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HomeMy WebLinkAboutBuilding Permit # 11/5/2015 J ,jAoRTH ,,- �SD 16 BUILDING PERMIT 1."'6 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Date Received 66 11 x� C14 5 Permit No#: Date Issued: A��6 all items on this page IMPOKI'ANT:Applicant must complete LOCATION L '` �� P i tin t PROPERTY OWNER-�:t rint 160 Year Structure yes no NG DISTRICT: Historic District yes no 0)MAP ODZLPARCEL: ZONING Machine Shop Village yes no TYPE 0—F IMPROVEMENT-— PROPOSED USE �0�!��l �- � Non- Residential Residential r [o] pKe family family 0 New Building [I Industrial 1� or more 10 zTwo or more family E701 Addition f u ts. [i Commercial No. of units: —El AlWa-tion Others:El Assessory Bldg Ei epair, replacement El Demolition Ei Other t e i s h-,, ❑ i,b� , I w h"'d D -A-K e . . .... 010- x . ..... h ❑ ERF® ED: DESCRIPTIO, pleAse Type or print Clearly Phone: OWNER: Name: I V\�o Zl Address: Contractor ontractor Name: f Phone: Email: Address: Exp. Date: Supervisor's Construction License: Eyn- Dat( Home Hoome Improvement License: ARCH ITECT/ENGI NEER Phone: Reg. No. Address: COST BASED ON$125-00 PER S.F. FEE SCHEDULE.BuLDING PERMIT.$12.00 PER$1000-00 OF THE TOTAL ESTIMATED Total Project Cost: $ FEE: 7 Receipt No.: � Check No.: NOTE: Persons contracting with unregistered contractors do not have accesy* the g arantyfund r Town of nuover 0 No. 2A �p ver, Mass,. Cl4tM`6m 512A 15 04A TE a P, ' BOARD OF HEALTH Food/Kitchen PERM- 1 LD Septic System THIS CERTIFIES THATT .................. ............................. BUILDING INSPECTOR .......................................................... ...... has permission to erect buildings on . Foundation .......................... .....- ........ . : .......... ....................... . Rough toa occupied as ............... ....... .. .... .. ....... .. . ..... ....... ..I '. . ....................................... 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 CONSTRUC:4T STARTS Rough Service ...�,.. .................................. Final BUILDING INSPECTOR GAS INSPECTOR OcCuDaLEF Permit Required to 0ecugF ink Rough Display in a Conspicuous Placethe Premises — Do Not Remove Final No Lathing r Dry WallBe Done FIRE DEPARTMENT Until e Building Inspector. Burner Street No. Smoke Det. JIOME IMPROVEMENTCONTRACT PI EASE READ IBIS Branch Name: New England Date/p IL01 15- Sold,Furnished and Installed by: THD At-Honie Services, file. Brautch Nuniber: 31 d/b/a The Home Depot At-Home S(.�rvices 908 Bonon Turnpike, LhAt 1,Shrewsbury NIA 01.545 IM Free 877-903-3768 Fideml ED 41751698460;IVIE fie 0 C 0243Y R!Conl-tic@ 16427 � ppCT tic#111C.0565522;N4A Home Improvement Contractor Reg.4 126893 Installation Address: 7 City State Zip Pun%nwrW: Work,Phone: Horne Phone: "01 Phone: 71 07-o?,2- 1 1 Horne Address: (if different from Installation Address) City State Zip Eamil Adl,ess (to receive prqject collullonications and Home Depot updates): I DO NOT will to receive any marketing em"s rtmu Vie Hmne Depot 11idemigned ("Cusfmieel Me owncis or we properly located at the above installation address, agrees to bay, Tmm"gftrvices, Inc. ("Tile Horne Depot") agrees to furnish, deliver and anange fm the inmall;nlimi ("Installation") ()1' all matuials ducribed on to below and on be referenced Spec Sheet(s), all of which are incorporated into this Contract by this n%ence, along with any aptilkable State Supplement, and Payment Summary attached hereto and all),Change Orders (collectively, "Coll traet"): YA, ,lot)#: 011ternalltererelico Broduds, ieet(s) rjoe —SRe—C 1�. cLAmount r Itzoollng 1jiu2 Winao"', EIGLI I teN/Cove El 'mr),Door, E] Ll 7(Fo 0 -- $ V540 $ is 012, �2 _MT _M'S i a�,—Ig Windows Tj Insulation Roofing FIGUtterS/Covers Entry Doors ❑ �"17 N 7 —ORoor lai ' 17 1 ng Ely 11GOWCovers E1EjitryDoors E] __ ltcacrtiug Wi 11CION N Wing , 0 11r ulrrtirarr E1GL1ttCrS/C.0VCrS 013ntryDoors N11ninnum 25%lkp mit of(2ontract Amount due upon execution of Mis cordrad, Total 0nAract moant, Nlaine Purchasers may lot(leposit more Mm one-flilrd of the Conhvct AnwtmL ClAimmer agees duh, inumdkody upon compotion of tile work lot- each Maduct, Cummmr wM execute a Cornplelion CerAllsoc (We RV each PMAwL as defined by an individual Slice Sheet) and pay any balance due. As applicable, each Customer under this Contractagrees to bejointlY and Severally Obh6"aled and.liable hereunder. The Home Depot reserves we N&to issue a Change Order or terminate this Contract ol-ally individual P1-0dUCt(S) included hCHill, at its(riso-edort, irThe Home Depot or As authorized service provider deter mines dim it cannot peramin its obligations due to a structural prohicin with We home, environmental hazards such as mold, asbestos or lead paint, othetsakly cmicerns, pricing cams or because work required W conylew the job was not indm4d I the.Coteact. Flijinent AlwarrNpIl The payluent Summary 4-1 -5V1.75 / . hichNed as pant of this Contract, sr tis ro -th tile total - 'al--j— — — Coldraclaniould and payincins required for(lie and filla deposits payments by f1roduct (as applicable). NOTICE TO CUSTONIER Voti are enihiml to as completely tilled-in copy or tile. contract at the dime you sign Do no! M a Colupidion CelARmte(nine: there is true:, Cmintplolon Cellit'icate tor each HsWd 11roducl as defitied by individual Spec Sheets) before work on that Pr odnet is coinpk,ate, In the evmH of K"WIMH011 of this Corthad, Custonwr ogirms to pay The E10rue Depot tile casts of"naterials, labor, expenses am! senims provided by Ile Home I)epot or Authodzed Service Provider through tile (late of termination, plus" any other amounts sel l'rorth in HAsAgreenien( or allowed under applicable lam ME HOME DEPOT NIAV WITHTIOLD AMOUNTS OWED q,O E IRM4E DEPOT 1ROM THF DEPOSIT PAYNIEN'17 OR OTI-JER PAYiVIFNTS NIADE, WITHOUT LIMITING THE HOPOIG INKI'MT 'S OHER REA410INES FOR RKLDVERY OF SUCH ANIOUNTS. Aqmgance and Authurkudm: CLIS(011lff au<rces and understands that this Agmancril is the.entire agreemmit betweeii Customer and The Home [kpot"it regard to the Products and InMAWkin saAces and supersedes all prior discussions and agreements, culler tar-at of written, redating w said Products and Installation, This Agreonent cannot he assigned or amended except by a writing signed by Customer and The Fforne Depot, Customer acknowledges and agrees tat Cuskliner has read, understands, voluntarily accepts tile, terins ofalid has -1ved at copy of'this Agrcenlel)L ubinitted by: The Commonwealth of Massachusetts = Department of IndustrialAccidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): /? Address: MIA r City/State/Zip: CQ Phone#: Are you employer?Check the appropriate box: Type of project(required): 1. I am a employer wi ` /1 employees(full and/orpart-time).* ], El New COIlSITI1CtlOri 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required] 3Q am a homeowner doirig all work myself.[No workers'comp.insurance required.]t 9. Demolition 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.E]Plumbing repairs or additions 5.❑I 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.t 13.❑Roqf repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ' ther 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. $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 isproviding workers'com enation insurance for my employees. Below is the policy and job site information. . _------ ti Insurance Company Name: Policy#or Self-ins.Lic.#: ' Expiration Date: f j Job Site Address: i City/State/Zip: l Attach a copy of the workers'compensation policy declaration page(showing the policy number an 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 cerkfy under the pail and en ties f perjury that the information provided above is ue and correct Signature: Date: Phone#: Official 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 5.Plumbing Inspector 6.Other Contact Person: Phone# 'D CERTIFICATE OF LI BILI T`Y I SU �T�� i DAr=,M>uDcrrrrr 07115/2015 THIS CERTIFICATE IS ISSUED AS A )!)ATTER 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 BETNEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER j IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) 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 (AINPHON FaAXC No: 3560 LENOX ROAD,SUITE 2400 E-mss: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC q 100492-HotneD-GAW'-15-16 INSURER A.Steadfast Insurance Company 26387 INSURED INSURER B:711dch American Insurance Co 16535 TND AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER c:New Hampshire Ins Co 23841 2690 CUMBERLAND PARKWAY,SUITE 300 ATLANTA,GA 30339 INSURER D:Illinois National Insurance Company 23817 INSURER E: INSURER F c COVERAGES CERTIFICATE NUMBER: ATL-003746646-13 REVISION NUMBER:8 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. )LTR I TYPE OF INSURANCE ADD V POLICY NUMBER MM/�DY� POLICY FRCP LIMITS A0310112015 031011016 X I COMMERCIAL GENERAL LIABILITY GLO4887714.05 EACH OCCURRENCE S 9,000,000 j� I I CLAIMS-MADE OCCUR DAMAGE TO PREM SES(Ea occu RENTED ) $ 1,000,000 If — LIMITS OF POLICY XS MED EXP(Anyone person) S EXCLUDED OF SIR:$1 M PER OCC PERSONAL&ADV INJURY S 9,00.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 9,000,000 X , I PRO- LOC JECT PRODUCTS-COMPlOPAGG S 9,000,000 POLICY I OTHER: S B AUTOMOBILE LIABILITY BAP 2938863-12 03101/2015 03/01/2016 COMBINED SINGLE LIMIT S 1,000,000 XEa accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS BODILY INJURY 'er accident) S NON-OWNED ED PROPERTY OAMAGE HIRED AUTOS AUTOS Per accident S S UMBRELLA UA13 I I OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE $ DED T I RETENTIONS S C WORKERS COMPENSATION WC017731493(AOS) 03/0112015 03/01!2016 X C AND EMPLOYERS'LIABILITY YIN 5TA U7E �RH ANY PROPRIETORlPARTNERIEXECUTIVE WC01T731495(AK,KY,NH,NJ,VT) 03/01/2015 03/01/2016 E.L.EACH ACCIDENT $ 1,000,000 D OFFICER/MEMBER EXCLUDED? IflN I A _ (Mandatory In NH) WCOIT731494(FL) 03/01/2015 03/01/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under CDnilnueti on Additional Pa DESCRIPTION OF OPERATIONS below ge E.L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) EVIDENCE OF INSURANCE t. 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 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukher)ee NA-144_k � ©1988-2014 ACORD CORPORATION. All rights reserved. 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