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HomeMy WebLinkAboutBuilding Permit #647-14 - 80 EDGELAWN AVENUE 3/20/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 6 q �_J Date Received Date Issued. 3F—AH IMP RTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER //�� ( Print 100 Year Old Structure yes rno MAP NO: (D_W—J PARCEL: ZONING DISTRICT:' Historic District yeso Machine Shop Village yew TYPE OF IMPROVEMENT PROPOSE E Reside al Non- Residential ❑ New Building 5,Crne family ❑ Addit' 11Two or more family 11 Industrial ❑ A ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ` ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed! District ❑ Water/Sewer Identificati n Please Ty or Print learly) OWNER: Name: Address: CONTRACTOR Name: f [_1 Phc Address: Supervisor's Construction License:` - Exp. Date: l Home Improvement. License: Date 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: $ �I 1JFEE: $ v Check No.: qo� Receipt No.: 2-� �� d NOTE: Persons contracting with unregister d contractors do not have access o e uar ty fund t. Signature of Agent/Owner ignature of contr cto _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ St ped Plans 11 Location No. Date, TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 7-C" Foundation Permit Fee $- Other Permit Fee $ TOTAL $ Check 2 73 6 8 Buil - ding Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED CONSERVATION Reviewed on . Sianature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: L Com Conservation Decision: Comments A Water & Sewer Connection/Signature & Date Driveway Permit DPW 'Tows! Engineer: Signature:_ Locatea 3M FIRE DEPARTMENT - Temp Dumpster on site yes no, Located at 124 Main Street Fire Departinent signature/date ' COMMENTS Jtreei 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: lies MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 1 no 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract o Mass check Energy Compliance Report o 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: Doc.Building Permit Revised 2012 V, rA �g r�0 ti J S u.Z a o m c t X \ O i.0i E +�ai + >. N U O_ Ln O U V1 Z m C O 0 "6 7 LL t 7 w N C U C LL O 0 W H ? Z m D J Qr t 7 C C LL d (A Z a u J W t to 7 d' O U (%j C LL Q V pW Z 0 a (7 t 0=0 2' C LL Z W W o W 5 LL L N i m O z y `1 N N Y O N O O V O :Ono - OE O oOEQ 31 L � la .V 0 O ` O �3 � J 2: im � c � L N O = a) > f/1 'a ° OV N O Ec 0 V• a)z Q c w An o �' c �— Oar � as cn f./ �• CD V O = c = N C ~ °V m N _ LUco �, O d W = -0 - O O li •0 CD 15to c FL= O W •E 0 W .5 = V Q ° •a N .L., U) O >;� C N .O O H -W n.ot) 2 z m CDz Cl) LUw a. W H W 0- E O o N Z 0 ^ = •� Q Co C o a�� L O N a O CL v J Z 0.0 O Z r� v � OCL � CL U) 0 The Commonwealth of Massachusetts Department of Industrial Accidents �� F=s� Office of Investigations 600 Washington Street Boston, AM 02111 ' ww>ss .mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pease Print Legibly Name (Business/Organization/Individual): Address: Phone #: Are you employer? Check the appropriate bog: i. am a employer with _ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors . ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance re aired ] comp. insurance.$ 5. ❑ We are a corporation and its ❑qofficers have exercised their I am a homeowner doing all work 'myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling g. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.E] Roo pa' 13. Other *Any applicant that check% box #I 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. $Contractors 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 enVloyees. Below is the policy and job site information. �--=-- Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: r�� Attach a copy of the workers' compensation/policy declaration page (showing the policy number and expiration date). Failure to secure rag required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,5 0.00 and/or o -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $25 .00 a day agads he violator. Xe advised that a copy of this statement may be forwarded to the Office of Investieatio of the DIA urance cov verification. I do hereby certify sande the p4fn� and p KaLft: y ' ry that the infiornm ion provided above is true a nj 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 #: CERTIFICATE OF LIABILITY INSURANCE i Ip T141S CERTIFICATE IS 158UED 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 T14E COVERAGE AFFORDED BY THE POL ICIE„ BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AU'I HOI IZ 413 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE FOLDER. 1 1MFORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) n:usi Te endcrse7Jlr SUBRO�'TION iS WA__!i7k la, � ._ xr;.-_1 the terms and conditions of the policy, certaln policies may re=quire zn endo: aemz: n,t. A• stitza-7, rit c„ t",a ce tl:ica:_! doe= a,y,.•r. conf=_r rights to •t: e {certificate holder Its lima of such endorseivent(s). I a�� _CONTACT I oi;ODUCER I PMRSH USA, INC. i TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 NArrE:—_--_-- -- — -- — { — A;( PHONE IL AIC N9, cxt : I ILA Not: E-MAIL — ADDRESS: INSR LTR 100492-HomeD-GAW-14-15 INSURER A: Steadfast Insurance Company 26387 INSURED • THD AT-HOME SERVICES, INC. DBA THE HOME DEPOT AT-HOME SERVICES 2455 PACES FERRY ROAD ATLANTA, GA 30339 INSURER 8: Zurich American Insurance Co 16535 INSURER C: New Hampshire Ins Co 23841 INSURER D: Illinois National Insurance Company 23817 — — INSURER E: I _. A INSURER F: I.VVGKAb12-9 I I - C(•K IIFN'OI I- NII IMRIZO. - ATI_nn99A9PAr Al OC(II QIAAI Alt 1I1RDCO.9 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. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIOD/YYYY POLICY EXP MM/DDIYYYY — LIMITS_ A GENERAL LIABILITY GL04887714-04 03/01/2014 03/01/2015 EACH OCCURRENCE $ 9;000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR LIMITS OF POLICY XS DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence)$ MED EXP (Any one person) $ EXCLUDED OF SIR: $1M PER OCC PERSONAL & ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 _ GEN'LAGGREGATELIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 9.000,000 X POLICY PRO- JECT LOC $ B AUTOMOBILE LIABILITY BAP 2936863.11 03/01/2014 0310112015 COMBINED SINGLE LIMIT 1,000,000 Ea accident X ANY AUTO _ BODILY INJURY (Per person) $ ALL OWNED SCHEDULED. AUTOS AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION$ $ C WORKERS COMPENSATION WC049101882 (AOS) 03101/2014 03101/2015 -X I WC STATU-OTH- CAtJY D AND EMPLOYERS' LIABILITY PROPRIETORIPARTNER/EXECLITIVE Y / N OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) . It es, describe under DESCRIPTION OF OPERATIONS below NIA - WC049101884 (AK, AZ, VA) WC049101883 (FL) 0310112014 03/01/2014 0310112015 03/01/2015 -DRY I IT -_ 1,000,000 E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 C WORKERS COMPENSATIONWC049101885 (KY, NC, NH, VT) 0310112014 03101/2015 (EL) LIMIT 1,000,000 C M049101886 (NJ) 03101/2014 0310112015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) EVIDENCE OF INSURANCE a.cicl Irwr+I c nvwcm THD AT-HOME SERVICES, INC. . DBA THE HOME DEPOT AT-HOME SERVICES 2455 PACES FERRY ROAD ATLANTA, GA 30339 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.— ,S'%ow�caiti..::. 1 Cir xt ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD l=eb261402:21a Derek Brown HOME IMPROVEMENT CONTRACT PLEASE READ THIS 603-384-1683 p.1 Sold, Famished and Installed c Branch Name: Boston North &South Date: THD At -Home Services, Inc_ d/b/a The Home Depot At -Home Services Branch Number: 31 and 33 908 Boston Turnpike, Unit 1, Shrewsbury, MA 01545 Toll Free 877-903-3768 Federal lD # 75-2698464; ME Uc # C 02439; RI Cont_ Liv# 1642' ! A Cr Lic # HH1C.0565522; MA �Hofine Improvement Contractor Reg. # 126893 Installation Address: l 1 � �` !�'� J I '" ' A" _ WVkA � *— Ciry State I Zip 6 1 F Home Address: (If different from Installation Address) City . 1 / tate Zip m Address (to receive project communications and Home Depot updates): E10 NOT wish to receive any marketing emails from The Home 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 Stare Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): Job #: n„re.".i m--) 13-61—f— Sner. Sheetis) d: Protect Amount Roofing 051ding indows hisulation . Q $ _3 l t 3 ❑Gutters! Covets a€ ❑ ntry Doors L) Roofing Siding Windows El Insulation S []Gutters/ Covets ❑EntryDoors ❑ Roofing Siding El Windows El Insulation $ i ❑Gutters / Covers ❑Envy Doors ❑ Roofing Siding Windows D Insulation []Gutters / Covers []Entry Doors ❑ Minimum 251/6 Deposit of Contract Amount due upon execution of this contract Total Contract Amount Maine Purchasers may not deposit more than one-third of the ContractAtnount. Customer agrees that, inunediately 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 e Cop act. Payment Summary: The Payment Summary # ( included as part of this Contract, sets forth the total Contract amount and payments required for the deposits an nal 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 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. Accepted by: X .rte �iwvi.-L Ok Customer's SignJure Date Customer's Signature Date CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT 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 Su mt ed b74411y x Sales sultant' Signaturre'� Date Telephone No. �% �t �'�— Salcs Consultant License No. (es applicable) NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT