HomeMy WebLinkAboutBuilding Permit #869-14 - 456 SALEM STREET 6/2/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: gal --I4 Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
177
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TYPE OF IMPROVEMENT,
PROP USE
4
CQNTRACT CT IN
Re ' ential
Non- Residential
❑ New B ' ding
6 One family
❑ Ad ' 'on
❑ Two or more family
❑ Industrial
❑ Keration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ eSeptic� ❑ Welly❑�Floodplai'n
®.Wetlands < f
❑ 1Naters_lied�®istnct-
❑;Water/;Sewer,,��
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- _ -
— - _ -
DESCRIPTION OF WORK -TO BE PERFORMED:
Type or Print Clearly)
OWNER: Name:
ArlrirP-,c-
d,J
4
CQNTRACT CT IN
Adtlress._
d�r
r
Supervisor's �Constructionlicehse — T ` '�
Exp Date;_
r -� y�
tl'InR.i,5, rn��cmon�':ll;ironcc' � ��G�?��
_
Fxri data'
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000F THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $_��
Check No.:�% . Receipt No.: —'? -I- _
NOTE: Persons contracting with unregistered contractors do not have access tX t telguaronty fi
Plans Submitted [] Plans Waived 11 Certified Plot Plan 11 Starhped Plans 11
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
.-TYPE_O'F--SEW,ERAGEDISP_OSAL '
-
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco.Sales 0
: Food Packaging/Sales ❑
Private- (septic tank, :etc_
-Permanent Dempster on Site ❑
THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT-
COMMENTS
EVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
,: DATE REJECTED:
_❑
DATE:APPROVED
Reviewed on__ Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
a _
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tovv.-2 Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAIII M1 N' Temp Dump`ster on site yes., no
Located at <124 -Mair Street
Fire Departure �t `s""ignatiare'/date ,
COI*M.ENTS' _....
-:Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
Total land area; sq. ft.:
" ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER.Z®NE LITERATURE: Yes No
MGL -Chapter 166 Section 21A=F and G min.$100=$1000:fin.e
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The foi ow-ing-it a=list of the required -forms to be filled out W the. appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/0'r C.S.L Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cas<s if a variance or special permit was required the Town Clerks office must stamp tfi'e.decision from the Board of Appeals
that the apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
9
Location49,00
N o. oc 1 -114 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL
Check
27633
BuildirI6 inspector
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HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold, Furnished and installed by:
Branch Name: Boston Date; THD At -Home Services, Inc.
d/b/a The Home Depot At -Home Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657-5182; Fax (508) 756.8823
Branch Number: 31 Federal ID # 75-2698460; ME Lic # C 02439; RI Cont. Lic# 16427
/, CT Lic # 111C.0565522. MA [ionic Improvement Contractor Reg. # 126893
Installation Address: 5=(�_ Al. AU, r
City State Zip
UIV "'t't' Work Phone: Home Phone: een roone;
�
�_ l [ ] [ ?7A 683-
Home Address:
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
❑ 1 DO NOT wish to receive any marketing emails from The Ilome Depot
Project Information: Undersigned ("Customer"), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for the installation ('Installation") of
all materials described on the below and an the referenced Spec Sheet(%), 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"):
lGg� Gur,Y
Job #: ow—a ncrrm,cc) Pradnets- Sner Shpet(sl H: Proieet Amount
/
71�/ Z 2Cf?
ng ❑Siding ❑ Windows ulation
❑Roofi❑Ins
[]Gutters /Covers ❑Entry Doors ❑
j Cj .Z jatf,
$ 5��j 5
Roofing Siding ❑ Windows Insulation
$
[]Gutters / Covers ❑Entry Doors ❑
[]Roofing []Siding ❑ Windows ❑ insulation
❑Gutters /Covers ❑Entry• Doors ❑
[]Roofing []Siding ❑ Windows ❑ Insulation
S
[:]Gutters/ Covers ❑Entry Doors ❑__
Minimum 25% Deposit of Contract Amount due upon execution of this contract.
Total Contract Amount
$
Maine Purchasers may not deposit more than one-third of the Contract Amamt.
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable. each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home 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 perform its obligations due to a structural
problem with the home, environmental hazards such as mold, asbestos or lead paint, other satety concerns, pricing errors or because
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary # Y76'_-'2,5_0 , included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable)
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product
is complete.
In the 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 allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS,
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement 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 Installation. 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.
Accept y: Submitted
�
X
Customer's St tune Date Sales Consultant's Signature Date
X Telephone No. (�O' ; -•- :Z75--- y g'
Customer's Signature Date
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE, TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY. AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
r•rcoTr`i�coo ar •rr
Sales Consultant License No.
(as applicable)
a
ACCOE TIIT F LIABILITY I :ANCA
DATE (MMiOD/YYYY) ;
F 0 21 1 912014 a
I 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, EXTENT) 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(lies) 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
MARSH USA, INC.
TWO ALLIANCE CENTER
3560 LENOX ROAD, SUITE 2400
ATLANTA, GA 30326
100492-HomeD-GA'N-14-15
It;7SURED
THD AT-HOME SERVICES, INC.New
DBA THE HOME DEPOT AT-HOME SERVICES
2455 PACES FERRY ROAD
CONTACT
NAME:
PHONE FAX
N Et): A1C Noi:
E-MAIL
ADDRESS:
INSURER S` AFFORDING COVERAGE NAIC X
INSURER A: Steadfast Insurance Company 26387
INSURER B: Zurich American Insurance Cc 16535
Hampshire Ins Co 23841
INSURER C: p
INSURER 0: Illinois National Insurance Company 23817
INSURER E
ATLANTA, GA 30339
- .
INSURER F:
0310112014
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED. NOTWITHSTANDING
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERAS,
CERTIFICATE MAY BE ISSUED OR MAY
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN RI
LTR
TYPE OF INSURANCE
ADDL
SUBR
I
- POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MMfDD1YYYY
LIMITS
A
GENERAL LIABILITY
GL04887714-04
0310112014
03/01/2015
EACH OCCURRENCE $ 9,000,000
DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
X COMMERCIAL GENERAL LIABILITY
EXCLUDED
CLAIMS -MADE OCCUR
LIMITS OF POLICY XS
MED EXP (Any one person) $ ——
PERSONAL R ADV INJURY $ 9,000,000
OF SIR: $1M PER OCC
GENERAL AGGREGATE $ _ 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS -COMP/OP AGG $ 9,000,000
$
O aBBI ED SINGLE LIMIT 1,000,000
(EaX
X I POLICYPRO- LOC
BAP 2938863-11
03/0112014
0310112015
B
AUTOMOBILE LIABILITYEC
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
ANY AUTO
ALL OWNED SCrHEDULED
SELF INSURED AUTO PHY DMC1
AUTOS
SAUTOS NOTO WNED
PROPERTY DAMAGE
(Per accident $
HIRED
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
HCLAIMS-MADE
C
DEDRETENTION
WORKERS COMPENSATION
WC049101882 (AOS)
03/0112014
03101/2015
X WC sTATu- OTH-
LIM T_C
E.L. EACH ACCIDENT $ 1,000,000
AND EMPLOYERS' LIABILITYWC049101884
YN
(AK, AZ, VA)
03101/2014
03/0112015
ANY PROPRIETOR/PARTNER/EXECUTIVE
N I A
1,000,000
D
OFFICER/MEMBER EXCLUDED?
WC049101883 (FL)
0310112014
0310112015
E.L. DISEASE - EA EMPLOYE $
1,000,000
(Mandatory In NH)'
If yes, describe under
E.L. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
03/0112014
03101/2015
(EL) LIMIT 1,000,000
C
WORKERS COMPENSATION
WC049101885 (KY, NC, NH, VT)
C
WC049101886(NJ)
03/01/2014
0310112015
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
EVIDENCE OF INSURANCE
IN
THD AT-HOME SERVICES, INC.
DBA THE HOME DEPOT AT-HOME SERVICES
2455 PACES FERRY ROAD
ATLANTA, GA 30339
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee�"-
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
NaM{13tistness�UrganzzaL��,uu�u�,..0 1
Address. `.
C tyMAI.
M.¢y, t{jpptePx Type of prosect (rec}aired):
pp
t: s
New cCO
tzaCtoF and I -.� � F _�: ,� � 4 ❑ � �m 6 ❑:onstrution
Imp h ve d ate Buil cdntractors delui '
Alf, C ��
l B* e� luted on tie at�tche sea
2 0 In Soerdi OttF 'These>b-contkactors have 8 [� DemQlihon
slI acid haven g�oetis emplQ�+epsdh"ave woxkers' g ❑ guildulg addition
vvoxkvng for �e trin�daaity . com �nswrance t
1p.❑Electrical repairs or additions
0. orkers' pompsiance 5 ❑Vire fire a co>pozatlon and its
re aired Plumbing re M or additions
�. ; ].; peers laavP e�e�a>:sed tEieir 11 [� �' .
3 ❑al.t� hgn4eamer do►g all worl n t oXempt�on per MGL 12 �] repairs
o workers} edm -, -
mysel€ and vK0 have .. no
13 Other
tnct>i �nCe xeglitred ] t p workers'
e�p�oyeea; �N.
comps uisurance required,]
iPc
iL
a plicant that clecic5 boX #2 rout also fill out the Season belowhowiug theiE a u ide eone,nsittors. must submitt a new affidavit indicating such•.
°AnY P K do vedtk, d then hue Q
1 Igmeo avn4rs who �ubrrut`this a$ina}�t Indicating t}iey are . Ingi
Eontractors ffiat cbe�k flits bomust attached an add�ttonal sheet snomg the time of the dub contractots and state whether ox not those entities have
' Io ees th must prov�c�e they 1v�1r?4erg comp �SoltcY number
etnpYoYee� if the sub-cQAtractots have Y ; ` 4 ee� Below as the policy and job. site
I10 0 90 .9 er Ilea{ �F
ro�adt�g wotkers' compeaassoaa assurance %r rs�y ernp }�•
tri, forawt><. :.
lnstzr�nce Co>npy?e
Expiration Late
Policy # or Self ins Lic .# U%---_
City/State/Zip l 1
JohSite Ad&' tie KY.number ana3 expaaation date)•
r eaesa4�om ®dac tleelaraon gage (sln®vanmgosltton.of criminal penalties of a
attach a coax ® thy£ qv@rkexs' C,Qffip p Y
Eaillue to secure eov�tage as xequed iit�deftiSectxon 25A of MGL c 152 can lead to;th6.=
p
0.0 00 and/or ons year unprisonmene; as well as civil penalties. in the`. form . b forTwardedOo th Office of d a fine
fine up o 1,5 . Ba aaYlsed that a copy of this statement m y
of up to $250 Oil a day aga>nsk the �iolat4�4
in�testigahons e for uisurance cove YeLlhlcahon
s 1 ate®ra i®vaaled cab®ve as a as c�rtect, .
Z;d'oreby ce
asn esaltae� o er eery fleet t9ce.aaefr®rive
Date. ....
.KIP