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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 %AORTN 9 O At�eo 6 ti BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ® 4 Date Received ^1 �OATeo 9SSACHU`�ti� Date Issued: tilt 11 MPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Y "t1 Print MAP NO: PARCEL: 'Z:ZONING_DISTRICT: Historic District yes n ;Machine Shop Viffage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building .<One family ❑ Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition E-Other ❑peptic ,,[:],Well ❑ Floodplain q-Wetlands ❑ Watershed.District Q Water/ ewer J Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: D J �0. f'-1 PI CONTRACTOR Name: Phine: Address: "Ad' 144)'M-Oe,�Af ' 4 Supervisor s,Construction License: Ex .� Date: Home Improvemenfi License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASE ER S.F. Total Project Cost: $ ,� � � FEE: S / Check No.: ," Receipt No.: ] P.M Persons contracting with unregistered contractors do not have access to t �guara7t fund Signature of Agent/Owner Signature of contractor in 4. t%ORTAlk AIL Iva v r"& r Town of .� y, ® • ,T_ _ T _ ' it h ver, ass, COCMICMIWICK �•9 A° grEo P �(C, Kmmm I -[ I- LDBOARD OF HEALTH Food/Kitchen P E Septic System THIS CERTIFIES THAT ............ . . .. . . ....................................................... ............................. ........... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ....��..:�........,�. :. . .... ............ Rough to be occupied as .... ..... .1: ..... ' .... ......... ......................................................................... Chimney provided that the person accepting t 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 VIOLATION of the Zoning or Building Regulations voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESSSr Rough — Service ............... ............................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BulldinRough 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. t SERVICES SOLUTIONS INSTALLED SALES CONTRACT MT . AL ITHORIZEDR FRES TA11VF NUMBER CUSTOMER —,) ----1 STREET ADDRESS I STREET, ADDRESS CITY � - STATE ZIT ' LITY i STATE JC, TEt EPH07 r � i DATE I.OWES CONTRACTOR LICE E NU,`.16ER ILL, ASN PWT: 1 C Fn Ct4}fil;r 7 This is rr t a q I r r d mer,_d;,.itand eth pr led Cel,h Tars 6ecemts an a9r6smehl upon payment.Upon pryment,tha enti e.,greemen Budin tha dxamen4 Inc Tomu and Cond+rions inGdded xitti Ins deq,mml and ary other aJdenda and altadiments herato.sha7 be reforred to hereto as this CvnVacL' PLEASE READ All TEWda"AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING, g specif n?y wmp'eled pages of this INSTALLATION STREET ADDRESS t-i r.a CITY STATE ZIP I t , — t z. _ r f t r , i r / i — a i a t , , 1 + , NOTICE TO CUSTOMER-PRICE CALCULATIONS.In order to properly pe�o m the f` installation of certain Goods,the Contract Price may Include more Goods than actually 1 vvill be installed based on the measured square footage of the Project Area.As a result, the parties agree that the lump-sum Price slated in this Contract is calculated upon both the value of estimated Goods required to fulfill 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 fulfill 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 and Total refunded once the Installation Services are performed. `applicable taxes included i NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamphlet Renovate Right.By signing this Contract,Customer acknowledges 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:ff rotted wood is dissevered during installation additional charges;wfll apply.You will be given a quote and a change order must be completed and signed by the customer for any additional charges;- Customer must initial. 'Any work or ruaterial not spetifed is not included in this contract.Any changes or additions will be at an adddionat 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 file 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,world-wide,if perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising,publicity,illustration,training and Web content.By initialing here,Customer agrees to the foregoing._ 9 9'` (Customer to initial to the IeRJ. Work rs to.,commence upon reasonable availability of Contractor and/or any special order or customer made Good(s)which is anticipated to he [fill fn date].Estimated completion date is Said estimated Substantial completion date 15 not of the essence.A statement of any contingencies that would materiallyfchangee ngencte said estimated substantial compie6on date is as follows: I t _r i r til applicabfe,inserta statement of such contingencies), This Contract provides til rt all claims by Customer or Lowe's will he resolved by BINDING ARBITRATION.Customer and Lowe's GIVE UP THE i'O GO TO COyURT to enRfoArLce this Contract(EXCEPT for mattthRIGHdmMALL CLAIMS COURT).Lowe's and Customer's rights v,in beT ARBITRATOR and NOT a judge or jury. Lowe's and Customer are entitled to a FAIR HEARING, But the arbitration In are SIMPLER AND MORE LIMITED THAN RULES APPLICABLE iN COURT.Arbitrator decisions are as enforceable as any court cyder anti ora subject to VERY LItv11TED REVIELV QY A COURT.FOR founMORE DETAILS:Review the section titled ARBITRATION AGREEMENT,WAIVER OF JURY TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION d in the Terms and Conditions of this Contract. —--- _ _ O NOT SIGN THIS UNTIL COMPLETE AND PAGES OF THIS CONTRACT.NTRACT.B YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON ALL SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON ALL'PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. - r 14111TNES5 OUR HAh1DiS1 AND SEALS)BELOW THIS DAY OF 1="! Lowe's Home Centers, LLC r v , Owner Lo re's Balt oozed Representative ,' _ I C�ner orV✓itness Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,may 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 55094 REV. 12/13 FILE COPYLa::c.';.� sand c n �'2004 by CLose ,b___..., � NOTICE (}FRIGHT TUCANCEL (enter date oftransaction) You may CANCEL this transaction, without any Penalty orObligation, within THREE BUSINESS DAYS from the above date. If YOU cancel, any property traded in, any payments rnade by YOU Linder the contract or sale, and any negotiable instrument executed by you will be returned within TEN BUSINESS DAYS foUmvvioyreoeiptbythoneUerofyoorcanoeUed|nnnutioa, ondunysocurity |nteroetohsingoutof the transaction will bncancelled, |fYOU oannn|. YOU Must mnokoavai|eb/e, tuthe seller aiyour residence, insubstantially ae good condition as when received, any goods delivered to you under this contract Or sale, or you may if you comply with the instructions of the seller regarding the return shipment of the � goodsat theseUe/sexpense and dsk. � If you do roake the goods available to the seller and'the seller does not pick them Lip � � within 20 days Of the date Of YOUrnOtiCe Of cancellation, YOU may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if YOU agree / to return the, goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. Tocancel this transaction, maUurdeliver asigned andd � notice orany other written notice, orsend otelegram, to [Name ofseller] at / NOT LATER [Address of seller's place of bUSinessl tEnt*date 3 business days after transaction date above(or longer mrequired � THAN MIDNIGHT OF byapplicable|aw);include sitvtdawbut[lot su"d^pand Federal wdicl^ysJ � � | HEREBY CANCEL THIS TRANSACTION. (Date) (Buyer's Signature) � � ACKNOWLEDGMENT OFRECEIPT OFDISCLOSURES AND CERTIFICATION � \ 'c — � On this f (yeah. each ufyou hereby acknowledges receipt of two (2) copies of the foregoing Notice of Right to Cancel; each of you who is a party to the Contract hereby acknowledges receipt of one (1) copy of the fully executed and dated Contract Number ' � - / ' NOTE: Each Customer who |aeparty tothe Contract must sign above. |mwwo09u no"(4/m} ' 5 AFee q-Urfurtd rimuddttUt UJ j_._--- A — --- --- Department of Industrial Accidents 5 Offtce of Investigations � = I Congress Street, Suite 100 Roston, MI 02114-2017 r fix. www.mass.gov/dice Workers' (Compensation]Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers .Applicant Informatio*H Please Print�egibiy Name(Business/Organization/Individual): �- IeL Co{1,.g�:1cq_k.cMCA tm&. Address:10 z3 City/State/Zip: ,P 10 Phone#: Are you an employer? ChecJr,the appropriate box: Type of project(required): t. I am a employer with 4._ general contractor and I �� ❑ I am a employees (full and/or part-time).* have hired the sub-contractors 6. ❑New�construction ?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp,insurance comp. insurance.' required.] 5. ❑ We are a.corporation and its 10.❑ Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions m self. o workers' right of exemption per MGL y � comp. 12.E] Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.® Other, S1 rj �V1 comp.insurance required.] E' MY applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iorneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, ontractors that check this box must attached an additional sheet showing the name of the'sub-contractors and state whether or not those entities have iployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an ernpto er that isproviding-workers compensation insurancefor my employees. Below is thepolicy and7ob site ¢orrnation. surance Company Name: dicy#or Self-ins.Lic.#: ,1 � � `? Expiration Date: Site Address: 0 City/State/Zip: tach a copy of the worlfers' compensation policy declaration page(showing the policy number and expiration date), ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to thdimposition of criminal penalties of a e up to$1,500.00 and/or one-ydar imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine ' up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of restigations of the DIA for insurance coverage verification. o hereby ce"'m &dpenaldes ofperjufy that the information provided above is true and correctature/ane Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4' Issuing Authority(circle one): L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector i. Other �ontact Person: Phone#: �� DATE(MIVDUNYYY) fk� CERTIFICATE F LIABILITY INSURANCE4/24/2015 THIS CERTIFICATE 1S 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(tes)mast 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 bolder in lieu of such endorsement(s). PRODUCER NAMEACT Judith George CIC,CPIA,CPIW FIAT/Cross Insurance PHONE. (603)669-3218 FAQ o:(603)645-4331 1100 Lim Street f12ADDRESs:7george@crossagency.com INSURERS AFFORDING COVERAGE NAIC f1` Manchester NH 03101 INSURERA:Union Insurance Company 25844 INSURED INSURERB;Acadia Ins Co, THOMAS A. DUBE CONSTRUCTION-PLUS INC. DBA INSURERC: Dube Plus & Dirt Pro; Watertown Village, LLC INSURER D, 10 BRICKETTS MILL ROAD SUITE C INSURERS: HAMPSTEAD NH 03841 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 All 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSADDL SUER POLICY EFF POLICY EXP LIMITS LTR7YPEOFINSURANCE POLICYNUMBER MWOD1MM(ODNYYyI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETORENiED A CLAIMS4AADE X❑OCCUR PREIiISES(Eaoow" encs 250000$ ' X No OL Deductible X CPA5028190-13 4/2612015 4/26/2016 MED EXP(Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP)OPAGG $ 2,000,000 JECT A!-Ormer/LesseeAConlractor•A $ OTHER: AUTOMOBILE LIABILITY t aB1NEOISINGLELIMIT $ 1,000,000 X ANYAUTO BODILY INJURY(Perperson) $ B ALLOAtIED SCHEDULED CAA5028191-13 4/26/2015 9/26/2016 BODILY INJURY(Peraatdent) $ AUTOS X H EDAUTOS AUTOS AUTSAVED PReO IY�tDAMAGE $ UnnsuredrnolodstpropedY $ 25,000 X UMBRELLALiAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESSUAB CLAIMS-hIADE AGGREGATE $ 1,000,000 D D I I RETENTIONS IGUAS028192-13 4/26/2015 4/26/2016 $ 11YORKERSCOMPENSATION HPA5DZB193-13 X PER ATUTE OER AND EMPLOYERS`LIABI LILY ANY PROPRiETOR(PARTNERIEXECUNVE YIN IIIA (3a,) tRl 5 DTR E.L EACH ACCIDENT S 500,000 B (Mandatory ntNH EXCLUDED? Thomas Dube excluded 4/26/2015 4/26/2016 El.DISEASE-EA EMPLOYE $ 500,000 If yes,describe E.L0ISEASE-POUCYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS Mow DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addittonal Remarks Schedule,maybe attached if more space Is requTred) Covering work performed by the Named Insured during the policy period. Lowe's Companies, Inc. and any and all subsidiaries are Additional Insured under General Liability and Auto Liability policies as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies, Inc. THE. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Installed Sales Insurance ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 111 N. Wilkesboro, NC 28656 AUTHORIZED REPRESENTATIVE <� J Geoxge CIC,CPIA,CPI #' ' ©4988-2094 ACORD CORPORATION.All rights reserved. ACORD 26(2014104) The ACORD name and logo are registered marks of ACORD INS028 omni} .s Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 47 License: CS-094372 LORTANN J LANPG kN -N 7 CREST ROAD ' KINGSTON NH 113848 Expiration Commissioner 07/31/2015 1 fGce of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 119623 Type: Expiration: 8/6/2015 Supplement C Dube Construction-Plus,Inc: LORIANN LANGAN 10 Bricketts Mill Road,Suite"C' -9�.6.: Hampstead,NH 03841 Undersecretary