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HomeMy WebLinkAboutBuilding Permit # 9/15/2016 IJILDI G E IT tdRTN' iNls TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit Flo#: ,.�, � - � Date Received ,, ��'SACHUSE^C Date Issued: "' �° _--_-- ___.. ----- IMP )WrANT: Applicant must complete all items on this page LOCATION P ° t PROPERTY OWNER MAP PARCEL: Print 100 Year Structure yes no ZONING C7ISTRICT: ..Historic District yes no Machine Shop Village yes no _ .......... TYPE OF IMPROVEMENT PROPOSED ISE Residential Non- Residential New Building One family C.1 Addition 0 Two or more family Li Industrial Alteration No. of units: 0 Commercial epair, replacement C1 Assessory Bldg F1Others: jD emolition f] Other _ M DESCRIPTION OF WORK TO pEg BE PERFORMED: a2 Coln Ident%i"catio - Please Tyne or Print Clearly OWNER: Name: Phone: Address: 5 '° Contractor Name: a1 Phone: � 1 _41 Email: Address: ail$� Supervisor's Construction License: ( +ft! Exp. Date:L ( t p / Home lrnproyemeqt License: Ex Date: f / ARCHITECT/ENGINEER Phone: Address: u 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: $ a&q.7 FEE: $ /6, / Check No.: Receipt II NOTE: Persons contractin w' nregistered contractors do not have access to I the grrrranty fund rR� MR- In/ Ir4]Nr'I e �li,(i j0 T a owe. of '00.L.-I.,� . �6 Andover _ ® D.Ts t —;X6 ri (% tAxE h ver, Mass, coc"Ic Kt WICK 1' 40 ATEU � u ' BOARD OF HEALTH Food/Kitchen E R IT T D Septic System 'PERTIFIES THAT ;'.*I... C.. .�►.*.�.. .! BUILDING INSPECTOR misslon to erect .......................... buildings on ,...co. . to.. fq!� ............. Foundation Rough )ccupied as ................................................................................................................................... Chimney led that the person accepting this permit shall in every respect conform to the terms of the application Final in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration.and ruction of Buildings in the Town of North Andover. PLUMBING INSPECTOR TION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI®N STA TSL Rough P Service ....... ... ,�. ....... ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® OccupE 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. Y CONTRACT# 0005005 LOWE'S AUTH0 "D REPRESS TATIVE - Nl1MBER 'g r CUSTOMER T _ E t1 _ A E.T O � fiE AGGR 6�d.t_ce 1. E55 ST d v��✓.aY 5� �,1$BCL S1"t��rJ . 7c- STORE NO STHE CITY STATE Zip TP - CITY STATE ZIP s ' �C Ala 4,L10ove A TELEPHONE ` TELEPHONE l 179 GAT LOWSS HOME CENTERS IACS MA HIC NO 148688 1.y CASH CZ LOC CHARGE FEIN 56-074835& k ,. - L.' a-.�.-u `r.� A nisi; -'�i{z'•r'"- a - ���'�E 0.vaS W0> elel - tbdnreBf,,�TefihGand-Cmdelbd�nx9 � *1! , INSTALLATION STREET DRESS CffY L^ _ STATE ZIP `�._...-. � � JT�uI<: ' -c c C- 4Ur� ovlr�.t. /ham D NOTICE TO CUSTOMER—PRICE CALCULATIONS:In order to property perform the installation of certain Goods,the Contract Price may include more Goods than actually will he installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of estimated Goods required to fulfit€the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfil[the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed. Are permits required for this installation?:[Ifles [ ]NoContract Total y applicable tax included �Sv9 NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right By signing this Contract;Customer acknowladges having received a copy of this pamphlet before work began Informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed In Customer's dwelling unit. NOTE:If ratted wood Is discovered during installation additional charges will ppl YpU will be.given a quote and a change order must be completed and signed by the customer for any additional charges. X., . 'Customer must Initial. 'Any work or material not specified is not Included In this contract.Any cfianges or additions will be at an additional charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and Independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use In all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs In print and/or electron€caliy,and agrees that Lowe's may use such photographs for any lawful purpose,inctu g,but not limited to,marketing, advertising,publicity,illustration,training and Web content.By snit€at rig here,Customer agrees to the foregoing. [Customer to initial to the left]. Work ist c m nae upon reasonable availability of Contractor and/or any special order o s er made Good(s)which is anticipated to be !(o [fill in date].Estimated completion date Is [fill in date]. Said estimated substantial completion date is not of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. COMPLETE~THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: (1)Deposit$ to be paid upon signing contract.Deposit should be 1l3 the total Contract price;and (2)Payment of$ to be paid anytime afterth€s Contract is signed and before commencement of installation,ilWe authorize Lowe's to do one of the fallowing(check appropriate box below): [ ]Charge mylour credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or .. ._ [ ]Deposit mylour check for the amount of the payment Indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both partes'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M G.L.c.142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c.142A.THE SIGNATURES OF THE PARTIES BELOW APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE BY LOWES.PLl@LSQANJTQM.G.L. E OWNER MAY BE PERMITTED TO INITIASE ALTERNATIVETE R EaN-WHERE THIS SECTION IS NOT SEPARATELYIGNED EPA .if customer'has a complaint which cannot he resolved Informally,the home Improvement Contractor Law(M.G.L.c.142A)may provide Customer with the right to request arbitration through a private arbitration program approved by the Director of the Office of Consumer Affairs and Business Regulation,as an alternative to court action.The same right is not afforded to Lowe's unless this Notice Is signed and dated by Lowe's and Customer- Cf ims by Customer orLowe's concerning this Contract which cannot be rosolved lnformalty,and which are.not covered by M.G.L. i ] c142A or subject to the'urisdlcti n of small claim• 6ourt,shall be resolved by binding arbitration as Wtonh'the General Terms and Conditions. By: �Zl �' Lowe's ad: adRepresenia' BY: Y. Customer DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF.THIS PAGE AND THE FOLLOWING PAGES OF THIS. CONTRACT.YOU ARE ENTITLED TO A COPY QF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HANDS)AND SEAL(S)BELOW Lowe's H e ent rs, Lowe's Aulho5 ed Representative Owfiar Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,ma cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. o IT Lane's®Lowes and 7119 Barrie dealgn _ �..�........ aro _mrar„a tranonwrks M mF Coreoratian. The Commonwealth of Massachusetts x x Department of Industrial Accidents 1 Congress Street,Suite IOD Boston,MA 02114-20117 www.mass.gov/dia lVorkers'Compensation Insurance Affidavit.Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. ArInlicant Information Please Print Le ibl Name (Business/OrganizatioMndividual): Ronald Address. j0 9,4& Dflile City/State/Zip: QLl44 I�1 t� a z 155 Phone#: 4 f 7- rJ"V-143b q Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with T, rnployces(full and/or pan-time).* 7. ❑New construction 21 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. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10 ❑ 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,❑Roof repairs 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 MGi.c. 14ther„ �IQ+4., 152,§1(4),and we have no employees.[No workers'camp,insurance required.] Any applicant that cheeks box Hl must also fill out the section below showing their workers'compensation policy information. t Itomcowners 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 my employees. Below is the policy and job site information. Insurance Company Name: x, rn Mvivt t -Thr nn a Co-, Policy#or Self-ins.Lic.#: A(JCG Vd—70A55 qT ”-AA1 14____ Expiration Date: .3 ,q- Job Site Address: Idiv 64;-64 CitylState/Zip: Attach a copy of the workers'compensation po icy 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 fanvarded to the Office of Investigations of the DIA for insurance coverage verification. I do Irerehy c the pains and penalties of perjury that the information provided above is true and correct. Si na ure' Date: Phone#: r Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2,Building Department 3.C41Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#• Page 5 GREEINS-01 LCARUSO ,4co�rvw CERTIFICATE OF LIABILITY INSURANCE DATE(MM)DD1YYYY) `•� 512612016 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 pollcy(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). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLCc°NNo Ext):(781)933-31 QO we No: (781)933-9048 445 Main Street E-MAIL Woburn,MA 01801 ADDRESS:Insurance.Services@Salemfive,COm INSURER(S)AFFORDING COVERAGE NAIL d INSURER A:Safety Insurance Company 39454 INSURED INSURER B:Safety Indemnity Ins.Co. 33618 Greene Installation Co.Inc. INSURERC:AIM Mutual Insurance Co. 0913 Ron Greene 10 Rita Drive INSURER D: Medford,MA 02155 INSURER E: INSURER P: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR 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 POLICY EFF OLIC E P LIMITS LTR INSD WVD POLICY NUMBER MMIDD1YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE NOCCUR X BMA0008519 0510812016 05108/2017 DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY D JEC ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 £a accident B ANY AUTO X 6208932 01/3012016 01/30/2017 BODILY INJURY(Per person) $ ALL OWNED �( SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X NON-OWNED HIRED AUTOS X AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION x AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIFTORIPARTNER/EXECUTIVE Y#N WC-400-7025594-2016A 03/0412016 03/04/2017 E.L.EACH ACCIDENT $ 500,000 OFFICE � .R/MEMBER EXCLUDED? N#A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,400 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Lowe's Companies Inc.any and all subsidiaries are named as additional insured as respects to the General Liability and Auto Liability policies per written contract or agreement. 30-Day cancellation clause CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc.and any and all Subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IS Insurance P.O.Box 1111 North Wilkesboro,NC 28656 AUTHORIZED REPRESENTATIVE xn(1� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD Office ui C insu er Affairs&Bus'�ess Regulation NOME IMPROVEMENT CONTRACTOR Type: Registration: 102957 Yp <L' Expiration: 713/2018 Private Corporation GRE' En INSTALLATION CO.,INC. Ronald Greene 10 RITA DRIVE �.- MEDFORD.MA 02155 Undersecretary II �,-