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HomeMy WebLinkAboutBuilding Permit # 11/5/2015 dyORTH BUILDING PERMIT °t�.QLFo 'g 6 TOWN OF NORTH ANDOVER ® APPLICATION FOR PLAN EXAMINATION Rq Co[NIc crt`y Permit No#. l Date Received ��'s�ATED CH Date Issued: I IMPORTANT:Applicant must complete all items on this page LOCATION tint PROPERTY OWNER e. Printtyes Ono 16o Year Structure MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Resid ntial ❑ New Building ne family [i Two or more family El Industrial ❑Add'tion ❑ Commercial ❑ ration No. of units: ❑Assesso Bldg ❑ Others: epair, replacement ElDemolition ❑ Other D str,ct ❑ Watershed i t ❑ Septics`❑ Well , ❑ Floodplain ❑Wetlantls ` �� � r , ,W,%° ,w ,�❑Water/Sewert r � _ "DESCRIPTIO K T RFOR ED dentification- Peas 'Type or Print Clearly Phone: OWNER: Name: } Address: [Home actor Name: Phone: Address: visor's Construction License: Exp. Date: w Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Reg. eg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ .� FEE: $ Receipt No.: /2_C1 Check No.: s to the guaranty fund at ' NOTE: Persons coratrac rng ath �nre estered coatraco no have actsq %AORT11 Town of Andover 0 e. No. "Ih ver, Mass, 1 ?e"66 Al A'rp D P, BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 0 S BUILDING INSPECTOR THIS CERTIFIES THAT ..................... ............................................... ........................................ Foundation has permission to erect .......................... buildings on ..... . ... ... . ....L..... ...........:............. Rough ...............................4&'6.................................. to be occupied as .............. ......... LA,)\.. ............ 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough Service .................. ............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupa r v Permit ccs Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. fa(rPa�O/!!�I i�f��� �rwwuwmre��www,ovmrr C"DM ' IMPROVEMENT CONTRACT P%il;ASE ATEA"TMIS Sold, Furnished and Installed by: Branch I arne> New England Dates°�//,5/ THD At-H'otne Services, Inc. d/b/a The Home.Depot At-Home Services Branch Number: 31 908 Boston.Turnpike„Unit 1,Shrewsbury, M.A 01545 Toll Fred 57700317013 Acic.ral GD 4 75069EiX&ME Lk#C:'00139;RI C:onL Lie# 16427 CT Lie#I-GIC'..0565522;MA Home Improvement Contractor Reg.#1.26693 Installation A eldr ess: F ° ro �, 1 A City `hate lip Purchaser(s); Work Phone: floraae Pyrone: Cell Phone. -79,577._..._� Eforne.Arlt r~ess: (II'differeant from Installation Address) City State Gip E-nia11 Addr•eass(t:o receive project corninuaaications and 'Home Depot updates): ___ _.___._._._......._._.... 0 1 DO NOT wish to receive any marketing ernails from The.Home Depot 1%dect Ilralor rnatiorr: 1-idersigned("Custorme), the;owners of the property hearted at the above insttall;ttion address, agrees u buy, and TIJ-D At Home Services, Inc. ("The Rome Depot") agrees to furnish, deliver and arrange Or the installation Clushdiataon") of all material;; described on the below and e:>n the. referenced Spec; 5heet(s), all of which are incorporated into this Wturact by this reference, along with My applicable Stater Supplcanent and Payment Snnrmary attached licreto grid any ChmWe Was (c:ollectively "Contract'j: Job#; arnre m RePerermee) y i crclarcts: ..__.._.....Sprec Sheet(,)#. IlRooAng ❑`Siding indows ❑Insulation a ❑Ciaatcrw l C'crvers noy 17oors r-1 ���� ❑C artt ng Siding Windows ❑ Insulation /C'ovcrs ❑Entry Doom ❑_,_ []Roerhng Sadirig ❑Windows ❑ Enwulaation ��— ❑Ciuuers,/Covers El Entry Doors❑ ❑Roofing (PSrding ❑ Windows ❑ InsTulation ❑C;uttur:s/Cower:; ❑Gantry Doors ❑__,_.........._ _ Alinimuni 25%Deposit of hintr act A.rturnt due upon ewecutron or thus e ottkam Total CAntrac t Amount l �� G/ blue Purch ase rs rn ay not deposit more than one-third of the.Contract Arnount, � � � Custorner agrees that, imniediate'ly upon Completion of the vvorlc for each Product, Customer will cxmnm .a Wripletion C'uidNate. (cane• for cac n hadmi as defined by an imlividural Spec; Sheet) and pay any balance clue. As applicable, each Cu,Stonner uicleT this (.,'ontract agrees to bejointly and severally obligated and liable hereunder, The Home Depot reserves the right M Wan ar C;hange.Wer or terminate dais Comma or arty indivW Product(s)included herein, aat its discretion,if]"'hte Home Depot or its authorized service provider determines that h canuol perfornr its oldiptimm duc to wa strucon-al problem with Me home., csnvironr emW hazards such as mold, asbestos or lead paint, other salty concern, pricing errors, err hecaause work rcapuire d to e::mMew the job was not inckded in the:/Coratr act Payrrarcnt S1a 11]L a 'Cite Payment Sunin-1 ary t�'t_�� G �� -. included as part of this C'ar7tratct, setsfr�rtfr wemal amount and payment;required for the elc�.l�iosits and final paynients by Produc( (as.,appficahles). NoTiCI TO C:;l.1S'l oN,1 ✓"11 You are endtled to a completely nlWd4n copy o'1'the Contract at the tune,yy:m sigm Do not mign at Corulr lion C'enifiude>.(mW there is;a,a,ne C:'orraWWAn C°Wl°i We Rw each Wed Pro&wt as deMwd by hrdivicfmd Spec: She:e°ts) berove work on that Product is cornpwtcn In they evnd (al'tertidnation of this, C mitract, CarMunwr„ aagr°ces to pay The Horne Depot the costae of araartedahq labor, vxpense s and r,aanims pr~raided by The Horace Depot or Authorized Service Provider thr„ernoi We dole of termination, plus any Wher armarrntss set forth in this Agr•esss..naa nt or aGh v d under„appiscable hw, INE HOME DEPOT MAY 'I'i fl't"tfl:fliOLD�y]y�flC)tJi "l��` WINIE r I I�ktaUTIN 1`lfll"H�Di�II DEPCD'IS OTI-03t I�IaflMEI�II�groDFOR llfl( D�a"I+ylitY O �S� + SUCH A 1ICDt6i�1'i;Sd'I'S MAW, W1111010 Acceptance arrdAqthor rzationr Customer ay'ree.s and understands that Clans Agro nnent in the cmires agreement between Customer nand he Homc Depot with regard to die Prrduct;,y aid Installation services and supcar,wdes all prior discussions and ay,�rsesrnents, either oral crt � i l, , relating; to said Products and Installation. ilk Agreement caannot he assn;ned or aorto°ided except by a writing signed by/�us(onier raid The Hotrlc pot cic Costontcr anowledl�e:s and agrees 111W C;Caslomeer has reach, understands. voluntarily accepts the tInas t,f and h-s receiv De=i c(ipy of ditty Agrc enrent. c.cepted Q. Submitted hy=; P,- ✓� _ Work area will be contained B A ` Pre-Renovation Form Oatefo NAT-19276 This form is used to document compliance with the requirements of the Federal �k Lead-Based Paint Renovation, Repair,and Painting Program after April 2010. Customer Address Job Number(s) 00i /0jt 41 OCCUPANT CONFIRMATION Dust will be minimized Pamphlet Receipt I have received a copy of the lead hazard information pamphlet informing me of l � p � t the potential risk of the lead hazard exposure from renovation activity to be t= performed in my dwelling unit. I received this pamphlet before work began. Home Year Built /A—q ' Enter the year my home was built. ®9 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 PrinteC(Name of Own -occupant nature f0wris cu a i Signe tur of Per n C6aifyrnq Lead Pamphlet Delivery SEE STATE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massachusetts Department oflndustrialAccidents a o X Congress Street,Suite 100 Boston,MA 02114-2017 wwmmass.gov/dia j-rarkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le bl Name(Business/Organization/Individual): Address: I M t ti Ci /State/ZtY i P� 10�_I___?Phone #: A�eyo�n ,mployer?Check the appropriate box: Type of project(required): 1. I am a employer wi / employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, [:]Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself t 9. ❑Demolition ❑ g y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.$ 13.E]Q]Roof-repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.L1 Omer 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. 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 am an employer that isproviding workers'com enation insurance for my employees. Below is thepolicy and job site information. ` Insurance Company Name: j Policy#or Self-ins.Lic. A Expiration Date: J _ Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declarati n 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. Ido hereby certify under the ain a per hies perjury that the information provided above' ue and correcL Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offrciaL 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#- AcCA'itiMlCC;^f!':i CERTIFICATE OF LIABILrTy INSURANCEif i 07.1151<Oi� ' THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT IF!C ATE HOLDEN THIS CERTIFICATE DOES NOT AFFIRIriAT•IVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 9Y THE POLICIES BEL1.OW: THIS.-CERTIFICATE OF INSURANCE DOES-NOT CONSTITUTE A CONTRACT BETtVEEN THE ISSUING INSUR;=R(S), AUTHORIZED REPRESENTATIVE_OR PRODUCER,AND THE CERTIFICATE HOLDER If INTFORTAP": If the certificate holder is an ADDITIOINAL INSURED;the p0licy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject t0 - the terms and conditions Of the poiicy,certain policies may require an endorsement: A statsmant on this certificate.does not confer rights to the ceitiiicate holder In Lieu of such endorsement(s). PRODUCER MARSH USA,INC. CONdTACT NAME"=' 1'r40 ALLIANCE CENT ER PHONE FAx 3560 LENOX ROAD,SUITE 2400 EMAIL _ Lac,Nol: ATLANTA,GA 30326 ADDRESS: 100492-HomeD-GAW'45.16 INSURER 5 AFFORDING COVERAGE NAIC 9 rNSURED •- - -INSURER A..Steadfast Insurance Company n23W84i THD AT-HOME SERVICES,INC. INsiiAlst3 a:A!�-Art4il ah lhsurance Co DBA THE HOME DEPOTAT-HOME SERVICESNist)ttER c New Harripshite Ins C02690CUMBERLANb.PARKWAY,SUITE 300 ATLANTA,Gk 30339JNsi RER D:Illinbis Na(idnal Insurance Company INSURER E COVERAGES ..• . . .:. ,. INsuR�ai=' -.:: _. .. . . .. . . :. GERTIFICATE NUMBER: ATL-003746fi4618. REVISION NUMBER:8 THIS i5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 155UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.',NOTVVITHSTANDWG ANY REQUIREMENT,TERM OR CONDITION'OF ANY•. Oj_'" i O_R,QTHER DOCUMENT 11VITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED QR MAY PERTA)N,`THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERA45, EXCLUSIONS AND CdNDIT10NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDIjCED BY PAIL)ELAltv1S: I'JSR ADD USR LTR TYPEOFINSURANCE POLICYEFF POLI YEXP A X COMMERCIALGENERALLIAH!LITY P011CYNUMHER MIvvDD/YYYY MWDD LI NITS GLD48877i4.05 D3/0112015 03ID1I2018 CLAIMS-MADE OCCUR EACH OCCURRENCE, S 9,Ob0,OD0 DA A ETORENTED. Iq LIMITS OF POLICY XS PREMISES Ea.dccurcence S 1,000,OCO OF SIR:SIM PER OCC MEq EXP(An.Wh16 Person) S EXCL pEp GENT AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ALZV INJURY S 9,DOp,000 X POLICYU JECT LOC GENERALAGGREt;A7E $ 9,DDOODD I.OTHER: PRODUCTS-COMP/OPAGG S 9,goo,.wo ' D AUTOMoeILE LIABILITY BAP 2936863-12 s _ 03/01/2015 03/01/2016 COMBINEDSINGLELIMIT X ANY AUTO lEd accident S 1,000,069 LA LLOMM_EO SCHEDULED BODILY INJURY(per person) $ AUTO$ AUTOS ' SELF INSURED AUTO PHY DMG BODILY INJU,p.Y,P.;acc den) 5 HIREDAUTOS NON-0WNE0 AUTOS PR9PERTY DAMAGE - S Peraccident '.. UMBRELLA LIAB OCCUR 5 EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE g OED RTENTION S .. AGGREGATE S C WORKERS COMPENSATION WC017731493 A05 S C AND EMPLOYERS'LIABILITY YIN ( ) 03.10112015 03/0112016 X PER 0TH- ANYPROPRfEI`OR)PIARTNERlEXECUTIVE WC017731495(AK,KY,NH,NJ,V1) 03/01/2015 03/01/2016 STATUTE ER OFFICER D (Mandatory IASERIn'NH)EXCLUDED? N� NIA E.I.EACH ACCIDENT $ 1,000OCO (Mandatoryb NH) 0017731494(FL) 0310112015 03/01/2016 D es,describe under EL DISEASE-EA EMPLOYE S 1,000,800 DESCRIPTION OF OPERATIONS below lConitnued on Additional Page E.L.DISEASE-POLICY LIMIT S 1,CCD,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additl EVIDENCE OF INSURANCE onal Remarks Schedule,may be attached it more apace Is required) CERTIFICATE HOLDER CANCELLATION TND AT-HOME SERVICES,INC. DBATHEHOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE'. WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. �y ,�• .v.�.r .-r�r::o_-3.•.-^.r .`I��'/_f 7r F.,.1yl�rl3'�.F?��!..{1f,'.':`,+-,rst !,.::rr_,r -' .o--., �f 53, '^'t"a"i �£ �l�i—`jlj��`''� S;;%'�it:�•=.1�. r • It je17,0 6--d Co*ufr�dfor Regis ont Card 813 M15 THD AT HOME,SERVICES, INA" RR 1 6ai BI Tl r�Y �aT'i•&J�zr:7J � ..........._--••-'----�.......�.-.�--•----..—._. _.�--�-. upemIa Adds mod To?]I vast Af-rk Y�-^I�i:'.;srl�ln.:i•JJ- �1�s��r of>;�n r� ua p Ja51>3 t u3aSia i ly��m�P3^-'stm,ion valid#ax;adia�PI 1aS�On pp_.q J �..qq y.. n .�(� p(� �q9 }� i44ra the ia � ' aadn a7��tu,q �j'•j ��jF'�4P1'81W 5hS71�I1-rdJtJWI9�4.1d�J li-11�IJV� '•1 S 4" J:i�`,;Iluill'4�. �'-•{�sL;:r c- . : .., _.•r i'. _ <��9�rY•+Sl��`vlS��i+��Sril"t��`,�2E'uRYJ�'�iut151Pl�ts`"' t'.C:,�.'��� U�w�1<l!P�p1Ly�`V; iir �' �. 1�'GG�: ���G1'���u•J• nM�99`L?'�.�'�� S}.;i-;:,. '�cpoc�u•�ro:,•�i�l�D�'� ;aur©i�'tn�n!•�a�U ion r _ ��4�• OgHbME1 DEET AT hi�Nl�s�f�vlcE� ` V � G;nz'ler Creta P atva gs srgna t° J . 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