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Home My WebLink AboutBuilding Permit #644-12 - 99 MARIAN DRIVE 3/7/2012TOWN OF NORTH ANDOVER 12, APPLICATION FOR PLAN EXAMINATION Permit NO: , Date Received Date Issue k - IMPORTANT: Applicant must complete all items on this page _FKUFEKYY OWNER Unit # Print MAP NO: PARCEL:/ZONING DISTRICT: Historic District Machine Shop Village 100 year-old structure TYPE OF IMPROVEMENT PROP D USE Resi ntial Non- Residential ❑ New Building One family ❑ Ad tion ❑ Two or more family ❑ Industrial ❑ Afteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �u PSeptic Well ®F oodplam W Hands Watershestnc;.l dilater/Se 'verb - ._. - •• 3 I_�J�t►`I�1NI�iIM\ Lei awAynlNCr[IJ :1M■9a:»r0 .9701�j�� (rd n#ifcatio le pe or Print Clearly) OWNER: Name: I I maw, /� n11-- rvc pvro /I Address CONTRACTC Address: Supervisor's Construction License: (�3s Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ 05D FEE: $_ (meq _r_ Check No.: e?7 6J,027 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have i Ir 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 ❑ 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/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) ❑ 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: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Tanning/MassageBody Art ❑ 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 COMME CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED 0 DATE APPROVED A Reviewed on Si-qnature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street yes no 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.$10041000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Location qi Dat TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # 3--� og:�- 25,078 Building Inspector BOB DANGELO 9785157765 p.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS l ;?/w::-- � 6 Sold, Furnished and Installed by: Branch Name: Boston Date: !C1 .77, 2012 .4THD At -Home Services, Inc. ---� / d/b/a The Home Depot At -Home Services 345A Greenwood Street, Unit 2, Worcester, MA 01607 Toll Free (800) 657-5182; Fax (S(18) 756-8623 Branch Number: 31 Federal ID # 75-2698460; ME Lie # C 02439; Rt Cont. Lica# 1,6427 CT Lie # HIC.0565522; MA Home Improvement Cun Tactor Reg. # 126593 installation Address- &Aiyt pr AM o/.RYT . City State Zip PurrhaswrfcL- W ork Phone: Home Phone: Cell Phone: CtJ 1 I`!d ?I C115 Horne Address: (If different from Installation Address) City E-mail Address (to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing entaiIs from The Horne Depot State Zip Pro'ect Information: Undersigned ("Customer'). the owners of the property located at the above installation address, agrceN Io buy, and TUD At -Home Service%, Inc. ("The horse 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 or 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"): Job #I: ttnu-mar Rrrmwn Products: Rnrr Rhnntrcl !t- nr..:....a a Customer agrees that, immediately upon completion or the work for each Product, Customer will exectue a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer und& this Contract agrees to he 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 1'r0duct(s) included hef4,31, al its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obli.:atious due to it structural problem with the home, environmental hazards such as moll, asbcslos or lead paint, other sately coucorns, pricing errors or because work required to complete the job was not included in 1he Contract. Payment Summarv: The Payment Summary.# S-77 7c>7 incia(Icd as part or this Contract, ,cls forth the total Contract amount and payments required Tor the deposits and final payments by Product (as appli4ahlc). 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 »•ork on that Product is complete. In the event of termination of this Contract, Customer agrees to )ray The Thome Depot the costs or materials, labor, expenses and services provided by The Home Depot or AuINwized Service Provider through the elate of tern irnation, phis any other amounts set forth in this Agreement or allowed under applicable fait. THEE R+ilh• E' IDEPI)T iiAV WIT! II10r.i1, AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR ilT' hR PAYMENTS MADE', WITHOUT LR7ITING THE HOME DEPOT'S OTHER REM VDI N;S FOR RECOVERY OF SUCH AN-10iI N'I'S. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreemeni 110wON11 Customer and The [-ionic Depot with regard to the Products and Installation services and supersedes all prior disCussion, rind azrecmerzts_ either oral or written, refitting to said Pro tlucts and Installation. This Agrevntint cannot he a;;i-ned or amended C Cept h; a +.citing Signed by Customer and The Horne Depot. Customeracknowledges and agrees that Customer has read. undersiands. voluntarily accepts the terms orand has receive([ a copy of this Agreement. Accepted by: }( /V'� "l ❑Rooting ❑Siding Window% ❑ Insulation ❑Gutters / Covers ❑Entry Dcors Q y_ �1 4 ��D p d { 3 $ U ❑Rooi'iog ❑Siding ❑ Windows ❑insulation - Da C []Gutters / Covers ❑Entry Doors ❑_ ❑Roofing []Siding ❑ Windows ❑ Insutation ❑Gutters / Covers []Entry Doors El $ ❑Rcofina []Siding ❑ UVindows ❑ Insulation - - ❑Gutters / Covers C]Eutry Doors E1_._ Minimum L1;% Deposit of C retrad Anwunt due ups extortion of this contract Maine Purchasers deposit Total Contract Amount $ s— 7 �� Mary nut more than one-third of the Contract Amount Customer agrees that, immediately upon completion or the work for each Product, Customer will exectue a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer und& this Contract agrees to he 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 1'r0duct(s) included hef4,31, al its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obli.:atious due to it structural problem with the home, environmental hazards such as moll, asbcslos or lead paint, other sately coucorns, pricing errors or because work required to complete the job was not included in 1he Contract. Payment Summarv: The Payment Summary.# S-77 7c>7 incia(Icd as part or this Contract, ,cls forth the total Contract amount and payments required Tor the deposits and final payments by Product (as appli4ahlc). 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 »•ork on that Product is complete. In the event of termination of this Contract, Customer agrees to )ray The Thome Depot the costs or materials, labor, expenses and services provided by The Home Depot or AuINwized Service Provider through the elate of tern irnation, phis any other amounts set forth in this Agreement or allowed under applicable fait. THEE R+ilh• E' IDEPI)T iiAV WIT! II10r.i1, AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR ilT' hR PAYMENTS MADE', WITHOUT LR7ITING THE HOME DEPOT'S OTHER REM VDI N;S FOR RECOVERY OF SUCH AN-10iI N'I'S. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreemeni 110wON11 Customer and The [-ionic Depot with regard to the Products and Installation services and supersedes all prior disCussion, rind azrecmerzts_ either oral or written, refitting to said Pro tlucts and Installation. This Agrevntint cannot he a;;i-ned or amended C Cept h; a +.citing Signed by Customer and The Horne Depot. Customeracknowledges and agrees that Customer has read. undersiands. voluntarily accepts the terms orand has receive([ a copy of this Agreement. Accepted by: }( /V'� "l Submitted by: .ry -{ r.0 U Custom _ I*.er's -tore Date Salts Consultant's Signature Da C X I "f <-irnhnnr Nn of' Public Safi.'t.% I; Bo-ird of Bull(firw laflons mid !stalldarlls License: CS 29328 RICHARD L KEYES 11 16 LAWRENCE RD SALEM, NH 03079 p 9/11/2013 3870 The Commonwealth ofMassachusetts Department of Industrial Accidents litOffice of Investigations 600 Washington Street Boston, bass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual) : City/State/Zip:i �� Phone#: f Are y an employer? Check the appropriate box: 4. ❑ I am a general contractor and I 1. Cam an employer with employees (full and/or part time).* have hired the sub -contractors 2. ❑ 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 required] comp. insurance. # 5.0 We, are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm 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 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ;R/� 13.Other *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation poficy information. j Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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, the must provide their workers' eom olicy number. I am an employer that is providing workers' co enation insurance for my employees. Below is the policy and job site information. ' Insurance Company Name: Policy # or Self -ins. Lic. Job Site Address: Expiration Date: 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage v ation. I do herby Print Name: Off tial use only City or Town: penalties of perjury that the i Phone #: above is true and correct. Do not write in this area to be completed by city or town official Permitllicense #: Issuing Authority (circle one): 1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #• Contact person: -.0 } XPMCI-�'r' S _� tel• �` NFRC �....__ .._'- a • `Natlonal �enestratian ,: s:. is �:°: i:.:, •:. ..: s:. s ......,,. _ -_..r ._ Radng CounciTI l® ENERGY PERF EVALUACION OE E ��I�Errto��R�CO��S ' R U-Factor Solar Heat Gain Coefficient Coeliiclente:Ganancia de Energia Solar Factoru .-•^tusn•vt po%erdcasn �' • ' �DAIiIONAL PERP®RMANcE RAI INNS EVALUACION SUpLEMENTAPIA DE RENDIMIENTO ! y e Visible Transmittance Tra smrs '0 i n de luzwi • n j.ble 44 whole appocable s uct pedQrM=e-NFRC Manulacturer stipulates Ihatthes s conn nh to conditions a FRCtacosPecproduct s ie.NF C duenotaecommend any product I ratlngs are determined for a Axe set at and does not wanant the suttabARy or any product for rl as1101n use- C4fls°uQtmanufacturers rterature tar. other product peri°rtnance Este rabdcante estipula qua estas wares cumplen con los pf0(un Glentcs n unto fqo dapilcae co di • es de fn 9pamb enara ttales y un %amara de produeto erminar el rendiffll!Oft total !' dos a l - son detertnlna p ConsuRe can el as par NFAC use a eciltca ducto.las vatares used p sea adecuado para un sP .. pro no anti?, que et producto coo gar un Y especAtco.NFRC no ncomienblato p►odu . bpelo del fabdcante para el use aproplado de este produda.veun�enhearg _ • 'ay mor EN�t. , •�� uatiLt • • rn4ricalst: NurtheYa. North �,�.O:��r� 4atrsl, 5•erth Con rs+t, g^srhe•a' .'r�r...•�, . f.te unidarl r.�rl.ifira it'll;: 29 ' e $ 4:•a STAR; l +� Hueey C2nLcdi, Sur Cantca., 1/S•• pru5olar15-;.CcS , . Watesd aiza: "u • r• j- "2 110,Z3^v: R�unr:o JGlVirr>.� 3.13 ncu/ S Z • 9 Pcobado: .ZLI.9 m X ZU� DP .•+7y—J t1 Taato cnt ., .. rrto'� x W 1 Y.9 A—, 97, � " APp:icaulea 3eas� Stan•;e�disl: AN:;SJAAXAjN �1�•21A4�J-OS,& !LL 5Z,4AjCSA&01/,;- .. A;•uiwacu.'csa�ailx.s.�taa�o-oa. AC"R" CERTIFICATE F LIABILITY INSURANCE �/,ox/27/zaaz DATE27/2IY2 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 1-866-966-4664 Marsh USA Inc. CONTACT NAME: PHONE FAX No Ext : A/C No A DRIESS: homedepot.certrequest@marsh.com Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURERS AFFORDING COVERAGE MAIC# INSURER A: Steadfast Ins Co 26387 Fax (212) 948-0902 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. INSURERC: New Hampshire Ins Co 23841 INSURERD:Illinois Natl Ins Co 23817 2455 Paces Ferry Road NW INSURERE: NATIONAL UNION FIRE INS CO OF PITTS 19445 Building C-20 Atlanta, GA 30339 INSURER F: Illinois Union Ins Co 27960 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. INSR LTRimalm TYPE OF INSURANCE SBR POLICY NUMBER MM/DDY EFF MM,DOY EXP LIMITS A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE TO 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES EaENTED occurrence$ MED EXP (Any one person) $ EXCLUDED CLAIMS -MADE OCCUR PERSONAL BADV INJURY $ 910001000 X LIMITS OF POLICY XS % OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OPAGG $ 9.000,000 $ X POLICY PRO- JECT LOC B AUTOMOBILE LIABILITY BAP 2938863-09 03/01/13 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS $ X SELF INSURED PHY DMG UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ C WORKERS COMPENSATION WC019736915 (AOS) 03/01/1 03/01/13 WCSTATU- RI LIMIOH- ETR X I D EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE YIN WC019736917 (FL) 03/01/1 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 E OFFICER/MEMBEREXCLUDED? (Mandatory in NN) NIA NCO19736916 (CA) 03/01/1 03/01/13 E.L. DISEASE - EA EMPLOYE $ 11000,000 ,000, 000 E.L. DISEASE - POLICY LIMIT $ 1,000 ' If yes, describe under DESCRIPTION OF OPERATIONS below I E Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/7501000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers BS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is requbed) RE: EVIDENCE OF COVERAGE w SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA ACORD 25 (2010/05) Jthornton_hd 25776028 to Iutla-LUTV AL.VKLJ 1;,VKrVKA1Ivil. hu nynw /cool vau. The ACORD name and logo are registered marks'gf ACORD