HomeMy WebLinkAboutBuilding Permit # 12/6/2016 N4R'Py
BUILDING PERMIT o�K'"IE 16'���
TOWN OF NORTH. ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: °" l 6 Date Received
SACHU
Date Issued:
.
I P RTA1wdT: A}plic ant must c,ornplete all items an this arc.
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TYPE OF IMPROVEMENT PROPOSED USE __ ---
- -
Residential Mon- Residentia
El New wilding 1-.1 One family
❑Addition 0 Two or more family C:l Industrial
❑Alteration No. of units: Ei Commercial
_.. _
O
+ epair, replacement D Assessory Bldg Dt ers:
Demolition Cl Other
D Septic Cl UU II [ Floodplain �- Wetlands � Watershed:Dist
r r
' r
r r
DESCRIPTION OF WORK TO BE PERFORMED:
-
identification _ Phoney
Please'Y'Yl re or Pant f lean
OWNER: Name: :
Address: __-- -
+
Contractor Iarr�e �
r r /,,,
>, ;Phone
Email ,
i
�up�rulsor s C�nstru�tMon License � +„ ,
r %
1 + rne, mprowrleit License '
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.: 7? 3 Receipt No.:
NOTE: Persons contractin I with rgnregistered contractors do not have access to the guaranty�uncl
'S • Signature of contractor a �
Signature of Agent/Own ” �"
VAORTH
own o
LAndover .
Ak® .�
h ver, Mass, 2i to
a LAKR ?
`S1A COCNiC"twicK`y
RwT E P P`4� (5
U BOARD OF HEALTH
Food/Kitchen
Septic System
THIS CERTIFIES THAT ...................
PERM ! TT
..... .... ', .......... BUILDING INSPECTOR .
has permission to erect......... ................ buildings on .... .... .. ... ... ......
....~...... Foundation
Rough
to be occupied as .... .. ... ,.. . .,. .... ......... �.. .. .... . .,. .. ................... Chimney
provided that the pe so acce tin this ermit hall in eve respect conform to the terms o e application p p g p every p pp 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
PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT N STARough
Service
.., .. ,/ZV
...................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy V Permtt Required t0 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.
HOME IMi`itt}x F.Nik\tt ON'It ACF
RI-AD IIIIS
tisrld,I uininlicd and Iri:€aEScd hti_
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Branch Name.Ar„Elle and tale:_ ll) Si,,eco li;c.
dli±ii, 1 he€luminc D"I",;At-11i i-
Branch\vmbrrc33 lti ltt„tnn Currtpil e-t`itit 1.Strev+,bnt).MA 01.4
1,,11 1 rcc 177-90*I-376'i
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t"I l it t*1IIC.Pz€„3m'�siiA l lIfrTllc Inaxrosenntsxt�t of,trret,�r it" - I-'A'193
Ensialtatiatz:lddress: _- ,5` 1�Lt' t`. 1.'t: /t/,_. r'ttYLltlL.i'-- ”-�0
-- -- tih, S(zte Zip
Pureh;iscr(s): _li- r6 1'honc'• Ilome Phone: Celt Phone:
Home Address:
{l€'dsllcna an,from In,tallation Addresal
tit} S'taft Zip
E-msit,itidress{to rac-cire pmfcet canunanicatioi'.aial tlonte llc#-ot tapdaic�h � _��---_L-1 11)0 1 1)0'«T t,iaz to receikeally!n zrl min ci zaii,Ir nz rile I i inc i)-ihn
Project information: Undrr.z,nad 1 Customer'),tile,u h -1 l di I r,p.t,locatad nz)Ile iban installation addrs>,sa l ac to bud'.
and TIM At-lWinc Scitiitc,.Ill,:-C')Ile Ilotne I)epnt )z,rcca ,hvzu,lt,d-litcr:ind orrni C li± chi imstalira int-Installation'*)1,
all maternal d+cribcd ,if the bei,,,, and oil tits rc€u nerd Spec Slzcct(c) all x I,chich are incorporated inti,thin Cim , t til chi,
retcrcnce.along,tit','am applicable Stene Suppienzcnt aril€'.t}m<nt Suinxntn-auachcd lxreto and any Chan c UrSrr.{-ulc�at,el4�.
"Contract"):
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\linimum a6l?a mir ofC-nnst�Y-Anawnr due ulxst rseaoh,n ofthis zntr-ia-t. -t mail contract A ill t S
1laine Purchs.erc mal not deI>ahir Warn than i�-thtni efzhe Cnnrract inxrune.
Cu �.t r t n i r ,tor i a t ! Ft I i t t t t ncr+,irl ctccntc ci C u I C e
an. SpCc a n h r:...ac due :1;apI€ica €e,malt tu:tc. r a
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Contract ,
NOTICE;Ttt t i SIO"E_E2
lore reoneiticd1Completion Pcrtitica tEletl r Clips aaah€i�cdil roduct a.defirittA bs f tie Contract at the fill' to liriidn:il\dxrt\Ixri 1
,7 ticiirlrrtork oilthatPnralua-t
theis
is compic tie.
In the e,ent of tcrminitiur of this C�ntr i (-ustn•n r a'rrr t pal 1 he llr,nie of€, t the costs of materials,IP r,rv�nu
and sersicc,pro,idrd hs I he 1p mr Ihp t ,r iuti nrca3\tr icr F'rnrul•r Q10111V DI xron h thr a 1 of trrmfnatlbu.Lia\\10tt\Is,
t)liEUaT{?
forth
rtF i€€h\i1 fiE F giilE rFrltfi\I llo—d
IIF tllil ISitis1IIlle 1'\Sr\11€\€lI OR wilt l.tiE�it Mt's 1Iti I\€lkill l) i\Itif\i+
LI>2tTIy(: FtlE-HOME tiEP{FI w tl IIiF 1t HE vin Tilts till,ItE t tt11 Is1 tit It t It ivItH v Iv { =
.leer tante anti \nth rata a,.n
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VINYL SlDiNG SPEC SHEET n�?3 ic1
ea:,nY DESCRIPTION OF WORK
f CUSTOMER INFORMAIION
Cx.
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1e`
5s kcC a;:. e,.- 3 t} 75!�
S..+y Ori
VINYL SSOINO
AREAS to IN,SIDED PRODUCT d PROFILE CORNERS COLOR(S)
C—Board Market Square Portsinouth Shaka Standard Srdincj
T CL3 Ri3rdl s C'.x:va-d .. . OIl:side Comers
F '
i o'%Lt tR3.VC, 45 DI:43:a^ H,n. Rplit( 55"IrLsula32d' $hakO
tk S 1 &ti€ S Sawn a Cta-t,,atL'i q,a y red �
R 2 Pc't'Ct-.n StKlk3 t_.1 ltd' NIA
Cc nV L 5. Oracles Carolina Sands Hall Rounds 0— INSULAT1ON: 19'� a
SS-D- Ya si 1~-L'lzu5- 'ami .imca.,,m .Ye;
N.
_..__ a-CFa board ''^gar a< vxeh,aNa6b HOUSEWRAP:
SOFFIT.FASCW,FRIEZE BOARD
AREAS is N COVERED
iZr1 Ea:a Lc R'aht Other Axeaa 'COLOR'
Sn1.18 Fara j
'Cares F—*8—d xi N' PVCC ave.CSI-7—� OR Ve,Sat`.tl_3 Tuck Fascia Uader G.— Yes� NO
CUSTOM WRAP WITH PVC COIL REMOVE L REINSTALL
O^: 'COLOR' r w O
....:r., Slatm Wnd—! ? A+anm uP IO$
Gari 'Raf.0 � SIM+n Da I A—m"O+e,tl-�
Dw.^`r Gt.-3x L'Rt I j B' r 8.rtr- Ea1SidR^y$MI.'.
Bungl r Bars Can by rtmaved.bbt ndt r I-tailed,
REMOVEE>USTING SFMr-* No= It Ycz: L'rrtyL'4YBW Alvn:r�urr.O
F—DWot wrC NOT rema.'e-b—l-main .
FUROVERMASO.NRY PORCH CER.ING.BEAMS&POSTS NEW ACCESSORIES
r
y`N S---.� i Calc, GABLEVENTS
� J
'COLOR' EKsxan
NEW SHUTTERS
SPECIALTYWRAPS 'rt `COLOR' Yat Part 'COLOR'
r <s I Ra:srd Paaei El
REPLACE ROTTED WOOD
Pty—d Sp—!t the
D 1 Sattdy Cha Lotaiioa
SPECIAL CONS TIONS
i ha+a
--d aad an sSrs—,.b ,d 1 h.——k-.d—d aDtM wroth R.
SPeti#!Tis a Cw —..b—! -d.ei tt Y Ye iw ICumfs* ) SWC S--
d r,,.d—1 is disco+-a+od AFTER rtrt` q the ee:a:n.i+,a ft4.w A a eaWd wt L•�__._—'DL ire§�rrm of aha,
mYrt.M+u bt Yn add.€met tax a+f Pea Sd.Ft t>;r Ft f-O}ewens.€aaI L--
a€anrSw t /jft+L_ Dv.
r< Whnt -Tlss Herne DeP Yat`aw.Cutwme+
TIze Coinnionwealdi of-Massachusetts
D qm
rtmeid of M(AcyYrialAccidents
L - tions
Offict qf nveyfi,al �
I Cr)?1,t,11TVS Street, SUite 100
M1 0,2114-2 M"
www.mrass, ov/dzrt
Wortc.ers' Compensation Lasitrance-Jiffida-vit: Builders/Contractors/Electricians/Plumbers
Applicant Wormation Please Print 1,
e "blv
Name (Business/Or-,anizationifndi,ridual): 17ALZ;
Address: J0 12
city/state/zip:
4EY5' Phone 9:
A k e ap ropi Type of project(required):
Are you an employer? Check the ap ropriate box:
i.F-1 I am employer with—_ 4. 1 am a general contactor and 1 6, C]New construction
employees(Rffl and/or part-time).* have hired the sub-contractors
Remodeling
2.1-1 1 am a sole proprietor or partner- listed on the attached sheet, 7. []
`These sub-contractors have 8. F1 Demolition
ship and have no employees employees and have workers'
working for me in any capacity, comp.insurance.r 9. ❑Building addition
p,ro workers, comp. insurance to. Electrical repairs or additions
required-] 5. ❑ We are a corporation mid its
officers have exercised their li.Rpt (ling repairs or additions
3.Ll Jam a hoMe0Woer doing all work:
0 tight of exemption per MGL 12. oftepairs
myself. [No workers' comp, c. 152, §1(4),and we have no F0,the,
insurance required.] 13. the
otnployees. N, o workers'
comp,insurance required.]
1'.- 'J'applicant that checks box 91 must also fill out the section below sbowing their workers'compensation paticy information.
t Homeowners who submit this affidavit indicating they ass doing all work and then hire outside contractors must submit a new affidavit indicating mch.
I Contractors that check this box must attached an additional sheet showing the umno of the s0-contractors and state whether or not those duftcs have
employees. If the Sub-cannactors have employees,they must provide their workers'camp.policy number.
I ayn an employer tit at Is providing workers'compensation insurance for ray employees. Below is the policy and job site
information.
a)
Insurance Company Name: A 116_� afil s "f
Policy#or golf-ins,Lic,ff: Wt Expiration Date:C,
Job Site Address: City/State/Zip: JI) YgA
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A oCMOL c. 152 can lead to the imposition of crkahal penalties of a
fine up to$1,500.00 and/or one-year jmprisorrment,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. Be advised that a copy of this statement may be forwarded to the Office Of
Investigations of the DIA for insurance coverage verification,
I do hereby certify thepains an enalties oftedray that the information provided above is true and correct
Date: c
Si c:
5ipat,rrc-.
Mono M-:
Official use only. Do not write in this area,to be completed by MY or tow"official.
0
f 'aL
e......e-,,,,,
V,
508 6-.
City or Town: PormitfUcense A
Issuing Authority(circle one):
1. Board o Health 2. Ruflding Department 3.City/Town Clerk 4, Electrical 7finspector5.Plumbing Inspector
6. Other
Contact Person: Phone
DATE IMMIDDNYYY)
AC" CERTIFICATE OF LIABILITY INSURANCE 02124/2016
`�
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:
PHONE FAX
TWO ALLIANCE CENTER a Alc Na
3560 LENOX ROAD,SUITE 2400 EMAIL
ATLANTA,GA 30326 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC#
100492-HomeD-GAW`-16-17 INSURER A:Sleadlast insurance Company 26387
INSURED INSURER B:Zulrh American Insurance Go 16535
THE HOME DEPOT,INC.
HOME DEPOT U.S.A.,INO. INSURER C:New Hampshire Ins Co 23841
2455 PACES FERRY ROAD,NW INSURER 0:Illinois National insurance Company 23817
BUILDING C-20
ATLANTA,GA 30339 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-003741310 OB REVISION NUMBER:O
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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MMfDD1YYYY MMfOOIYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY GL04887714-06 0310112016 03/01/2017 EACH OCCURRENCE $ 9,000,000
CLAIMS-MADE El OCCUR DAMAGE TQRENTEO S 1,000,000
PREMISES Ea occurrence
LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED
OF SIR:$1 M PER OCC PERSONAL&ADV INJURY $ 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000
X JERT LOC PRODUCTS $ 9,000,0(70
POLICY 0
OTHER:
B AUTOMOBILE LIABILITY BAP 293BB63-13 03!0112016 03/01/2017 coEa accidentMiBINEP SINGLE UNIT $ 1,000,000
X ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED SELF)NSURED AUTO PHY DMG
AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE S
HIRED AUTOS AUTOS Per accident
S
UMBRELLA LIABOCCUR EACH OCCURRENCE $
EXCESS LIABHCLAIMS-MADE AGGREGATE $
DEP RETENTIONS 5
C WORKERS COMPENSATION WC015519215(AOS) 03101!2016 010112017 X PEROTH-
AND EMPLOYERS'LIAaILITY STATUTE ER
C ANY PROPRIETORIPARTNERIEXECUTIVE Y!N WC015519217(AK,KY,NH,NJ,VT) 0310112016 03101!2017 E L EACH ACCIDENT $ 1,000,000
D OFFICERIMEMBER EXCLUDED? N/A
(Mandatory In NH) WC015519216(FL) 03101/2016 03101/2017 En DISEASE-EA EMPLOYEE $ 1,000,000
Dyes, IPTIONunder Continued on Additional Pae 1,000,000
DESCRIPTION!4F OPERATIONS below g E.L.DISEASE-POLICY LIMIT 5
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORO 101,Additional Remarks Schedule,may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED 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 1VL.auoraa t �i4�,c�r �t
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
F ffice of Consumer,Affaus.&Business-Re
guiatian
i� HOME IMPROVEMENT CQtITFiAG4R
r;J Registration 126893 Type:
Expiration 8/3/2018 Supplement Card
THD AT HOME SERVICES,INC
THE HOME DEPOT AT HOME SERVICES
MARK NIADNA .
2455 PAGES FERRY ROAT},..HSG _—.—
ATL'ANTA,GA 30339
Undersecretary
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