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Home My WebLink AboutBuilding Permit # 3/9/2016 11 BUILDING PERMIT 0 TOWN OF NORTH ANDOVER ° � APPLICATION FOR PLAN EXAMINATION - h Permit NO.9v Date Received °4 a;-'<• Date Issued: 421, "lu i %� �9SS�crau5�`��y IMPORTANT: Applicant must complete all items on this page LO. A�`I1; .. Print,„ 'a?RQPERTYOWNEI 'ri t,- MAP NOS PARCEL` ZQNING DISTRICT Historic District yes no ;MC chineZhop,,,J age, yes, no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family Addition ❑ Two or more family ❑ Industrial ❑ pderation No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ElsepticoWell ` ; ❑ Flaidp(ain Wetlands ❑ Watershed District ❑V�Xater/Seaver 4 Identification Please Type or Print Clearly) OWNER: Name: ' " Phone: a A Address: to GONTRACI`OR Name Pb` �- Address: Supervisor's Construction;lac, nse U Exp „ Date t Hpme Imiprovement Lices Exp ;Date f 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: $ FEE: $ Check No.: Receipt No.: t 0 NOTE: Persons contracting with unregistered contractors do not hss t the guaranty fund Signature of Agent/Owner Signature �>4 co �`" v � Town of Andover ® _ h VAI' Mass o L„K� coc"Ic Ml Wlcx 11' .................................P RATED PE`��,cGj U. BOARD OF HEALTH Food/Kitchen ! IT T D Septic System THIS CERTIFIES THATS. BUILDING INSPECTOR has permission to erect .... ��(� .t ................ ..... .. ..... Foundation ........o................. bul dings on .... ..... ....... ........ .... 1 Rough am to be occupied as ............ .1... . ................ .....®............................................................................. Chimney provided that the person accep ' g this 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 Regulkfons Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR . UNLESS l AR Rough Service ..................... .... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy�uildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall ToBe Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Feb 20 16 10: 04p Rick Odonnell 6033780151 p. l Sold.Furnished and Installed by: Branch Name: Now H neland Date: "fHb At-Hume Services,Inc. (1!h1a The I Ionic Depot At-Hone Service% Branch Number:31 908 Boscott Turnpike, Emit 1,Shrewsbury,MA 01545 Tull Free 877-903-3768 Federal [D#75-M98460-.htk Lic#CO2439;RI Cont.I.ic# 1027 CT Lie#HIC.(1565522;MA Home Imprurernent Contractor Reg,# 126893 Installation Address: `- 9 �t�7(1'llr`i' A /y (ri1�0yCr _ /f . City State Zip Purcha%er(s): Work Phone: Monte!'hone: Cell Phone_ _�-- (9590-03 K Home Address: — State 7_tp (ll'different from Installation Address) City E-mall Address(to receive project communications and Horne Depot updates): ❑ I DO NOT wish to receive any marketing emails Irani The Home Depot Proiect Information: Undersigned("Customer"),the owners of the property located:t 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 tx o�+ and on the referenced Spec Sheel(s), all of which :uc utcorprnat�d into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): �rt%M - Cpr od ct Job#; nm<rna1R<r<rm«� Products: 5 ec 8h #•eoa(s1 5. PrUJII't Amo'tnt Bowling iding Windows Insulation r r j I.3o 2 Roo 90-3 /0�z ❑Gutters/Covers ❑Entry Doors El (� Q Roofing Siding Windows Insulation 5 �� ❑Gutters/Covers ❑Fntry Doors ❑ Roofing Siding Windows Insulation $ ❑Gutters/Covers ❑Entry Doors❑ —___J11_Roo1flngSiding Windows Insulation $ 1 ❑Gutters/Covers ❑Entry Doors ❑ Imolmum 25%Deposit of Contract Amount due upon exeartion of this contract• Total Contract Amount $ g( Q Maim Pumhawrs may not deposit more than one-third of the ContractAmount, Customer agrees that, immediately upon completion of the work for each Product. Customer will execute :t Completion Certificate (one for each Product as defined by an individual Spec Slice() 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 such as mold,asbestos or lead paint, other safety concerns, pricing errors or because problem with the home, environmental hazards work required to complete the job was not included in the Contract. Payment Summary' The Payment Summary # included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final 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 nit that Product is complete. Iasi 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 throughthe date of termination,plus any other amounts set forth in this Agreement or allowed under applicable lass. THD?HOME DEPOT MAY WITHHOLD AMOUNTS OWED Tp THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY Or SUCH AMOUNTS, mer Acce tante and pooAuthorization:w egard to the Prodmer ucts and Instalees and a tions sererstandsvices hat and uhis persedes all eement is tile priorentire d discussionsent and agreemc atweell greements.either and The Home p 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 tetras of and has received a copy of this Agreement. Accepted douo/161:1 ed Submitted by: p d"-ti 1:10PM FST X ��_!57 il(1lYl.!/ GP7M11-SQll-HW87-SQGC }� d _- O' Sales Consultant's Sianature Date Customer's Signature ate Telephone No._ � — y7�V y -fl X Date Customer's Signature Sales Consultant License No. tai applicable) CEL CANCELLATIONTCUy" M10ERT 9m MAY net.t[`ATIO IN The Commonwealth ofMassachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, ALL 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): e Address: 1Af) 61 ,1_J 1S�� City/State/Zip: Phone#: ` Are you a employer?Check the appropriate box: Type of project(required): 1. I am a employer with�_employces(full and/or part-time).* 7. New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. [:]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I LM Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑R re These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14. Other ° 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section 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 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 ney employees. Below is the policy and job site information. Insurance Company Name: ` N - Policy#or Self-ins.Lic.#: Expiration Date:*/Jl Job Site Address: City/State/Zip: Attach a copy of the workers' compen ation policyec arahon VNge(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 verificati Ido hereby certi and r th pal and p nalties of perjury that the information provided above 's true and correct Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense# 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#: AC® ® DATE(MMIDDIYYYY) CERTIFICATE LIABILITY INSURANCE IAC 02/18/2016 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(les) 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). CONTACT PRODUCER NAME: MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER AIC o Ext AIC No: 3560 LENOX ROAD,SUITE 2400 E-MAIL ADDRESS: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIL# 100492-HomeD-GAW`-16-17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co 16535 THD AT-HOME SERVICES,INC. 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER c:New Hampshire Ins Co 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:8 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. (NSR TYPE OF INSURANCE INSD SUB- POLICY NUMBER MMIDDY EFF POLFCYMMI DI EXP LIMBS LTR A X COMMERCIAL GENERAL LIABILITY GL048BT714-06 03/01/2016 03/0112017 EACH OCCURRENCE $ 9,000,000 DAMAGE TO RENTED CLAIMS-MADE �OCCUR PREMISES Ea occurrence S 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 POLICY ❑JECT PRO- ❑LOC PRODUCTS-COMROP AGG S 9,000,000 X S OTHER: B AUTOMOBILE LIABILITY BAP 2938863-13 03101/2016 03/01/2017 COEMBINED SINGLE LIMIT S 1,000,000 a accident X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ '.. AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ Per accident HIRED AUTOS AUTOS '.. S UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ C WORKERS COMPENSATION WC015519215(AOS) 03/01/2016 03101/2017 X STATUTE ER AND EMPLOYERS'LIABILITY YIN 03/01/2016 03/01/2017 1,000,000 C WC015519217(AK,KY,NH,NJ,VT) E.L.EACH ACCIDENT $ ANY PROPRIMB RlPXCLU13 /EXECUTIVE � NIA A D (Mandatory in ER EXCLUDED? WC015519216(FL) 03/01/2016 03/01/2017 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee Mctuve� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD h CSSL-09982 DZNUTRY BROVIN 70 NORTON AVE �nc�e�t�rNH 03l0g 06®26'2016 Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 - Boston, Massachusetts 02116 Home Improvement:.:Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2016 THD AT HOME SERVICES, INC. RICHARD FALLONE 2690 CUMBERLAND PARKWAY SUITE 300'; ATLANTA, GA 30339 Update Address and return card.Mark reason for change. '—�1 Address ❑ Renewal J Employment E, Lost Card SCA 1 0 20N1-05/11 / `=��c �r77z7)�nJiiceCZCflz r` lLa i��r�u.J�fli _Mice of Consumer Affairs&Business Regulation License or registration valid for individul use only a before the expiration date. If found return to: s .VIE IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ,Registration; 126893 Type: 10 Park Plaza-Suite 5170 Expiration: g/3/2016 Supplement Card Boston,MA 02116 THD AT HOME SERVICES,aNC THE HOME DEPOT AT HOME_SERVICES RICHARD FALLONE 2690 CUMBERLAND PARKWAYS =-- X'ff 9'A, GA 30339 Undersecretary Not lid wi out signature