I DO NOT wish to receive any marketing emails from The Nome Depot 9P IU-4 X17..5 1 1 ?
Proaect information: Undersigned("Customer").the owners of the property located at the above installation ad ess,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(collec' eI
"Contract"): �
Job#: tlacem.t x�rcei Products: Sm Sheets #: Project Amount
—CTRoofing Siding U
Window Insulation
' � C3Gtr�crs/Covers ❑Entry boars
Roofing OSiding Windows 0 insulation S
(]Gutters I Covers ®Entry Doors C3
Roofing Siding LJ Windows Insulation
[]Gutters/Covers []Entry Doors[�
Roofing OSiding 0 Windows El Insulation
! $
❑Clutters/Covers C]Entry Doors Q
Mini nurn 15%Deposit of Contract.Amount due upon execution of this cantruct. Total Contract Amount
NUne Purrlumn may not deposit more than one-third of the Contract 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 Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products):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 Aitb 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 # R69 C Z 7 , 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 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 Horne 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 lava. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OAVED TO THE HOME DEPOT FROM THE DEPOSIT PAWENT OR OTHER PAYMENTS MADE, WI THOLIT
L LMITING THE.HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authoriztion: 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, v=oluntarily accepts the
tod has received a copy of this Agreement.
A ep b "e___L Submitted lay:
20)4_
9-1q- 201L-
Cust mer s Signature Date Sales Consultant's Signatures Bate
X Telephone No. 6 " 7`91757
Customer`s Signature. Date /!
CS?IPC f"'nrrcritra»,t irr+ncr>tin Ai rt 4
71
•
aco CERTIFICATE OF LIABILITY INSURANCE ='Q'u"awrrm
THUS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEL 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
REPFtESENTAT"OR PRODUCER,AND THECER7IFlCATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the potiry(Iesj must bs endorsed. If SUBROGATION IS WAIVED,subject to
Al terms and ecnditlons of the pollcy,certain pollcles may requlre'an endorsement A statement'on this certlfieats does not canter rights to the
ceitttleate holderfn lieu Of such endorsementfsl.
►RODUCFJt ow ACI
htgMUSAiNG }II ►NONE FAX
T140AL11ANCECENi"uT Ar wo.
2550 LENOX R=SUITE 2AW E•iaAIL
ATLANTA.GA 70726 A R
' INSVRERfS A►►OROIHC GaVERAG! NUC f
ION g2-Hi=D•GAWI1-15 INSURER A I SleaCasl'M=:e Campuly ZE391
a usuata LudrhAmemminsww=CO 1E535
THO AT-HOME SERVICES,INC, INSURER 0!
03A'THE HObt DEPOTAT•HOM"c SERVICES INSURER C,New Hamp Mrs int Ca 127541
2455 PACES FERRY ROAD INSURER o 1 nwis National Insuran:e Company 122911
ATLANTA,CvA 3-1739
INSURERS I
INSVRE0.C 1
COVERAGES CERTIFICATE NUMBER: ATl•N324269501 REVISION NUMBER:?
7m:S IS TO CERTIFY THAT T=E 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,
IL 1R I' TYPE OF INSURANCE IANC L n POLICY NUM9cR I IAPI/DA/uj DTM•VYI IUUrLDICY EXP Dr+'YY�" I LIMBS
A GENERALLIABILITY uL04y5T114-W 03101311 07,0112015 EACH OCCURRENCE I S 9,0D0DDD
X COMMERCIAL GENERALUABI'.17Y D^MAt 1,000.000 .
CLNMs•LIADE OCCUR LIMITS OF POLICY XS M-_D pIP(Anyone Corson) I i EXCLUDED
OF SIF,'tIM PER OCC PERSONAL 6 a7VINJVRY I f 9.000•G:�
G ENERAL AGGRE GATE S 9.DOD,DOD
GEN'LAGGRE('GATELIMRAPPLIES PEN PRODUCTS.COMPIOPAGG S M.-0-0i
X POUCYI ATIPc - 0 LO__ - 71 ' _ i
B AUTOMOBILE LIABILITY BAP 2939E53-11 C7N1QD14 DMI015 I COM01H_0INGLt LJM11
X ANY AUTO •, '^!LYINJJRY(Pit,s:xanl i!
�OOWNED SCHEDULED ccLF INSURED AUTO PHY OMu ::ODILY INJURY(P11
2=dSN) s
AUTOS
HOWOWNED PROPERTY DAMAGE f
HIREDALTOS AUTCS _
r . Is
UMBRELLA LIAB. OCCUR EACH OCCURRENCE I f
EXCESS UAB CW US.MAD� I I AGGREGATE Is
DED-1 I RETEIInONS Is
C WORKERS COMPENSATION WC0491018S21AOSI C1rJiQD14 010112015 x jrSTAOcMI
AHD EMPLOYERS'LIABILrTY V D
D ANY PROPRIETORMARTNERE7r<CLMI/E YI- N r A WCD191D1BBI(AK,AL VA) OS. 12014 D1FJ 112015 EL EACH ACCIDENT I f 70-00-300
D OFFICERe•7EAIBEREXCLUDED? (�J W".Od91D1EE] rL 1.00O.D00
(M snasmry 1n HH) I ) 01001Q014 o3A112 EL DISEASE•EA EMPLOYc i
Il re s.auvee sna sr 1,000.000
DESCRIFTION OF OPERATIONS be'D E.L.DISEASE•POLICY LILLT I f
c.C (WORKERS COMPENSATION I IWCD491C19!51N �NZ-,NH,q, 10101/2014 IolYJ112o15 I("LI LIMIT 1•�3•D00
O:SCRIPnON DF OPERATIONS ILOCATIONS I VEHIDLES IA ns:A ACCORD 101,Amu-LI Asmsru$Chi OU11.I1 mar,Ip."is n0.ulr,d) '
EVIDENCE OFINSURAN::
C=RTIFICATE HOLDER CANCELLATION
T-0 AT•HOWE SERVICES.INC.
C3ATHEHON:C�POTAT•HOME SERVICES SHOULD ANY OF THE ABOVE T DESCRIBED POLICIES WILL
CANCELLEDDErV RSO IN
' 2<r_SPAC=SFE?_fi'RO1J � THE EXPIRATION DATE THEREOF, NOTICE WILL_ 6E DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
ATLANTA.GA 3:733
AUTHOR
_`O REPRESENTATNE
of Us K1lSA Inc
ManashiMukherjee
O 1988.2010 ACORD CORPORATION. All rights reseryod.
; \ 1:,j� �.v�nr�turtrhett:c�t UJ tIAUS;SaCIIU.YLILS
Department of Industrial Accidents
Okce of bjj esdaadoizs
-1 congress Street,Suite 100
Bostdi MA 02114-2017 '
wwwmassgov/dia • r� "
r
' VPoikers'.Compensation'Insurance�davit:Builders/Contractors/EleefricianslPlumbers
A 'cantlnformatioh* Please Print Le 'b`lwI
` IDe(Btuinesslorganizadon/Individual):
J
Address:
��
Ci '/State/Zip: �L •'� Phone;T: —� � �J��•
Are you an'employer? Check the appropriate_bo/�. • Type df project(required}:
I'.[]'I am a employer with " 4• dd 1 am a general contracioi and I: ' 6.•❑New construction
employee's full and/or art-time).* have based the sub-contractors
P Remodeling
2.❑ I am a sole'proprieior or partner- listed on the attached sheet. 7. ❑
shin and have no employees These sub-contractors hav6• g, ❑Demolition
workingfor me in an capacity. employees and have workers'
y p ty. 9. ❑Building addition•
comp.insurance.*
[No workers' comp:insurance 10.❑Electri:al repairs or additions
required.]' '' •5. ❑,W e are a corporation and its , • • • ., .
omcers ha exercised. their 11: Plt mbi: repairs or additions
3.❑ I am a homeowner doing all wort; ❑
y P right of exemption per MGL 12.❑KO7ther
i-s
m self. o workers'.com ��;
insurance required.]t c. 152,§1(4);and•we liave.no 13. i
"employees. [No workers"
comp.insurance required.]
`'Any applicant rig .hocks box 91 tz-,"t at, flu out the section below showing their workers''compensation policy information..
t'Homeowners who submit t is affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the came of the sub-ca and'state whether or not those entitis have
employees. If the sub-contractors have ctnployccs;they must provide their workers'comp.policy number. ,• - '
I ani ail*employer that is providing workers'conipertsation insurance for ray"entployees. 'Below is thepolicy and job site•
•••'•iJtforntation. r"" '
Insurance Company Name:
Pdlicy or Self-ins.Lic.rt/v: � Expiration Date:.
�
Job Site Address; e 7 P—A CirylState/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 e. 152 can lead to the imposition of criminal penalties of a
fine•up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of.a STOP WORK ORDER and a fine
of up to 6250.00 a day against-tht:violato-r. Be advised that a copy of this statement may be forwarded to the Office of
Investi.gatiers-of the DLA for insuranee•coverace.verincation —
I do hereby cerci pa': and el alri c erju7 that the information provided above is true turd correct
� �/
Signature: Date: -
Ph
on
Ofjuial use only. Do not write in this arca, to be completed by city or town officiel.
B
City or Town: V Pern-it/License
Issuing Authority(circle one):
I.Board of wealth 2.Building Department 3.City/•I'o'Am Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone R:
I•efmlt tierviCBS 4U1 'L40 Y0506AL
p•'�
C771f22 ��s^/1?iti�"Lt?�2r'l1P.r.,l2;✓�2 fl-" ��f/!,t;cr!�:)�IL#2�:if� "
Office of Consumer Affai andBusiness Regulation
10 Park Plaza. - Suite 5170
Boston, Massachusetts 02116
Home Improvement*Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC. Expiration: 81312016
RICHARD TROIA ----�-
2690 CUMBERLAND PARKWAY SUITE 300 . . —"—
ATLANTA, GA 30,339 __ _.....__ ..........___
Update Address and return card.Mark reason for change.
sca 1 t•, zota-:m Address J Renewal Employment Lost Cwrd
o �7i1!'�Pll/liry✓I/:P//�/�'�;^�irClrr,�li;ri�' .
Ofiiee of Cuasuner Affairs&BnsinessRegulation License or registration valid for individul use Only
`DOME WIPRG4 E.ME`�T CONTRACTOR
M-Pi'
before the expiration data If found return
.N Office of Consumer Affairs and Business Re_. ...ion
Registration: •126993 Type:
10 Pirk Plaza-Suite5170
=
Expiration:.SW.016 . Supplement Card Boston,MA 02116 "
7,47,A7 HOME SERVICES.INC.
THE HOME DEPOT AT FtOt SERVICES
RICHARD TROIA
2690 CUMBERLAND PARKWAY S
Ao15M GA 30339 Undersccretary Not valid,, outsi afore
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SBL■READ MA
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