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HomeMy WebLinkAboutBuilding Permit # 3/15/2016 TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received SSAGHUS� Date Issued:-,311151i IMPORTANT:A2pficant must complete all items on this page LOCATION rint PROPERTY OWNER rint MAP NO.: PARCEL: F ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Resintial Non- Residential ❑New Building C.10ne family ❑Addition ❑ Two or more family ❑Industrial ❑ eration No. of units: epair,replacement ❑Assessory Bldg [.1 Commercial ❑Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIULON OF W TO IPE PREF0 ,- M97 _c Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Q Phone: Address: jo Supervisor's Construction License: Exp. Date: Home Improvement License: �_ p l Exp. Date: —V-o/m, ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASE ON$125.00 PER S.F. Total Project Cost :$ x12.00=FEE:$ Check No.: � 1 Receipt No.: 1 Page 1 of 4 NORTH Town of Andover p ® _ h /AVS ver, ass O LANE � � COCNIC MI WICK �• A�RATeoP L S U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ..�, , ............... BUILDING INSPECTOR ................... .. .. .... .. .............. ......... ... .. .. .......... .. Foundation has permission toe t .... building on / • . . . . .... .. . . Rough to be occupied as ...... ... ... .......... . . . ... .... .. .. ... ... .%�... Chimney provided that the person accept g this permit shall in every resect conform o the t ms 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 Final PERMITI IN MONTHS ELECTRICAL INSPECTOR UNLESS TIO STARTS Rough Service ............ .... . . ... ..... ................ fir.......... ............ Final BUILDING INSPECTOR GAS INSPECTOR eeupaney Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. HOME IMPROVEMENT CONTRACT All)PLEASE READ'I HIS Sold, Furnished and Installed by: Branch Nanie: NeFv England Date,._1_23A_2 THD At-Home Services, Inc. d/b/a The Home Depot At-Home Services Branch Number: 31 908 Boston Turnpike, Unit 1,Shrewsbury, MA 01545 Toll Free 877-903-3768 Federal ID#75-2648460;ME Lie#C 02434;R I Cont.Lie# 16427 CT Lic#HIC.0.565522:MA Home Improvenlcnt Contractor Reg.# 126893 Installation Address: _ - &. - ol ' City State Zip Purchaser(s): - Work Phone: Monne Phone: Cell Phone: E7�11 69 --,� Home Address: — __--- - (I1-different from Installation Address) City State "Lip E-n-tail address(to receive project communications and home Depot updates): . ❑ 1 DO NOT wish to receive any marketing emails from The Home Depot T l'rajeet Information Undersigned("Customer"), the owners of the property located at the above installation address, a.,2rees to buy. and THD At-Home Services, Inc. ("Tile Thome Depot'') agrees to furnish, deliver and arrange for the installation ( Installation") of all materials described on the below and on the. retetenced Spec Sheet(s). all of which are incorporated into this Contract by this reference. along with any applicable State Supplement and Paymcnr Summary 'Machecl hereto and any Change Orders (collectively, "Contract"): Joh#: (Internal wrcrenccl Products: _ __ Spec Sheet(s)#: Project A_nnoutit ❑Roofing ❑Siding Windows ❑ Insulation - - 06 ❑Gutters/Corers ❑Entry Doors ❑ - y 2V1 ❑Roohnu ❑Siding ❑ Windows ❑ Insulation — -- - - ❑Gutters/Corers ❑Entry Doors ❑ S ❑Roolina ❑Sidinl, ❑ windows ❑hlsulalion - - --- ❑Gutters/Covers ❑I nn-s Doom❑ S ❑Rootin« ❑Siding ❑ Windows ❑ Insulation -- - ---- - ❑Guttcls/Covers ❑Entry Doors ❑ S -- j Alinini um 2517c Deposit of Contract Amount due upon execution of t1lis contract. - - ltainePtiseattsars may not deposit more than one-third of the Contract Amount Total Contra Amount Customer .1wrees that, immediately upon completion of the work For each Product, Customer will execute a Completion Certitieitte (one Iot each PrOdUCt aS (tciine(l by an individual Spec Sheet) and pay tiny balance due. As nppliC;IHC, each CUStOliler under this Contract agrees to he jointly and severally obligated and liable hereunder. Tlie Home Depot reserves the richt to issue a Change Order or terminate this Contract or any individual Produc (s) included herein. at its discretion, it"The Home Depot or its authorized Service providCr determines that it Cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold ashestos or lead paint, other safety concerns, pricing errors or because work required to complete the Job was not included illthe Contrtwt. P�Yllient SulliniarYThe PaVolent Sutnill 11-V H /�=wq included as part 01 this Colltract, tier lUll_Il tile tolal Contract arnount and payments required for[lie deposits and tina(paynients by Product (as applicable). NOTICE.TO CUSTOMER You are elifitled to za Completely filled-in copy of the Contract at the time you sign. Do not Sign a (_'omplelion Certificate (note: there is one Completion Certrticale for each lirsted Product as deCned by individual Spec Sheets) before work on that Product is coinplete, 1131 ihe event of termination of this Contract, Customer agt•ee,s to fray The Houle Depot the Costs of materials, lahor, cNq)e-nses and servicespralo:ided hyo 'l'lae Iloane Depot orituori � thrcd Ser;iCe Provider fhroUt_fll the date of terrrlinafio€a, plus any other iarsaotrnls,set forth in this Agreement or allowed under applicable law, TIII 110N,1E DEPOT JUAY �,VITt1HOLD ;�lv16cNTS Oyu,'[D TO THE HONIE DEPOT FROM THE DEPOSIT Pty Y Il'�°T € R O Told k� P�, NIENTS N,IA E, WITI-4)Ul' d,IM11 ING THE 110 !E DI+POT`S OTHER REMEDIES Foli RECO a'1+I va OU SUC[i A' Acceptance allot ;'uthorizafion: Custonlei U'rces and un(lfrstan(is that tlatti Artrermellt is t11e entire aiereetnent between Customer and he Home Depot with regard to the Products and Install)tion services ,tad supersedes all prior diSCn1,Sio ns and .rprcenlent,, either oral or written, rclatill" to said PYOdUCtS and Installation. This A-reement cannot he t siL-nc(l or amended c.Ncepi by a wlitim, .si-oned by Customer :uul The Home Depot. Customer acl:nrnvicdgcs and a,;rces that Cusininer fists read. undcrstan(Is, voluntarily accepts rile ternis of and hats received a copy of-this A:Ireerncnt. t i Accateei�fi A 1 p�r�� l�1• `�//v � I Submitted by: i Work area will be contained 're _ g w. 0 ti a -Renovation Forma Date: —27 �7 ti r d fir. IAT-79276 This form is used to doccurnont compliance with the requirements of the Federal Lead-Based Paint Penovation.Repair,and Painting Program after April 20'10. Customer Address Job Number(s) c. .. OCCUPANT CONFIRMATION Dust will be minimized Pamphlet Receipt } s � 1 have received a copy of the Dead hazard information pamphlet informing me of qgr rthe potential risk of the lead hazard exposure from renovation activity to be 4�t �' performed in m} dwelling unit. 1 received this pamphlet before work began. As "' "A" �! Horne Year Built 4a M1�� Enter the year my hone was built_ ��� If my Home Year Built is Pre-1978, my home requires lead paint testing to determine whether Lead-Safe tl;'ork Practices are necessary per EPA or State regulations. Work area will be cleaned up If my Home Year Built is 1978 or after, Lead-32fe Practices are not required. thoroughly Jf alfa® t s, Printed Narne of Owne occupant Com / 4 Skinature of O,. .er-occupan, r `�. -�,z`3'` 4 t t 1�t• '1 �M l; -z v 5 R, sign, . o ,eri,�n C_=rlifying Lend Par phle' v „ - - - 't � -3zi t 'I � ' x� �:^...� Ott: ? `•y 4 � r- De,i et, z SEE STATE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massachusetts � (1 Department oflndustrialAccidents (1 1 Congress Street, Suite 100 n? Boston,MA 02114-2017 www niass.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: (' City/State/Zip: ; G Phone#: Are you a -employer?Check the appropriate box: Type Of project(required):1. I am a employer withemployees(full and/or part-time).* 7. EI New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] . 9. F-1 Demolition 3.®1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q 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 11.❑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.❑RO ef repar Wirs 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. 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. 1 ant an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site itifOrtttation. Insurance Company Name: J` l - - Policy#or Self-ins.Lic.#: ) ) Expiration Date: Job Site Address: �a q1, City/State/Zip: l� Attach a copy of the workers' compensaii n policy declaration page(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 verifi ation. I do hereby i ;fy t ld the ains and penalties ofpeijury that the information provided above 's true and correct Si natu 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#: DATE(MMIDDPCM) CERTIFICATE IFICAT E F LIABILITY IN Csup 02118!2016 TE N HE CER T T1 THIS CERTIFICATE DOESSNIOTUAFFIRMATIVELY ER OF OR NEGATIVELYON AMEND, EXTEND OR AS ER NO RTIHETCOVERAGE AFFORDS UPON THE EDABY THHEDPOLIC EER IS CERTIFICATE DO BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. K IS toIS to IMPORTAN and coth nditions of the policy,certas an in policies coesD INAmay INSURED, a an endorrse(ment A statement on this cerjes)must be en OTsed. if SUBtificate aGe do0es not conferDrights,totthe the ter erm certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: MARSH USA,INC. PHONE �C No C o E#' TPJO ALLIANCE CENTER E-MAIL 3560 LENOX ROAD,SUITE 2400 ADDRESS: NAIL# ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE 26387 INSURER A,Steadfast Insurance Company 100492-HomeD-GAW-16-17 INSURER e:Zuricii American Insurance Co 16535 INSURED 23841 THD AT-HOME SERVICES,INC. INSURER C:New Hampshire Ins Co DBA THE HOME DEPOT AT-HOME SERVICES Illinois National Insurance Company 23817 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:8 IND IS TO CERTIFY NOTWITHSTANDINGRTIFATTHE POLICIES ANY OF INREQUIREOD MENT,TERM OR CONDCE LISTED WIONVOFBANY CONTRACT OR OTHER DOCUMENT WITH REEEN ISSUED TO THE INSURED NAMED ABOVE O PECT TOLWHICH ICY TIHIS CERTIFICATE MAY BE ISSUED ONS OR MAY SUCH OLICIIES LIMITS SHOWN MAY HAVE CE EBEEN REDUCED BY PAID CLAIMS.D BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AN gDDL SUBR POLICY EFF POLICY EXP LIMITS INSR -rypE OF INSURANCE D WVD POU NUMBER MMIDD MMIDD 9,000,000 LTR. GL0488T/14-06 0310112016 0310112017 EACH OCCURRENCE s A X I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 1,000,000 PREMISES Ea occurrence CLAIMS-MADE a EXCLUDED OCCUR LIMITS OF POLICY XS MED EXP(Any one person) S OF SIR:$1M PER OCC PERSONAL&ADV INJURY S 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEITLAGGREGATELIMITAPPLIES PER: PRODUCTS-COM /OPAGG S 9,000,000 PRO- POLICY❑ EEl LOC S j I OTHER: COMBINED SINGLE LIMIT I S 1,000,000 BAP 2938863-13 0310112016 0310112017 Ea accident B AUTOMOBILE LIABILITY BODILY INJURY(Per person) S X ANY AUTOBODILY INJURY(Per accident) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG PROPERTY DAMAGE $ AUTOS AUTOS NON-OWNED Per accident HIRED AUTOS AUTOS S I EACH OCCURRENCE S UMBRELLA LIAB OCCUR AGGREGATE EXCESS LIAB CLAIMS-MADE $ '.. DED TI RETENTIONS WC015519215(AOS) 0310112016 0310112017 X STAN Eft C WORKERS COMPENSATION 0310112016 0310112017 1'000'000 C AND EMPLOYERS'LIABILITY Y/N WC015519217(AK,I(Y,NH,NJ,Vi) E.L EACH ACCIDENT S ANY PROPRIETOR/PARTNERIEXECUTNE N NIA 0310112016 03101!2017 1,000,000 OFFICERIMEMBER EXCLUDED? WC015519216(FL) E.L.DISEASE-EA EMPLOYE S D (Mandatory in NH) 1,000,000 If yes,describe under Conitnued on Addi Tonal Page E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS below 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 S,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THD AT-HOME SERVICEI DBA THE HOME DEPOTS, HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherjeeA"��'t"` ! ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD � 7 J iy Office of Consumer Affairs and Business Regulation == 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home IrnprovementContractor 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. _ J Address Renewal Employment Lost Card ;cat =Mice of Consumer Affairs&Business Regulation License or registration valid for individul use only Z w Mbefore the expiration date. If found return to: E IMPROVEMENT CONTRACTOR _f office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza-Suite 5170 Exptratton 81312Q16 Supplement Card Boston,NKA 02116 THD AT HOME SERVICES,INC i HE HOME DEPOT AT HOME-SERVICES :RICHARD FALLONE'` 2690 CUMBERLAND PARKWAY S 4' L�1N , GA 30339 Undersecretary Not v lid wi hoot signature �s r CSSL-099623 BIS® 70 NORTON A 06/26}2096