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HomeMy WebLinkAboutBuilding Permit # 6/24/2015 F t%ORTH q BUILDING IT .y0�'•<4 TOWN �.W,...m..., __-ars 0 OF NORTH ANDOVER ¢� 6. APPLICATION FOR PLAN EXAMINATION Permit NO: 1,6 Date Received pATED Date Issued: '� C�'�'�� IOItT T4 Applicant must complete all items on this page rr, „r r r r rr ,r /r r, /! r„ / / TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building .,One family ❑Addition ❑ Two or more family ❑ Industrial ❑ A ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other M Identification Please Type or Print Clearly) OWNER: Name: Phone: R "/ .. Address: r�,�� „rr / /, rrr � % �, „/ �/,�', ,� �, r , �� Yi 1ir� ✓///� �l r/l /� /i r r l rr. rr , / / / t /, / r� r ( 1 , / 1, / / / I ' r / 714 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDIMG PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 6 M Check No.: Receipt No. DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund o � tur� Agt/ urr �rld /, r `:, „ NORTH own of ndover O - :` "A o h ver, Mass, Io1IL 7b I'T CoCKIC"t-ICK �- S V BOARD OF HEALTH PERMI T Food/Kitchen Septic System THIS CERTIFIES THAT ...................................�. ...... .�.�!!. .. .. .. ............... BUILDING INSPECTOR Foundation erm .......................... . ......... ... has permission to erect buildings on ... �.. ... . � " p Rough to be occupied as .......`.�........ !/lR. .......................................... Chimney provided that the person accepting t s 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONRT Rough Service ....................... ........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. HOINIE ImpROVEMENT CONTRACT PLEASE R END THIS Sold,Furnished and Installed by: �° THD At-Home Services, Inc. Branch Name' Royston North&South Irate d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1.Shrewsbury,MA 01.5.45 Branch Number. 31 and 33 Toll Free 877-903-3768 Federal ID#75-2698460-1 NIE i.ic#C 02439,RI Cont.Lie# 16427 CT Lie#HTC.056.5522;i,4A Howe Improvensent Contractor Re,,,.# 126593 Zq�Installation Address: Cat} State Zip Work Phone-. "011ie Cell Phone: Purchaser(s): Home Address: City State (Irdifferent frorn Installation Address) I:-mail Address(to receive project eonnnunications and Home Depot updates): --- �A� ❑ I DO NOT wish to receive all),nituketing emails from The 1Ho�1�1i Depot rty located at the above installation address.ag1, S to bt�5�! Project Information: 1Jnderstbuaed( Customer"),the owners property all deliver radar are incorporated into this Contract n this and THD At-Home Services, ]nc. ("The Home eDepot") agrees tod Spec Sheet(s)�cliver and arrange for the installation ("Installation all materials dese,ribcd on the below le State Supplement and Payment Suannatu•y attached hereto and any Change Orders(collectively, reference, along with any applicab "Contract"): ts: — 5t)ec Sheens)#:_ Pr�lect amount job${: r7ntenral Reference) roduc $ 7� ��y1'q �j ❑Rooting siding N\rindo���s ❑ Insulation � g� ❑Gutters/Covers ❑-ntry Doors ❑ _— — — iCt���/' ❑Rooting, ❑Siding ❑ Windows ❑ Insulation ❑Gutters/Covers ❑Entre Doors ❑— ❑Roofing ❑Siding ❑ Windows ❑ hrsulation , ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding ❑ Windows ❑ hasulatioia $ ❑Gutters/COVers ❑Entry Doors ❑_ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Total Contract Amount. $ 7011 iMaine Pamhasers nray not deposit snore thtun one-third of the Cont"act Amount. ll ipletiOn Customer agrees that, innraediately upon completion of the work for each any balancuct,e (too. ,; applicable,ceacl Customler under Geis ('one for each Product as definers by an individual Spec Sheet) and pay y 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 orally 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 su'uctural problem with the home, environmental hazards Stich its tnuld, asbestos or lead paint, other safety concerns, pricing errors or beC It e work required to complete the job was not included in the Con I'tVttaettt Sunimary: The Pa meat Sunv»ary +.,_�_..� �..—_ included is part of this Contract, sets forth tlic t:�t:31 Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTONTE R Yoit are entitled to a completely filled-in copy of the Contract at the time you, n. Do not sign Completion Certtficnte mote: there is one Completion Certificate for each listed Product as delisted by ilt(fividtlal Spec Sheets) before work on that Product is complete. in the event of termination of this Contract, Customer a�rtes to pay The Ilon3e Depot the €osis of nlaterlrls labor, expenses and services provided by The Horne Depot or Authorized Service Provider fhrough the date of t€rn ination, plus ally other antounts set forth in this Agreement or allowed under applicable law. THE HONM' REPOT )MAY M' AHOLD A�IJ W�,T'_ ONVED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OT14ER PAYMENTS IMADE, II ITHOI T LIMITING THE, HOME DEP01"S OTHER I ENMEDIES FOR RECON ERY O SUCH AMOUNTS, Aceetstance. and Autlaortrttiot7: Customer agrees and understands that this Agreement is the entire agreement betncen Cttstem and The Home Depot with i egard to the Products and Installation services and supersedes all prior discussions and Zgreenaents eattru oral or 4vritten, relating to said Products and lnstallation. This Ag-reement cannot be astiir�ned <ar amended except b_,;� a r �itrng ,ig- by Customer and The Nome Depot. Customer acknowledges and agrees that Customer has read, understands. Voluntatii) accepts ua terms of and has received a copy of Ihis .Agreement lccepted by: ,I subn�itted by: ® , _ ill be Work area wEFA ' �' Date: , m. Fire-Renovation Fora NAT-19276-1 This form is used to document compliance with the requirements of the Federal Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. .IOI7 Number(s) tiCustomer Address — 130 s t� fi r IS .A OCCUPANT CONFIRMATION Dust will be minim- lzed Pamphlet Receipt f ) 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 performed in my dwelling unit. I received this pamphlet before work began. 'dome Year Built I L i Enter the year my home was built. II If my Nome Year Built is Pre-1973,my home requires lead paint testing to determine whether Lead-Safe Work Practices are necessary per EPA or State regulations. if my Nome Year Built is 1973 or after, Lead-Safe Work Practices are not required. Work area will be cleaned up thoroughlyi i Printed Name of Owner upani Signature�c t Owner-occupa+a Signature pf,Person Ce �Ni 9 Le 6 phlet Delivery 1 SEE STATE SPECIFIC FORMS ON REVERSE SIDE v, y L .. � 1.. I, . ��ergYltr.nran—tncan.gc.ca . L 7 • SA�� for lulure relerenee ail^-t Cu'�al lns�e�lion', . .I pe;,�ov- izbel. Wezlher Shleld ' •CPD€ CSO-A-5'72 Dper'zlin9 ouble `lung ,� x Alum ol..d The UF • ��. . .. 31� Inch Gla'ting n �v how Alr 'P,a 1uGs • � � CE RA i I EIycRGY pFR%ORNIA� sDf�r,:� .,L��o:fr,�:nt U_FL-t Ll O.� Iii�t,.rn R�,a�1G� RA t 111 • N 511—rf sislLl•:: DDIi1D1�AL . Y1L1bf:1>✓•sr,?511:� 0 F 0 .�0 rjC[�Y ILL b�- •' nL�u xrfa=�nLr et t a • �b HFr,�n S L`KFF=r Cou Lol rtz'n^'�' uU�l htl CLa n1r.;L In od R Lc vu. �revlrcviLrr*.+t Pn:L:I rit r,r peroi p�jtL Prsdrel G:Y Ly .R1 cd (.0 Hol 9 fiiv.t 17 0`✓'{!� Lnlo nylon. Lt rd cl el ccnrntT u'W rte'+ bnn�n' . cnC(ICI nLl rt:rv.lUl r`UC�owcl Ptl L Lnlc w,S lioGu� gni I st,nun n P,�vu.m • ar-vll mcwVr w.ILlr=.onul InISSIrL i>o t C Lrd .E.L.C. j;j �.p1 SUt1.1-17 .S k.rLU of c.:LtCL ri.`C.. � - 1c❑cC td iKS t•U' ' \D (P n_LC%S 14'-Yl t,-•C1 /1 4, 1 f SmLt rL uu1/�F .•��-- N_t::s ILu:^sot e r �Ll:n • IfOISCGi1flY.iiD - .. The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www,m ass.gov/dia `Workers' Compensation Insurance Affidavit:Bw11�dersl//Co AtTIH�sR/I l�ectricians/Plumbers. TO BE FLLED VdITH THIS Please Print Le ibl A licant Information Name(Business/Organization/Individual): Address: Phone#: City/State/Zip: Type of project(required): Are you an employer?Check the appropriate box: 7, New construction 1,R I am a employer with employees(full and/or part-time).* ❑ 2,❑I am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 d E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on MY property, I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12 R plumbing repairs or additions pr netors with no employees. 5, I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[] 6f repairs These sub-contractors have employees and have workers'comp.insurance.- 14 Other 6.R We We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] eir workers'compensation Policy t'on *Any applicant that checks box#1 must also fill ng the section redbelow aU work o k'and then hire outside contractors mast submit in-forma new affidavit indicating such. t Homeowners who submit this affidavit indicating Y g -Contractors that check this box must attached an additional sheet showing the name of the sub olic number.and state whether or not those endues have employees. If the sub-contractors have employees,they must provide their workers'comp.policy mpensation insurance for my employees. Below is ihepolicy and job site Yam an employer that is providing workers'co information. Insurance Company Name: � Expiration Date: v a Policyrr or Self-ins.Lic.,- Cattheatoli t number . Job Stte Address: p y and expirationate). Attach a copy of the workers' compensation policy declaration page(showing on Failure to secure coverage as required unk�MGL enalties�n§he fors a ret of criminal OPiWOtItK ORDERIandya ffne ofne pto up to$1,500-00 a and'or one-year imprisonment,as v°ell as p ent may be forwarded to the Office of Investigations of the DLA for insurance day against the violator.A copy of this statem coverage verification, if}� and saltie erjury that the information providedv�t+"^�td•c�°-.rrG correct. I do hereby cert Date: SiRnatr / u 1 Phone#: [6.0 al use only. Do not write in this area,to be completed by city or town official. iPermitUcense# r To,rm: g Authority(circle one): Ins ector ard of Health 2.Building Department 3.City1To-,vn Clerk 4.Electrical Inspector 5.Plumbing P herPhoneact Person s I DATE I MM/DDlYYYY) CERTIFICATE OF LIABILITY INSURANCE F =412015 THIS CERTIFICATE IS AFFIRMATIVELY OR NEGATIVELY TER OF AMEND,IEXTEND OR ALTER THECOVERAGE AFFOAND CONFERS NO RIGHTSRRDEDABY THE POLICITE HOLDER_ ES CERTIFICATE DOES N 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 WALED,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 �certlflcate holder in lieu of such endorsoment(s). !E-MAIL TACT - PRODUCER E: MARSH USA.INC. NE AIC No TWO ALLIANCE CENTER 3$60 LL?rOX ROAD,SUI c 2400 RESS: ATLANTA,GA 30320 NAIC INSURE S AFFORDING COVERAGE 26387 INSURER A:Steadfast Insurance Company 11492-Homo4GAW-15-16 16535 INSURER B,Zurich American Insurance Co INSURED 23841 THD AT-HOME SERVICES,INC. INSURER C:New Hampshire Ins Co DBA THE HOME DEPOT AT HOME SERVICES lliinois Nalmal Insurance Company 23817 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D: ATLANTA,GA 30339 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: ATL-003242665-09 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. NCITVVITHSTANDING ANY REQUIRDAENT, TERM OR CONDITION OF ANY CONTRACTOR 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 ALLVE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UBf2 POLICY NUMBER tMMTDDY EFF POLICY IOArLDI CDY EXP LIMITS LTR TYPE OF INSURANCE 9,000,OOQ (31-046B7714-05 031012015 03101/2016 EACH OCCURRENCE s A GENERAL LIABILITY 1. PR SES Ea oxrce unce S X COI,lM,ERCIAL GENERAL LIABILITY CLAILSSJ.4ACE � OCCUR LIMITS OF POLICY XS MED EXP(Any one Person) S EXCLUDED Or SIR:5111 PER O'-C PERSONAL E ADV INIURY S 9,000,000 GENERAL AGGREGATE S 9,000,000 PRODUCTS-COtAPIOP AGG S 9,000,000 GEN'L AGGREGATE UIMT APPLIES PER: S X POUCY I P'-RO_ LOC BAP 293886312 03101/2015 0310112016 Ea ac oen SVJGLE LIMIT B AUTOMOBILE LIABILITY 1,000,000 LY IN l BODILY INJURY(Per Person) S X AIJY AUTO ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per adddent) S AUTOS AUTOS PROPERTY DAIAAGE S NON-0t44JED Per a � enl HIRED AUTOS AUTOS 5 EACH OCCURRENCE S �BRIEE UAB OCCUR AGGREGATE S R CDD RETENTIONS VJ(1 STATU- OTH- C WORKERS COMPENSATION WCOIT731493 (AOS) 03!01/2015 03101/2016 X AND EMPLOYERS'LIABILITY '4 1 N \NCO 17731495(AK,KY,PIH,NJ,VT) 03/01!2015 03/01/2016 s 1.000,000 EL EACH ACCIDENT C ANY PROPRIETOR/ARTNER/E?:ECUTIVE 1,000,000 NI D OFFICERJMEMBER ECCLUDED7 P' N'C017731494(FL) 03101/2015 03/01/2016 E.L.DISEASE-EA EMPLOYE 5 (Mandatory In NH) 1,000,000 If�as,descnbe under Conilnued on Additional Pace E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS bela.v DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddlUonal Rcn arXs Schedule,H mom space Is required) EVIDENCE OF INSURM4CE 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 DEl1VERED IN 2;55 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORr1-cD R=PREESENTATWE of Marsh USA Inc. Manashi Mukhedee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD: Hermit J0NIC8S J 4U1 L4t)'Lt5tD0 P•2 l xxio ' Office of Consumer Affairs and Business Regulation l 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement'Contractor.Registration Registration: 126893 Type: Supplement Card Expiration: 8/312016 THD AT HOME SERVICES, INC. RICHARD TROIA --- 2690 CUMBERLAND PARKWAY SUITE 30.0 . . -- ATLANTA, GA 30339 -- _.....__.. ......._.___ Update Address and return cac d.Roark reason for change. seg cm Address J Renewal o. Of[icc of Cunsurner AM-irs&Business Regulation License or registration valid for individul use only ._ AME IMPROVEMENT CONTRACTOR bofore the expiration date. Cf found return to: 5; {' Office of Consumer Affairs and Business Regulation ?C' Registration: "126893 Type 10 Park Naza-Suite 5170 Expiration..813!2016 Supplement Card Boston,MA 02116 THD AT HOME SERVICES,INC. THE HOME DEPOT AT ILOME SERVICES RICHARDTROIA ' 2690 CUMBERLAND PARKWAY S GA 30339 Undersccretary Not validwi out signature c a 43 Glll,, �NOUGI-i=ROAD �,' '."... Plaistow NI-I 03805 �� ,�; O 02/1 912 0 a �