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HomeMy WebLinkAboutBuilding Permit # 12/3/2015 �o�ar�r R4`�D ,� BUILDING PERMIT °� �"b TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINA 1 ION � i myh ,, '� � �`o�.^wry �• Date Received �RpD�HTE De PeR`y�� (Permit blas#: �Ik l . Caaus�R Date Issued: ellp " IMPORTANT:Applicant-must complete all items on this page LOCATION Print PROPERTY OWNER I 100 Year Structure yes Print MAP i PARCEL: ZONING DISTRICT:-Historic District yes o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Reside tial ❑ New Building ne family ❑Addition ❑Two or more family [I Industrial ❑Alt tion No. of units: ❑ Commercial epair, replacement ElAssessory Bldg 11 Others: El Demolition Other Demolition .?. ."i i // ''' /%+i✓ 'IS r //rr , ,R ;❑.%1Watershed!lD,istnct �ri�/ /„10;r ., food I��n y r❑ ,„?,r? �"r �� Cir/, i ( r /v,r,, r/ /r/r ❑ I” r /r r r / r1 y l 11 ✓r ,,I ,�I.1 �i /,�❑I .f „ ,. ?./, �: �© r lvrf/,! ..✓ir h... /. r ,,,. ,... ?,,f�..(, fir., r h, � r�i,�,lf%rr �r�;?�,, -. ❑ r / �,, rr r, , f r r r/ r r/� � � l ,� .,?, d / �, , f Lr?..,/� / l.r/rr%//?.r r %, ✓.lfi fP it o ,/ �, 1,/J r/.,,, � ji , r,/ r�i'�I �r ,!,/ J a„A /! �% �<�. � � rr � ,✓ 1, / r, r ,.f,J/ �/.. ,� r.. ,,,/ 1 //a✓ .,r? ,. /, .r r r. // :�,?. ,: r /r.. .�i�/rl/G_, . �., 3,i �?GI�I? � `� ,,� ri � /,�i/, -�-� r, ��,�,/r r��r/ilr i../JI ,� r� // �fr, �/.�'...,n� /ir �2�11 r.r.;�.,✓_, , ✓J� ,u� //�� ..,,��� r�r /�JGGri/�� ,,,r/A✓��/ o,, I N �r�. �� ,,r�/, � �//l,, �1�r/ ,/�l / r//d 1 �,//,r,/✓�).I,,/>,«,r ,J,,.0, ( DESGRIPTICIN OF OR T® PERF'®RIMED: r tification- Pl e T Pe or Print Clearly ° OWNER: Name: Phone: Address: Contractor Name: Phone- Email: Address: Supervisor's Construction License: Exp. Date: Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ - Check No.: ” ° Receipt No. q:_ NOTE: Persons contracting with unregistered coaataacto��do not have acc � the �cr�anty faaaacl f_�g� -- 9 6WHOM-1-11 NOW i 67-1 MR!A FIC)MI UMI'RC9VFEMENT CONTRACT PLEASE DEAD THIS Sold,Furnished and Installed by: Branch Name: New England Date:L//�kl TIID At-Home Services, Inc. d/b/a The Home Depot At-Home Services Branch terrahea: 31 908 Boston Turnpike,Unit I,SIUMSbury, ivlA 01545 Toll Free 877-903-3768 Federal ID#t 75-2698460;riME Lic#f C 02439;RI Cont.Lie# 16427 Jf CP Lie#HIC.0565522:MA Home lmproverucnt Contractor Re,,.#126393 Installation Address: b City State Zip Purchaser(s): _Work Phone: Home Phone: Cell Phone: Home Address: (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): ❑ I DO NOT wish to receive any marketing emails from The Home Depot ProjectInformation: Undersigned("Customer•"), the owners of*the property located at the above,installation address,agrees to buy, and THD At-1 tome Services, lmc. ("The Home Depot') agrees to furnish, deliver and arrange for the installation (`Installatloxh") 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#: Qnrcrnar Reference) rOdlletB' Spec Sheets)#: _ Project!kniount �j ❑Roofing ❑SidingWindows ❑ [nsulation � ����7 ❑ uttEntry 11 t�d Gers/Covers Ent y Doors ❑ ❑Rooting ❑Siding ❑ yN'indows ❑ Insulation - ❑Gutters/Covers ❑Entry Doors ❑ $ ❑Rooting ❑Siding, ❑Windows ❑ h�sulation � ❑Gutters/Covers ❑Entry Doors❑ _ �' ❑Roofing --- -- ❑Siding Windows ❑ hhsulaton � _-- ❑Gutiers/Coverts ❑Envy Doors ❑_- Minimum 25%l:),ipusit of Conti act Arnohmt due upon execution of this contract. � �� Total Contract Arimint 1 Jaine Purchasers ma} not deposit more than one-third of the Contract Amount. Customer agrees that, immediately upon completion of the wort: for cacti Product. Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any halance due. As applicahle, 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 sal'ety concerrns, pricing errors or because work required to complete the.lob was not included in the Contract. Payment Sul1maarNr: The payment Sturmuary 7q- 2,9 r c.ude 1 ls part t of this r Cont act, sets iorih the ioiai Contract atmotmt and payments required for the deposits and final payments by Product (as applicable;). NOTICE TO CU SToMER Voir are entitled to a completely ldle(leirs copy of the. Contract at the time you sign. Do not sign a Completion Certificate (note: there is one Completion Certificate for earclilisted Product as defined by individual Spec Slims) befot-e work orb that Product is complete. In the event of termination of this Contract, Customer agrees to pad The Home I)epot tile.costs of raaaieri als, bIlaor, expenses and set-vices provided by The Home Depot or Authorized Service Provider through the date of te.rnairaafion, plus array other aillottnts set Forth in this Agreement or allowed utader applicable law, THE HOME DEPOT �NIAV VVITIIDOLD;'010UNTS MVED TO THE H€)>'t'iE DE'13 T FROM T14E DE.POS.IT PAy'i TENT OR OTHER hA�bNI EhsTS MADE, WITHOUTLE1,41TING THE 110A1E DEPOT3S OTHER RfENIEDIE S 1,OR RECOVERY OF SUCH AMOUNTS. Acceptataee anti Anthoriration: CUSLOmer agrees and understands that this Apreernent is the entir< areennent hetwecn Customer and The Home-Dcpot with re(,a trd to Che Products and Installation scrtitecs and supersedes all prior discussions and agreements, either oral or written, relating to said Products and Installation. This Agreement czmnot be rssigrned or amended except by a hvriun­ si fTncd by Customer and The Home Depot. Custonhet acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms of and has received a copy of this Agreement. : cec.el by: Submitted-� tted by: Work area will be contained - Pre-Renovation Form Date: NAT-1 9276 ,tea' rte � compliancez�?1tS�6�'f't IS used to� uta:,t7! t,l'€�i the I..qU(ie}:cv'Tis of the Fed-era Lead-Based- Pain,Renova fio -Repair,a€C F'F Tit-lig Program after r+` 10, Customer Address job Number,) r� OCCUPANT CONFIRAFFATION Dust will be minlimized \ \ ar phlet Receipt \\ \ \ \ \ \ I have received a copy of the lead hazard information pamphlet info �j t'^' #3citl informing 1;1 Chi` 'he potential risk of the lead hazard exposure from rend a ion activity, to be _ performed In my dwelling un,,. ?received this pamphlet before work began. Home Year Built En er hu year my home was built. If my Home Year Built is Pre-1978,my home requires lead panni testing to dekermme whether Leacs-Safer Work Practices are necessary per EPA or State regulations. Work area will be cleaned up If my Home Year Built is 1978 or a;er. Lead-Safe Work Practices are not rerauired. thoroughly \ \ \ �\ PriRiBC Name of S_ignature&Owner-occupan, j 1 try fail= ui P0 y g Lee=s Parnptijet Delivery SEE STATE SPECIFIC FORMS ON REVERSESIDE The Commonwealth of Massachusetts - Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apulicant Information Please Print Leilibly Name(Business/Organization/Individual): Address: City/State/Zip: 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. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. [f 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 L❑Electrical repairs or additions proprietors with no employees. 12.F�Plumbing repairs or additions SQ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El RO epairs 'Illcse sub-contractors have employees and have workers'comp.insurance.1 14. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. Other 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. 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 ant an employer that is providing workers'comp isation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.Lie.#:_ 1�(��(� � �t `f ` Expiration Date: l Job Site Address: I> 104 1 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dat Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine tip 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 certify ui der t pa' s a t penalties of peijwy that the information provided above i U'ue and correct. Si nature: Date: Phone#: Official use only. Do not write In this area,to be completed by city or tolvn 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#: c � CERTIFICATE OF LIABILITY I 021242415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT)FICATE HOLDER. THIS CERTIFICATE DOES NOT AFt=1EtMATiVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must 170 endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions ofthe 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). PRODUCERJCCT MARSH USA,INC. tQ11TATWO AWANCE CENTER FAX 3560 LENOX ROAD,SUITE 2400 AIC NoATLANTA,GA 30326100492 HomeD GA41F1516 INSURE S AFFORDING,COVERAGENacr�lrrsuREO - Steadfast Insurance Company 26387 THO AT-HOME SERVICES,INC. INSURERS:Zuddl American Insurance Co 16535 DBA THE HOME OEFOTAT-HOME SERVICES iNSURM C:NOW HBMP91111119 IIIS Co 23841 2890 CUMBERLAND PARKWAY,SUITE 300 ATLANTA,GA 30339 INSURER D•161mois Nathnai Insurance Company 23817 INSURER E: rNBURER F COVERAGES CERTIFICATE NUMBER: ATL-=2426M9 REVISION NUMBER:7 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. ILTR TYPE OF INSURANCE A°DL PDIICYEFF PDUCYExP POUCYNUMBER MIDD MM D LIMBS A eENERALt3AHItlTv GL04887714-05 0310112015 0310Si2016 X EACHOCCURRENCE S 9,000,000 COMMERCIAL GENERAL LIABILITY LIMITS OF POUCYXS EMISES Ea c nce S 1,000,000 To RENTED CLAIMS�lADE Q OCCUR - MEA EXP(Any one person) S EXCLUDED OF SIR:SIM PER OCG PERSONAL&ADV INJURY 5 9,00,000 GENERAL AGGREGATE 5 9,000,000 GENLAGGREGATE UMIT APPLIES PER: X POUCY PRO-! LOC PRODUCTS-COMPJOPAGG SzCT 9,000,000 S B AUTOfi.Oe[tELAB1LIiY.� BAP 2938863-12 03/01/2015 03101/2016 CEOaao eo?ING OMIT s 1,QW,000 X ANY AUTO AUTOS AUTOS SELF BODILY INJURY(Perperson) S SELF INSURED AUTO PHY DMG BODILY INJURY(Peracctdanry S Hn2'I AUTOS NONgWNEO '.. AUTOS PR�OPEF2�TY . S '.,... UMBRELLA UAB S OCCUR prC�UAB EACH OCCURRENCE S CLAIMS-MADE AGGREGATE- g DED RETENTIONS C WORKERSCOUPENSABON WC017731493 AOS S AND EMPLOYERSLWBtitTY ( I 03(01!1015 03N712016 jELEACHACCIDEW WC STAN- 0TH G ANY PROPRLETORIPARTNERIEXECUnVE YIN WODIM1495(AK.KY.NH.NJ,VT) 03V 015 03!0112016 T D OFFICERrMEMBEREXCLUDEDT E NIA $ 100,000 (Myyandatwy InNH) WC017731494(FI.) 03/01/2015 03!0112016 OISPASE-EA EMPLOY S 1,000000 DMRIP ONOFOPERATIONSbelvrr CombuedpaAdditfwWPageDISEASE-POLICYUMrT S 1,000,000 DESCRIPTIONOFOPEMMONSILACAMONSIVEHICLES(Attach ACORD 101,AddiUonaiRemarks Schedule,Ifmorespaceisrequlred) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. DBA THE HOME DEPOTAT-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. AUTHORMDD REPRESENTATIVE of Marsh USA Ing Manaehi 14lukhegee ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD CORPORATION All rights reserved. r '•,f'-i=F; lL .. .-�t'v;r. .rf;:rlY;• ` -� 9'li �- r T t ,z. :+'i '°`1'�`� +I .Fit al coat °1s p - A yam] ,,qp,Ra ZZ�• t�.y�p4_�� �-�' I-!.16P1 al'S,Fly 'ldsT'1 LJ�'L'.�✓ _ ^---'---_... ` fe-nom fill up&u Ad W097d AUT 7 Jjaip 0""'3J d� -'"''1I tSi�t/!'f/!..'t•J!' 0 9�5��per F l/f•t]rLlCtrl/t:I�f�C- h 430E3 410Y1'TR �D Ilb'�3911?1q. -Y1�7 � ���f Cin �s i } are tl P 2T. �.xg� 7wttsi�� ire n1E§ir � � � �-34 ��t�t C�s:ftF•?�.�`�1;�� ` C�,�"mi������a��sa�•��r�e�ar+ .• --,j aupn a11f qct 1-��•f-1tJVti1�l3E�'1��f•1�M�.��;��IGE�• ,. `0 MP AL INp F'A�Y. AY Go a atvA ca $n