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HomeMy WebLinkAboutBuilding Permit # 4/22/2016 �ORTi-1 BUILDINGPERMIT o��t�en TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION zA' Permit IMO#: (� ` Date Received �,'4go�°ATEp PPpy+(5 1 d a �SSAC q Date Issued: s IMPORTANT Applicant must complete all items on this page >. .„,:. r^ .,✓:,r r : s 7 r"1u//r /r,r� rue ° -:`r r r F,✓ �':` r/�,.�.: f �+` �' u: ,.,.:- „r; t s- -r' v r:-..,- .:f ,.., Mir J/ 4',, ,,r`;^ ,-i"; Y 37:v.,J' ✓. .r rr r„r ,�. !!/7f Jr. .ir' ;,r f.,,,g sr / ,;,} ,<" ✓ H; s .r` ,. .,,.�„,.. l:^. .,.-<, ..,,�.. �.,rr r. r..,f r�>,. ,�:, .. rr.. 'r",. .�. ,sff✓ 't! :u^, 6. ✓r^r ...r..r 1�,..,?. Fr'r�k u.:m%?, ,,..: ..�✓,'' <zv �..�,fi. :,;.`i. y..r .e:rr^^f � .. : fm_. r� /.�..:. na. l' : /F.� F.: /:,"�, ,...,✓ s �r"a. u. 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Y ' 1 l f'Jr'^`rf .� ,r ��� 7�r-�^!F .rUlr�,a.xf...�. $ 9 � r ��.F r.r r6--.r,:.,^" � �..„� ,"��.: .. s :, r.,s.r'',° .mm�T%��rr'�' ✓'/� - -,..: - .r. "�' r.. ,J' r .r, t k'rr e�' 7 r ,s..r r has�sr,. �,�,�rrs? s<,�. r.. .„ ,, rd'"r;, tr�ur .,,:r; r' r,::-,:,,.,r. wti? ,.N r .^i ;,ura z ✓�/ J �t,2J.,u,F. r �i"m, r. ,r ( r .xtr., � ;�x,.�r. >r.rl :/ Sya r; J,..a'rr 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.: o77 Receipt No.: 30 a NOTE: Persons contracting with unregistered contractors do not have access the guaranty fund ;Signature of Agent/Owrier gnature°of contYact O®RTH Town ofiAndover 0 ���. h . ver, ass, ® 1. COC NICMlwI[.( V BOARD OF HEALTH PEKIVI- IT T LD. Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .......... r. .4.:� ZY S �• ...... .......... .......................................................... Q � 1� p Foundation has permission to erect.......................... buildings on ....Q......4�d.�,1.Cu.sf �...I..L0.d....���:�..Q04, Rough "� to be occupied as`: ..... s............ 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS TI STA Rough ..................... Service .................... ......... .............. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by: Branch dame: New England bate:�/�/ THD At-Horne Services, Inc. d/b/a The Home Depot.At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1, Shrewsbury,NIA 01545 'roll Free 877-903-3765 Federal 1D#75-2698460;ME Lie#C 02439;R1 Cont.Lie#16427 CT Lie#HIC.0565522;MA Home Improvemennt��Conntractoorr Reg.# 126893 Installation Address: ` �� +� N. ~ — `A 6 City State Zip Purchasero)' Work Phone: Home Phone: Cell Phone: Home Address: _ (If different 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 Proiect lnformatiort: Undersigned ("Customer"),the owners of the property located at the above installation address, agrees to buy, and THD At-Home Services, Inc. ("The Monne Depot") agrees to furnish, deliver and arrange for the installation ("Installation")of all materials described on the below and on the referenced Spec Shect(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"): Joh#: (Internal Reference) Products: Spec Sheet(s)#: Project Amount 9 ��� � � ❑Roofm- ❑Siding Windows ❑ Insulation "' -- ❑Gutters/Covers GntryDoors ❑_�__ � � L ❑Roofing Siding ❑Windows ❑ Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ ✓ ❑Rooting ❑Siding ❑ Windows ❑Insulation j ❑Gutters/Covers ❑Entry Doors❑_ $ -- ❑Roofing ❑Siding ❑ Windows ❑ Insulation ❑Guuers/Covers ❑Entr_y Doors ❑ Mininhmn 255%Deposit or Contract Amount due upon execution of this contract. Total Contract Amount � iylaine Purchasers may not deposit more than one-third of the Contract Ninotmt. Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for each Product is defined by an individual Spec Slice[) and pay any balance due. As applicable. each Customer under this Contract agrees to hejointly and severally obligated and liable hereunder. The Honkie 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 perforin its obligations due to a structural problem with [Ire home, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because wort:required to complete thejob was not included in the Contract. Payment Summary. The Payment Summary #_.. 1 1'7,5_(,0�� ____ included as part .of this Contract, sets forth the total Contract amount and payments reduired for the deposits and final payments by Product (as applicable). NOTICE TO CUSTONIEE You are entitled to a completely filled-in copy of the Contract at the Lure you sign, Do not,sign a Completion Certificate(note: (here is one Completion Certificate for each listed Product as dellned by individual Spec Sheets) before work on that Product is complete.. In tlae 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 alloNved under applicable law, THE HONFE.DE''POT MAY WITHHOLD ANr5OC7NTS OWED TO THE, HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS NIADE, NuTHOUT Lli Il 1 hi'Cz THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AIN11OLINTS, Acce�and Authorization: Customer agrees and understands that this Agreement is [lie entire ggrcement 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 histallation.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 terms of and has received a copy of this Agreement. AcAce ed by: Submitted by. � � � Work area will be contained Pre Renovation Form Date: i (SAT-19276 This form is used to document compliance with the requirements of the t Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010. T Customer Address Job Number(s) JOA Dust will be minimized AA OCCUPANT CONFIRMATION Pamphlet Receipt I have received a copy of the lead hazard information pamphlet Informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began. Home Year Built t Enter the year my home was built. yyy If the yea ur home was built is Pre-1978,all work will be done following lead safe work practices. Work area will be cleaned up Prime Name -occ nt p thoroughly Si ature P nt Si at e o- rson r fying Lead Pamphlet Delivery SEE STATE SPECIFIC FORMS ON REVERSE SIDE I' i, '? no Commonwealth of Massachusetts Depa ent of Industriral Accidents 1 Congress Street;Suite 100 ' Boston,MA 02114-2017 -�. www.fnassgov/dia Wpricers'Compensation insurance Affidavit:Builders/Contractors/ElectricianslPiumbers. TO BE FMED WITH THE PERrNnTTING AUTHOR'TY. A �jcanInformationPlease Print Le 'bName(Bu4anization/Individual)�° R1`14 Address: a4 ( 11> City/State/Zip: 6 LI Phone M Are you a employer?Check the appropriate box: Type of project(required): em to ecs full and/or art-tune.4� ;7. ®New construction 1. I am a employer with P Y P )a 2,®I am a sole proprietor or partno sbip andbave no employees working forme in $. ®Remodeling any capacity.L14a-svorkers'comp.insurance required.] 9. Demolition 3.®1 am a homeowner doing all work myself[No workers'comp-insurance required.]+ 10❑Building addition � d.®I am a homeowner and will be hiring contractors to conduct all waork on my property. i will I 1 Electrical repairs or additions ensure that all contractors eitherbave workers'compensation insurance or are sole proprietors with no employees. 12.®plunibingrepairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,®Roofzzda��_ Thesesub have employees and have workers'comp.insurance.t ld the6 Q We are a cor poration 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 ru 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 am an employer that 1sproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 Expiration Date: Policy#or Self-ins.Lie.#: Job Site Address, ' City/State/Zip: Attach a copy of the workers' compensation policy declarati n page(showing the pef ey number and expiration date). Failure to secure coverage as required under MGL C.152,§25A is a criminal violatiRonKp RDER ari Ya fine of p t$1,500.00 $25�0Q a and/or one-year imprisonment,as well as civil penalties in the form of a STOP WO day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. fy un er tl i and enalties of perjury fl:at the information provided above's true and correct. I do hereby cel Date: SiQrtature: Phone#: L401 1 Official use only. Do not write in this area,to be conepleted by city or town officlaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.BuildingDepartment 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person; Phone#: ATME T' I6 LIABILITY INSURANCE 002<1B@016DIrrrY) 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 ib15URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CEITIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION 1S WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement Astatement 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 No TNO ALLIANCE CENTERo t 3560 LENOX ROAD,SUITE 2400 E-MAIL -ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE MAIC d 100492-HomeD•GAW'4647INSURER A Steadfast Insurance Company 26387 INSUREDINSURER 8.Zurich American Insurance Co 16535 THD AT-HOME SERVICES,INC. NewHompshire Ins Co 641 DBA THE HOME DEPOT AT-HOME SERVICES INSURER c 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Il is National Insurance Company 3817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: AT600374664&14 REVISION NUMBER:6 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 8E 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. zz ADOLSUHR POlICYEFF POLICY EXP - � YPE OF INSURANCE D 4UrrD POLICYNUMBER IDD MlDD RCIAL GENERAL LIABILITY GLO48BU14-05 0310112016 03/0112017 EACH OCCURRENCE 5. 9,000,000 I• DAMAGETO RENTED S 1,000,000 IMS-MADE M OCCUR P EMISES Ea occurrence LIMITS OF POLICY XS MED EXP(Artyone person) EXCLUDED OF SIR:$1M PER OCC PERSONALbADV INJURY S4 9,000,000EGATE L1M17APPLlES PER: GENERALAGGREGATE $ 9,OmnPRODUCTS-COMPIOPAGG S , ,000 ECT F LOC S : COMBINEDSINGLELIMITE LIABILITY BAP 29388fi313 03f0112016 0310112017 Fa accident S 1,OW,000 TO BODILY INJURY(Per person) S LHIREDAUTOS OWNED AUTO ULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S NON-OWNED D PROPERTY DAMAGE S AUTOS Peracadenl S UMBRELLA LJAB OCCUR EACH OCCURRENCE 5 EXCESS Lutes CLAIMS-MADE AGGREGATE S S DED RETENTIONS C WORKERS COMPENSATION WC015519215(AOS) 0310112016 0310112017 X EATIITE OERm C AND EMPLOYERS'LIABILITY v r N WC015519217(AK KY,NH,NJ,VT) 03101120L 16 0310112017 E EACH ACCIDENT S 1,000,000 ANY PROPMETORIPARTNERIEXECUTiVE N I A D �OFFICERfMEMSEREXCLUDED? WC0155192161FL) 0310112016 03101)[2#17 Fl DISEASE- EMPLOYE S 1,000,000 (Mandatory In NH) 1,000,000 ' es,desaibe carder Conbi ued on Additional Page EL DISFASE-POLICY LIMIT S 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 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 Mukherjeea��`" `'t I ©1988-2014 ACORD CORPORATION. All rights reserved. J, 0 f C o L-1,S)U 0 ffli rnerA 1rsandBusinf-assp-,ecula e 10 Park Plaza - Suite 5170 Boston, assachus,tts 02116 Home lmproveme�-Qontractor Registration Registration: 126893 Type: Supplement Card Expiration: 813/2016 THD AT HOME SERVICES, INC. RICHARD FALLONE F 2690 CUMBERLAND PARKWAY S 0 1 ATLANTA, GA 30339 Update Address and return card.Mark reason for change, Address D; Renewal 7-1 EmpEmploymentLost Card License or registration valid for individul use only rice or Consumer Affairs&Business Rec,'uh1tion before the expiration date. If found return to: �Wa=MNIE IMPROVEMENT CONTRACTDRRcaulation office of Consumer Affairs and Business Registration; 126&93 Type: 10 Park Plaza-Suite 5170 Exp ration 8131�G3o Supplement Card Boston.MA 02 116 "HD AT HOINIE SEERVlQE&-,-=jNa---7f.-!- FHEE HOME: DEPOT KT RONIt-s3fRVICES ?ICHARD FALLONE 2690 curviBERLAIND PAOKWAY 8 Not lid wi out signature aT5�Pn,GA 30339 Undersecretary fl v " I, u 111 y IIIIIIIIIIIIIIIIIII 1111111111111111111 111111111111 I uV 111111 r�J r1J , 1 ��� r / r r i "�'I'I'I'I'I'I'II�"''IIIIIIIII / / f / l ! lull. I / Wil I / , III I VIII I I �;ipy VIII 111116111I� �� II I muui��iilpuuuuum uulo�i r r p r Ni i^ u 'I / /, rr /ii% � � mei r / � rGr��i/!,fl ,,J// r✓///�„ iiir/„r r, ,r��� ,�/i,r/� , i rr/i Z 2 r s r r Now ..,.,.J 2�.f�✓!���I��/������,[�illl�l��r����r,f��r .,.,s,.,.,, �,_„_��l �,,;/,/ro, .,�r,, C,,,;, ///,,,ii%�,,,,, ,,,,r,,,,r,,, ;/�/,r,d,,r/rr r/�r%/�i�/Il / a,.MINE— !- 11