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HomeMy WebLinkAboutBuilding Permit # 3/2/2017 BUILDING PERMIT QF `'°sT" TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ~ _ Permit No#: i q- ,o 17 Date Received 3- �ssRCHu��� Date Issued: LWORTANT: Applicant must complete all items on this page LOCATION ... _ Pnnt PROPERTY Pnnt 100 Year Structure MAPPARCEL Al _ �, ZONING DISTRICT .. Hrstic District yes no' Machine Shop Village yes no TYPE OF IMPROVEMENT PROP ED USE Res' ential Non- Residential ❑ New Building one family ❑Addi n ❑ Two or more family ❑ Industrial ❑6gration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well F1 W' Wetlands ❑ Watershed district ❑,water/Sewer'..' DESCRIPTION OF WORK TO BE PERFORMED; T/LULTU fZ0- L 0AItIC�FS Tdentifxcati Please Type or Print Clearly (� OWNER Name: ��' 1`e. 'L 0 1!0 Phone:-1� ��° 73 Address: t 14 4)o LJ Goritra -tor Name. �c t Phone. . .. �,Address Supervisor's Constructian LEcense exp, Date Home lm rovement License: E D to � + P xp a ARCHITECT/ENGINEER Phone: 1 Address: Reg. No. FEE SCHEDULE:BULDING PERMIT. $12.00 PER$4000.00 OF THE TOTAL.FSTIMATED COST BASED ON$125.00 PER S.F. dotal Project Cost: $,_5� FEE: $_ , Check No.. . Receipt No., ,_ NOTE: Persons contractin with unregistered contractors do not have.acres to the gua anty fund -- - 5�grature o Ag nt/Owner i c S►gnature of cantracte� TC ca ✓ ..................................... ............................ ------- .. ..... ............ T OORTH own of over ® No. ` �/ _ JJ CO L^K1 ver, Mass, OIL jL0 r0c.0c"t 0 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .....AMA__4#9 .¢.....11 BUILDING INSPECTOR . ........ ..#-Ctab i .,. ... has permission to erect .......................... buildings on ... ........ ........ Foundation Rough to be occupied as ..........1.Q01.(00­1"*A+­....W!ftb"S....... ............. Chimney provided that the person accepting this permit shall in every respect conform to the terms of thea pplication 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 IN 6 MONTHS ELECTRICAL INSPECTOR, UNLESS CONSTRUCTI A S Rough "T' Service ....................... .......... ..A.... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy By 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 Depot Contractor License Numbers: MA Home Improvement Contractor Reg,#126893 Salesperson Name and Registration Number: Leonard Racite : R-1-073-14-00023 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: a Medolo oston North 9851519 u:r --- First Name Last Name Branch Name Ue—ad_ff 64 Meadow Ln, North Andover, MA [NOR7TH ANDOVER I M F1 845 tuttorn,e_rAddross State zip 1(978) 683-7383 1 Home Phone# Work Phone# Cell Phone# tonylaura25@verizon.net Customer E-mail Address NOTICE OF RIGHT-TO CANCEL-:YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address city State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: 02/16/2017 XCustomer's signature Date Contract Price and.,P"mentSchedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. Includes all applicable discounts, rebates, and , taxes. Contract Price $ 5977.50 Excludes finance charges.* Minimum %deposit$ Due Immediately Remaining balance $ Due upon completion Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will F]will not V be used to pay some or all of the total amount of sale. Description-0 Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipgted a9#yM_Qate / Installation Schedule Approximate Start Date: 04/13/2017 Approximate Finish Date: 05/11/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. choose. If you Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. E _]— " Initial arrange for Service Acceptance and.Authprtzation- By signing below, you authorize Home Depot to (a) arra Provider to perform Installation and/or (b)order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. Date X1 Customer's Signature Date Co-Signer(if applicable) 02/16/2017X I — Date Sales Consultant's Signature License number(s) held by or on behalf of the Home Depot: 2 I 71se Commonwealth of Massachusetts Department ofrndustrialAccidents ' Off of Investigations s a 1 Congress Street,Suite.100 r Boston,AM 02114-20.17 www mass.gov/dia ' WorkersCompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1 Applicant Information Please Print Le 'b ly Name (Business/0rganization/Individual): Addxess: 17 a City/State/Zz : G o S�SPhone#: Are you an employer?Check the appropriate box: Ty;E] f project it 1.❑ 1 am a employer with 4. fg I tun a general contractor and 1 ? employees(frill and/or part-time). have hired the subcontractors 6. New construction listed on the attached sheet. T ❑Remodeling I 2.❑ 1 am a sole proprietor or Partner- These sub-contractors have ship and have no employees 9, LJ Demolition employees and have workers' working for me in any capacity. 9. ❑Building addition [No workers' comp.insurance comp'i a corpora ❑Electrical5. ❑ We are a corporation and its 10. lecUrical repairs or additions required.] 3.El l:am a homeowner doing all work . officers have exercised their 11.E]Plumbing repairs or additions right of exemption per MGL myself. [No workers camp. 12.0 Ro rep s i t c. 152,§1(4),and we have no / insurance required.] 13. Cher ! / _ I employees. [No workers' comp.insurance required.] *Any applicant that checks box 41 must also fill out the section beiow showing their workers'compensation policy information. t Homeowners who submitthis affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name oflhe sub-contractors and state whether or not those entities bava employees, if the sub-contractors have employees,they must provide their workers'comp.policy number. Insurance for my employees. Below is thepolicy andjob site Y am an employer tlrat is providing workers'compensation infonnation. Insurance Company Name: I tI?�d/ " ��� t/i-e °— Policy 4 or Self-ins.Lie.#: Expiration Date: , Job Site Address: City/State/Zip: 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 of MGL e. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby certify d r i.ltetrains and enalties of perjury that the information provided above is true and correct; Si ature: l%� int Date: �J Phone t Off ictal use only. Ao not write in this area,to be completed by city or town oft7ciaL II i 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#: ,ACC®® DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 02/1712017 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: TWO ALLIANCE CENTER PHONE CN o Ext.k No: 3560 LENOX ROAD,SUITE 2400E-MAIL ATLANTA,GA 30325 ADDRESS: INSURER 5 AFFORDING COVERAGE NA1C# 100492-HomeD-GAW-17-18 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:Agri General In511ranco Company 42757 HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD BUILDING C-20 INSURER D; ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003741310-11 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. INSR ppp OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDlYYYYI IMWDDIYYYYVLIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 310022 03101!2017 0310112018 EACH OCCURRENCE $ 9,000,000 CLAIMSMADE F-7-1 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence S 1,000,000 LIMITS OF POLICY XS MED EXP(Anyone person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL a ADV INJURY $ 9,000,000 GENT AGGREGATELIMITAPPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY El PECOT- F—]LOG PRODUCTS-COMP/OPAGG $ 9,000,000 OTHER: S A AUTOM0131LE LIABILITY MWTB310021 03/0112017 03/01/2018 CEa OMaBINEDnt SINGF E LIMIT $ 1,000,040 ccide x ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY Per accident S AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Par accident UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAW&MADE AGGREGATE $ I 1T DED RETENTIONS $ B WORKERS COMPENSATION WLR C49112300(TN) 03141/2017 03/01/2018 X PER OTH- C AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETORIPARTNERIEXECUTiVE Y!N WC 023102423(AK,NH,NJ,VT) 03101/2017 03/0112018 E L EACH ACCIDENT $ 1,000,000 C OFFICERIMEMBEREXCLUDE[ E NIA (Mandatory In NH) WC 023102424(WI) 0310112017 03/0112018 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under Continued on Additional Pae E.L.DISEASE-POLICY LIMIT $pESCRIPTtON OF OPERATIONS below 9 1,000,000 DESCRtPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is requlred) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1C0.00SGOODST. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. 9 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukherjee _ Ceti,err: ,e4u"Lh�.s,L ©1988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 100492 LOC#: Atlanta ACC?R" ADDITIONAL REMARKS SCHEDULE Page 2 of NAMED INSURED AGENCY HOME DEPOT IJ.S,A,,114C, MARSH USA,INN, DIBIA THE HOME DEPOT 2455 PACES FERRY ROAD POLICY NUMBER BUILDING C-20 ATLANTA,GA 30339 NAIC CODE CARRIER EFFECTrVE DATE. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE. Certificate of Liability Insurance 'Norkers Compensation Continued: Carrier.Indemnity insurance Company Of North America Policy Number.WLR 049112294(AL,AR,FL,ID,IA,KS,KY,LA,MS,MO,NE.NM,ND,OK,SC,S0,WV,'ivy) Effective Date:0310112017 Expiration Date:03/0112018 (EL)Umit:31,000.000 Carrier:Now Hampshire insurance Company Poky Number WO 023102422 tDC,DE,HI,IN,MD,MN,MT,NY,RI) Effective Date:0310112017 Expiration Dale:031020i 8 (EL)Limit 511,000,014 Carrier.ACE American insurance Company Poilry,Number INCV C49i 12282(QSI)(AZ CA,IL,NC,OR,VA,'A!A) Effective Date:0302017 Expitallon Date:00112018 (EL)Limit$1,000,000 SIR:$1,000,000 SIR for the states of AZ,CA,IL,NC,OR,VA,WA Camer:National Union Fire Insurance Company Policy Number,WX 6583144(QSI)(CO,CT,GA,ME,MI,NV,OH,PA,UT) Effective Data:0310112017 Expiration Dale:03101018 (EL)Unut S1.000,000 $1,000,000 SIR for the states of CO,MEMV,Ml,OH,PA,UT S750,000 SIR for the state of GA 5350,000 SIR for the state of CT Camer National onion Fire Insurance COMP3AY Polo Number.XWG 6583145(OSI)(MA) Etfectiye Date:03101/2017 Expiration Dato:03001016 (EL)Limit 31,000,000 SIR:5500,000 TX Employers XS Indemnity Carrier1flinlos Union Instrance Company Policy Number,TNS C48613202(TX) Effective Date:0310112017 Expiration Date:0310112016 (EL)Limit$10,000,000 SIR:111400'000 2008 ACORD CORPORATION, All rights reserved, ACORD 101 (2008101) The ACORD name and logo are registered marks of ACORD fit and Sl,,�ndl�.Vds CSSL-099699 ROBERT POGZOBUT 172 WHALERS LANE SALEM MA 01970 02108/2018 lie crtairtrvuuealf/r.�^illtr��rrc�rr eC7 fete of Consumer Affairs&Business Regutatiou ` HOME IMPROVEMENT CQNTRACTOR Registration 126893 \ Type. Expiraiion..8/3/2018 Supplement Card THD AT HOME SERVICES INC THE HOME DEPOT ME?SERVICES MARK NIADNA 2455 PACES FERRY ROAb. HSC _— ATWTA,GA 30339 Undersecretary