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HomeMy WebLinkAboutMiscellaneous - 1401 GREAT POND ROAD 4/30/2018 (4) I'loP,..& i BUILDING FILE -- L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N®: 7 • f Date Received f Date Issued: —o IMPORTANT:Applicant must com lete all items on this page LOCATION .0 � . �eePrint � PROPERTY OWNER Girl 1 Y1.4 riot � MAP NO:*-e-PARCEL: ZONING DISTRICT: __ Historic District yes n nit Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE El New Building Reside Non- Residential ne family ❑Addition 0 Two or more family 0 Al ration No. of units: 0 Industrial epair, replacement 0 Assessory Bldg 0 Commercial 0 Demolition 0 Other 0 Others ® Seji�Well• � til?- FWetlands ._ ®aTjlood lain Tazer/Sewer c`` �'" =� ❑ Watershed+Di tri 7 _ . s T, � DES CiR�LION OF T - � TOE - r0, i 1 n D: S I� OWNER: Name: ntification ease Type or Print Clearly) . Phone: Address: CONTRACTOR Name: Phone: �Q���r✓�3 Address: Supervisor's Construction License: Date: 9.79 )�. Home Improvement License: i a(, 173 Exp. Date: ARCHITECT/ENGINEER Phone: Address: . Reg. No. FEE SCHEDULE:BOLDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S F. Total Project Cost: $ �� �(� FEE: $ Check No.: NOTE: Persons contracting with unregistered contractors don thane a o Sr'w---; -:— --- -- - - - _ ccess fhegu rantyfund -- - Lz__.gnatur^e S� nature f ontra_ J 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 i' ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Peri Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Confii•aco. ❑ Flo or/Crossection/Elevation Ilan 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 Perm 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 ' L Dimension Number of Stories:__________Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: - ELECTRICAL.: Movement of Deter 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 s � i U Notified for pickup - Date i i Doc:.Building Permit Revised 2008mi — l _'`� r Certified Plot Plan ❑ Stamped Plans ❑ , Plans Submitted El Plans Waived Elf TYPE OF SEWERAGE DISPOSAL Swimming pools Public Sewer ❑ Tanning/Massage/Body Art El Food Packaging/Sales Well El Tobacco Sales Private(septic tank,etc. El Permanent Dumpster on Site I THE FOLLOWING SECTIONS FOR OFFICEFORME ONLY INTERDEPARTMENTAL SIGN i DATE REJECTED DATE APPROVED ❑ i PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comments Conservation Decision: Comments Drive--Permit Water & Sewer Connection/signature&Date DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR'I`IVIENT -Temp Dump ster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location /910/ V V nl No. Date f / �aRT� TOWN OF NORTH ANDOVER O Floww p ^o Certificate of Occupancy $ K ..�__. .. J�cMus`� Building/Frame Permit Fee $ Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ Check # Ca 24548 Building Inspector NORTH Town of _ Andover _ No. Ili- }}(( �, 0 dover, Mass., - 0 - 11 Y o LAKE COCHIC MEWICK ��S RATED AP�,t'C`� BOARD OF HEALTH Food/Kitchen Septic System PERMIT ..T Dh BUILDING INSPECTOR THISCERTIFIES THAT...... ......,..................... ................�.,.................................................................. Foundation has permission to erect........................................ buildings on ......�......... ...... .........��"!C,q' �pv�!!o�........... �...... Rough to be occupied as.... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. PENT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS V LESS CONSTRUCTARTSRough .................. ............................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. IF_sEE REVERSE SIDE Smoke Det. i • - r N '- -rut-al _..fratertion Agocig -� 4latles DrPartment do(Pt f c Ssfet" J r * Baan10(Bo:l4tia�Rer7shties"amStuedard. l 'anstru�ior±Super�+isor Uceasp- fillicaeor:,t4at 9 CS aB756 N `}� f�trSde6 t¢ 00 IG SCOTT A MAC7lbfl.l M 10 P. RK AVE f _�, �'• SALE A.NH 03079 CD Expiration: 3?ZM12 tD �w f'nitmifeiYwta' TrA: 14662 f � �S '�tits B�'�C'�Q ._ - •VO�?�t��UC6[ - Z r'� :• r_.-� OTw of Consumer Af in&B-k—Rtgarlum • t HOME tWRQVFffENTCONTRACiDR . Rag3str+fitvll.. .i58306 Espimt*L.117M12 Tr0 291290 L L ` �• _ 3n � t CONTRACT u ING SCOTT MACMILI-Ax - _ 1 D PARK AVE. SALEPA,NH 03D79 Ua U U This babfPC y is v9W ftbm ft t ifimaimejk& �{* �, Q _«vs•a.ie^K:i7_G':!:'t����:iM•�; aa•rs• a:... 3'�e..•;. '"__ .....� � .� E'�{t < ��ssxv�9LR'jcmrPi�da16�:Qr�7DO.d�My�H[�in ;i. - . -r� P?�im- •:; - .. dpi 2011-08-03 00:01 3484-PHONE CNTR/EXPD 603357317 >> Home Depot AHS P 1/8 fiU.t►7�L'!�l°dif V Y1s:.N!!::'4'1't;()!*1`1'tIA l;!' I'i:;G:ASIP.1dPAI)T"K Sold,Furfvishvd fantt install:d hy: Braneh Natft,- Mstoii .0.ate: THD At-HoiTw•,%rvices;ltic: ,a #ilktla i he I{ante amu.�#t-t:Iiatue.Sc t vices.' .345A(irecnw<xsd Straot,Ili*2.Worcester,MA:1).16()7 'J-arJ'1}'ri;t;Ill4i(}}$575.182.;Etta f:5(}8) Bmttch.Number,31. 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Cusko#tar's}ice aaturz Jute i Shit:,¢Qmsultant.License Na. A1 14 CANCELLATION: CUSTOMER MAY CANCEL THIS f {sap;�icaHic) --- AGREFtiIE+T WIT PV-NAI,TSr CTR OBLIGATION,] BV I)I?IJAW11ING 14WI-I"t?>ti N(MCF.To THE IIC)_?kIE DF.Y(71' " I�TU)IV'GGT ON THE THIRD BUS MI MS ! DAY AVrKR-SIGNING TIUS AGRIMMON'T. THE STATE KPPLEIY ENT Art'A{C14YA) HERETO t f'(T YT'A.INS A FORM TO USE IF ONE IS j MCIFICALLY PRE.SCREM) NY LAW LN j CUSTOMER'S STA`T'E. \OTIM ADDITIO:\Ai.'1."MMS Anka LY,t;wFMVIOM ARE STATF_D m THE RFVER.0•:S)U.E AND ARE:'.PARTt)t THIS C'()NTAA4r1' tt^$t^it}r'rSC untllaa-Rranaah t�P Y92iKrw-(:usStutter. . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations P, . ,, 600 Washington Street lk' r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): + � � _ Address: City/Sta /Zip:_ C---4Ar of hone <3co (�?�Z7 Are y an employer? Check the appropriate box: Type of project(required): 1. I am a employer with e1ZD 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp. insurance comp. insurance.: 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.[:] Roo epairs insurance required.] t C. 152, §1(4),and we have no employees. [No workers' 13. ther IA) I n JOIA74 comp. insurance required.] *Any applicant that checks box 41 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. tContractors 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: C' NY741 I C Policy#or Self-ins. Lic.#: ] t5a A Expiration Date: 1 A _ Job Site Address: `7Ti-Voi WCity/State/Zip: � &IX I 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 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 tip 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 insurance coverage verification. I do hereby certify under t e ains nd nalties of perjury that the information provided above is true and correct. Si nature: 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#: /,... 3 ' 5a O ATT-,(MM?2011_ 9 v 02/211 A s h CERTIFICATE of LIAR � T I `U NCE D CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TH15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AN CERTIFICATE DOES NOT AFFIRMATIVELY INSURANCE OE GOES NOTLCO ST UTEY AMEND, �A CONTRACT BETWEEN TEND OR ALTER THE OTHE ISSUING NSURER(S),rAUTHORIZED BELOW. THIS CERTIFICATE REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate the certain Opa icOiesAmaySegREO an endorstie ement A statement o endorsed. certificate do0es not YconferDights)to the the terms and condition policy, uir certificate holder in lieu of such endorsement(s). LF CT - •- 1-404-995-3000 "FAX-------� - PRODUCER Marsh USA, Inc. p, x4) _ —SB'&�hcmedepot.certrequest@marsh.comTwo Alliance Center, 3560 Lenox Road, Suite 2400INSURERS AFFOROING- J•�----- 2638T Atlanta,-GA 30326 ERA: Steadfast Ins Co —__ _,_Fax (212) 948-0902 -- Zurich American Ins o16535ER a: 23841 wsuRED New Hampshire Ins Co-'^�-�—�•__"`•- _The Home Depot, Inc. ERC: 23817 Home'-Depot V.S.A., Inc. ER o: IllinoisNatl _Ins Ca__ _�—_2455 Paces Ferry Road NW NATIONAL UNION FIRE INS CO OF PITTS19445BuLlding C-20 RERE__ 27960 Atlanta, GA 30339 RERF: Illinois Union Ins Cc COVERAGES DO CERTIFICATE NUMBER: KBOVE FOR 14834682 REVISION NUMBER: NSURED NAMED THIS IS TO CER WITHSTANDING ANY ICI S OF INSURANCE LISTED -MOR CONDITION TION OF ANY CONTRACT OR OTHE ITHER DOCUMENT WITH RESPECT TOLWHICH ICY ITHOIS INDICATED. CERTIFICATEONS AND CONDITIONS OR OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.SCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUS _ _ "' - POLICY EFF PO.UCY EXP LIMITS _ AOUL SUBR POLICY NUMBER MMIODIYYY MMIDOIYYY INSR TYPE OF INSURANCE 03/01/12 9,000,000 --.. LTR ' GL04887714-01 03/01/1' EACH S A GENERAL LIABILITY I�AMAG�O N 0 S 1,000,000 PREMISES fEa occurren ,- _ X COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) S EXCLUDED _-- Ct AIMS-MAOE X1 OCCUR PERSONAL 8 ADV INJURY $9,000,000 X LIMITS OF POLICYyXS9,000,000 -- GENERAL AGGREGATE S _ X OF SIR: $1M PER OCC PRODUCTS-COMPIOPAGG S 9.000,000._- — GEN'L AGGREGATE LIMIT APPLIES PER: S X POLICY PRO. LOC 03 01 03 01 12 COMBINED SINGLE LIMIT 1,000,000 HAP 293BB63-08 E a i ret -•-•---- H AUTOMOBILE LIABILITY BODILY INJURY(Per person) X ANY AUTO BODILY INJURY(Per axi an ALL OWNED SCHEDULED PROPERTY DAMAGE S AUTOS AUTOS P r cid n ---••- NON-OWNED S HIRED AUTOS AUTOS X SIR AUTO P Y _ _.._._._... EACH OCCURRENCE S UMBRELLALIAB OCCUR AGGREGATE __^—_ s -------• EXCESS LIAR CLAIMS•tuIAOE S OEO I RETENTIONS Q;/01/12 X WCSTATU• 0TH* C WORK ERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 E.I.EACH ACCIDENT $1,000,000 AND MPLOYERS'LIABILRYWC061967354 (FL) 03/01/1 D ANY PROPRIETOWPARTNERIEXECU7IVE Y❑ NIA 03/01/12 E.L.DISEASE-EAEMPLOYE S I,000,OOQ E (MandatoryMEMBE EXCLUOE07 N r WCO61967353 (CA) 03/01/1 E.L.DISEASE-POLICY LIMIT S 1.000,000 II yes.describe under OESCRIPTIINOFOPERATIONS below {�C061967355(KY,MO,NY,WI. )D3 01/1 03/01/12 C workers Compensation TNSC462441SI (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/iM F TX Employers XS Indemnity I) 03/01/1 03/01/12 SIA 1M E Workers Compensation WC1192378 (QS DESCRIPTION OF OPEftATI0N5I LOCATIONS I VEHICLES(Attach ACORO 101,Additional Remarks Schedule,if mors space is required) RE: EVIDENCE OF COVERAGE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN THE HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD NW ' AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA l - ©1988.2010 ACORD CORPORATION. All rights reserved. ArORD 25(2010/05) e The ACORD name and logo are registered marks of ACORD SCl�(N,Pr��;;�t: C�C:E US�GGf V,t ,,na�idc:sr �r 10 . 32. . . 1. . [)MOt4ALPER.FJORWCE RATINGS •. . 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Expintso�+._8WQ12 (iorrie Po 'Adt; �s i RICHARD'FALLCINE , 2690 CUMBERLAND,PARK\NAY S