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HomeMy WebLinkAboutBuilding Permit # 9/21/2015 BUILDING PERMIT tkORTtl TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION -Z Permit No#:—�—��� d Date Received TED PPP C5 �SsaCHU Date Issued: 6 I IMPORTANT:Applicant must complete all items on this page LOCATION 16� mL,"L ll) z I Print PROPERTY OWNER 0We-)gOMi4�- Print 100 Year Structure ye n Do MAP t'� I PARCEL:.W�J ZONING DISTRICT: Historic District y S no Machine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Reside.,-ntial Non- Residential El New Building ne family El Addition El Two or more family El Industrial El #6 rat i o n No. of units: 0 Commercial Xr Repair, replacement 11 Assessory Bldg El Others: El Demolition El Other E CRIPT N OF WORK TO B �i, RM p Z,T ql�l F) Iden-tific OWNER: Name Location Address:- 11�) ryi Im Date Contractor Namej Email: Address:—Y—VTOWN OF NORTHA VER wv Supervisor's Construction Licen� Certificate of Occupancy Building/Frame Permit Fee $ 1 -1-JF Home Improvement License: Foundation Permit Fee ARCHITECT/ENGINEER Other Permit Fee TOTAL Address: FEE SCHEDULE. BULDING PERMIT.$1� Check# Total Project Cost: $ Building Inspector Check No.: NOTE: Persons contracting witi --- 0" Sig con raq or2, W, 77 SignatU7 0, FMN�0,Ne w, F ril—I AM FORTH H 0 w. , 0 Im- ndu v ur 0 0% No. BOW O9 COC NIC Ic"t MC W,CK ��• AORATEED) U BOARD OF HEALTH Food/Kitchen P R Septic System IT T LU THIS CERTIFIES THAT ............ ..... ... .... !`!N�.. ... ... ....... . .. ........ ... .. BUILDING INSPECTOR ...... ........ ...... .... .... . .. . .. has permission to erect ........... buildings on ... ............... Foundation Rough to be occupied as .. ... . Q!. .. .�. .��!!!ea 4P-kE`A*Ite.... ............... chimney provided that the per on accep ng this permit shall in every respect conform to the terms of 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 UNLESSTI T S Rough Service .............. .... ......... ....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Sold,Furnished and Installed by: Branch Name: Boston North&South Dater/4t/f5—, THD At-Home Services, Inc. d/b/a The Horne Depot At-Home Services Branch Number: 31 and 33 908 Boston Turnpike, Unit 1,Shrewsbury,NIA 01545 Toll Free 577-903-3765 Federal ID#75-2698460;VIE Lic#C 02439;Rl Cont. Lie# 16127 CT Lie#HIC.0565522;MA dome Improvement Contractor Ree.#126893 Installation Address: �U A� City State Zip Purchaser(s): 'fork Phone: Hoare Phone: Cell Phone: Home Address: (if different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails boar The Home Depot Project Information: Undersigned("Customer'), the owners of the property located at the above installation address,agrees to buy, and THD At-Hosie Services, Inc. ("The Hone Depot") agrees to furnish, deliver and arrange for the installation ("Installation") 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"): Q—*I ,101)#: Qnlcrnnl Reference) P Spec sheet(s)#' Project Amount Cyd 7 0-Roofing ❑Siding Windows ❑ Insulation �352- Gutters/Covers Eithy Doors ❑ ���✓ ❑Roofing ❑Siding ❑ windows F1 Insulation � �� (e El /Covers Envy Doors ❑ 1 6 �� ❑Rooting ❑Sidi g ❑ Windows ❑ Insulation $ ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding=. ❑ Windows ❑Lisulauon ❑Gutters/Covers ❑Entry Doors E]_____ \lininrum 25%Deposit of Conk act rinrount due upon esecatior of this contract. Total Contract Amount p 'Maine Purehaseis may not deposit more than ore-third ofthe ConttactAniount. Customer agrees that, immediately upon completion of the wor9k for each Product. Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Slice[) and pay any balance (Inc. As applicable, each Customer under this Contract agrees to be.jointly and severally obligated and liable hereunder. The Home Depot reserves the ripht 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 Scrvice provider determines that it cannot perform its obligations dueto a Structural problem with tine home, environmenrtl hazards Such as mold, asbestos or lead paint other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Part SgnSutnnrai-y: The Payment Summary # % i included as part of this Contract, sets forth the total Contract anwunt and payments required for the deposits and tin<tl payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Cornpletion Certificate (note: there is one Completion Certificate;for each listed Product as defined by individual Spec Sheets)before work nn that Product is complete. in the event of termination of this Contract, Cusfonrer alyrees to pay The Houle Depot the costs of rn<aterials,labor, expenses and services provided by The Hoare Depot or Authorized Service Provider through the (late of termination, plus MAY other arsonists set forth in this Atbreenrent or allori�ed under applicable law, THE HOME DEPOT NIA ' WITHHOLD ANJOUNTs ONVED TO THE fl[ONI E�DE POT FRff1v,-1 THh [3EP6si'r 111AYN4ENT OR OTHER P..,kY IENT,, MADE, WITHOUT LINJITING THE HOME DEPOT'S OTHER RETIWI?DIES FOR RECOVERY OF SUCH AMOUNTS. ,yceotance and Authorization: Customer t��rees and understands that this A�>reement is the entire a��rccment between Customer and The Home Depot with regard to the Proo-IUCt1 and Installation services and supersedes all prior discussions and noreentents either oral or written, relating,to said Products and IrStallation. This Agreement cannot be assiLned or amended except by a writin2, signed by Customer and The�Home Depot. Customer acknowicd-cs and aorees that Customer Ias react, Lill Cirrst:anCIS, voltmtarily accepts file terms of and has received a copy of this Agrrecmcnt. Ac i ed I Submitted by: . �, I Work area will be contained ERS Pre-Renovation Form Date: g 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 Job Number(s) OCCUPANT CONFIRMATION Dust will be minomized 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. 4' Home Year Built _=F Enter the year my home was built. M5 g If my Home 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 Home Year Built is 1978 or after, Lead-Safe Work Practices are not required. thoroughly N"la.,a4e 6 �a ; ter r s Printed Name of Owner-occupant f S�r t x� t S�.Y� `:4?. �t L.''l �*,4', ix�iea�"t �^ z� \ttai't�'����`t "•'t� � yi Y f ; , Signa re of Owr-occupant r Signat e of Perpowead Pamphlet Delivery i SEE STATE SPECIFIC FORMS ON REVERSE SIDE �r'1 r.w,,,s.n � i•n ��nCi vt I V � I - rr' ` l • {�;T.:11C nY-AR;S Y1.t,XT nla ntl, '-, J.'; : lv ct„�?t 1. 11111 '� J -• • • :tu,l`u.itn='d votl• u{ uC,'"J'`I•�•'.n^ vnun;t,iur.:*{nv-u 11'y"� n,l,vvaul I'n7u( %11y VY .�tr•_:a Hvt 1 L� �SITI ti Iva19'" 1*,'^u`rrV a, la,� Y• :aFao Lv ��,a:a y:a3u ,.ya:i I:�,u,:,7u! Ir•`l' „na l^�"1 � ,aa nal �i�,, tivlu -.lilt x:1+nu >r�^.114 til{n:u .::-t�iti:yu;i}•�6%i'=' ���C Iif�V����QY I: ei rn ,SIS_ —G59 rGc� ��� • �. 10 ;11yc 7aul� :.. ti s1�' rr--f:r tm ' •e�ut—ue:.tu'1t�1�6i�ue ;1,E •IUt:�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/Electricians/Plambers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly NaI110(Business/Organization/Individual): Address: 2 City/State/Zip: • ��� Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.O I am a employer with employees(full and/or part-time).' 7. []New construction 2.O[am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9, []Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance requimd.3 t 10 Building addition 4.❑[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 p rietors with no employees. 12.[]Plumbing repairs or additions 5. tam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs ; These sub-contr2clof5have employees and have workers'comp.insurance.:. 14 7- then 6.❑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.] 'Any applicant that checks box#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. er or not those entities have 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state wheth employees. Uthe 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. a / �)�C Insurance Company INTame: / Policy r or Self-ins.Lie.r: w t/ Expiration Date: Job Site Address: City/State/Zip: PF Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under I�IGL 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 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certand naltie erjury that the information provided aabbjove isltrue and ct ify Signa / Date: Phone Official use only. Do not write in this area,to be completed by city or town official. i City or Town: Permit/License r Issuing Authority(circle one): Lns Inspector 1.Board of Health 2.Building Department 3.City/Tovr-n Clerk 4.Electrical Inspector S.plumbing. P 6.Other Contact Person: Phone r: t I N8ffY11I J8NIC6S / 4U1 Lob L?3t)b p.2 I 07 U AL2 �C�??���`?�Z•�11P�.,1�.��`2 fl���f/{->;t%�J�lv�`2GG;����• ' t Office of Consumer Affairs and Business Regulation 10 Park Plaza. ® Suite 5170 Boston, Massachusetts 02116 Home Improvement-ContractorRegistration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 813/2016 RICHARD TROIA ---------- 2690 CUMBERLAND PARKWAY SUITE 300 . --- ATLANTA, GA 30339 _.....__. ........-.___ Update Address and return card.Nlark reason for chnngc. SCA r 2W-05-111 Address ' Renewalmplo}'cr:cr„ cyst Car e v. �'i//•, i'i'N/L/o/q/'M/��J!��^�,/r/1ifr�//:ri�' '.,.. Officc or Consumer AM-irs&Busintss Rtgulation License or registration valid for ind-tvidul use only 5 t{OME IMPROVEMENT CONTRACTOR before the expiration date. Cf found return to: ! s Office of Consumer Affairs and Business Regulation "mss Registration: .126693 Type: 10 Park Plaza-Suite 5170 Ex 813/2016 . Su ement Caryl P� PPI Boston,TvfA 02116 , THD AT HOME SERVICES,INC. THE HOME DEPOT AT'HOME SERVICES RICHARD TROIA 2690 CUMBERLAND PARKWAYS IN GA 30339 Understertory t valid wiLtnature AC R ® CERTIFICATE �LIABILITY INSURANCE DATE(MMIDDIYYYY) ®tl 0712512015 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 policy(ies)must 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 holder in lieu of such endorsement(s). PRODUCER CONTACT NAME, - MARSH USA,INC. PHONE FAX Not: TWO ALLIANCE CENTER -I&C.No.EaU' 3560 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 DDRE S: INSURERS AFFORDING COVERAGE 0_ 100492•HaneD-GAVJ'-15-16 INSURER A Steadfast Insurance Company 126387 INSURED �U.S.A. ,i,INC. INSURER CINSURER B,Zurich American Insurance Co 16535 HOME DEPOT U THE HOME DEPOT,INC. New Hampshire ins Co 123B41 2455 PACES FERRY ROAD,NW INSURER D•Illinois National Insurance Company 123817 BUILDING C•20 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003155301.06 REVISION NUMBER:0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT WITHSTANDING 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, 11TR TYPE OF INSURANCE INgR U D POLICY NUMBER MMIDDIYYYY POLICY M DDIYEYXYY LIMITS A GENERAL LIABILITY I GLO4887714-05 036112015 0300016 EACH OCCURRENCE s -- 9.000.0 X DAMATO R NT D COMMERCIAL GENERAL LIABILITY P X11 1,� $_()a occurren o s 1 CLAIMS-MADE 111 OCCUR LIMITS OF POLICY XS MED EXP(Any one person) s EXCLUDED OF Slit SIM PER OCC PERSONAL&ADV INJURY_ S 9.800,0 GENERAL AGGREGATE $ 9,000.000 �GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 9,000,000 POLICY nPRO- LOC S B AUTOMOBILE LIABILITY BAP 2938863-12 10310112015 03101/2016 ICD1.1B.1NED ntSINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY tPer person) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accJdcnl) S AUTOS AUTOS NOWOWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per ecodent S UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION S S C WORKERS COMPENSATION WC017731493(AOS) 0310112015 03/0112016X WC STATU. oTH- AND EMPLOYERS'LIABILITY WC017731495 AK KY,NH,NJ,VT 0310112015 03/0172016 BYLOd 1,000,000 C ANY PROPRIETORIPARTNER/EXECUTIVE YIN N ( ) EL EACH ACCIDENT S OFFICE,.ry in NH) ( )BER EXCLUDED? O N/A D (Mandatory In WC017731494 FL 0310112.015 0310112016 E.L.DISEASE-EA EMPLOYEE $ 1,000.000 It yes,descnbo under Continued on Additional Page 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16000SGOODST, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2010 ACORD CORPORATION, All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD of ,,,,p u1ir, C I.c + �anLrl CSSL-099823 DZAUTRV]ap® y, 70 N®RTO 1®AAV $L' Bnchestee NH 0109 = 06®26/2016