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HomeMy WebLinkAboutBuilding Permit # 9/30/2015 V%ORTH BUILDING PERMIT 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMdINATIONI Date ei Permit NO. T.CHUS Date Issued'.. all items TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential Ei New Building One family [i industrial o Addition Ei Two or more family [i Commercial ED] eration No. of units: o Others: Repair, replacement o Assessory Bldg----------- o Other v WTI, o Demolition x g SO , IN—A 09 0t t-10 Identification Please Type or Print Clearly) Phone: -4- OWNER: Name: Addr ARCHITECT/ENGINEER Phone: Reg. No. Address: ESTIMATED COST BASED ON$125-00 PER S.F.SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL Total Project Cost: $ FEE: $Receipt No.: Check No.: registered contractors do not have access e Puar my fund NOTE: Persons contracting w Un 71 c ra gnai,,u,,e,,Q�,yqni eb FORTH ' ]rown ot An do,ver ® y. No. 40q , p(� S. i �• h ver 0� 9 KAKWCOCMICKV • S U BOARD OF HEALTH Food/Kitchen v ERL U Septic System THIS CERTIFIES THAT ........ C li►�� ..................... ....... ..............Ct.......................... ....... ...................... BUILDING INSPECTOR 24 Foundation has permission to erect .......................... buildings on .. .. ...... . ..... ... �L�, .................. Rough .e to be occupied as ............... .......et��•-... .... ... .. ......... ,,Q. ., ......................... Chimney provided that the person accepting this permit s all 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 PERMIT EXPIRES Final ITIN 6 MONTHS ELECTRICAL INSPECTOR LESS ST TIONA S 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. HOME MPROVENIENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston North&South Date. /� THD At-Home Services,Inc. d/b/a The.Home Depot At-Home Services Branch Number: 31 and 33 903 Boston Turnpike,Unit 1,Shrewsbury, MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460:ML Lie#C 02439;RI Cont.Lie# 16427 CT Lic#HIC0565522;MA Home hnprovement Couu-actorr Reeg.## 126893 Installation Address: Cite tate Zip Purch,-ser(s): Work Phone: Houle Phone: Felt Plione: Borne Address: _ (If different from Installation Address) City State Zip E-mail Address(to receive project connntin ications and Home Depot updates): ❑ I DO NOT wish to receive any marketing cmails 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 burnish, 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"): ,lob#: Onlernal Reference) Products: Spec Sheet(s)#: Project Amount ❑Roofing ❑Siding L1 Windows ❑ insulation ❑Gutters/Covers Entry Doors ❑ 277 ❑Rooting ❑Siding. ❑ Windows ❑ hnsulatiou $ (� ❑Gutters/Covers ❑Entry Doors ❑ ❑Roofing ❑Siding ❑ Windows ❑ insulation ❑Gutters/Covers ❑Ent.ry Doors❑ ❑Roofing ❑Siding ❑ Windows ❑ insulation $ ❑Gutters/Corers ❑Entry Doors ❑ Mininnunn 25%Deposit of Contract Amount due upon execution of this contract, `(oral Contract Amount $ 1N4aine Purchasers may not deposit more than one-third of the Conti-act Amount. Customer agrees that, immcdiately 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 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 or any individual Product(s) included herein, at its discretion, if The Moine Depot or its authorized service provider determines that it cannot perform its Obligations due to a structural problem with the home, cnviroomental hazards such as ruold, asbestos or lead paint, other safety concerns, pricings errors or because work required to complete the job was not included in the Contract. 11ayrraent Summarv: The Payment Sulninary #. , included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product (as applicable). NOTICE TO CUSTONVIER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before 1vorh on that.Product is complete. In the event of termination of this Contract, Custoannev ,grees to pay The Home 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 outer amounts set forth in this Agreement or allowed under applicable lana. THE HOINJE DEPOT XkIAV wiTHHOL.D ANIOUNT s ONVED TO THE' HOi?aM DEPOT FROINI THE D)sPCisa PAVIMEf IT OR OTHER PA` NNIENTS NIADE, WITHOUT LENHTING TME 110TWE DEPt3' "S OTHER REMEDIES I+OR RECOVERY OF SUCH AAMOUN T S. Acceptance and Atalh(rJzation: Customer a-l-ccs and understands that this Agreement is the entire agreement between Customer and The IIome Depot with regard to the Products and Installation Services and supersedes all prior discussions and agreements, either oral or written, relating to said Products and installation. This Agreement cannot he assigned or arnendcd except by a writing si�lned by Customer and The Home Depot. Customer acknowledges and aprecs that Customer has read, understands, voluntarily accepts the lernis of and has received a copy of this Agreement. A e d b Submitted by: Work area will be contained Pry Reno ' Date: Pre-Renovation For NAT-19276 . i 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) r OCCUPANT CONFIRMATION Dust will be minimized m m 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,t Florae Year Built 4� .� xv I Enter the year my home was built. �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 Nome Year Built is 1978 or after, Lead-Safe Work Practices are not required. thoroughly Printed Narne of owner-occupant 3'z 4 . a ignature caner-occupant i' Signatur of Person ertifying Lead Pamphlet Delivery s SEE STATE SPECIFIC FORMS ON REVERSE SIDE 1'dae tC®via ®nreadt6a of Massause S Deparment ofIndustrial Accidents O ce of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/lJlectricians/Plumbers - �• ¢xa dsnffi, �4:��, Please Print lLeglbly - Name (Business/Organization/Individual): 1_—b-i Address: �2&00±: City/State/Zip: Zt4rl& &A C( Phone#: tre��employer?Check the appropriate bo : Type of proj:.Iition ired):[2. a employer with 4 ❑ I am a general contractor and I 6 E]New ion employees (full and/or part-time).* have hired the sub-contractors ❑ i am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remo ship and have no employees These sub-contractors have g, [�Demo working for me in any capacity. employees and have workers' 9. Buildingon [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electirs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11:❑-Plumairs or additionsmyself, [No workers' comp. right of exemption-per MGL ' 12.E]R staransg require t c. 152,A 1(4),and we have no amp oyees. [No-workers comp.insurance required.] *Any applicant that checks box#1 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. tContractors 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 aura an employer that is providing workers'compensation insurancefor spay employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lica#: Expiration Date: Job Site Address: City/Mate/Zip: Attach a copy of the workers' compensation policy eclaration page**(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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' urance coverage verification. I do hereby certify un er h aipa ars pet ies of perjul y that the informati�Dat rovided abov is trace and correct 1 Si store: e: Phone L[6.0ther use only. Do not write in this area,to be completed by city or town official, own: Permit/License# Authority.-(circle one): Board of health 2.Building Department 3.City/Town Clerk 4:)'Electrical Inspector 5.-Plumbing Inspector Person: Phone#: CERTIFICATE F' LIABILITY I U i �, � �A �,��M�D� rr'� _ ! 0711 1201 t HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS f CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES j i 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BET'IUEEN THE ISSUING INSURER(S), AUTHORIZED i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, j 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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD,SUITE 2400 E-MAIL U" A1C Nol: ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 9 100492-HomeD GAW'-1516 INSURER A:Steadfast Insurance Company 26387 INSURED Zurich American Insurance Co THD AT-HOME SERVICES,INC. INSURER 8 16535 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire fns Co 123841 2690 CUMBERLAND PARKWAY,SUITE 300 ATLANTA,GA 30339 INSURER D:Illinois National Insurance Company 123817 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-13 REVISION NUMBER:8 THIS 1S 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. ItdSR' ADD UB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY GLO4887714.05 03/0112015 03/01/2016 EACH OCCURRENCE s 9,000,000 _ CLAIMS-MADE OCCUR DAMAGE TO RENTED C PREMISES Ea occurrence $ 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED OF SIR:$1M PER OCG PERSONAL&ADV INJURY $ 9At3,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,00,000 X POLICYI PRO- — JECT D LOC PRODUCTS-COMP/OPAGG S 9,000,000 OTHER: S B i AUTOMOBILE LIABILITY BAP 2936863-12 03/0112015 03/01/2016 EO BINEDISINGLE LIMIT S 1,000,000 ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY Mw accident),S HIRED AUTOS NON-OWNED I PROPERTY DAMAGE AUTOS Per accident S S UMBRELLA LAB I I EOCCUR EACH OCCURRENCE S EXCESS LIAR 171 CLAIMS-MADE AGGREGATE $ DED RETENTIONS S C WORKERS COMPENSATION WC017731493(A05) 03/0112015 03/01/2016 X PER 0TH- AND EMPLOYERS'LIABILITY STATUTE ER _ C ANY PROPRIETOROARTNER/EXECUTIVE Y/N WC017731495(AK,KY,NH,NJ,VI) 03/01/2015 031OW016 D OFFICER/MEM8ER EXCLUDED? a N I A E.L.EACH ACCIDENT S 1,000,000 (Mandatory In NH) WC017731494(FL) 03/01/2015 03/01/2016 E.L.DISEASE-EA EMPLOYEE $ 1,00,000 Ifyes,describe under Conitnued on Additional Pa DESCRIPTION OF OPERATIONS below 9e E.L DISEASE-POLICY LIMIT S 1,OCO,Lw DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) EVIDENCE OF INSURANCE c I 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 DELIVERED IN 2455 PACES FERRY ROAD ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukher)'ee kz ©1988-2014 ACORD CORPORATION. All rights reserved. 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