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HomeMy WebLinkAboutBuilding Permit # 7/10/2015 IJIL IN P MIT NorarH ®��.1Le� l6q~� TOWN OF NORTH ANDOVER N EXAMINATION APPLICATION FOR PLA -A _ n Permit No#: Date Received �gA�a�TEa aP°�c5 Date Issued: 7 SSACHuS�` IMPORTANT: Applicant must complete all items on this page LOCATION 57q 0't+Wco4 Print PROPERTY OWNER 4� Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District es no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Re idential Non- Residential ❑ New Building O�f�amily❑Addition ❑Two ormoreamily [I Industrial ❑ Iteration No. of units: [I Commercial epair, replacement ElAssessory Bldg [I Others: Demolition ❑ Other uraraavx �+ ii x r iol/ r r fr' uagr-„a,; I 71'r' JDI/Iri... „;/(((li°W,11('41 e r edi IJ,ME [J C7 0' KSS r rEd DESCRIPTION OF WO . TO BE PERFORMED: . Identific tion- Please Type or Print Clearly OWNER: Name: Phone: I-ev Address: I e-�T7 oy-&� Contractor Name:_ Bow) eH Phone: loll- Email: 1 -Email: Address: cats Supervisor's Construction License: i Exp. Date: t "° Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 411w Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12A0 PER$1000.00 OF THE TOTAL ESTIMATE OST BASED ON$125.00 PER S.F. Total Project Cost: $- -7 , 9 FEE: $ 1 g ' . — Recei t No.: M Check No.: 1 P NOTE: Persons contracting with unregistered contractors do not have acces uaran fund ._.,. _..,,.. r.. r -r-n., 1� rr Drrii� d/r'JrJrr %%ifrJ/ ,r; -'Tr „ Til .. ..... . . ✓,IJi.fi///It„r ,n rr. //% ,,.mm,,o r- :-� ,r 71r,.a./J� //!/,rf/,%... r ,.., r i/, r3 c r/% ., / FORTH - Town of Andover ® ® y o LAKF h VeI°y Mass, COCHICMQW.CK ® RATIED S u BOARD OF HEALTH Food/Kitchen P E T L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ................ ... .. .. .... ............................................... has permission to erect ......................AOL. buildings on ...... ..... .....� .. ........ .. ...A................... Foundation Rough tobe occupied as ........ .. .............. ....... .. ........k......... .... :......................... 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 EXPIRES IN 6 T ELECTRICAL INSPECTOR UNLESS CONSTRUC S TS Rough Service ............ . ..... ....................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. e 6010290169 RR Donnelley 02013.All rights reserved.—G667 � r ' � RACT CONT # r MASSACHUSETTS SERVICE SC;LUTll, INSTALL D ACES C JNT ►CT LOW 'S LITHO IZED REPRESENTATIVENUMBER CUS MER K LIM rAl TREET ADDRESS STREET ADDRESS STORE No. S C „ 4 6 , J12 � CI STATE ZIPCTY STAT ZIP �^�J *tea. i 1 � ��'ti "' TELEPHONE ,�V/ � TELEPHONE . ` � 'I ` ,.. �.... 'CA�SH III ' BANK LCC REG DATE ? OWES HO 835 ENTERS,LLC'S MA HIC NO.:148688 l�J CARo CHARGE This is only a quote for the merchandise and services printed,below.This becomes an'agreament upon pdymont.Upon paymi, t;Abe entlro agreement,including,ihe specifically completed(Sages of this document;.the Terms and Conditions includedvvith this diraUmentand,�ny othei ddeYrda'and-aNae�(ments-hereto,shall be rafen'sd tahereio as this"ContfacL" PLEASE READ ALL TERMS AND'C'ONDITION3,ON THE REVERSE SIDE OF.THIS"PAGE,AND FOLLOwiN6 PAGES`BEFORE SIGNING. INSTALLATION„STREET ADDRESS CITY STATE ZIP t,�"��`6c:^' � �.«�Q ��'b' �G�' 4 �u��• � z"`ro .., It t e �'ii,l,.i ,0 °�N COY, � Y”. �°k� "'Y,°` �'°k, '� ��nr'„. r ✓ t?"'A 6' & NOTICE TO CUSTOMER—PRICE CALCULATIONS: In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated 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 osts which may not be refunded once the Installation Services are performed. ontract Are permits required for this installation?: Yes [ ] No *applicable able tax Total ncluded 7>4;::g NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signingthis ontract, Customer acknowledges havingtreceived a copy of this pamphlet before work began informing Customer of the potentiai.,risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling'unit. NOTE: If rotted wood is discovered duringinstallation additional charges will apply. You will be given a quote and a change order ' g � pp Y� must be completed and signed by the customer for any additional charges. - Customer must initial. *Any work or material not specified is not„included in this contract.Any changes or additions will be at an additional charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to takehotographs of the Pretpises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocar grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in 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,imiuding,but not limited to,marketing, advertising, publicity, illustration,training and,Web content.By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. Work' tq�cp me a upon reasonable availability of Contractor and/or any special o e Amer made Good(s)which is anticipated to be �er � / [fill in date].Estimated completion date is [fill in date]. i Said estimated substantial completion date' t of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicable, insert a statement of such contingencies). IF"ITHQCONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. COMPLETE 1 1a SECT AIJWHEN THE.CONTRACT TOTAL EXCEEDS$1,000.00: [ ] Customer to Pay in Full; OR �""T"""']�6tastwer to use the following payment schedule: (1)Deposit $ to be paid upon s gftitrg-®eat ct. Deposit should be 1/3 the total contract price;and (2)Payment of $ to be paid anytime after this Con ' ed and before commencement of installation,1/VVe authorize Lowe's to do one of the following(check appropriate box below): ' ° [ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this ContYaisjned; kC or { [ ] p it payment r 100.0 to e o u on e payment etlo a In t d o hk r thq Je”tib ctmn: % ° Deposit m /our check for the amount of the mdtcated above an I e after th d to this Contract 1s st ned and �� } (3)Final paym $ 4 p„d nm,,,� �� i- ,1f/OTfCE"'RLGit1wRD G'"' T �7'i"�N``°r 4�I+CE� ECVT'�OIiI�C`L'AlIV1° f'CO1'I"El2MY 1111.G.L:6:142A This Is only a quote for the nergkaendise,and services Ori nted,below. This,beeotnes an;egreetrignk upon payelepk:.,Upon paymehtiAe entire agrkrnent,Jhcidding-ihe s'perafically completed pages of this documetr,tha Tenns grid C:ohdikrdns'induited-with this do6urnanI and,any ntha(idderrde and anal(irnei'M6 Iheteto,s;hpli ba I n ieridd to hbrsln,as'fhis',Cahtract." PLEASE READ ALL TERMS„ANb G4Nb?IONS 6N THE'REV8R'SE SIDE OF TH18 PAGE'b FOLLOWING PAGES BErORE SIGNINb, INSTALLATION ATREET ADDRESS CITY q� STATE ZIP IMI A,Ath e p� (vi�Pel r a k”v trwl F t 61 I ae i fa. G t NOTICE TO CUSTOMER—PRICE CALCULATIONS: In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated 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 osts which may not be refunded once the Installation Services are performed, r ontract Are permits required for this installation: D4 Yes [ ] Noa ill able tax Total pp included � �. * NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this dontract, Customer acknowledges having;received a copy of this pamphlet before work began informing Customer of the potentiat,risk,of the lead hazard exposure from renovation activity to be performed in Customer's dwelling`unit. NOTE: If rotted wood is discovered during installation additional charges will 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 material not specified is not included in this contract.Any changes or additions will be at an additional charge for the material and labor. PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and,independent contractors the right to takhotographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevoca grants to Lowe's all r,ight,title and interest in and to the photographs for use in all markets and media,worldwide,in 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. [Customer to initial to the left]. Work,W cp e e upon reasonable availability of Contractor and/or any special oo es mer made Good(s)which is anticipated to be ✓ "r� � [fill in date].Estimated completion date is " ;[fill in date]. Said estimated substantial completion date'y t f the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: g I (if applicable, insert a statement of such contingencies). IF T,H,E CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in frill. COMPLETE TnECT°ON-QNL V_HHEEN THE CONTRACT TOTAL EXCEEDS$1,000.00: [ ]Customer to Pay in Full; OR []r0-t4& er to use the following payment schedule: (1)Deposit $ to be paid upon slgnttTg 86tat ct.Deposit should be 1/3 the total contract price;and (2)Payment of $ to be paid anytime after this Con r d and before commencement of installation,Me authorize Lowe's to do one of the following(check appropriate box below): " [ ]Charge mylour credit card for the amount of the payment indicated above anytime after the date this C nTr°ctti ned; or 3 Final a menu ocheck for the amount of the payment indicated above an I after th to t ' Contractis slined and r. [ ] Deposit my/aur P Y ,. - Yu � . hf5 O p $10p.QQ to bepaid upon c "mpJetkrrr of tle inetallaah anddothpartids Aatis ction. NOTICE R EGARDfiNG AR T 6 TI N AGREIEMENT FOR CLAIMS COVERED�BY M.G.L.c'142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE OF CO SUMER AAFFAIS AND BUSINESS REGULATIONS ANDTHEOWNER SHALL BE REQUIRED TO,SUBMIT TO SUCH ARBITRATION AS P ID By:Lw 's Home Centers,LLC By ... f. tf,.., 4 .m.. Date. Owner SignatureI I THE SIGNATURES OF THE A T ES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONSCONTAINEDON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A COP F THIS CONTACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW THISDAY OF t , Lo rs LLC Lowe's Alith f 4 . .��. orized ep a - Owner Co-owner or Witness 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. FILE COPY ©2004 Lowe's.®Lowe's and the gable design 55102 REV. 12/13 are reg,istered trademarks of LF Corporation. ;N The Commonwealth of Massachusetts :1— - Department of IndustrialAccidents -' ` Office ofInvestigations 600 Washington Street Boston,MA 0211.1 } www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): h�( k2ier2 Address: Qi Dr. City/State/Zip: Im � UY1/'f D;Z 13Y- Phone#: (l 7- 5%Z-430 Q Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. E] I am a general contractor and I * have hired the sub-contractors 6. El New construction employees(full and/or p time). 2.❑ 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 workingfor me in an capacity. employees and have workers' Y P t5'• 9. E]Building addition [No workers'comp.insurance comp, insurance., required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: ,j,Jt/,1y4 =hsuavl(L Policy#or Self-ins.Lie.#: A wc` 1400-70; 5 5 I+Aol Sn Expiration Date: Job Site Address: 'wood Jf City/State/Zip: i velMAo Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hhembY'—ceI u der he ' sand penalties of perjury that the information provided above is true and correct Si tUre. Date: Phone Official use only. Do not write in this area,to be completed by city or town ofcial. 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#: GREEINS-01 KMCMAHON AG CARL) DATE(M.M IDOfYYY`r) �.. CERTIFICATE OF LIABILITY INSURANCE FE(MMID IY 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: M the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WANED,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 Ilou of such ondorsamont(s). PRODUCER CONTACT _NAME Salem Five Insurance Services,LLC PHONE tc, �(781)933-3100 FAX Ne). (781)933-0048 446 Main Street EMAIL Woburn,MA 01801 Ao-DRESS:_insurance.services@salemfive.com -- INSURER(S)AFFORDING COVERAGE ', NAICO wsURERA:Safety Insurance Company 39454 INSURED INSURER B:Safety Indemnity Ins Co. 33618 Greene Installation Co.Inc. wsuRERc:AIM Mutual Insurance Co. 0913 __. _ 10 Rita Drive INSURER D:_ Medford,MA 02155 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILTDAR OF I --._ ----- –ADDL SUER -------- ------- -....__ POLICY EFF -POLICY E%P.. LIMITS. . TYPE OFINSURANCE POLICY NUMBER MMIUOKYYY MMry A X COWERCUtL GENERAL LIABILITYEACH OCCURRENCE 1,000,000 iDAMAG TORENIED CLAIMS-MADE X OCCUR BMAD008619 10510812016 05/08!2016 DREMisEs(Ea dOCL7ran b) s MED EXP(ar,y ma Perw^) .S 10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER % GENERAL AGGREGATE _S 2,000,000 '.. X POLICY JECT LOC j PRODUCTS-COMP/OP AGO S 2,000,000 OTHER:. _- - .S _ AUTOMOBILE LIABILITY COMBINED SINGtE UL+fT S 1,000000 (Ex mcddnn) B - ANY AUTO6208932 01/30/2015 01/30/2016 BODILY INJURY(Per peerson) 5 -.--._ -- ---- ALL OYwNED X SCHEDULED AUTOS ( BODILY INJURY(PeraWdan>) 5� ANON UTOSED PROPERTY DAMAGE-- _ __. X HIREDAUTOS X j (PorocdEor9) UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESSLIAB GRANS-MADE AGGREGATE _ .. _ _.—__._._....e..__.--.. •S DED RETENTION S WORKERS COM PEN SATION �..._.. X STATIiTE OER� AND EMPLOYERS'UABILITY C ANY PROPRIETORIPARTNERrEXECu7IVE MUNI NIA A AWC�00-7026694-2016A 09!04/2015 0310412018 E.L.EACH ACCIDENT s 500,000 OFFICER/MEMBER EXCLUDED? _J -- - -- (MandatoryInNH) E.L.DISEASE-EA EMPLOYEE 5 600,0-00 If ym,dnurnbo�don DESCRIPi ION OF OPERATIONS CeIow E L DISEASE-POLICY LIV37 S 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES tACORO 11911,Adortonai Rtmarks Selladu)o,may be tNachad A morn apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Winchester THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN emo Town of W 71 Mount inche Street ACCORDANCE WITH THE POLICY PROVISIONS, Winchostor,MA 01890 AUTHORIZED REPRESENTATIVE {r�r� 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(20141011) The ACORD name and logo are registered marts of ACORD at' � massa usetts N Department -safety Board of Building Regulations and Standards License- CSFA-0617 99 k� RQ14ALU fit.GR 4X 10 RITA k COMOV f=E � � 1.1 .3.1 FAX 781 301 0624 (.'REENE INISTALLATI(IN (A) LOWES W INST o I C) 'g, Q ME IMPROVEMENT CONTRACTOR nolstrition: 102957 Type; -xpirution: 71.3/2016 Private Corporatio GREENE INSTALLATION CO.;INC. Rona!d Green© 10 RITA DRIVE MEDFORD,IVIA 02155