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HomeMy WebLinkAboutBuilding Permit #200-13 - 77 MARTIN AVENUE 9/12/2013 pIORTN BUILDING PERMIT oF�t�eo -6'9tio 2 0t '• �_''•96 O TOWN OF NORTH ANDOVER -� - APPLICATION FOR PLAN EXAMINATION Permit N0:�' Date Received 9 i ATE, gSSACHUs��� Date Issued: I Z41 z,-- IMPORTANT: IMPORTANT:Applicant must complete all items on this page JXi b A PROPERTY�°®WNERl. _ — s :— =�_=— 7 iPnn MU - ti 210 - FPAR:CEL' '��ZONING DI TRICTt'� Aistonc ®istriet3 yesFhn:oj "�,.. Machine SfiopVllage� yep1OOYyesl TYPE OF IMPROVEMENT PROPOSED USE Reside I Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alt tion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0?Septic D;W I �1F of odp airij ®iWetlands WatershedDistnct 0over/$.ewer DESCRIPTION OF WQfKTO E ERFORMED: Identif cation le se T pe or Print Clearly) OWNER: Name: Phone: Address: C®NfTJRACTt.OR? 'Warne T Address: -- ---- Supervisors.}CorstructronLicense: _ Exp; IJate? F __ om9 1ImprOVement�''Licen�se��;_-�_ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 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 con n ith re ' ered contractors do not have access to the g t1'.fuaran unci er 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 ❑ 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 NOTE: 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 ❑ 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 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) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: 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 2012 ig afure�ofA'gent/Owner. _ �j -_ Signature ofconfactor �_ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning B,)ard of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I{ 5 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located at 384 Osgood Street—978-685-0950 FIRE DEPART E TTemp Dumpster onsite_ yes nog. Locatedtat12`4tMainStreet97,8688;9590 Fire)Departrne"SO, nature/date) 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 I NOTES and DATA— For department use N2 i i ❑ Notified for pickup - Date i Doc.Building Permit Revised 2012 Location '`' No. Date 4017-- TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ . Foundation Permit Fee , r ^ Other Permit Feep TOTAL $L�) .O_ Check 2570 Building Inspector r cnl DATMM7/OD E' N.`tr/) AIC- CERTIFICATE LIABILITY INSURANCE � oz�ar�zol� 'y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEIR.•Tu-I„S - 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). 1-866-966-4664 CONTACT PRODUCER NAME: _ FAX Marsh USA Inc. PHONE AIC o Ex �(A/C.No): _------ E-MAIL homedepot.certrequest@marsh.com ADDRESS: —Two Alliance Center, 3560 LenoX Road, Suite 2400 INSURERS AFFORDING COVERAGE NAIL# Atlanta, GA 30326 Fax (212) 948-0902 INSURER A: Steadfast Ins Cc 26387 INSURED INSURER B: Zurich American Ins Cc 16535 The Home Depot, Inc. INSURER C: New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 Building C-20 INSURER NATIONP.L UNION FIRE INS CO OF PITTS= 19445 - Atlanta, GA 3033927960 INSURER F: Illinois Union Ins Co COVERAGES CERTIFICATE NUMBER: 25776028 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. ADDL SUBR POLICY EFF POLICY EXP INSR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDNYYY LIMITS A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 DAMAGEO ENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ CLAIMS-MADE a OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL&ADV INJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,X1/13 000 POLICY PRO- :,LOC $ B AUTOMOBILE LIABILITY SAP 2938863-09 3 0 (Ea acccidentINED SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per accident) $ HIRED AUTOS AUTOS $ X SELF INSUR D PRY DMG UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ $ WORKERS COMPENSATION WC015736915 (AOS) 03/01/1 03/01/13 X WCSTATU- 0rR TH- C AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNERIEXECUTIVE Y N I N/A WC019736917 (FL) 03/01/1: 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEO$ 1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below 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 f LOCATIONS I VEHICLES (Attach ACORD 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 /. ATLANTA, GAGA 30339 USA ©198 =2010 AC,O,RD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORDI=` r 1- NORTH - w: :: : : . . s c : ve"0 � No. dow' t _- , h ver, Mass _ Zo 12. coc«uMewic« 04ATED ►P�,`�y 1 V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ...............Terl.. ...... .... 14. ..... ..... � +a ...................... ....... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .......3................... ... mj.. *AS Rough tobe occupied as ..........77....... .. . yr... ...�1 ..... .�.....................................`................ 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 U0 ELECTRICAL INSPECTOR UNLESS CONSTRI TIO S 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. SEE REVERSE SIDE C� fice of Consumer Affair and Busines Rego atioil 10 ParkPlaza - Suite 5.1.70 5� Boston, ssachusetts.02116 Tloixie T�cnprove . ' contractor R:egist'< tion ReqistraVon: ..128893' r . Type; Supplement Card _ y F�cplration: 813/201 The Home Depot At-Home Servi •. .r w RICHARD :EALLONE M 2690 CUMBERLAND PARKWAY :f ATLAI<ITA; GA 30339 `0't� s "� ppdate Address and return eat•d-Mfrrkrenson,for cltnngc. tir syr Address Renewal' Q .Rmployntent r l Lost Cnrd DpS-GAiLicanse or 50Pd•04l04-G��10)]1218�J ������' .f , ,:JfiB VJ69)t.Oft04tlllP.6W/+• ��" "�LfJdB . s`-r office or Consumer Affnirs&'Business Regulation before tiro expiration dnte.!If founds r turn to, OMR IMPROVEMENT CONTRACTOR: office of Consumer Affairs and Business Reguintion ; r,= 9 •:Type: 10 ParkPlazo-Suitc 5170 Registration:;,126893 • . Supplement Card Boston,WU 02116 ' ExpTref(tin: t1�3' (l4 PP rhe Homa Depot;A H4tne-'- ?y(F�es RICHif ARD E;: •y ;` _ 7.690 CUN1EiERl1l�1D:1?4tFZCTtP'�S ��-�`-� � -�` :� iVot valid-with ut sl nature F"f lrAh!` i `GA 30339 Undersecrefnrx. . a i ��� The Commonwealth of Massachusetts Department of Industrial Accidents YRS ' Office of Investigations 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARpficant Information Please Print Legibly Name(Business/Organization/Individual): Address: Mlo City/ t; /Zip: P&L �' :`Phone#: :.AVI `an employer?-Check the appropriate box: Type project(required): 1. am a employer with _ 4. ❑ I am a general contractor:and I employees(full and/orpart-time).* have hired the sub-contractors .6. ❑New construction 2. 1 am a sole proprietor.or partner- listed on the aftached sheet.. 7. ❑Remodeling Ship and have no employees These sub-contractors have g, {]Demolition i working for in an capacity. employees and have workers. . g Y p ty 9. 'E]Building addition [No workers' comp.insurance comp.insurance.1 required.] 5. [] We are a corporation and its 10.0 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 12.0 Ro epairs insurance required.]t C. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 roust 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 contactors must submit anew affidavit indicating such., IContractors 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 and job site . information. Insurance Company Name: Policy#or Self-ins.Lie.#: imtion Date: Job Site Address: City/S(tate/Zip: r) �L Attach a copy of the workers'compensatio 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the.DIA for insiu'anee.coverage verification, I do hereby certify u der t e pains nd Wallies of perjury that the information provided above' true d correct: S' atur -— Date: (�� Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - Contact Person: Phone#: Aug 25 2012 8: 58PM MIKE SIDMHN 6038345514 P. 1 ti�)1�tt0i�N��'A) C'1r . PUASE 11MADIM Sold,PMhmisbed and•Iattallcd'byt' 1e2Nh.NaM Bosun •DRW T10 AtrKmesaviax,•lttc.. M Tho tituua DW At-Hma 3mvicaa 9%Swim Tttmpike,•Unit 1.$bstwdwy6 WA 01513 . 'folt.iVa(600aasr-5162;�x(SCID)tpi5�17• t3nngb 1+tap0ber:.�11• PeW.M#75-20W;M35 Lit a C POW 2t amt.40 W. Ci`!ic N IiIR.OlrtsM MAA Ha=t btiprove nest Gva 4nr>6,a8, 1.2 3. chy State zip: .P s *wk PhwA- Citi(i7bow irr �4� [q -97 I� (if diffamt 4vrin hadlodw Address) City State Zip &mel['Addrica(0thiceiveprr*dommunl¢tttidosaadiiunthh19epat>apd ft)' (311)6 NOT Wish-torer,>A*imy n1adwiftwrafs frOff 77is Hmw Dapk Vitcle Mined "Cbattiwt er"),the owners of tbd y mcau d at the above ib®tallAdw Wdrt6e.. to bht7r, atm. a�at uvices,.Inc.( Home Dcpot")x8�ees Ur 1bm�deflwer and anange for the ht�al)atiot►("Intddl l of all trowsaids described vn heti below and on i x�vcibam and Sw Slim(s),all of which arc+ncotpotated igo%Ws.Cqp rW bV.this along witb,M...•appliogble Stata•3eppiatneet atttl�"ayuleat.Jrasnahaty attmd+txl 1 and any Chimp Ordas(coilch Qey, Ile 1tlb#; uste,tisth,n.f.,i,b (lfI chi aR ads xA r AUD job4amlc�,wi uli)eyRm-� V7 7' US":U Windgwr ' WWdihm• �tlatvars l•Ca�er►•QBttry Daoeti�• pl ng' av i tai 11,6 a, 7 pephadt aa�nsa loi.pasfzil anel' atttaaq. lroW CAMtraei Amosmt $ 1,I t� MdwPat mleotdspmIIfl 4=004h art heCattwttA�aat�G t X Castmm 40e".chat,i iuteilisphly ppnoi�romg]suoti of.thew�ark.fat'eaeh,.Ptadµot,(X►at=er Will execute a•Corrtpbatjoa t rtioc.ps (ono fit cio Pradnct eA de$aed by aa,mdivt64 Spec$hoa)'&d lKy any Imlance due, As applicable.each Custisixar wi tt ihjs CaNttwcyt e' r=to be.ondy snd kwr ll y vbjigated and liable heaound+a. 't9te Eiahhle•l�epot teservea the r4h to-ism ht t bmV.Orda ercarninete this Cotractttr any individual Prvdnet(s)included lswdn;at its diseredon.if The Home Depot.cr its o b wtu d sttvled pvWa.,determintr Char it cant peftm its oWiga gwia Atte to a somaotai ploblam With ft hoalq,enuinootnemtal ltaMds ouch At mdd,aabcstos Or lcad,paiot,other safety soncorne,prioahg errnss or.becauae work t gWwd tD oa W*tba Jab mss not kidudeq in/.ttt 4.0 ontract... ParmoW.Marnsirs. Tha Pay t ShsmntofY d.Ip %/ included-as plat oi'this Comract,so fotib•rho acral Comet amddt tmd•ltsytneht fflghtlted,fttr Raducl(v Mlicatile). IxQTLC1gTO CUSfONW.4 •Ytthi are nod to a`. ftd'�opy hi the Ctnp@ adCh1Y tit Mme g6ti . Lib trot sign a Cempletton C3eltfl�fte f Robe: titers Is ane Cotn�et�te for ash I�bed Pevdh>tct a:: igh�hitdnl�t Spee'slleehi}tielvre woelr tier riser]'trail test Is mmihtete. Is the event ofttertntnstion of"Contract;CwOcmer aVom to pay The Hmm Depot the cow of rmm rlala,labor,eapawa and servloea pmided by The Home DeW or Atalhetised Servlet Provider drouSh the date of mrroinstlan,pIhss aq other amoents set forth io fl:ia Agreement or allowed under a�l1tcthbie law, THE HONZ DEPOT MAY WITHHOLD AMOLVM OWED TO THE ROMA DEPOT FROM THE DEMS T PAYMENT OR OTHAR PAYMp:M MADE, WITHOUT LIM1Tlr1G THE HONZ D>3P0 M OTMM ABELMIFB EDA MCOV8,R'it OF SUCH AMOUNTS. e��B 1 �: Customhrr t�tece and undess4wds that this Aproommt is rim entire adtcemant bct�vtrort Customer e 1 pot w t regaM to the Products and installation str dee and oupandes all prior dimsslons and agreements,either oral or written,nelating to said ProdwAx and Installatim.This Apeemcet caannt be awsilloal or amended except by a writing sighed by Costcasa and The Hama Ocpat.CuO and 4cknovdledges and egress that Costmer hot read,tmderatsnds,vol,mvsrily ascan;tho two of and has rwdv ed a copy of this A prement. A pted fly: Snbmtmed by:t,. _ 's a Date sales Cense 'A Sigthathuro Data ; gnium S1Data Solo Condom Uccm Na AG1tETA M �j : CUSTOM MAY CA14CEL TSIs t,s aVACIL k) OUT PO4ALTY OR OBLIGATION BY MLIVBI U40 WRI2'i"Y EN-NOTICE TO I=M)NM DEPOT BY MIDNIGHT ON nM THIRD BUSU& DAA' AFTER•SIGNING TM AtitltEE24EN T, T= sTATz tsuPPt:,slt MT ATTACHED HZR rO CONTAMS A P'ORNI TO LW IF ONE 1113 SPKMCALLY PRIED BY LAW IN CUSTOMER'S STATE, 1ifi0=1 AtIOMONAL 71QRttlti AND C.MDMMS ARE alAWS,(]LATHS REVERSE BIDE AND ARL PART 01 TI ttl CONMAt'r WMIS 044 W18te—amriChAle Yellurr—CaeteshMr