HomeMy WebLinkAboutMiscellaneous - 250 BEAR HILL ROAD 4/30/2018N
Location a��o 6-e r`i L ��-k
No. Date "" -
. r
NORTH
TOWN OF NORTH ANDOVER
Certificate Occupancy
of $
�,SSACHUS t�
Building/Frame Permit Fee $ 'r
Foundation Permit Fee $
Other Permit Fee $
$
(TOTAL
Check #
19945
Building Inspector
Permit NO:
Date Issued: �7'd
TOWN OF NORTH ANDOVER
NORTF/
APPLICATION FOR PLAN EXAMINATION ot,.�•o
. c
Date Received
IMPORTANT: Applicant must complete all items on this nap -e I
LOCATION
Pri t
PROPERTY OWNER ��..��a►SZ.,ar-
Print
MAP NO.: 6 L=� PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES 0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
9 Alteration
,9 One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving relocation
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address: mac. r•�. e Q�1 - (v�`l �j�2
CONTRACTOR Name: )A-C2-r%JP Phone:
l
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: 1,,, is Exp. Date: F5 — 3 " a
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERM 12 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S, F.
Total Project Cost :$ 2, Lf U � FEE:$ 50
Check No.: N La (-95 5 Receipt No.:
Page I of 4
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM09
Page 4 of 4
TYPE OF SEWERAGE DISPOSAL
Art ❑
Swimming Pools 11F]Tanning/Massage/Body
g
Public Sewer
Well F1Tobacco
Sales ElFood
Packaging/Sales=,, ❑
❑
Permanent Dumpster on Site 11
,
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Signature of contractor
.qzCz::1A
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE REJECTED
11
Q
DATE APPROVED
DATE APPROVED
Q
DATE REJECTED DATE APPROVED
FIFE DEPARTMENT - Temp Dumpster on site
Fire Department signature/date
COMMENTS
El
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Re uired Provided Require Provides Required Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
l'Nv i nn ana Lw ra — (Vor department use
Page
Created JMC. Jan.2006
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a 600 Washington Street
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: LA � �� 12 OLOW8
City/State/Zip: `Xp 0VU4,42-r' Phone #:
Are you an employer? Check the appropriate box:
1. [X I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
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.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Lj 1 n� ,
Policy # or Self -ins. Lic. #: �p L d O( `-1 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 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 insurance coverage verification.
Ido hereby certify under thepains andpenalties ofperjuty that the information provided above is true and correct.
Signature: �� Qel±� Date:
— c--) 1 qt't — _'77
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 #:
21
J,,
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its -political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used na-a-reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled.out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to completethis affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.govldia
MARSH , CERTIF.ICATS Of INSURANCE ' CER„FICATENUMBER
ATL-000915907-11
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA, INC,
NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
ATTN: BRENDA BOOKER (404)995-2594
POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
MAYA MCCLURE(404)995-3206 OR -
AFFORDED BY THE POLICIES DESCRIBED HEREIN.
TAMI ROUSE (404)995-3430 FAX (404)760-5663
3475 PIEDMONT ROAD, SUITE 1200
COMPANIES AFFORDING COVERAGE
ATLANTA, GA 30305
COMPANY
100492-IPUSA-GWA-03/04
A STEADFAST INSURANCE COMPANY
INSURED
COMPANY
THD AT- HOME SERVICES INC.
B ZURICH AMERICAN INSURANCE COMPANY
DBA THE HOME DEPOTAT- HOME SERVICES. INC.
COMPANY
HOME DEPOT USA, INC.
2455 PACES FERRY ROAD NW
C NEW HAMPSHIRE INS_ COMPANY
BUILDING C-8
COMPANY
ATLANTA, GA 30339
D AMERICAN HOME ASSURANCE COMPANY
COVERAGES,, ";:: This certcate supersedes and replaces
any previously issued' certificate for the policy period noted below: 3
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE
BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE(MMIDDIYY)
POLICY EXPIRATION
DATE(MMIDD/YY)
LIMITS
A
GENERAL
LIABILITY
IPR 3757608-01
03/01/06
03/01/07
GENERAL AGGREGATE $ 4,000,000
X
COMMERCIAL GENERAL LIABILITY
'LIM ITS OF POLICY ARE EXCESS'
PRODUCTS -COMPIOPAGG $ 4,000,000
CLAIMS MADE � OCCUR
'OF SIR: $1,000,000 PER OCC'
PERSONAL &ADV INJURY $ 4,000,000
EACH OCCURRENCE $ 4,000,000
OWNER'S & CONTRACTOR'S PROT
s
FIREDAMAGE(An oneflre) $ 1,000,000
MED EXP (Any oneperson) $ EXCLUDED
B
AUTOMOBILE LIABILITY
BAP 2938863-03 AOS
03/01/06
03/01/07
COMBINED SINGLE LIMIT $ 1,000,000
X ANY AUTO
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
(Per accident)
HIRED AUTOS
NON-OWNED AUTOS
PROPERTY DAMAGE $
X ELF-INSURED AUTO
HYSICAL DAMAGE
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT $
OTHER THAN AUTO ONLY: -
ANYAUTO
EACH ACCIDENT $
'
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
AGGREGATE $
UMBRELLA FORM
$
OTHER T14AN UMBRELLA FORM
G
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
6610998 ( AZ, ID, MD, VA )
03101106
03101/07
C STA OT ..
X TORY LIMITS ER
EL EACH ACCIDENT $ 1,000,000
C
6610995 (AOS)
03/01/06
03101/07
EL DISEASE-POLICY LIMIT $ 1.000.000
G
E
THE PROPRIETOR/ X INCL
PARTNERS/EXECUTIVE
AREC�E EXCL
6611326 (OR)
6610999 (NY,WR
03/01/06
03/01/06
03/01107
03/01/07
EL DISEASE-EACH EMPLOYEE $ 1,000,000
OMOF—W—ORKERS
E
COMPENSATION CONTINUED
6610997 (FL)
03/01/06
03/01/07
D
16610996 (CA)
03/01/06
03/01/07
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
CERTIFICATE HOLDER
CANCELLATION,
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAL q0. DAYS WRITTEN NOTICE TO THE
FOR INSURANCE PURPOSES ONLY
CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE
ISSUER OF THIS CERTIFICATE.
ARSH USA INC.
BY: Walter Gilstrap B M%
MM7(3/02) VALID AS OF: 02/27/06
Installed
Siding and Windows
.,a :'�lAr �o.�i�u .sur,..=rz1li {f:", llctn..rrrrzri�n v
\ Board or Building Regulations and Standards
I51
'' HOME IMPROVEMENT CONTRACTOR
i r Registration: 126893
Expiration: 8/3/2008
Type: Supplement Card
THE Home Depot At -Home Servic
9UNROEUN CHHOUY
3200 COBB GALLERIA PKWY #20��
AtIANTA, GA 30339
Administrator
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rin 1301
Boston, Ma. 02108
Not valid without signature
Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor.
345 Greenwood St. Unit 2 • Worcester, MA 01607 • 508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182
JAN -19-2007 12:04PM FROWHME DEPOT
+9T9 -T62-4313 T-995 P-006/006 F-509
HOME IMPROVEMENT CONTRACT
Sold, Furnished and installed by:
Branch Name Date: �� TIED At -Home Services, Inc -
d/b/a The Horne Depot At -Home Services
r� 345A Greenwood Street, [Worcester, MA 01607
Branch Number: _ P/!/ dub # Toil Free (800) 657-5182; Fax: 508-756-2859
Federal ID # 75-2698460 ME Lic # C 02439 R1 Cont tic# 16427
cr [ie # 565522: MA Home Impmvement Conuactor Reg. #126893
Installation Address:
City State
purchase a Last 4 D 'b nfDriveei Lie. # & Mwyr. Work Rome Phu C.
-.5'737,F 7)
z c ) c )
Home Address:
(Ifdiffmcnt from Installation Address) City state Zip
E-mail Address (m receive updates and promotions from The Home Depot):
Pr 'set 1 ' I/W9/You ("Purchased'), the owners of the property located at the above installation address, offer to
contract wr�epot U.K., Inc. (-Home Depon to &Imish, deliver and arrange for the installation of all materials as
described on the attached Spix Sheet # , incorporated herein by reference and made a part hereof,
Home Depot reserves the right to cancel this contract IL upon re -inspection of the job, Home Depot determines that it
cannot perform its obligations due to a structural problem with the home, pricing errors or because work required to
complete the job was not included in the Spec Sheet or Contract.
CONTRACT AMOUNT spy
*LESS DEPOSIT $ �! ,
BALANCE DUE
ON COMPLETION $1339
*Mittimumm 25% of Contract Amount due upon
clemdon of this contract'.
Indicate Payment Method For
BALANCE DUE ON COMPLETION":
1 -,-, -_wvv+ ( 04CA-
"May he subject to Credit Approval, Ximd
Verification and/or Credit Card Authariution
DEPOSIT PAYMENT OPTIONS
(Subject to rtmd variticatiun andNa credit approval.)
1- Check, Cashiers Cheek or US Postal Service Money order
Oda& payable to The dour depot).
2. Credit Card• and/or other payment op"Is - Ciede Our Below
Viso MnmarCard Discover American h"tprr m
The tiaute Dep« Hoar Itnprovetncat Load The Route Depot Cnxlll Card
0 New Account O ftktiag Account (HIL d OWC ONLY)
MAW* Credt'r. S GILL & HDCC ONLY)
Aoa#_ f Exp. Darr.
Nam"it appears an card:
*By my/our signature below, T/We agree to allow Hioate Depot to
charge the above relkreaced credit card for The deposit indicated.
Cunlholdces SiDare
M. or HDCCotization Codes
Dc sit
F"mal P t
#
#j
Purchaser agrees that immediately upon completion of the work, Ptuchascr will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder_
Entire Ae ment This agreement and its aUachments, including any financing agreement, contain the complete agreement
between the parties and can not be amended or modified unless in writing in a separate agreement signed by both
parties
NOTICE TO PURCuASltR
Do not sign this contract before you read it You are entided to a completely filled-in copy of the coutract at the time
you sign. Keep it to protect your -rights. Ito not sign a Completion Certificate before this project is complete. Law
prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to
the actual completion of the work to be performed under the contract.
You may caned this transaction any time prior to midmglit of the third business day after the date of this contract. See
Notice of Cancellation for an explanation of this right There will be a service charge equal to 10% of the contract
amount if job is cancelled by Purchaser AFTER the third business day, but BEFORE materials are ordered. There Will
be a service charge equal to 25% of the contract amount if job is cancelled by Purchaser AFTER materials are ordered.
BY MY/OUR SIGNATURE BELOW, T/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE
OF CANCELLATION -
By MY/OUR SIGNATURE BELOW, VWE UNDERSTAND THAT THE AGREEMENT 1S SUBJECT TO REVIEW OF
MY/OUR CREDIT HISTORY AND 7/WE AUTHORIZE HOME DEPOT TO VAWy AND RL. VIEW MY/OUR CREDIT
RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY
INCURRED FROM INAD OMIS ONS ]IItRO
SUBMITTED BY- Date 6 7_
' n r
ACCEPTED BY: Date: �_
Hum
Date-
klomeowncr
NOTICE: ADDITIONAL. TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE
AND ARE PART OF THIS CONTRACT
10.24-M GSC Whlte-.BrdnchRhe Yabow-Customer P1nk-Seim Consultant
I TLOM I I � �_
Form of Notice of (ngtrnity Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 313
TOt Building Contmigsfoner or hoard of Ilealth or
Ltspector of Buildings Board of Selectmen
Town of N. Andover__) ( Town of N. Andover
addresses
N. Andover, MA 01845 ) ( N. Andover, MA 01845
REt Insured, Heinz & Marget Kage,rer
Property address: e250 Bear Hill Road,
N. Andover, MA 01845
Policy No. HP 1548691
Loss of April 13, 19 93
File or Claim No. WAP 16255 (wind)
Claim has been made involving log-;. ,lnn►nge or destruction of the above-enptioned
property, a hielt cony either exceed 411.1000.011 or enngo MASS. GEN. LAWS, CIIAPTER 143,
SECTION 6, to be applicable. It any notice ander MASS. GEN. LAWS, CII. 189, SEC. 3B
is appropriate please direct it to the attention of the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or file number.
Adjuster
litlet
On this date, I caused copies of this notice to be sent to the persons named above
at the addresses indicated above by first clnse mail.
PATRICK J. DONOVAN ASSOCIATES, INC.
P. 0. BOX 110 -.l! 6/14/93
WAKEFIELD, MA 01880 �'1—'� -
Stgnnture and date
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