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HomeMy WebLinkAboutBuilding Permit # 5/13/2015 BUILDING PERMIT taoRrH q. OF�tLEo Ib�•YO TOWN OF NORTH ANDOVER 00 APPLICATION FOR PLAN EXAMINATION ` .A _ 4( i` :." 4 � �J oo wp t Date Received �, �.� « Pf Permit IVO}}'. ,4 rEu Sa1f S f�V CHS Date Issued: A1 IMPORTANT:Applicant must complete all items on this page LOCATION Pint PROPERTY OWNER Print 100 Year Structure yes 6no MAP�C PARCEL: I ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑AXeration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other s = r€ ❑ Flood a lain ,❑Wantls \Natershed ,District I _616�` �r �_ ,%,✓a Water/Sewer"'� t,:.'�f 1�y,. ''€,.��f ,...,2;"".`,,,.vY ''. ", `tm'""'„r/^r ,... ,,�' ,ki r,srs,,, r.r;re." ✓. ,i..: ,.,€�"c'�.?.,' ,`;1�";";'" �F `1 �. �v,fl,,.. �- - RIPTION OF WORK TO BE PERFORMED A149 r P= Identificat' - lease Type or Print Clearly h® _ ''� y OWNER: Name: 16r - Phone: l� Address: Contractor Name: Phone: 74 Email: Address: cry Supervisor's Construction License: � z � Exp. Date: / I � , Home Improvement License: / Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ I a l �r Check No.: I� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to r fund r1� r, 'I tkORTH Town oft E I�l Andover 0 : - ® y h ver, Mass, cw oLAKE 1. COC HICHt W.CK V �d TIE 1) S V BOARD OF HEALTH Food/Kitchen rERMIT T LD Septic System THIS CERTIFIES THAT 1 BUILDING INSPECTOR se6K...................................... ...........................................................................I...... Foundation has permission to erect .......................... buildings on .Iz . 5 .; + ...•••••...••••••.••.•••••• . .... ... Rough .,.... to be occupied as ...... .................... .. ........... .............. ...! ",\!!e+ C.4�. .. 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. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA7S Rough Service ............................. .. .. . ... . .. ... ............ Final ILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BuildlnRough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by: Branch Name:Boston North&South Dater/ THD At-Home Services, Inc. d/b/a The Home Depot At-I-lone Services Branch Number: 31 and 33 908 Boston Turnpike, Unit 1,Shrewsbury, N4A 01545 Toll Free 877-903-3768 Federal fl)#75-269ti4W IME Lic#C 02439;Rl Cont.Lic# 16427 CT Lic#HIC.0565522;NIA Home Improvement Contractor Reg.# 126593 Installation Address: 1 66757A I � City State Z p� Pm c aser(s): Work Phone: Home Phone: Cell hone: Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive prgject communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails from The Home 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 on the referenced Spec Shect(s), all of which are incorporated into this Contract by this reference, along with <my applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): ,lob#: Oniernal Reference) P Odnets: Spec Slieet(s)#: PrQject Amount / ❑Rooting ❑Siding Vindows ❑ Insulation alt/ D ❑Gutters/Covers Entry Doors ❑ ❑Rooting ❑Siding El Windows ❑ Insulation ❑Gutters/Covers ❑Entry Doors ❑ "Roofing ❑Siding ❑ Windows ❑ Insulation ❑Gutters/Covens ❑Envy Doors❑ ❑Roofing ❑Siding ❑ �Vindo,vs ❑ Insulation �- ❑Guttel:s/Covers ❑Entry Doors ❑_ il,fininium 25%Deposit of Contract Annount due upon e.xecafion of this co— TN IaincPmrhasel n>ay not deposit more than one-third of the ConttactAmount. Total Contract Amount 2—1 Customer ogees that, immediately upon completion of tae 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 (Inc. As applicable, each Customer under this Contract agrees to be jointly tend severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products) included herein, at its discretion, if The Hume Depot or its authorized service provider determines that it cannot perform its obligations due toZ1 structural problem with the home, environmental hazards such as mold asbestos or lead paint, other sal'cty concerns, pricing errors or because work required to complete the joh was not included in t pe ontract. I�ayment Surn'nmar'a`: The Payment Summar7(9 y #_-A%C0 — included as part of this Contract, sets forth the total Contract amount and payments required for the deposits Mud final payments by Product(as applicable). NOTICE TCI CUSTO1bI> R YOU aiT entitled to a completely filled-in copy of ale Contract at the tintc you sign. Do not sign a is complete, Completion Certificate(note: there is one Completion Certificate for eaell listed Product as defined by individual Spec Slpeets)before «�oilc on that Product In the event of termination of this Contract, Customer a-tees to pay The Home Depot tine costs of materials, labor, expenses and Services provided by The Horne Depot or Authorize(I Service Provider through the date of terndnation, plus 'any other amour is,yet forth in this Agreement or allowed under applicable laiv. "IIIE HONIE DEPOT MAv wrrm-101,1) AMOUNTS OWED TO THE HONIE DEPOT FROG-1 THE DEPOSIT PAYNTENT Olt OTHER PAYMENTS MADE, WITHOUT L1')MITING THE 110NNIE DE POTS O'T'HER REMEDIES FOR RECO�`ERV'OF SUC H AMOUNTS. Accelptance and Authorization: Customer Drees and understands that this -agreement is the cnlnC a-rceantni bettvectp Custc;nncr and The I Iome Depot with t'eoard to the Products and Installation ser Vice, and supersedes all prior discussions and agreements, either oral of written, relating to said Products and Installati<m. This Agreement cannot be tssi-ncd or amended except by a writing sinned by Customer and The Home Depot. Custom ' ael:nowlcdges MId agrees that Customer has read, understands, voluntarily accepts the terms of and has received a copy of this Aoree el . Aeted 1p, Submitted 1p4': l Work area will be contained Pre-Renovation Fora NAT-19276-1 Date: g1l) t This form is used to document compliance with the requirements of the Federal Lead Based Paint Renovation,Repair,and Painting Program after April 2010. Customer Address Job Numbers) OCCUPANT CONFIRMATION C3 NF1 13tV1AT10N Dust will be minimized Pamphlet Receipt I 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 F; performed in my dwelling unit. I received this pamphlet before work began. Rome Year Built Enter the year my home was built. M3 If my Nome Year Built is Pre-1978,my home requires lead paint testing to determine whether Lead-Safe Work Practices are necessary per EPA or State regulations. Work area will be cleaned up If my Home Year Built is 1978 or after, Lead-Safe Work Practices are not required. thoroughly �'�...r a?�T�� �;'"`a',. are a•, �`�` � c �� y" r �P Printed Name of Owner-occupant d �4 C gnature of Owner-occupant Signature f P rso;C5 yi ead Pamphlet Delivery EE STATE SPECIFIC FORMS ON REVERSE SIDE - ' � enelgy�tai.nrcan—rnean.gc•ca • Remove label.after rural Inspection; SAVE lar tutu re relerence Weather Shield CPDa 050 A-172 p e�a�ing 0-?,rftC Model 8108•Double Hung p Alum clad Thermal Frame 31A inch Glazing , liNl�f'r :n 022 Low Fr-amp- -E we�aa. ZD—E . Argon Fill Griile in Alr Space ENERGY PERFORMANCE RATINGS Sow c�r SA_P itklnc151 ADDITIONAL PERFORMANCEoRIA RATINGS Ylfl6lt lrtnlmtllao�c o 0.40 hrm m ypPnc.blf HFnC Procadul t br crnmw cc HFA'Hing'f NFRC dou aoI =-n'rT'c"d urcubc><rru ctpulttt hit 1gr9 ningsro° rodrei'lass d.ltnrlalnq •hdt ptvdfd r�iryr P al1c todad m+ ���edtc usa. Lird cal of.arlronmtnW cvndiAi h .++d u� ctbnr,HCl InbmuEcn. f ��product rnd'doct nil rt:ranl tfia wl Md o P LZrosull mmuladunl f Rl1fl11rf br eQwrWwutlltrn.0 ulr►manit C, Air Inllrtrstlon Pc end LE.G• Mrals or ezcead, N.EC., C.E.G.• 1KSIU.A u)j"WDx IWLs.2-17 ltpcdtd (D P) (ps�l H-LC35 t< 1tsr.dt.uIA'UWOUe-CA loin UTA"T-OS N-LOS 111"TZ"1u2901 I pet VW9rttbrtl "• Olean ' ' 610ISCQtI.118SiQ rrnKidldr,-1-1 — —_-. The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 _ www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMMING AUTHORITY. Applicant Information Please Print Le ibl Name(Bus iness/0 rgan ization/individual): Address: City/State/Zip: =Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.F-1 I am a employer with employees(full and/or part-time).* 'l, E]New construction 2.f-]I am a sole proprietor or partnership and have no employees working for me in $, F�Remodeling any capacity.[No workers'comp.insurance required.] . 9. ❑Demolition 3.F_1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F�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 prietors with no employees. 12.Q Plumbing repairs or additions 5V I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. of repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Fj We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subprit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit i dicating 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 providirtg workers'contpertsation insurance for my employees. Below is the policy and job site information. �)6t2C l� Insurance Company Name:_A4W 1/)�� Policy#or Self-ins.Lic.#: wcl�14 0 ®! Expiration Date: Job Site Address:- ( 6�1 �l/�� rd%/ i/� 2-141' 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 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cernN�nand naltie erjury that the information provided above is true and correct Si atu Date: Phone#: Of use only. Do not write in this area,to be completed by city or town official. 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#: CERTIFICATE LIABILITY I °ov 420150IYYYY) 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(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). CONTACT PRODUCER NAME: MARSH USA,INC. PHONE TWO ALLIANCE CENTER ac No: 3560 t.ENOX ROAD,SUITE 2400 EMAIL ADDRESS: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIL A 100492-HomeD-GAW-15.16 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co 16535 .THD AT-HOME SERVICES,INC. New Hampshire Ins Co 23841 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685-09 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 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 ALL4VE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL UBR POLICYEFF POLICYEXP LIMITS LTR TYPE OF INSURANCE INSR WVQ POLICY NUMBER MM/DD MMIDD g,000,OOQ A GENERAL LIABILITY GLO4887714-05 03/0112015 03/0112016 EACH OCCURRENCE S X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S 1,000,000 CLAIMS-MADE a OCCUR LIMITS OF POLICY XS MED EXP(Any one person) s EXCLUDED OF SIR:$1 M PER OCC PERSONAL&ADV INJURY S 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 9,000,000 PROT LOC COMBINED SINGLE LIMIT S 1,000,000 B AUTOMOBILE LABILITY BAP 2938863-12 03/01/2015 03/01/2016 E7X POUCYa cadent g ',.. AINY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIREDAUTOS AUTOS eraccident X 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ C WORKERS COMPENSATION WC017731493 (AOS) 03/01/2015 03/0112016 X vJCSTArT OTH- AND EMPLOYERS'LIABILITY YIN WC017731495(AK,KY,NH,NJ, 03/0112015 03101/2016 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 D OFFICER/MEMBER EXCLUDED? a NIA yyC017731494 FL 03/0112015 03101/2016 1,000,000 '.. (Mandatory In NH) ( ) E.L DISEASE-EA EMPLOYE S If yes,descr be under Conitnued on Additional Page E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS belay DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addltlonai Remarks Schedule,if more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Kerma Services / 4U1 "Lot)Lt$00 p.l �� �/ 9'L2i �(/�'i�?�i2•�!�-�ir..l�,��`7/ tJ��t;ti.�:1�1��-IiGU,�f�iG'U,l . Office of Consumer Affairs and Business Regulation .. . 10 Park Plaza ® Suite 5170 Boston, Massachusetts 02116 Home Improvement'Contractor'Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8/3/2016 RICHARD TROIA ---------- 2690 CUMBERLAND PARKWAY SUITE 3Q0 . --- ATLANTA, GA 30339 -- _.....___ ........_. _ Update Address and return card.Roark reason for change. SCA i Address J Renews! "mployr;+c:: J ost Crirc. orrice of Cunsumer Aft'airs&Busincss Regulation License or registration valid for individul use only r, k{OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: .126b.93 TYPO: 10 Park Plaza-Suite 5170 Ex ration..BM2016 . Supplement Card Pt PP! Boston,MA 02116 THD AT HOME SERVICES,INC. THE HOME DEPOT AT'HOME SERVICES - RICHARD TROIA 2690 CUMBERLAND PARKWAYS 9� I GA 30339 Undersecretary t valid wi out signature BROVIIN 'A ............. '10 NORTON AVE Manchester NI-I 03109 06/26/2016