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HomeMy WebLinkAboutBuilding Permit # 11/18/2015 �O R TH BUILDING PERMIT ®��g��o TOWN OF NORTH ANDOVER C, APPLICATION FOR PLAN EXAMINATION 1. d ! Date Received 9RA�'?H7e Df0P�\y�5 Permit No#: ACtau5`�R Date Issued: MPOR.TA T:Applicant must complete all items on this page LOCATION 1 int Pnnt PROPERTY OWN100 Year Structure yes no Print MAP I PA7C:EL:_L�ZONING DISTRICT:-Historic District yes no Machine Shop Village yes- no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Re ' ential ❑ New Building ❑ One family ❑A=ration ❑Two or more family [i Industrial No. of units: [I Commercial ❑ ❑ Others: vfzepair, replacement ❑Assessory Bldg ❑ Demolition ❑ Other 11 ❑ Septic' ❑Well ❑ Floodplain ❑Wetlands �� '1Na'tershed D stnct ❑�WaterlSewe,r, - °= DESCRIPTIO K T ERF RIMED: Identification- lease Type or Print Clearly OWNER: Name: Phone: Address: Contractor Nam: b'�L� Phone: f �` Email: Address: Supervisor's Construction License: � ��� Exp. Date: f. Home Improvement License: Exp. Date: I� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �; FEE: Check No.: Receipt No.: NOTE: persons contracting w unregistered contractors do not have access to the guaranty fund gnatuoe of_ nt - tkORT H U do,&vci ti to ® z - ver, t•6s��SS' T LAKE .I. O COC NIC Kf w1CN y1. AORATEO S u BOARD OF HEALTH ER D Food/Kitchen Septic System U .,. BUILDING INSPECTOR THIS CERTIFIES THAT .................. ........................ .......... ....... .......... ..................... Foundation has permission to erect .....1..riv ............. buildingson ..3��..... ...x .........'!� ..... p ` Rough to be occupied as . U....1.�. ............. .... ..... ..................................... Chimney provided that the person accepting p rmit 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 ONT S ELECTRICAL INSPECTOR LESS CONSTRUCTION ST TSS 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 Approved by the Building Inspector. Burner_ Street No. Smoke Det. Nov 04 15 02:49p Rick Odonnell 6033780151 p. 1 H V1VM Hv1r1CV v 11.1v1L'1V A l."IN l lcat.l PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:New England Date:_/ / THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 �I CT Lie#HIC.0565522;MA/Home Improvement /Contractor Res.#126893 Installation Address: 3 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: [9T ]6sz-(,E Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ 1 DO NOT wish to receive any marketing entails from The Home Depot Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc. (`"Phe Home 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"): Job#: (1.1-1 M--1 Products: Sec Sheet(s)#: Project Amount Roofing Siding loWindows EJ Insulation ❑Gutters/Covers ❑Entry Doors ❑ Q ! d�'G $ ❑Roofing DSiding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors El $ Roofing EJSiding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding El Windows El Insulation $ ❑Gutters/Covers ❑Entry Doors ❑ Minimum 25%Deposit of Contract Amount due upon execution of this contract. r Total Contract Amount $ ! 6 Moine Putrhasers may not deposit more than one-third of the Contract.Amount. Customer agrees that, immediately 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 Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental 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. Payment Summary: The Payment Summary # 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 CUSTOMER 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 work on that Product is complete. In the event of termination of this Contract,Customer agrees 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 other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home 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 be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accep ed by: Submitted b X Zv1S X y a Cost er' ignature Date Sales Consultant's Signature [� Date X Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERIIIS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 08-03-15 White–Branch File Yellow–Customer 0711�20i I CERTIFICATE OF LIABILITYIN-SURANCE -MIS CERTIFICATE IS ISSUED ASA MATTER OF INFO€ih9AT)ON_ ONLY AND GOIIFE.AS ISE}RIGHTS UPON t T;iE C-ER T IFICATE.{OLD€i� THIS � I GEf27'(F16ATE DOES)46T�FF!__I�1fi�ATI1f_cr_,LY-OR.:NE.6A*nVFI Y-t'MENp, E(T)=t4D'OR ALTER THE COVER-AGE AFFORDED BY THE"POLICIES BELO+N. tH1S--+ ERTIEItATE QF'-1,I51ji?ANCEI)OES'i�laT CQiV5FITTJTE A CONTRACT $ETbVEEiy THE ISSUING I�I3URER(S), AUTHORIZED i EAt3ESE 7A l IVE•QR.FRQsDUQEk�,AI�1I�.TkII�GEKIIF(CATE NQLDER I IINPGRTANT: If the_t:eriit`seate holder is sn ADDITIQiVAl.1N URE6,ii`le'pDlicy�es)lriust.be endored. If SLJBROG.ATION IS WAIVED,subject to the terms and sDndltioris 9f.the po!Icy, certain paliciee may.re4u)i'e an endotsenen A atat4erlent an this certificate.ides not conger rights to the cer.111 Ee holder in 1Jels of such sndoi'semeint(sr, PRODUC�t. ..:- CONCT MARSHUSArI "'tUITATA TWd ALLIANCE CEM'!`ER Min FAX 3560 LENOX ROAD,SUITE 2400 ° A1C Nol: E-MAIL-'•: ATLItNTA,.GA.303i6• AODREss: - -- iNSUREft'S)AFFORDING COVERAGE NAIC9 1C94�2-HomeD-GA'hl•_i5-is "- - $teadiasl'su INSURED •. lNSURERA:• _ 11GL'COmp y X87 THD AF IiOMESERVICES,INC. IflSfiRER 6: A!ijencail lilsurance Co 1G535 DBA TAN HE I:iC1ME Oj pro T HQh1E SERVICES ' 2690*CUMbftb.PARK4YAY,SUITE300' 1HsuL+ERc:= erttTarripsiliieliisCo- 23841 ATLANTA,GA 30339- INsua Ria:I PP.119669 lnsu'rance Company 23817 COVERAGESI MR . CERTIFICATE NUMBER: REVISIaN�IUNIBERse... Afil (137fifi4&13. THIS ISTD CERTIFY THAT THE POLICIES,flF tNS,C1RANCE t]STED BELQVN HAVE•BEEi�1$ l)EL�TO T!i) ,IFISURED iJAIE(?A$C1alE.FUff THE POLICY PERIOD INDICATED.';IIQTt�1!'fFiSTANDItJG ANY REQ(71REfv1ENT,T!Rta1 OR�CQ(;bitlON.OF.'F1IJ�f:CgZJTFtAC�pR f27(IER.•DOC,11(VIENT I1tATki-RES`PEG7 TO WHICH THIS CERTIF7GATt MAY;BE ISS.tJED Q(� 14fAY PERTAIIJ,'THE INSCIRAFlGE A5FC3R[JED BY TIiE.FOLICIES[IESCfR113 D N>REIN 15 5t1BJECt TO ALL THE TERh�S, " EXCLUSIONS AND CdND(1 IOhlS OF SUCH f.--...-!U LIMITS SRCIM NIA HAVE BEAN REDt1GEt)BY, AIC}ELAtINS: ' LTR :TYPE OFINSuRANCE ADD -U9R :- . POLICYEFB BOLI. Y EXI? PollCYNUMeER M115D/YYYY MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY ULU488TI14-05 03101)2015 0310112016 E`tch occiiRA MN s 9.O*00 CwhiS-MADE OCCURORENTEO, :>, LIMITS OF POLICY XS P EM15E5'E.'8 tiirence $ 1,00(!,060. EXCLILDED MED EXP'(AO¢'tine person) 5 OF SIR:$1M PER OCC PERSONAL,jADVINJURY 5 GEN'LAGGREGATE LIMIT APPLIES PER: 5 9,OOD,OOD_ GE(yERAL-AQQpik ATE X POLICYJEST LOC PRODUCTS,COt1PlOPAGG S 9,000,OOD ' OTHER: S . ..- 8 AUTOMOBILE LIABILITY BAP 2938863-12 03/01/2015 03/0112016 COMBINEDSINGLELIMIT X Ea accident S 1,000,000 ' ANY AUTO HOMILY IfJ_JURY(perpeison) $ ' ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG o;r AUTOS 90DIL1 1NJIJRY(. , acddenl) 5 HIRED AUTOS NON;OMED AUTOS PROPERTY DAMAGE - S Per accident' ' S UMBRELLA LIAR OCCUR E H GCCURRENCE S EXCESS L1AB. CLAIMS-MADE AGGREGATE .. S DER'.._ ftFC1TION S.. C` G COMPENSAIQN AND EMPLOYESWC017731493(AOS)A03101I2016a X 0TH- S YIN. STATUTE -ER ANYpROPRit7o ARir�Ei c�cunvE WC01T)31495(ASC,KY,NH,NJ,VT) 0310.1/2015 03/0112016 D OFFICE] 4EM@ER EXCLUOEO? a NIA EL.EACH ACCIDENT• $ 1,000.06. {Mandatory In Nii) C01T131494(FL) 03101!2015 03/01/2016 EL DISEASE-EA EMPLOYE ; 1,Og0,000 1Iyes,desaO under Conbl uedonAdditionalPage' DESCRIP70NOFOPERATIDNSbelow E.LDISEASE-POLICYLIMIT S pESCR(PTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddlUonal Relnaiks Schedule,maybe attached it more space la requlmd) EVIDENCE OF INSURANCE CERTIEIGATE HOLDER CANCELLATION THD AT-ROMEHOME sI KNIFES,INC SHoAriA-VY OF THE-ABOVE DESCRIBED PDLICIF5 BE CANCELLED BEFORE 2455 HA HOME DEPRO'Ab OME SERVICES YHE E7 PI1R11710N DACE THEREOF, NOTICE WILL BE DELIVRRF� IN ATLANTAEG FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS; ATLANTA,GA 30339 - .. AUTHORIZEd REPRFSFNTATNR u The Commonwealth of Massachusetts 4 Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www niass.gov/dia NN%arkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Infdrmation r Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip: Uel '� one 4: Are you an employer?Check the appropriate box: Type ofproject(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8• Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition I[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I LEJ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROof r pairs These sub-contractors have employees and have workers'comp.insurance3 14. they "4 r 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#11 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. _ Insurance Company Name: 11M Policy#or Self ins.Lie.#: �,( �0 Expiration Date: ` Job Site Address: �� � Q,xCity/State/Zip: Attach a copy of the workers' compensation policy declaration 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 verificatio I do hereby certify tnd r t 2 p ns a dpenalties of perjury that the information provided above is true and correct. Sipmature: r!l t 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#: �.7 _ Yf 1 3.^"''^ ,., •:.� ^:f 71i_. 1,T'�=• :"•s?��4—�i����.���i,lL ''���'�rri:^'_,�.?,l_^' Nn ��.� .�=r-. ._.•-�_. . = � Sim Chu "A ' trAeto-I Registration Tj _ --d ICES, INC, dal Adams }�das j "rt al J i:p 3s: �,d , � � f f ar�srr. rrrY:r�i'�r ^--�ji lf/lltxi Q�OFI�a3ifl ini�i �ToS.pr�1y BUN ipslP�ilLis32n� �l"shMDY3° � 1° c •a.. ��q,i�`o-fes.��OipYc�n Sa�3'C.L�}� Dasa tha� sl�iirr>a Y}• KXd`rh�w 1�21�'I;-9'SvJi�'c��t�1'��5:11���,.��`�1;�� - �.�t��>'Cti��a�say'Daae� ani 7�znie+��1:rN� �'T;�•�f.�� ,t�=: a ��•' ��'• .-. 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