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HomeMy WebLinkAboutBuilding Permit # 1/21/2016 BUILDING PERMIT 0 ttF�D tao TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �y'�RgTEo�PP��y Date Issued: l — $ IMPORTANT: Applicant must complete all items on this page LOCATION > c Gz F k:e a , ; J _ int PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: `" ZONING DISTRICT: Historic District yes �n td Machine Shop Village yes10-1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial X Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed Distract Water�Se�uei- 1 , I)ESCRIPTION OF WORK TO BE PERFORMED: re Gf''. Identification- Please Type or Print Clearly OWNER: Name: I wide c Phone: Address: , k-)0 x � C F 1✓ ��o 4c)o# F�!y IV Contractor Name: I urs �fT�r Phone: Email: rte _: raF;_ ray:. Address: `..,. . Supervisor's Construction Licenser " C> �> `�' Exp. Date: Home Improvement License: �J -Exp. Date: � Y ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ 41-1 Check No.: / Receipt No.: NOTE: Persons cont acting with unregistered contractors do not have access to the g. r d -' ` �oRYH 'Town ofz L ndover ® y. No. z ver, ass 1 OCOCHICEWICK 1 RATED PPa`,`�5 S U BOARD OF HEALTH Food/Kitchen Septic System PERMIT LINIF ,.... BUILDING INSPECTOR ...................... ...... THIS CERTIFIES THAT J. ............ ...........................................�.... .......... .. ............... Foundation ......�G......... ..... has permission to erect .............. buildings on .... .� Rough do .............................................................. Chimney to be occupied as . ... ...... .16� ................................... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file'inthis office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final FRIT EXPIRES IN 6 THS ELECTRICAL INSPECTOR LESSCONSTRUCTS S Rough Service ............... . ........ . ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — ®o Not Remove Final DEPARTMENT FIRE No Lathing or Dry Wall To Be ®one Burner Until Inspected and Approvedthe Building Inspector. Street No. Smoke Det. -- Construct<ion Co,. R13MCJUL"LINCi SPL'C:IALI57"S P'74T.® -1®T5 KeenConstructionCo.coM Hunt,Teddie&Gene 19 Boxford St. N. Andover, MA 01845 Contract#5571;Appendix A January 21, 2016 Remodel 632 Chickering Rd.: a Remove existing tub and wallboard around it a Supply&install Sterling Ensemble fiberglass tub/shower unit, re-using existing shower valve ® Disconnect power to code '.... a Patch walls around new shower-unit where needed a Secure dishwasher to cabinetry a Replace all smoke detector batteries a Qrganize electrical work(work to be billed separately) a ,Prep and paint all walls,trim, heat casing and ceilings in unit '... Total Price:$9750(nine thousand seven hundred fifty dollars) Price does not include cost of permits or repairs to any unusual, unsafe or non-code compliant existing conditions not addressed in this quote. Payment Schedule: $1000 due upon signing contract $2000 due when shower unit is installed $2000 due when plaster is complete $2000 due when painters begin $2750 due at completion of contracted work /Y t1" --� Customer Robert A. Keen , ?/ & 2- 1 1 L7 Date Date PO Box 935 Page 1 of 1 P:975-091-5201 N.Andover, MA 01345 F:978-042-3231 G5L#076691 5aIe99KeenGon9tructionGo.com HIG #10,5353 L4 6+w. �' �' a Eli CONSTRUCTION C . °- 1175 TURNPIKE STREET PROPOSAL NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors 04 Tel: (978) 691-5201 engaged in home improvement contracting, unless Fax: (978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted ( r with the Commonwealth of Massachusetts. Inquiries To: y— I � .4r1 I about registration and status should be made to the Director, Home Improvement Contract Registration, 10 Park Plaza, Room 5170, Boston, MA 02116 617-973- 8787 Owners who secure their own construction 15 related permits or deal with unregistered contractors I will be excluded from the Guaranty Fund Provision 1 of MGL c.142A. 1 PHONE DATE f REGISTRATION NO. D INNO. , 2 � MA. H.I.C. 108383 —3783401 f p > CIS = Customer Supplied S + I = Supply + Install ❑ See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: ICJ f � i > Construction related permits: WOR--K'---S--Q"-H--'E'DlfLE l The Commonwealth of Massachusetts Department of IndustrialAccidents r I Congress Street,Suite 100 d Boston,MA 02114-2017 www.mass-gov/dia y�•V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le ibl A licant Information r Name (Business/Organization/Individual): ���V1 C� Address: c-) n i p: 93 6),2-5 P one#: 97�— ��,`�`'1 �� 1 City/State/Zi Are you an employer?Check the appropriate box: Type of project(required). Z- employees full and/or part-time).* 7. [:]New construction 1.�I am a employer with 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• 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 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12•Q plumbing repairs or additions proprietors with no employees. $,❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[J Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.FJ 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#1 must also fill out the section below showing their workers'compensation policy information. o submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. t Homeowners wh $Contractors that o subheck mit 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. n insurance for my employees. Below is the policy and job site I am an employer that is providing workers'compensatio information. Insurance Company Name: Cc,v>r f e r5 In-5 457 // �� Q Q �l 2 — �� Expiration Date: Policy#or Self-ins.Lic.#:C� U ;;IJ // r_I�g' > Ci /State/Zip: Job Site Address: l� l �` r� Attach a copy of the workers' compensation poll y declaration page(showing the policy number and expiration date). on punishable by a fine up to Failure to secure coverage as required under civil penalties enalties in the form of STOP25A is a criminal 1WO1RK ORDER and a fine of up to$200-00 50.00 a and/or one-year imprisonment,as w p 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 n et•t pa' sand penalties of perjriry that the information provided above is true and correct. Date: I � f Si nature: - Phone#: L �� E[Other only. Do not write in this area,to be completed by city or town official. Permit/License# n: hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: rson: DATE(M1WDD/YYYY) ACil CERTIFICATE OF LIABILITY INSURANCE 10/23/2015 10/23/2015 THIS CERTIFICATE IS ISSUED AS A MATTER 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)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 NA E:ONTC Barbara McDonough Gilbert Insurance Agency, Inc. PHONE0,Eli (781)942-2225 1FA (781)942-2226 A1CX No 137 Main Street AEDORIESS:bmcdonough@gilbertinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURERANorfolk & Dedham Insurance 23965 INSURED INSURER B:Safety Insurance Company 39454 Keen Construction Company INSURER C.Travelers Ins. Co. 0031 483 Chickering Road INSURERD: INSURER E: North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER CL1552101779 REVISION NUMBER: 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. 0 POLICY EFF POLICY EXP ILSR TR TYPE OF INSURANCE POLICY NUMBER MIDDNY LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 1,000,000 A CLAIMS-MADE FxI OCCUR PREMISES aoccurrence $ _ 100,000 ND-P-010078/000 3/13/2015 3/13/2016 MED EXP Any one person) $ 5,000 PERSONAL h ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PCLICY�PEC- F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 E OTHER: AUTOMOBILE LIABILITY COMBI ED SINGLE IT $ 1,000,000 e accWen B ANY AUTO BODILY INJURY(Par person) $ ALL OWNED X SCHEDULED 6220007 COM 01 5/23/2015 5/23/2016 BODILY INJURY(Per accident) E AUTOS UTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS eraccidenl Underinsured=tons] $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ , EXGE93 LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATIONO S ATUTE I I ER TH AND EMPLOYERS'LIABILITY ANY PROPRIETOW ARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 OFFICER'i In N )EXCLUDED? 6HUB-9991M58-2-15 10/8/2015 10/8/2016 E.L.DISEASE-F-A EMPLOYE $ 100,000 C (Mandatory In NH) _ UIyes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space le required) CERTIFICATE HOLDER CANCELLATION (978)623-8320 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS02512014Bn Massachusetts -Department of Public Safety Board of Building Regulations and Standards n___.___ • �.1111�L1 41 L11/11 J1111C1 YI\lll License: CS-076691 ROBERT A KEEN- 12 E WATER ST North Andover WA 0 r Expiration Commissioner 08/16/2017 �e rpanvz�zaiuuea�Lz a�C�Jucl uae� JOffice of Consumer Affairs&Business Regulation IMPROVEMENT CONTRACTOR rME gistration: 468383 Type: piration: ; 8[18f20.16 DBA r �u KEEN CONSTRUCTION CO, `I s Kenneth Keen �i. 1175 TURNPIKE ST NO.ANDOVER, MA 01845` Undersecretary