HomeMy WebLinkAboutBuilding Permit #039-2017 - 81 PADDOCK LANE 7/13/2016 U
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�� BUILDING PERMIT * b3 ob
A � o
TOWN OF NORTH ANDOVER
0� APPLICATION FOR PLAN EXAMINATION i
Permit NO: 1- ��� Date Received ' +
Qp<Otn[n. y1'
Date Issued:
�9SSACHUS
IMPORTANT:Applicant must complete all items on this page
LOCATION I tl4
Print
PROPERTY OWNER
Print
MAP NO: PARCEL:Je2 ZONING DISTRICT: Historic District yesno
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resid tial Non- Residential
❑ New Building ne family
0 Addition ❑ Two or more family ❑ Industrial
❑Meration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic Well . Floodplain Wetlands Watershed District
E Water/Sewer
10
Identification Please Type or Print Clearly)
OWNER: Name: Qbdz
Phone:Address:
CONTRACTOR Name: Phone: on 1!J
1
Address: r---
bum
Supervisor's Construction L cense: ` Exp. Date:
t
Home Improvement License: Exp. Date:
M
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: $ x,1, (7 FEE: $ i .
Check No.: l-1d3y Receipt No.: cot0
NOTE: Persons contracting with unregistered contractors do not have access the Puarantyfund
Ignature Of Agent/Owner Signature of contrac
ry .
Lx V -
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 Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
' Planning Board Decision: Comments
G
Conservation Decision: Comments
Wafter & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
_ _ Located 384 Osgood Street
FIREDEP,ARxTMENT TempDumpster,on.tsite eyes.
•Locafed�af
Fircitepar"1Mpnt}sigpature/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
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$1oo-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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 j
Building Permit Application
Workers Comp Affidavit
4. 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
OTE: 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
OTE: 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)
:r Copy of Contract
2012 IECC Energy code
4, Engineering Affidavits for Engineered products
OTE: AIJA-umpster 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
Location i PAS S U C
No. ���' 2 C, + Date l ii3 l t,o
• • TOWN OF NORTH ANDOVER
� Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
.r'
Check# �U 23Y
r t Building Inspector v
f
NORTH
Town of n over
O `' ~Y
No. O _ ( * -t
( h ver, Mass Q 26*
C. K.
cocNic141WICK 1'
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ........ .Zjr- �........ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR
.......... &010 ...... .. .......
has permission to erect buildin son g.� � .1,rk Lj Foundation
p .......... ............ g ... ........ ............�.................
.... ..
• Rough
to be occupied as ............... ....... ..,............................................................... Chimney
provided that the person accepting thi 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
UNLESS CONST N S Rough
Service
.. .. ..... ... ..... .41iN
"' Fina
BUR
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.
Ill 01%1E in tPROVI?iri.FN'I'('UN•rRACT
PLEASE RFAD THIS
Sold.Furnished and Installed hy:
Nnurrh Ynna•:Noir Gligland 1)alr:�Qlt!tiG/. THD At-Hume,Scrvtces,Inc.
ltrant lY,Vuuttn r:�{ d1b/a The Hume Depot At-Home Services
908 Boston Turnpike,Unit 1.Shrewsbury.MA 01545
Toll irrcr tt77-903.3768
Fedeml 11)N 75-209460.MIS Isis X('02439.Rt Cont.1.X31 16427
Cl'1_ic It IlIC 0565522:MA Home improvement Contractor Reg.'11 126893
Instilllutlon Address: N a -Nor __ ����
Cny Stats Zip
Port hncei^1s): _ Work Phone: Home Phone- Cell Phone:
Itonm:.ltdrrw: .,� _ .
tit di(fcirnt front Insilti ion Address) City StatZip
p t
K,040 Address(tit receive proiect communication-,and Home Depot updates): r� �p b �j_�+�_(� n• ,r.
i I.1 V()1'wish itt receive tory marketing cinail.from The lione Dapot "
I'r_ t �_ct tnfortnitlion: IIndersigned("Customer").the owners of the property located it the above installation addre<s,agrees to buy
and t'Ult :U-Uumr ticr�jers.Inc. t"The,• Iforne Depot")agrees to furnish,deliver and arringe for the installation ("Installation")of
lit) mtu.•ti:ds ticscrilkd un file below and On the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
rcicrcuce, alum;oral any applic.rhie State Supplement and paynicnt Summary attached hereto and any Cliange Orders(collectively.
'Cnut mist"l:
,fU11 lt: Quk n+n1 ittrrn—
Produets: Sec Sheet s)#: Project Amount
kuoling Siding, 0 Windows insulation R /1
( A /Covers ❑Entry Door. ❑ /� Z $
l✓_l(;u
/Covers C]Entry poors QCiWindnws 0 Imulativn (�
❑R++++tine []3uiing [rWindows Ej Insulation
0(iuuen/Cover, 01int y Doom 0 $
[jR�u�line- SittiOg Winnows 0 hi tlation
0Guile-/cove r, ❑6itury Doors 0 $
Atininnim�5^;.ik p>.wit nr Conirritti Amami ties upocontract. Total Contract Amount $
ldturn asm Punlre awy nix dcptxit rnrtre than one-third ifthe Contract Amount
Cuctonler agree., that, immedimely upon completion of the work for each Product. Customer will execute a Completion Certificate
tone for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under thin
Coutracf agree,to lx jointly:utd;,everally Obligated and liable hereunder.
Tile I•latnc repot reserves the right to issue a Change Order or icnninate this Contrail or any individual Product(s)included herein,at
its discrcfion.ii•"i'he Hone Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
pruhlem with the home•environmental ha<ards 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.
Pavment Summary: The Payment Summary #_ , included as part of this Contract, sets forth the total
Contract anrrtunt and payments required lir the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
Von nre entitled to a completely filled-lin copy of file 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 evoni 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
anarruitc sct forlb ill this Aga-ccurcnl or:dlortrd under applicable la". 'CHE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO 11'H1; 1101ME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT
IXNICI•IN6 THE 1110111:1)l l'O'C'SOTHER REMEDIES FOR RECOVERY OF SUCH AtNIOUNTS.
:1rce carr' acrd Authorization: Customer agrees and understands tint this Agreement is the entire agreement between Customer
an+ The HOnu Depot with regard to the Products and Installation cervices and supersedes all prior discussions and agreements,either
orad or wrinen. relanng to said Prmiuets avid Installation.This Agreement cannot be asci ned or amended except by a writing signed
by Cumotner and The Home Depot. Cuslomcr acknowledges and agrees that Custon .• •mad.understands. voluntarily accepts the
tennis of and has received a copy of this Agreement.
Accepted - � Su ed ,•
. -
t"asiotiiL 'S JigiruMV Date Salcs Co sul[at I .'izn ore
X Telephone No. 3.21- 6�Z0 �T�ttitn)
C'ustofnt is Signature Date, l'
Sales Consultant license No. _
CANCELLATION: CUSTOMER MAY CANCEL THIS (asvPlicable)
AGREEMENT WiTHOUT PENALTY OR OBLIGATION
BY DFLIVERiNG WRCt"1'FN NOTICE TO THE HOME
Dfsl'OT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AVI'FR SIGNiNC THiS AGRVF;MENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAiNS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER.S STATE.
NOTICH:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
08-03-15 White—Branch File Yellow—Customer
jLIX
The Commonwealt/r ofMassael[usetts
Department oflndustrialAccidenis
tkwi 1 Congress Street,suite 100
Boston,MA 02114-2017
www.massgov/dfa
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
ArnilicantInformaflon. TO BE FILED IVM ME PEMfrrMG AUTHORITY.
Please Print LeLriblv
Name(Business(Orgoaizetion/Individual):
Address:
City/State/Zip; Phone#:
Ar�youaployer?Check the appropriate box:
Type of project(required):
ployerwith r�cmployees(dill and/orpart-time).
2.0 lam a sole proprictoror partnership and have no employees working for mo in �' El New Construction
any capacity.[No w6rkers'comp.insurance required.] 8. ❑Remodeling
3.E]F am a homeowner doing all work myself,(Pio workers'comp.insurance required.]t. 9. ❑Demolition
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I%vitt 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. I i- Electrical repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 12' PI Ing repairs or additions
Theso suh-cont actors have employees and havo workers'comp,insuranco.t 13. oof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. KE]Other
152,$1(4),and we have no employees.(No workers'camp.insurance required.)
;Any applicant that checks box 4 I must also fill out the see tion below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tConlractors 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 subcontractors havo employees,they must provide their workers'comp.policy number.
I am an employer th at Is provlding workerscompensatlon Insurance for my employees Beloty is the policy and Job site
Information.
Insurance Company Name:
Policy ff or Self-ins'.Lic.#:_ _ r �� �
Expiration Date;
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 MGL c. 152,§25A is a criminal violation,punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification'
I do hereby cer y U a the Ins d penalties ofperjury tlrat the lbtfortuatlon provided above!s true and correct.
Si nature:
D te:
Phone fI:
Offlelat use only. Do not wrlte in t/11s area,to be coritpleted 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
ACUREY CERTIFICATE OF LIABILITY INSURANCE r DATE(MMIDD/YYYY)
12124/2016
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(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).
PRODUCER CONTACT
MARSH USA,INC. NAME:
TWO ALLIANCE CENTER PHONE FAX
3560 LENOX ROAD,SUITE 2400 -MAiL Arc No):
ATLANTA,GA 30326 ADDRESS:
SNSURER(S)AFFORUIN6 COVERAGE NA1C#
100492-HomeD•GAW'-1617 INSURER A:Steadfast Insurance Company���� 26387
INSURED THE HOME DEPOT,INC. INSURER B:Zurich American insurance Co 16535
HOME DEPOT U.S.A.,INC. INSURER c:New Hampshire Ins Co 23841
2455 PACES FERRY ROAD,NW
BUILDING G20 INSURER D:Illinois National Insurance Company 23817
ATLANTA,GA 30339 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-003741310-08 REVISION NUMBER:O
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 ADDLISUBRI POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY) (MMIDDIYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY GLO4887714-06 03101r1016 03/0112017 EACH OCCURRENCE S 9,000,000
CLAIMS-MADE OCCUR SDAMAGE TO it.
PREMISES Ea occurrence) $ 1,000,000
LIMITS POLICY MED EXP(Anyone person) S EXCLUDED
`F din. th?CR vCC PERSONAL&ADV INJURY S 9,000,000
LOC
MOTHER:
L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000
POLICY❑PRO- aJECTPRODUCTS-COMP/0P AGG S 9,000,000
S
B AUTOMOBILE LIABILITY BAP 2938863-13 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT S 1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG
AUTOS AUTOS BODILY INJURY(Per accident) S
'HIRED AUTOS NON-OWNED PRO1'FRTY DAb1AGE
AUTOS
a Iden
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLA"MADE AGGREGATE S
DED
RETENTION
C WORKERS COMPENSATION S
WC015519215(AOS) 03/01(2016 Q3/012017 X PER oTH-
C AND EMPLOYERS'LIABILITY STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC015519217(AK,KY,NH,NJ,VT) 03/01/2016 03(0112017
D OFFICER/MEMBER EXCLUDED? a NIA E.L.EACH ACCIDENT S 1,000,000
(Mandatory In N}i} WC01552921.&(FL) G3?01/2{116 031fl1t20i 7 E.L.DISEASE-EA EMPLOYEE S i,000,Ltirii
If yes,describe under
DESCRIPTION OF OPERATIONS below Continued on Addtional Page E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER
IW,OSGOOD ST. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
NORTH ANDOVER,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjeemk; \�
0 1 988-201 4 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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un, Affairs aa
10 Park Plaza - Suitt 170
hs 02116
Bo5tori, Mq5�au -Luseft
Home Improvement: Registration
Registrafion: 126993
J Type: Supplement card
Expiration: 8/312016
THD AT HOME SERVICES, INC.
RICHARD FALLONE !-4
2690 CUMBERLAND PARKWAY
ATLANTA, GA 30339
Update Address and a return card.mark reason for change
Address 1 Renewal [] Employment L Lost Card
'S
f Consumer Affairs&Business R,viation License or registration valid for individul use only w
Uie 0 m
before the expiration date. If found return to:
141E[NIPROVEMENT CONTPAcToR,
Office of Consumer Affairs and Business Reaulation
—0–FRegistration. 10 Park?laza-Suite 5170
Typa:
supplement ca-M Boston.NU 02116
-ID AT HOME SERVid-Q;--6-tl`lJ0:
AE HONG DEPOT ATFOMIR k\iICES
ICHARD FALLONE
390 CUMBERLAND PAR' K'%jcl: 8
GA 30339 Undersecretary Not lid wi out signature