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HomeMy WebLinkAboutBuilding Permit # 6/11/2015 BUILDING PERMIT �osarH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION °- �e �. ✓ �q e`enlenew[n`V Permit No#: v Date Received �AAr PQM �5 �ssgcwus'�R Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION C pint 4,0 PROPERTY OWNER °'� �.��. I Pri t 100 Year Structure yes no MAP PARCEL: ZONING DI TRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition El Two or more family ❑ Industrial ❑Alt ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg. ❑ Others: ❑ Demolition El Other P / „ I .. ,,,I�, „� ,� � ,� � � I H� �/�,/ /✓.>y/// � 1J/� �i,��, / /,�J/Ill ti�ofi c�� a��iiYJ�/,,/ii,i/is r l .ry i �+i/,�Yiw✓Ht k /, l r r�i /Jl�,�u/n �1 f rr/ , ! � 1/,Uatershed„D;IStrICt�,�/, /i/, :� ,i � ��Well��✓J�,/�//t�/� �� ,�'ood lal ////�/i❑,Wetland //,�f �/ � � Vit//��i�,arc D r , l / / r, r�% P 7ON OF W RK TOB ERFOR d It n - C .. n- Please Type or Print Clearly Phone' „�. Identifi tiboG OWNER: Name: ®' a Address Contractor Name: 1 `� � ��► Phone: m f 2h Email I t ' Address: � w Supervisor's Construction Licenser _ Exp. Date: Home Improvement License: Exp. Dater 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: $ t FEE: $ Check No.: Receipt No.: NOTE: Persons contracting witlz unregistered contractors don lave ac ess tot nd pranty ie,pfA ' NORTjj Town of E 11, ndover 0 ® ver, Mass h T O LAKE .t COC HIC ME WICK � A04ATED `S iJ BOARD OF HEALTH Food/Kitchen rERMIT T LD Septic System /� BUILDING INSPECTOR THIS CERTIFIES THAT .......6 { �C�roc. % .............................................................................. .................... �••..........•..•.••••••.••.. Foundation has permission to erect buildings on .L/y;C?...... /e.••••••••••••••• p .......................... ) ..... Rough :�F ............... Chimney tobe occupied as ............ ....................................... .. ................................................... � e 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 M NTHS ELECTRICAL INSPECTOR LESS C STR CTI STA TS Rough Service ............................................................. Final •�� BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents a X 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 PERMITTING AUTHORITY. Ao licant Information Please Print Le ibly Name(Business/O rganizationUdividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required); l.n[am a employer with employees(full and/or part-time).' 7. F-1 New construction IF—]I am a sole proprietor or parmership and have no employees working for me in 8, EJ Remodeling any capacity.[No workers'comp,insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No worker'comp.insurance required.]t 4.F—]I am a homeowner and will be hiring contractors to conduct all work on my property. I'AU 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 LQ Electrical repairs or additions p netors with no employees. 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the a .attached sheet. 13Of repairs 'These sub-contractors have employees and have workers'comp.insurance. f/` 6.❑We are a corporation and its o fiicers have exercised their right of exemption per MGL c. 14, Other t) 152,§1(4),and we have no employees.[No workers'comp,insurance required.] 'Any applicant that check box 41 must also fill out the section below showing their workers'compeasation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating 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 ani an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site IIIfOYniat1071. a / Insurance Company Name: /ll// Policy#or Self-ins.Lic.#: W6- Expiration Date: Job Site Address: l !✓ City/State/Zip:! t i 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 cern jjand naltie perjury that the information provided above is true and correcd S i Etta 01 1z Date: Phone Official 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 S.Plumbing Inspector 6.Other Contact Person: phone 4: HOME IMPROVEMENT CONTRACT PLEASE READ THiS P Sold,Furnished and Installed by: Branch Name:Boston North&South THD Al-Home Services,Inc. d/b/a no Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Uc#C 02439;RI Cott,Lip#16427 CT Lip,#H1C.0565522; A Home improvements Contractoriteg.#126893 Installation Address: Y City Slate Zip Purchaser(s): Work Phone: Home Phone: Cell Phoar, Home Address: (If different from Insialla' Address) City State, Zip Email Address(to receive project communications and Home Depot updates): 111 DO NOT wish to receive any marketing entails from The Home Depot Prosect Infrialmlion, 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 Shcet(s),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"): Job#: nmmm Reremnre Pr ts:. Spec Sheel(s)#: Project Amount Routing Siding induws insulation $ []Gutters/Covers (]Entry Daws LJ Ci 33(o1 L � Roofing Siding LJ Windows insulnliun lJ []Gutters/Covers[jEntryDoors❑ Roofing EjSiding LJ Windows Ll insulation ❑Gutters/Covens(]Entry Doors Q Routing Siding Windows 0 insulation []Gutters/Covers ❑lindry Doors❑ Minimum 25%Depnsft of Contract Amount due,upon exectiflon ofthis contract. Total Contract Amount $ Maine Purchasers rimy not deposit more than onrhhdrd of the Contrail Amoont. C SO Customer agrees that,inuuediately upon completion of the work for each Product.Customer will execute a Completion Certificate (one for each Product as defined by-,in individual Spec Shect)laid pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder, Tl)e 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 no Hunte Dcpot or its authorized service provider determines that it cannot perform its obligations duo to a structural problem with the home,environmental hartrds such as mold,asbestos or lead paint,oltter safety concents,pricing errors or because work required to complete[lie job was not included in the Contract. Payment Summary: The Payment Sunun:uy #__f052included as part of this Contract, sets forth the total Contract amouni and payntenis required for the deposits and final 1mynienls by Product(as applicable). NOTICE TO CUSTONIF.R You tyre entitled to a completely filled-in copy of the Contract at the time you sign, Do not sign it Completion Certificate(note: there is one Completion Certificate far each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event or termination or this Contract,Customer agrees to pay The home Depot the costs of materials,labor,exImnses and services provided by The Home Depot or Authorized Service Provider through the dale of termination,likes any other amounts set forth in this Agreement or ullinvLA under applicable taw. THE HOME DF,POT MAY WITHHOLD AMOUNTS OWIiD TO THIS HOME DEPOT FROM THE DEPOSIT PAVNIGNT OR OTHER PAYNIENT'S SIADE, WITHOUT LIMITING THE HOME,DEPOT'S OTHER REMEDCES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is theentire agreement lxhvecn Custontet' rmd The Honte Depot reit)r�ud to the Products and installation services and superudcs all prior discussions and ttgrcentents;either oral or written,relating to said Products and Installation,This Agreement cannot bLamigucd or amended except by a writing signed by Customer amt The Home Depot.Customer acknrnvledres and agrecs that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. pted h Submll rl by: usiomer's Signature Date Sales Consulbtnt's Sigmore I Daae X Telephone No, 1 22--_7 77 1 6, Customer's Signature Dale Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS tasnppucaMct 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 STA'T'E SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, NOTICE:AI)DITIONAL TERIISS AND CONDITIONS ARK b WK lh,D ON THR REVERSE)SIDE AND ARE I'Airr OF Vila CONTRAV17 02-03.15 White—Branch File Yellow—Customer • �' enzt4Yt�r:nrbn—tnean.gc.e? �ml t �'�' �' •u ,,luta C: SAVE lof Nk", rylVl.n ° • bel 7�1 ru',zl ln�evhto'n'I , ' '.�=�;,�v`': la a1a1 ti,�ozlh�r Ch1°Id • r_ •� ;'��f-j, C?DE CED-•A_SiZ ';�un� D^vo�l•tn0 �' },1ode1 65DB Doubl t"(Z" Z ��-'x-' Alum glad ih.- — • i.•�,;n. r.�'�'� ZO- .. .D72 t.oW ' Alt SPz;.� r"`� A;�on "rill Grille 'm ;5 „ I�• M��CE R� YiyFRCI' °ERrOR S ,,� r,_� ;,•;�,co:t�- . I U-iylu O� 1 111 ' •.I 01 ;0 �Cl1U ICI b� 1 tn1 iC-1l n111 Prrr7 bl l ht1 htsx nu+11 .�XFI,C n xFFY. lots ullct G;rt.� � Rcp1c un L'nulltvnl�*Jt pnitLl r.ir,f cJ pndrd S°n. t-rlGlcn�'ul� lt`(°I 1 1° b Rl e� o rtirT nlvcl/tl nuc ntc is I"tAll Y .,-A tial ❑vlr,m Hyl wellmw U:uniltvnun bl L•J 1,� t�lr=•°n tiJlttn1lon A' 1 7 u� v91V'.S.1-1 N..c_C.. C.E.C.. trs 1t�cLu jov ' c:ttLel , �Dp` �p,i1 n_v_a,Lu�pv�ccs Ln v t ) 1 I lmlt u u,l v. n 6tlti• , AC®RE)® CERTIFICATE DATE(MWIID/YYYY) F LIABILITY B 6 L ' 02/242015 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the temts 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 1FAX 3560 LENOX ROAD,SUITE 2400 E-MAIL 1C NO): ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIL# 100492•HomeD GAW1516 INSURED INSURER A:Steadfast Insurance Company 26387 THD AT-HOME SERVICES,INC. INSURER B:Zurich American Insurance Co 16535 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 23841 2690 CUMBERLAND PARKWAY,SUITE 300 Illinois National Insurance Company ATLANTA,GA 30339 INSURER D: p y 23817 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-003242685-09 REVISION NUMBER:7 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 SUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP A GENERAL LIABILITYMM/DD/YYYY MM/DD LIMITS GLO4887714-05 03/01/2015 03/01/2016 9,000,000 EACH OCCURRENCE CE S COldMERCIAL GENERAL LIABILITY X PREMISES Ea occurrence S 1,000,000 CLAIIlSJdADE [flOCCURLIMITS OF POLICY XS EXCLUDED ' OF SIR:$1 M PER OCC MED EXP(Any one person) S PERSONAL&ADV INJURY S 9,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,000,000 X POLICY PRO- PRODUCTS-COMP/OP AGG S 9,000,000 T LOC B AUTOMOBILE LIABILITY BAP 2938863-12 S X 03/01/2015 03/01/2016 Eaala�dentSwGLE LIMIT $ 1,000,000 ANY AUTO - ALL OWNED SCHEDULED BODILY INJURY(Per person) S '.. AUTOS AUTOS SELF INSURED AUTO PHY DMG LY INJURY(Per accident) S HIREDAUTOS NON-OWNED BODILY ',.. AUTOS PROPERTY DAMAGE S Per accident) 5 UMBRELLA LIAB OCCUR EXCESS LIAB EACH OCCURRENCE S CLAIMS-MADE — DSD RETENTIONS AGGREGATE 5 C WORKERS COMPENSATION WC017731493 AOS S AND EMPLOYERS'LIABILITY (ADS) 03/01/2015 03/01!2016 X V�STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC017731495(AK,KY,NH,NJ, -- FP D OFFICER/MEMBER EXCLUDED? � N/A 03/0112015 03/01/2016 E.L EACH ACCIDENT S 1,000,000 (Mandatory In NH) WC017731494(FL) 03/01/2015 03/01/2016 If es,dePTIOscibN Oe under E.L DISEASE-EA EMPLOYE S 1,000,000 DESCRIF OPERATIONS below Conitnued on Additional Page 1,000,000 E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi MukherjeeAtitLO ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4 s�ilaf i'Idd ili�l9 alp S it CSL_m106006 r • �tr�.h; BENJAMIN PARKER sy � - n Plaistow NI-I 03865 Ex 1 rceltE�Fi . S 02/111201 1 x :u ' .,. qUl'L4b'LaotS GC%:JCI Otzice o� Constuneriai and Business g 10Parl: -Plaza - Suite 5170 Boston, Massachusetts 011 a�S�at1On F,ozne Impzovement,Contiacto: R� i;"rat"'on. 527813menl card yni HD sRVIC�s, ?IG-La D Oli '�Y SUIT 3`00 . ----- �_-- 2- CU}JisERLAND PAR ARKVr.`'. , _ •- _ G JJ� UP Aid�s and ;cNrn car0,rn crate •JI L.,=xrd I— 111711—n on azzlid Cor ind Yidvl c o�y F Cul�ucn Liccczt cr r o: z [(C od rcluro -r�irs&Eos.c.., = 0�I;c cf Co❑s•.racr, =S�tf i G KTi 1 ,'On O i,^of Comscmcr AC zi;s a P1.:a s u 5 1 ; °y3 S' r�=moral �� B°ricn,M..D2116 II-.D f1I ,'{VK=J 1\'V1•...—S �r•S_•R`✓� �� �+/ ^IC-v RD iRO� a•or.�h';,Y S ��� 25�GUI;.3=RlrN-, .. ✓ Ncf v>.lid w'r'.hev.�.�n�r= _ .. _._