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HomeMy WebLinkAboutBuilding Permit # 3/2/2016 `aORTH BUILDING PERMIT TOWN F NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION n � Permit NO: �� Date Received Date Issued: k IMPORTANT: Applicant must complete all items on this page LGICATION ' .... ...&"""" Print; PIOPERTYOWNEF ' -MAR NO-'NO: P1kRCEL ZC ( ING DISTlIC`f Historic Drstrict yes; no„ h" Shop: liilag yes , no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family El Addition ❑ Two or more family ❑ Industrial ❑AAeration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Sepfiic ❑Well [ Floodplain` 0�Weflands ❑ ,Watershed District ❑Water/Sewer An Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name Phone ' Addr4 6; 1 Al ess. Super�cisor's Constructtor� Lac nse `;- 0 J Home Irrrprouement Ltconse Exp Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ C- .— FEE: $ Check No.: Receipt No.: -L- NOTE: Persons contracting with unregistered contractors do not have access t the gu, anty fund a Signature of Agent/Owner " Signature of contrac `, j tAO R T of Andover Ind o � �..K. h ver, ass, Ab coc L:"14 AD�RTED S U BOARD OF HEALTH Food/Kitchen PF= RMI T L D Septic System THIS CERTIFIES THAT ..... BUILDING INSPECTOR ................................................................................. .................................... LFoundation has permission to erect .......................... buildings on:3!1.\. ...... . . ..........�............... Rough to be occupied aS .. .... ... ... .. ®!...... .. ........... .... '.� G.`!6. chimney provided that the person accepting 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 Regulations Voids this Permit. Rough p� Final PERMI I ®NTS ELECTRICAL INSPECTOR UNLESS TI ST S Rough Service ..................... ....................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Perinit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingor Dry Wall ToBe ®one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Feb 18 16 10: 17p Rick Odonnell 6033780151 p. 1 HOME IMPROVEMENT CONTRACT PLEASE READ'THIS Sold,Furnished and htstalled by: Branch Name:New England Date.—/—/ THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,IVIA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lie#C 02439;RI Cont.Licit 16427 q //,, CT c HIC.00I5�65522/;MA Home Improvement Contractor Reg.#126893 6 Installation Address: 3 / uo(363 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: [x'1430-a6 V% a CL 1�] 96-0-3 y 9 Home Address: (Ifdifferent from Installation Address) City State zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Mo.("The Home 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 of 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#: (10 1 RIF—a a) Products: Sec Sheet(s)#: Project Amount ❑Roofing ❑Siding Windows ❑Insulation 00 90/73/7 ❑Gutters/Covers ❑Entry Doors El293-3 102 $95-37 Rooting []Siding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors ❑ S ❑Roofing ElSiding ❑Windows El Insulation $ ❑Gutters/Covers ❑Entry Doors❑ RootingSiding Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors ❑ Minimum 25%Deposit of Contract Amount due upon execution of this contract Total Contract Amount $ Mune Rrrchase s may not deposit more titan one-third of the Contrtc4Amount l a j v Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for tach Product as defined by an individual Spec Sheet)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 problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete die 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 on that Product is complete. In 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 through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed L v Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the t s of and has rec 'ved a copy of this Agreement yy Xe 44 I Submitte . Custom s Si n tture ate Sales Consultant's Signature Date X Telephone No. Customers Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL,TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 08-03-15 White-Branch File Yellow-Customer The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 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): Address: � t ii City/State/Zip: Phone#: � Are yyu�ua -employer?Check the appropriate box: Type of project(required): i. a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I 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 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E]Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.F1 Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roop e airs These sub-contractors have employees and have workers'comp.insurance.t 14. ther 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. t 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 ane an employer that is providing workers'compensation insurance for ney employees. Beloit,is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: - /1 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration age(showing the policy number an expira ion 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. n I do hereby certify u4ider hep its d pen lties of pet jury that the information provided above 's true and correct Si ature: Date: Phone#: Ck 10 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#: q ® DATE(MM1DDIYYYY) CERTIFICATE OF LIABILITY Y INSU NCE 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(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 CPHONE E i FAX No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIL# 100492-HomeD-GAW`A 6-17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance CO 16535 '.. THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 23841 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURERF: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR WVD POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY GL04887714-06 03/01/2016 03/0112017 EACH OCCURRENCE S 9,000,000DAMAGE TO '.. CLAIMS-MADE M OCCUR PREMISES Ea occurrence) $ 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:rv1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S 9,000,000 X POLICY❑PRO- JECT D LOC PRODUCTS-COMP/OP AGG $ 9,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAP 2938863-13 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 Ea 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 $ HIRED AUTOS AUTOS pera.d t S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ '.. EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ C WORKERS COMPENSATION WC015519215(AOS) 03/01/2016 03/01/2017 X IPER STATUTE ER AND EMPLOYERS'LIABILITY C YIN WC015519217 AK,KY,NH,NJ,VT 03/01/2016 03/01/2017 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ( ) E.L.EACH ACCIDENT $ D O(Mandatory NH)BER EXCLUDED? N/A WC015519216 FL 03101/2016 03/01/2017 1,000,000 (Mandatory in NH) ( ) E.L.DISEASE-EA EMPLOYE $ If yes,describe under Conitnued on Additional Pae 1,000,000 DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE-POLICY LIMIT $ w DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 MukherjeeCt��noo►� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD p.5 CSSL-099623. y BROVIN 70 NORTON AVE Msnchester INH (3108 06/2662016 Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, Mai§achusetts 02116 Home ImprovementContractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2016 THD AT HOME SERVICES, INC. g RICHARD FALLONE 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA, GA 30339 Update Address and return card.Mark reason for change. Address — Renewal Employment Lost Card ;CA 1 :S 20M-05/11 � (�n77i:77zr12.CGacG�ff7-.O/,✓, �CiJ�trf7 CiJ eC�r flee of Consumer Affairs&Business Regulation License or registration valid for individul use only iAMMQ7 before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation _ Registration 126893 Type: 10 Park Plaza-Suite 5170 ExpiratioFl_-8L3120 = Supplement CardBoston,MA 02116 rHD AT HOME SERVICE$ INC _ THE HOME DEPOT AT,F(OME--$ERVICES RICHARD FALLONE ?690 CUMBERLAND PARKWAY S -- --"— AYDAM,GA 30339 Undersecretary 1_4N, 4,wvit signature