HomeMy WebLinkAboutBuilding Permit # 9/8/2016 NORTH w•
BUILDING PERMIT 44. 6� o
TOWN OF NORTH ANDOVER ►�� ;�
APPLICATION FOR PLAN EXAMINATION
Permit NO za— Date Received
lig ,OAF..rpa�45
Date Issu VS CHUS
IMPORTANT: Applicant must complete all items on this page
LOC
TJON
PRPEIT
t
MkF NO P�CEL y ONIG OITRtT totld
TYPE OF IMPROVEMENT PROPOSED USE
Resio6ntial Non- Residential
F1New Building ne family
Ad 'tion 7 Two or more family I Industrial
1AXeration No. of units: Commercial
/Repair, replacement Assessory Bldg Others:
Demolition C::] Other
Stec � l Ftop� Ietlat I Wtest € srr�
teri �r
Identification Please Type or Print Clearly)
OWNER; Name: Phone. `'
Address: t
CONTRACTS rt��R
P9NORM
lr' �� L
NQ [rpoerot Lt ��
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.:
NOTE: Persons contracting with unregistered contractors do not have access iheguarantyfund
tgrture + l Ar► Oterlgrratur�; co' tracto
th®RTFj .q
Town of � _� �T bndover
No. .a
LAKE h ver, Mass,
4
COCHICKEWIL% 1'
sArea
U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT :.....1 .. .,.. .......................... . .. BUILDING INSPECTOR
do
has permission to erect .....Mdk...................... buildings on ......... Foundation
...... Rough
Aram
to be occupied as ........ ....... A&. ........ . .. . .. .....�......................... 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. I PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
�+ Final
PERMIT EXPIRES I 6 THS ELECTRICAL INSPECTOR
UNLESS CONST TI®N PS4. Rough
Service
.. .. ...... .......... ..... Final
BUILDING 1 CTOR
GAS INSPECTOR
Occupancy Permit Required to 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
_.. .�_ ---TTMIJ OV TViluNT CONTRACT
PLI;ASI,,RD1,AD THIS
Sold,Furnished and lnstallecl by:
j� THD At-Home Services, Inc.
l3rancl) Name: Mery England Date: Ili ilk._. d/b/a The Horne Depot At-Moine Services
t3rarrclr Number: 31 905 Boston Turnpike,Unit 1,Shrewsbury, MA O1545
Poll Free 877-903-3768
Vecleral Ill#75-2698460;ME Lie It C 02439;RI Cont,Lielt 16427
CT I it,it 1-11C.0565522;NIA Home improvement Contractor Reg.#1 126893
lwaR
11stallationi Address: ) -City State Zip
Pt€rchaser(s): Work Phone: Home.Phone; Cell Phone:
?"i
�_�._
Home Address:�. _ —. - State Zip
(if different Haar Installation Address) City
l &
E-mail Address(to receive project conlinunications and Home Depot updatok;): _.____ --
I DO NOT wish to receive any marketing emails front The Home Depot
I'rar€ect I►�t_ rtnation. Undersigned("�"nstotlter"), the owners of the property located at.tine above installation�rddress,ag€ees to buy,
and ]'FID At-Home SLr`vices, Inc_ ("`I he lOtne I�ePot") a;rcfs to ftirniSh, deliver and arrange forthe ills tallatiOil ("lnsttrllation") of
all nr-ttuials described on the below and ort the referenced Spec Sheet(s), all of which are incoil)nrated into this Contract by this
reference, along with ally applicabic Slaw Supplement and Payment Summary tnt.achcd hereto and al�y Change O1�(lers (callect[vely,
"Contract"):
'ro(Ilicts: Spec sheet(s)#: Pۥo'ec
i ,t A�rtonnt
,Io[)#t. (Internal lenience)
❑ltnntsn��5idinr Windows ln5c)lauon a
709 ❑Gutters I Covers Entry Doors ❑ -- ! _-.—
–� ]12ooting ❑siding ❑ 1'rfindo�vs ❑ insulation
❑Cutlers 1 Covers ❑L,;n4'y Doors ❑_ �. —.. _
❑ltuoting (Siding llrinc€ows ❑ I€3sulatiot)
❑chillers I Covets ❑1:intry Doors❑_ .�.
_– - 0[Zoofing ❑Sidin�� ❑windows [] lnsttt::tio11
❑Gt€tters 1 Covers ❑Entry Doors ❑
[ Iivfininunn 25°h lk€posit(WO)ntraet.Alnottnt(lite ut)ot)eXIM1 i0n of this eorttract- 'Total Contract Amount
M.rine pIovlIltscr s trray not.depiY-4t more than ont-third of the Contt ait.r l3lcit(iit. _
Customer agrees that, ilrlmcdiately upon i:omplet�on of the vNiorl< Ior- each Product, Customer will execute a Completion Certitirltc
(one ('or each Product as defined by all indivi.clual Spec Sheet) and pay any bahtnce clue, As applicable, each Clis[oaler uncler this
Contract agrees to bc. loiilt.ly and severally obli-ated and liable hereunder,
The Home Depot reserves the right to issue a Change Order or torillinate [hits Contract or any indiviclual PrOdelel(5)included herein, at
llti dLSCI'et1011, ll'�f he�lOnle Depot O1' 1l5 illltllUr]DA ServlCc prllFlder[lClei'i111i1e5 that it.Cin13H}t pcl'lorm its al)lIk i10Ung due to a 5t1lChlrttl
pro with the home, elivirolnilental hu-arcls such as mulct, as
bC5to6 QI lead p2llit, Otll € tialel}'concerns, pricing ert'i)1'S Ol l)ccittlSe
work€.equircd[o complete till;job wits not iuc.lude(l in the.Contract,
�� �, included as lin t -oi' shin Contract, sets Cordy the tots]
Pa �rr�arrt Srrirtnlar 'nc� Payment ,,u1tn1)a- #__ -
C()ilnact i€mount:€ncl p,€yilicnt,rcgiirud for the deposits and lin.11 payments by Protluet(as applicable).
NOTICETO CUSTOMER
otr are entitled to:�coniplotely fi le.(l-111 copy elf the C(nit.ract.at the tine you sign. Do not sib n It Cotrtlrleticr(t Certificate tif'icate(note:
urate r tent)jlc fled t leli(aar Certiticirte l'aDl' e�lelr li.,ted Ip€odtla[ as ticCi€)e(l by individuirt Spee Sheets) before work on that P11)( t€c
is col)ahlete*
lr3 sir€ e�etlt (rf'terlalin ttl()!1 rrf. this ;ot)trsrct, tl,tat)rcr asst ec:w tel l)ry 'Flie rile cost's of rtrtrtet ial sg ltrlror, expe.trse
and services provided try 'fire 1-ImIle Depot or Antlior'ired Service PI-Ovi€lel• tia; 11911 the (late of termirlatiOr)< pl)t5 ' other
itnOUNTS
rcrutats set 113rt1r it this Afrcer')cl)t(�t all ��t I1 lD ;I' 5➢Il)IsA'b' II bTle law. ' OR OTHER POME CjPAYMENTST AMAY yINIADE, WITHOUT
OWE' �O THE HOME' DEPOT I IZO
I,IMT'I lih]C� l'FI>1 HOME DEP0 OTHER 1�.E19�1_EDIES FOR REt<.4,�'IsR OF SUCCI AiiIO>(161T5.
eivlecn
Ace e}t ttiS1C{' iiP)tI l tltb4)I'i'L.<4tiO➢i: CelS1O111er a 1'L'(ti AnCI lln[lerStiln(l,5 t17��� �Sld l�L'I�(L�C�S all,I-celnent is tpriorIile t dist(ISS€�l'16 an(lent l i l e(11C leSt�lCtlhCl'
incl The Home Dept)[with r c.tird (a t'h(;PrC3dllClS.111c1 131tilall:.4f1011 S�.i'11cl
oral or written, relisting, to said I'roduciti and lnstallafion. `3'his Agreement cit rnOt Casilumer'Is�has a(1,�Ilcd �undcrtitnn cls voluntarily iacl7ts�thi
by Custuiner and The l lank DcPot, Customer acknowledges and a ices dla
terms of and has received a copv of this Agreement,
l ,NoWi)itted by;
.A ecgpAlky:
Work area will be contained
R �
Pre-Renovation Form Date:
nru��
r�
t � NAT-39276
� r
t" <
This form is used to document compliance with the requf cements of the
!' r Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010_
I �
C
ustomer Address
.lob Number(s)
f
'
AV . q _76
115.
Dust willbe minimized A) . 411 6IFY5
To
OCCUPANTCONFIRMATSON
Pamphlet Receipt
z� z l:,s,• $ _ _ "'__ - - l 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. € received this pamphlet
before wore pegan.
Home Year Built
Enter the year my home was built, if
if the ear your home was built is Pre-7978,all work will be done following lead safe work practices.
k area will be cleaned up
" Frinfed Narne of Owr, -o cupant
thoroughly
Signature of Ovrner•occupant
signatureof rson Cerfifyi g ad a phlet Cefivery
SEE STATE SPECIFIC FORDS ON REVERSE SIDE
i .
I he Commonwealth of'Massachusetts
.Departrnent`of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
4
www.massgov/dia
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ilbl
Name (Business/Organiza6on/Individual). '
flu
Kim JJM,
A ddiress:
City/State/Zip: hone M 4 � _
Are you an employer?Check the appropriate b 'Type of project(required):
1.E3 am a employer with 4. I am a general contractor and I 6. ❑New.construction
employees (full and/or part-time).* have hired the sub-contractors
2,❑ I anrt a sole proprietor or partner-
listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance, g, ❑Building addition
[No workers' comp.insurance 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Ro repairs
insurance required.)# employees. [Na workers' 13 Other�
Jozm�.
corp.insurance required.)
Vny applicant that checks box#t 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. ,.
.ontractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers'comp.policy inftrmtatinn.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. —�---Y.
surance Company Name:
)liay#ar Self ins.Lic.#: Expiration Date:
b Site Address: City/State/Zip-
:tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
.e up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDPRand a fine
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
testigations of the DIA for insurance coverage verification.
'o hereby ce i nd r th pains anti penalties of perjury that the information provided above is true and correct
nature• Date:
ane#:
Official use only. bo not write in this area, to be completed by city or town offrciaL
City or ToWii• Permit/License
issuing Authority(circle one):
L Board of Health. 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
5. Other
�_'ontact Person: Phone#: '
MM]
A V CERTIFICATE OF LIABILITY' INSURANCE D02124t20 sD '
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'
PHONE FAX
TWO ALLIANCE CENTER C A1C No):
3560 LENOX ROAD,SUITE 2400E-MAIL
ATLANTA,GA 30326 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC#
100492-HomeD-GAW`-1617 INSURER A:Sleadtasl Insurance Company 26387
INSURED THE HOME DEPOT,INC. INSURER B'.ZUfich American Insurance Co 16535
HOME DEPOT U.S.A.,INC. INSURER C,New Hampshire IRs CD 23641
2455 PACES FERRY ROAD,NW INSURER D:Illinois Nalional Insurance Company 23817
BUILDING C-20
ATLANTA,GA 30339 INSURER B
INSURER F,
COVERAGES CERTIFICATE NUMBER- ATL-003741310-08 REVISION NUMBER-.0
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 ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MMlDDA YYl MMlDD1YYYY
A X COMMERCIAL GENERAL LIABILITY GL04BB7714-06 0310112016 0310112017 EACH OCCURRENCE S 9,000,000
Al TO
CLAIMS-MADE M OCCUR PREM NES fER EITEaccurI nce 5 1,000,000
LIMITS OF POLICY XS MED EXP(Anyone Person) $ EXCLUDED
OF SIR:SIM PER OCC PERSONAL&ADV INJURY $ 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000
X POLICY 11 JET
LOG PRODUCTS-COMPIOPAGG S 9,000,009
OTHER: 1 $
B AUTOMOBILE LIABILITY BAP 2938863.13 03/01/2016 03101/2017 COMBINED SINGLE LIMIT S 1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Par person) S
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE S
HIRED AUTOS AUTOS Peraccide
5
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMSMADE AGGREGATE S
1:4
DED I I RETENTIONS 5
C WORKERS COMPENSATION WC015519215(AOS) 03/01/2016 03/01/2047 X PER oTH-
AND EMPLOYERV LIABILITYSTATUTE I JER
C Y1N W0015519217 AK,KY,NH,NJ,V 03/0112016 03101!2017 1,000,000
ANY PROPR€ETORIPARTNERI"ECVTIVE � N I A ( E.L.EACH ACCIDENT S
D OFFICER/MEMBEREXCLUDED?
(Mandatory In NH) WC015519216(FL) 03101!2016 031011207
E.L.DISEASE-EA EMPLOYEE S 1,000,000
If ESCRIPTIONOr-O ConfinuedonAddilionalPae 1,000,000
e tinder
DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE-POLICY LIMIT 5
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Addillonal Remarks Schedule,may be attached If more space Is regulred)
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRI13ED POLICIES BE CANCELLED BEFORE
16000SGOODST. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee LoL�n Wca+~% lc rWv est
"u
01988-2014 ACORD CORPORATION, All rights reserved.
j ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
z� Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Kassachusetts 02116
Home lmprover �ontractor Registration
--- -- Registration: 126893
Type: Supplement Card
Expiration: 8/312018
THD AT HOME SERVICES, INC
RICHARD FALLONE
2455 PACES FERRY ROAD, HSC
ATLANTA, GA 34339 -- -
_ Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
SCA
", iia F-cq)l/)2Glgl(�rL�ff2 r'!
ffice of Consumer Affairs&Business Regulation License or registration valid for individual use only
—NOMEIMPROVEMENT CONTRACTOR before the expiration date. If found return to:
1 office of consumer Affairs and Business Regulation
2 Reglstratian�� 68� Type 14 Parr Plaza-Suite 5170
Supplement Card Boston;MA 42116.
THD AT HOME SERVIRCIES,1NG` -.
THE HOME DEPOT;AT"�Uf)Y E'R. VICES
RICHARD FALLONE;_ -=_r
2455 PACES FERRY R'F W-'-,-HSC - — —
ATUANTA,GA 30339 Undersecretary 4otalid with t A ature
I v-
H
CSSL-0996ag
s � P
ROBERT pOCZOB T
172 WHALERS LANE
SALEM MA 01970
02/0812018