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HomeMy WebLinkAboutBuilding Permit # 6/29/2015 V%ORTII BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ATED, Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER. Print 100 Year Structure yesno L(,�S�V MAP PARCEZONING DISTRICT: Historic District yes no Machine Shop Village yes(, no TYPE OF IMPROVEMENT PROPOSED USEResi tial Non- Residential El New Building ne family 11 Industrial 0 Add* ion El Two or more family ration No. of units: 0 commercial El A ration e p ir, r [I Assessory Bldg 11 Others: pair, replacement El Demolition El Other -ep Xfg�wgui DPOR,IPTION OF ORKTO BE PEFORMED - Identification- P ase Type or Print Clearly OWNER: Name: y Phone'`' 7 )9 z 4 91 ) - 2,Z- )JIA- - °, ate Contractor Name: ,LAr-, Phone: Email: rA Address: G fw,mkl )'A Supervisor's Construction License: p. —ExDate: Home Improvement License: Exp. Date: ARCH ITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.MOO PER$1000-00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Siqnatur6bf bbntl—1 r-mr-9111 AM tkORTH fown ��'ofndover ® ti. 0 ® - CO LANE _` ver, Mass,' ' �- COCM�CNlWICK ��• ADRATED PC) NookS u BOARD OF HEALTH Food/Kitchen ERMIT L �u Septic System 00011% Ilk L THIS CERTIFIES THAT BUILDING INSPECTOR .... ..... . .. . ............ r% .. ., Foundation has permission to erect .......................... buildings on ...... ...... ............ ...........�... .................0 Rough tobe occupied as ................ ...... .. ... ..... .. .... ................. ~. ...�. ........................ 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT I IN MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STARough �� / ��/,�_ Service .................................................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Puildina 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. HOME IMPROVEMENT CONTRACT PLEASE READ THIS C` 0 Sold,Furnished and hasta>lled by: Branch]Same:Boston North&South Date / / THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Nmnber:31 and 33 903 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lie# 16427 C'Lic#HIC.0565522;MA Home Improvement Contractor Reg.#126893 Installation Address: A , &dovel< kA &�(YqS City State Zip Purchaser(s): Cork Phone: Home Phone: Cell Phone: Home Address: (If different from Installation Address) City Stats Zip E-mail Address(to receive project conununications 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 ("InsWlation")of all materials described on the below and on the referenced Spec,Sheet(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#: unternar Itererence) roducts: Spee sheet(s)#: Proiect Amount ❑Roofing ❑Siding Windows ❑hrsulation /11 4(1 i� I/ C ❑Gutters/Covers ❑EntryDoors ❑ ❑Roof ng ❑Siding Windows Lisulation ❑Gutters/Covers ❑Entry Doors ❑ ❑Roofing ❑Siding ❑ Windows ❑ Insulation ❑Gutters/Covers ❑Entry Doors❑ _ $ ❑Rooting ❑Siding ❑ Windows ❑ Insulation ❑Gutters/Covers ❑Entry Doors ❑ IVIinimtuu 25%Deposit of Contract Amount due upon execution of this contract. Maine Pin-chasers may not deposit more than one-third of the Contract Amount. Total Contract Amount 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 afn•ees to be jointly and several]),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 ]ionic, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work reduircd to complete the job was not included in the Contract, ]Payrncnt Surrrnrary: The. Payment Summary #__-_—/ /._ P included ars part of this ('ontract, sets forth the Lolal Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled ton completely tilled-in copy of the Contract at the time you signs 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 Horne 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 HONIE DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAVINIENT OR O'T'HER PAYMENTS NIADE, WITHOUT LIMITING THEE F10-N-J:DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH ANIOUN I S. Acceptance and Authorization: Customer grecs and understands that this Agreement is the entre agreement bet\Veen Customer and The Home Depot with regard to the Products and Installation services and superseders all prior diScnSlionS and agreements, cithet oral or written. rehlin�a to said Products and Installation. This A�-reernent cannot be assigned or amended except byca writing si-ned by Customer and The Norse Depot. Customer acknowledges and agrces that Customer has read, understands, voluntarily accepts the terms of and has received a copy of this Agreement. A e It ed la Submitted by: a Work area wflFbe contained Pre-Renovation Form Date:..( � NAT-19276 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 ,gob Number(s) t: let OCCUPANT CONFIRMATION 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 performed in my dwelling unit. i received this pamphlet before work began. i � Hoare Year Built Enter the year my home was built. 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 Horne Year Built is 1978 or after, Lead-Safe Work Practices are not required. thoroughly Printed Name of Owner-occupant Signature of Owner-occupant f Signature 6f sonC ing L amphlet Delivery EE ATE SPECIFIC FORMS ON REVERSE SIDE &M, , { cnclly"11I nrzan—tncan.gc.ca all I ao iabel.anei Cu al ln;�ection; SAVS for lu•lurc relet-nce ' �—'` 4tiiealh'.r Shield •C'pb C50-A—}iZ pp��lin9 . >�F� Vr`�ode1�6508bouble Hung 1j Alun glad The t al "rra 315 Inch Glazing All Space ' grille In "rill " GS '• A�tCE RAI 11� I r'���C.Y PFRrDR� c3uL�nGLcIIi—cnl . r C So1cY. � R -1 L'Itl •I0 V . 0.3 0 � �0 •. • I Ii I-,�Dn ) DRI�iAu�c R�NNG5 'I AD D I"l lO f•lr'�L P ER eecttcDs:iicn Rcs;tlt-r-e ' Ylslblc lr�+r'til.:: 0 . f I GAG _ nc•blt Hf A�p ncclt br b nt • lRuircvnt riPVIt CI htl pts nlr.;�:�HFF:nt^St r Co LdSc on. o1n9 •}..lt prh:i .n't r,S pu'o rJttorndrd ar'z' Q jn�nW t�&tcr,t tr! A �/�r°dcc'SnU•rM-vtN+. cl of ro rtrr ulli�l��P!c1 ftttintv^c ,nl pi>Gu1 v,C f+cl ntl rt:M lLh 11;t tt f t nit ' /,1r Inllll r+lion cut P• nm • •v w11 mcSv L:u ni S Stirn „fww.nlr_.o f't . t tf_S 1._,G.� uUkxV�L SCJl S.1-Si '1 Y..t tit of /2•''o Du L�,C t 1\ Jl� srrtt uut/x C U:n f101S:u 111YSiD — i The Commonwealth of Massachusetts Department of lndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 _ www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electr-icians/Plumbers. TO BE FILED WITH THE PERMrrMG AUTHORITY. A licant Information Please Print Le ibl Name(Business/OrganizationUdividual): �v Address: -�-/ City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. [-]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8, F-]Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F-]Building addition 4.7 I am a homeowner and will be hiring contractors to conduct au work on my property. I will ensure that au contractors either have workers'compensation insurance or are sole 11,[]Electrical repairs or additions pr rietors with no employees. 12.F-]Plumbingrepairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Rgdf repairs These subcontractors have employees and have workers'comp.insurance,', 14. Other it 6.F-]we are a corporation and its officers have exercised their right of exemption per MGL c. AdkYA4: -2 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box tt'1 must also fill out the section below showing their workers'compensation policy information. I 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-contactors and state whether or not those entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information, { 4e7-�-A-4 �zlInsurance Company Name: ' , / � � Y Polic Y or Self-ins.Lic.n: �/� 0 D C7�9 __ Expiration Date:26 Ci /State/Zip: Job Site Address: :: )I 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 certify and naltie erjury that the information provided aabrbbove is true and correct. Si--natur Date: I --- Phone rr: i iOfficial 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#: i r. IIermt Services / 4U1 'L4b'ZbtDb p.'L 1 , r �/ x":i' a �•Z Lr�� vl liGfiyl?iG'Ul Office of Consumer Affairs and Business Regulation 10 Park Plaza. - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contract or•Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8/3/2016 RICHARD TROIA ------ 2690 CUMBERLAND PARKWAY SUITE 300 -- ATLANTA, GA 30339 __ _.....__.. ..........___ Update Address and return card. N(ark.reason for chnn�;r. sca I Z, 204.1-0-111Address J Renewal mplo}rrcr.' m Lar c o. 0frict or Consumtr AM- rs&Business Rtgu13tion License or red stration valid for individul use only `~ ' 40ME IMPROVEMENT CONTRAC tDR before the expiration date Cf found return to: 5; .;` Office of Consumer Affairs and Business Regulation a Registration: 12H9-3 Type: 10 Parl(Pfaza-Suite 5170 Expiration:.8/3!2.016 - Supplement Carrs Boston,NIA 02116 THD AT HOME SERVICES,IN(f, THE HOME DEPOT AT HOME SERVICES RICHARD TRDIX " 2690 CUMBERLAND PARKWAYS A`f��tt GA 30339 Undersccretxry Notvalidwi outsignature r T F 1 i i.a r rc.or-e t.., ,Sb '�� �tq Re,gi'�a ��?E� �_ v� �sv.t'f.T4.,�_< r 1� Fi E 't° i Y'ttt t.! "ii s;t �a 19 Y¢" € iy'xti 13ENJAMIN PARKER 43 GREENOUGH ROAD Plaistow NH 03805 5 02111/201 .e Permit Services 401 246 2868 P.1 CERTIFICATE OF LIABILITY INSURANCE j °W5015OJr "YY, 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 poticy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain Pclicles may require an endorsement. A statemont an this certificate does not confer rights to tho certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSHUSA,!NC. TWOALLIANCSCENTER PHONE N Exq:.._.... ---._.__.� F�Col_a 3560 LENOX ROAD,SUITE 24 0 EMAIL ATLANTA,CA 30326 l OOaES$;...___ INSURERISI AFFDROINGCOYERAGE j NAICP- 100492-KOMCC,.'AW`•;o-16 INSURER A,Steadfast lnstsii ice Cwpany 126'&7 INSLI;F� Zur'^h AlrBocaC!n5Ur34Ce CO 'S 6- THE ffD4!EDEPDT.AC. INSURER e: � ; :.5 HUAE DEPor V.S.A,INC. INSURER C:New Ram0..hrehis C0 ;23E4; --—-- _ 245;PACES FERRY ROAD N'rYBULDING C-20 INSURER D:IlIn"s Naucna!^stsanco Ccmpary ATLANTA,GA 50=39 INSURER E: INSURER F:--._. COVERAGES CERTIFICATE NUMBER: ATL-003155301.06 REVISION NUMBER:0 THIS!S TO CERTIFY THAT THE POLICIES OF INSJRANCE LISTED BROW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'PM THSTAN DING ANY RECUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH?His CERTIFICATE +AAY DE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SJBJEC` TO ALL THE -ER.VS, EXCLLISICNS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY.HAVE BEEN REDUCED BY PAID CLAIMS. •QSRJ T0. TYPE OF INSURANCE IAOOLi;•U�R'I'---'-POLICY NUMBER _-- — HP1IDD+YE> Y ODrYYYYI I L!M!TS A GENF_RALLIABIUTY GI 04,1187714-C-5 ! _EACH OCCURRENCE S t`0D X !COtA+MERC 'J Ft-IAL GEN T HILITY i i I UnMAGEYiTA'ER 7 _`�` l - FREN15;$,(;.a_ctr nee t•CTiO•(Yj0 i CLAriIS-MADE II X OCCUR WITS OF POLICY XS - _ -_�-- l._� I` 11E0F•XP;Aar oneperccr) S c" EEll I OF SIR:31M-FR CCC � LeERSONAId:.OV IN;VRY y$ .,__._t�CL6 GENERALMGR£GA?E lSGENL AGGREGATE U ;T APPilES PER: ' ODUCTS-CO+MPIOP AOG SX POLICY I PAT 1 L ' �._i I � I I 5 9 AUTONoaILE LIABILITY !BAP 2338663.12 0301r7315 waxv COMBINED SINCLE L L1IT Ea acddcrp _ :,v rJ(Ov X ANY A'JTO c I I BOCh.Y IA'JURY 1Pcr Dersor? 5 AUTOS r�AUTOSUL D SELF INSURED AUTO PHY Dld3 aoD._Y!rtlJRY LPeraxdcNy s �~ - AUTOS ��AUTOS I HIREOAt1TQS AUTOS'MEO !PROPERTYRTY OAUAGEE � I AUTOS I Pc S : UMBRELLA LAB _ OCCUR CACH CCCURRENCE i S !EXCESS LIAH_J CLAIMS-MADE i I AGGREG.�TE_ .-- I C WORKERScoMPeNSAnoN I I'A' 17731493(ADS; 13Oi!2015 D3gtr101ti X wcs-asu• IorH_ •A W EMPLOYERS'UABILITY y 1314LI$1- C ANY PROPRIETORJPARTNERrEXECUTIVE Y IN I 1WCJi7731495(AV.KY.��H,NJ.V') .0210112015 �03'01.2D16 1,OOC,tL^0 OFF:CER/NC•MBER D(CLUDED� N/A' r EL EACx1l.CGIDL•.'tT D (Mandatory En NH) I =011731494(FL) 01101!7015 JUJI.0113 E.L.DISEASE.fit EMPLOYEE!S t.DOD,000 U KGs.Cdt"Ibo older ____...... _.. DESCRtPTON OF OPE3Ar ONS be�w iC.':hl:'.ndCd On AOd't'Oral Page .L.DISE`/SE.POLICY i1Mli I S 1.-300.000 I I i i DESCRIPTION OF OPERATIOVS ILOCATIONS 1 VEHICLES(Attach ACORD ICI,Additional Remarks Schedda if more space is required) CERTIFICATE HOLDER CANCELLATION "05HV OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 60005G0JOSI. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANOOV:R.MA 0184, ACCORDANCE WITH THE POLICY PROVISIONS_ AUTHORIZED REPRESENTATIVE o1 Marsh USA Inc. ManasniMukhcroo ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD