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HomeMy WebLinkAboutBuilding Permit # 11/18/2015 Vk0RT#1 BUILDING PERMIT S D TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION -7 Permit No#: �,,C? (4,;> Date ReceivedAE C US Date Issued:--M�4 9 -1 IMPORTANT: Applicant must completq all items on this page qrrg, �OCTI � ,� a � , r / PARGEL, ZONING DI TR , IrrY r „a pia TYPE OF IMPROVEMENT PROPOSED USE ResideAtial Non- Residential ❑ New Building &6-ne family [I Addition El Two or more family El Industrial El 9-1ration No. of units: [I Commercial Aepair, replacement El Assessory Bldg El Others: El Demolition El Other r6, 1 AN 1 U dlbulSr-t DESCRIPJ -F PERFIRIVIED: ed Ide t-'fiti P ea[!sg Type or Print Clearly OWNER: blame: Phone: Address: t L4rx) buyul�,l iJi &� l ,,, 1 ���j���/��/(�l ,,r/lf�h ., rr / , J f// />,. .,,,. � 1. r// 1A, 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: $ (07, 6,00 FEE: $ Check No.: t No.: L79 5 NOTE: Persons sere ing witli unregistered contract® on ac to the guaranty fand 0 0 ure 6 , n I r nat c , 'ftictor ,,' F NORTH A d ' i 'own of ® ti _ ® o LAK ver, ass, $ 26(5 cocHic"t ICK �RATEo rC, S u BOARD OF HEALTH ERM-IT TU Lu Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ......................................................... ... ......... .... . .. .. ... . Foundation has permission to erect . buildings on ..... ......................... ...... iA ..... ..... .................... .......................... a 1. .. Rough to be occupied as .......... ...... .. ...... ................. ... .................�...... Chimney provided that the person accepting th permit shall in every respect conform toCe 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 E I E IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION ST TS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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 Approved by the Building. Inspector. Burner, Street No. Smoke Det. DOME IMPROVE wN/IENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: New England Date/9)_/_ZTHD At-Horne Services, Inc. d/b/a The Home Depot At-Home Services Branch Nuraber: 31 908 Boston Turnpike,Unit 1,Shrewsbury, MA 01545 Toll Free 877-903-37681 Federal ID#75-2698460;ME Lic#C 02439:RI Cont.Lic# 16427 CT Lic#141C.0565522;MA [Ionic Improvement Contractor Re-,-.tf 12689 Installation Address: City State Zip Purehwser(s): Work Phone: Hoene Phone: Cell Phone: 64- Ronne Address: (If different from installation Address) City State zip E-mail Address (to receive project communications and Home Depot updates): F] I DO NOT wish to receive any marketing eiriails from The Home Depot Project Toiforniation: Undersigned ("Custorrier"), 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 fin-nish, 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, alont, with any applicable State Supplement and Payinent Stininiary attached hereto and any Change Orders (collectively, "Coil tract Job#: (Internal Rdaencel ProductsSpec Sheet(s)#: Pro'ect Amount ... [_lRoofin- FISidill", Windows El 11,sill ati on qY7/97`Po'Y77,65 s ZS EIGutters, E]EnrY Doors El- (P 0�3 S ElRoofing ElSiding El Windows EIGuttens Covers Entry Doors (0 E]Roofin,, DSidirfg F] Windows El Insulation DGuners 1 Covers ElLritu Doors n []Roofing E1Sidin2- F] windows 0 Insulation S E]Gutler0Covers ElEran'Doors F1 tVIfiriniurri 25%Iia pont of Contract Amount(Inc upon execution of this contract. Total Contract Amo till t $ MaillePulThasels luaa�not deposit more than one-third of the ContractAniount Customer agrees that, immediately Upon completion of the work for each Product, Customer Will execute a Completion Certificate L (one for each Product as defined by all individual Spec Shea) and pay any balance due. As applicable, each CLIStOYlIff MI&I- 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 ClUe to-I StRICILlral prohicill with the home, crivirolillierital hazards Such as niold, asbestos or lead paint, other safety concerns. I)rliCillO CI-1-01-S or 11CCUISC work required to complete the job was not ilICILI(led in the Contract, PaviLient Surilmary: The payment Surnmary If 11757:5-0-77--- included as part of this Contract, sets forth the total Contract alliouilt and payments reCIL111-ed for the deposits and final payments by Product('as applicable). NOTICE TO CUSTO'i\IER 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 Curtificafe for eacli listed Product as delloe(I by Spec Sheets) before Worlk oil that Product is Complete. In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs or materials, labor, expenses and services provided by The floille Depot or Authorized Service Provider through the dale of termination, plus any other amounts set forth, in this AurtTraelit or allowed under applicable law. TTIE I-TOME DEPOT NIA17 i.viTHHOLD AMOUNTS OVVED TO THE HOME DEPOT FROINI THE DFi3,6si,r PAY.1N.IENT OR OTHER PAYMENTS [\,IADE, WITHOUT LEA11TING THE HOME,DEPOTS OTHER RE�MEDIES FOR RECOVER'OF SUCH ANIOIJNTSo Acceptance and Authorization: Customer a-rccs and understands that this Aorceroctit is the entire aLrecilicill between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior diSCLISSiOlIS and aun-cenients. either oral or written, relating to said PrOdllct,, and Installation. This Agreenient cannot be assigned or amended except by a writing signed by CLIStOlIlCr and The Home Depot. Customer acknowledges and a-l-eCS that Customer has read, Understands, V01tillfarity aCCePIS the tcrnis of and has received a copy of this Agreement, <7 Accepte(!_,b�y` Submitted by: Work area will be contained y_ Pre-Renovation Fora Dater _1 NA 1-19276 This form is used to document compliance with the requirements o`the Federal \ NMI \ Lead-Based Paint Re. a_s n,Repair,and Paint[ng Program aft r€ ril 2010- Paint Customer Address Job Number(s) -7 � ARK 62 a OCCUPANT CONFIRMATION minimizedDust will be Pamphlet Receipt IS INS:1 he lead hazard information pamphlet in orming me of \ \ / the potential risk of the lead heard exposure from renovation activity to be \� ` performed=n my dwening unit. I received this pamphlet Del ore wo,k begun. ti Home Year Built Enter the year my home was guilt- - t If my Dome Year wilt is Pre-1978,my home requires lead paint testing to deterr ine whether ead-Safe Vi.fork Practices are necessary per EPA or State regulations. Work area will be cleaned up if,ny Home Year wilt is 19173 or after,'lead-Safe Work Practices are not required. thoroughly 7�0& ReIZ11-4- ted Mame c[O:ner-accu ant pp� tUre�f�"s" � Cu�cnt t � a- Sign u a of t son C ;F,rinc Lead Pamphlet Delivery SEE STAVE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massachusetts z Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia «'arkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERIYIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Yl Address: City/State/Zip: j Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. n New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. FJ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[:]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 1 LE]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. ® g 13.F]Roof repairs These sub-contractors have employees and have workers'comp.insurance 3 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14. ther 14)1 J0rt)5-- 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ _ Insurance Company Name: Vt/1 ' 1 [� Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 1 City/State/Zip: �-- Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expiuration 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 coy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify un er the ' s a dpeft hies ofperjury that the information provided above is true and correct. s' Signature: Date: Phone#: ( t� 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#: fl . I�r12ai ILIABILITY INSURANCE CERTIFICATE OF T}i1S CE=i1IF1CA?E IS ISSUED AS A MATTER OF:I(+irGR&WON ONLYAN6 GONF:kS iIF}RfrHiS U'rOil THE -CERTIFICATE iQL_D€R THIS � CcRTIFiGATE DOES:IdQT lrfIR1YTR*tLY.OIR.NEGATIVELY-.1MEIdD, EXTEND 614 ALTER THE Ct?�/?RAGE AFFORDED BY THE POLICIES i �ELO!lY THIS PERI lE3CATE QP.1;+lSUI?A�JGE DOES'N©T CON5 FITUTE A CONTRACT BEIIJVEEN THE ISSUING IUSUR;=R(S), AUTHORIZED LR PRESS iTA iVE.E�R.PI��t�fJG k,AIs2F .THE GERlIF1CAl E HQLDER tMPGf�TA1VT: If-the certKcate holder is an ADDITIONAL INSURED•-the licy(ies must be endorsed. If SUBROGATION IS WAIVED,subject to F k"=.. J 1 ) L the terms and conditions-o€fhe po()cy, ceLtain policle;may requ'a an sndorsement. A statarn-ant on this certificate.does not confer rights to the cerciiicate holder In']!eu of such endorsamdnt(sj, _ PRODUCER - CO TACT fARSHUSAiIIGC:' ' 1"A �, 7'KCl AiLlArrcE cErrF��R PHONE _ PAX 3 60 LENOX ROAD,SUiTE240o NO AFC Nol: E�1AIL-'.: ATLANTA,.GA.303i6• ADDR & 1COd�2 HomeD GA'N'-516 INSURER'Sj AFFORDING COVERAGE NA1C n INSURED iNsriiiiRA:•SlegfastirZ*mhde Company26367 'THD•At0.QMESERVI6ES,INC. INSURER a:Zur(d'ftL en,dh Imurance Co - 16535 0BATHE8QM5OVOTATHQAIESERVICES = : ' " ' 2fi90 CUMBER]ANp.PARK'�yAY,sun-7 300 iesURERc:° a Hairips[i((e I'ri's Co- 241 ATLANTA,GA 30339. Ir1Su RiII:6fno�s IJahonai(nsgrance Company 23817 COVERAGES. CER]]LIGATE HUMBER; AfiL 37 REVISION) t1MBER�B. . 4664&13•. THiS IS TO CERTIFY THAT THE POLiCIES,QF 1N5C1RANCE LI.M BELOW HAVE BE _';��tj![QTO�HI;_.I�ISUREQ IJAA��!I��EP.ABQ�IE.EPR THE POLiGY PERIOD (NDICATEb.'zi`tOTVVilFi5T11NDING AtJ`(REQUIREMENT,TERM OR'CON[7iTI0N.O�;F,IN`�CQ�I,_.dt OR_Q11iEf3=DOCU(ITENT VVITM•RESrPE FTO WHICH THIS CERTIFICATE A4AY•'BE ISSUED QR MAY.f?ERTA)N,'T}IE INSUR4NGE 4EFOR[7ED BY THE['Ot{CIES 19E5t,RIBED HERE}N 15 SiJBJECT TO ALL THE TER4�5, EXCLUSIOhIS AND CdIVDIT IONS Ol SUCH P0[[C1E5;LIMITS S[IOV+1N NfAY HAVE BEEN REDUCED BY PARC)6LAlINS. ' IPSP, ADD UBA ..... - LTFZ .TYPEOFINSURANG[ POUCYEFF: ,.-POLL YEXF POLFCYNUMBER MFODlYYYY MID A X COMMERCiALfiEN6F2ALLIAn1LITY GLD4667714�D5 -• -� - - 031DfiC20i5 � MDLIMITS 091011'LOj6 gni=HocciiRREric�, •s 9,000,GDO CL41Fd5 MADE OCCUR PA,;A E',O.RENjED, LIMITS OF POLICY XS REZEMISES Ea.dtclitrence S - 1,0(k1000 p- ,E06 a. EXCh OFD MEQ EXP.'(AUjt brie person) OF SiR:$i M PER OCC PERSONAL ARV INJl1RY S 9aODQ GEN'L AGGREGATE LIMIT APPLIES PER: 9 OOOUDtI X POLICY PRO-JECT r LOC GENERAL-AGG)'LGA7E 5 PRODUCTSr-COhtP10PAGG S 9,DOgP ' .OTHER: D AUTOMOBILE LIABIIM BAP 2936863-12 03101/2015 03/0112016 CDLdmNED.SINGLELIMIT X ANY AUTO !~d accid'enl S 1,000,000 ' ALLOWNEp SOIIEDULEO RODILY115JURY(Perpeison) 6 AUTOS AUTOS SELF INSURED AUTO PHY DMG 60DILY IN A' (•E,1r accident) S "IREDAUTOS NON;DMED AUTOS PROPERTY DAMAGE . S Per acdde I ' S UMBRELLA UAB OCCUR EXCESS LIAR. E(CH OCCURRENCE S CLAIMS-MADE AGGREGATE .. S .. .. oEo RETEi.ajbN S.. _ ' C AND KERSEMPLOYERS' YERS'LIABILITY WC017731493 (AOS) 03/0112015 03/0112016 PER p7H- S AND EMPLOYERS`LIABILITY X C Y f N. STATUTE ER ANYPROPRjefaiip7jj ii CLinvE WC017731495(AK,KY,NH,Ni,vT) 03!0111015 b3/0112D16 D OFFICER/gEM)3'c(t EXCLUDEO? �N I A E(-EACH ACCIDENT• I 1,000,0¢¢ (Mandatory in NH) 0773t494(FL) 03101/2015 03/01/2016 FFyes,descibsdrder EL DISEASE-EA EMPLOY ; 1,000,000 D9KNEMIOFOPERATIONS below roonitnued an Add&nal Oage ELDISEASE-POLICYLIMIT S Min: DESCRiPTi0NOFOPERATIONS IL6cxnoNSIVEHICLES (ACORD101,AddlUonalIternerksSchedule,maybeattacheditmorespacelarequired) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION TND AT-ROME$F,RVICES,INC, DBA THE HOME 6E1`&AT-HOME SERVICES 5kI0ULi2-KY OF ABOVE DESCRIBED POLICIES BE CAN_GELud BEFORE- 2455PACESFMPROAD THE EXpIRATION DACE THEREOF, NOTICE WILL BE DELIVI:RFD IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROV151DNS: ' AUTHORM REPRESENTATIVE e 7- 1,•^;':moi_j/.;::^.y,,•;�1 ' - �; � x .� ?� •�.�-1.a.-;a'=.^ .:', F_'1'.� ter. •- .. _� .a. _•+ - ,'�i'j.{: 1,���.:'�f� t'���>fr_:i•.%•,.s.,'r`Tff i � `� a Card THD AT H M5 8ERVICE-S-� PAR" AY 8 UITE z.00 __ Y _ — A.T MTA 9 11add���`a Addams 2737 se�7az��f� (e?xari�: . al J 'U�5J - y:p � e q 111! , • u 1 >drf u�v�rrre:r�r r-"^ (r ri�t'nyJ ma,ar7p' �)s:xge+�f��q ��ta''S�tziYRs Y '��1�>� _ Dara the r5t�i.lr� lsJS 11 w n><Cti�s� s� NNE `s' '� `�scpar���'rotifil�I�Or1� 5u�©l�cnant•Caiv $fly�i;n.' r � • 11'>�,•F1lJHi9f�•QEE�3�f°!�T'i�l�l�l�_��.��11GE`� - .: ,. �+t�,�3��L1MAN�I pA�Ift�VAY 5 .�` r�g_�� ', •. .� ,st � _ _..�-•--- y,. ... ... .. - .. , CSSL-099823 DZNuTRV,BROVIN 70 NORTON A F uliiVn Manchester NH (BIS 061261•• `I 6