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HomeMy WebLinkAboutBuilding Permit # 1/22/2016 I IL 1 G PERMIT 0 TaoRTy 1 RtLeD '6 R'O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ® ` _ Permit No#. A Date Received �SS�acHus�R Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION ��d�5� Lf rn // , - PROPERTY OWNER VCt l 0f'.L:,f Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes an TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ;❑ FCoodplam ❑Wetlands ❑r Watershed District ❑rWater%Sewed w,. � �„ ,,rr�,�, �, r ,', f r ,t ,. DESCRIPTION OF WORK TO BE PERFORMED" G 1lS/ x z 5 c.--n �0 r d� y1 6 Identificat'o Please T�,'& e or Print Clearly OWNER: Name: U , / 2 � % ( Phone: Address: ✓I J,5cw— Lo b , 4vi e v-&y® Contractor Name: 14�efl �05-bVC160 L Phone: 92 6 X91-921-61 Email: 5,� /e 5 as G'ee.� ifCyl 5� �a� �U l eu P Cc�� ,, Address: PC Lx. 9,3 , Ir, 014 61,TV5 Supervisor's Construction License: 65 0 '7 9( Exp. Date: 0/6, z/ 7 Home Improvement License: q 31,3 Exp. Date: /� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST SED ON$125.00 PER S.F. Total Project Cost: $ 12- 0 0 FEE: $ Check No.: Receipt No.: 2 t NOTE: Persons contracts g with unregistered contractors do not have access to the u r and a .,_ _ . -Owner--,, � .. 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swh'13ming Pools 11 Well ❑ Tobacco Sales ❑ Food Packaging/Sales 11 Private(septic tank,etc. Permanent Durapster on Site El THE FOLLOWING SEG TIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on mature COMMENTS V \,v\ V111 C) HEALTH Reviewed on /-r" Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street, FIRE,DEPARTMENT Temp Dumpster on site gyps FfedDe'i , p e nt,sJgijatdOare 'te COMMENTS ' r AM `•10RT1� *��town oi ®ver ® ;w y 1 0 No. _ 2,61 Y ZO LAKE �• ver q ass, C OC NICKEWICm y1. �.ys R�rEo Cl h.'. U BOARD OF HEALTH Food/Kitchen Septic System PERMIT T LD THIS CERTIFIES THAT Z .. .®, '....... ....... , BUILDING INSPECTOR Foundation has permission to erect .... buildings on ........ ...................... Cad...........teA..... .s.....&...... . Rough to be occupied as .I. ..... .... .. .............cbil.p..... .*000. 7 .................................................... 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 Rough VIOLATION of the Zoning or Building Regulations voids this Permit. Final E I EXPIRES I 6 ON HS ELECTRICAL INSPECTOR LES CONSTRUC T S Rough Service ............. ..... ......... ................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. A. _ Cons(rucfion Co, RGMC�UIil_INC: tiPGCIALI STS KeenConstructionCo.com Zablocki, Ed &Valerie 60 Windsor Ln. N.Andover, MA 01845 Contract#5562; Appendix A October 22, 2015 Create Sunroom: • Frame new sunroom (approx. 18'x 16')where existing sunroom is • Relocate exterior faucet to side of house • Supply& install eleven Andersen A-series double hung windows to match existing(approx. 2'10" x 4'4") and three Andersen A-series transom windows(approx. 2'10"x 1'4") • Supply& install three Velux FS-001 fixed deck mounted skylights (approx. 21" x 27") • Supply& install swing patio door to match existing • Supply& install PVC exterior trim • Supply& install Hardie siding to match existing • Supply& install roofing to match existing • Install temporary stairs off the back of the deck • Re-configure existing deck to attach to new sunroom • Includes$2000 electrical allowance outlets, lighting and switching Total Price:$34,267 (thirty four thousand two hundred sixty seven dollars) Price does not include cost of permits, painting, interior finish or repairs to any unsafe, unusual or non- code compliant existing conditions not addressed in this quote. Payment Schedule: $5000 due upon signing contract $7500 due the first day of work(plus permit fee) $7500 due when frame is complete $7500 due when windows and door are installed $6767 due at completion of contracted work _y Customer►` Robert A. Keen C7, c- 7 v i -. /v /Z-7 /5 Date Date PO Box 935 Page 1 of 1 P: 978-691-5201 N.Andover, MA 01845 F: 978-682-3231 CSL #076691 Sales@KeenConstructionGo.com HIC #108383 55f .I KEEN CONSTRUCTION CO. ° 1175 TURNPIKE STREET NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax:(978)682-3231 specifically exempt from registration by Provisions of ( 11// Chapter 142A of the general laws, must be registered ,�J Submitted c ` 2, b IO c k t with the Commonwealth of Massachusetts. Inquiries To: about registration and status should be made to the L� Director,Home Improvement Contract Registration,10 tG V� Park Plaza, Room 5170, Boston, MA 02116 617-973- 8787 Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PHONE DATE REGISTRATION NO. EIN NO. MA. H.I.C. 108383 46—3783401 > C/S=Customer Supplied S+I=Supply+Install 1 See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: C. '�'A 2 Sin --o 0 M x I� > Construction related permits: WORK SCHEDULE Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractors control,the work will be completed by (date).The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 8 4 following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contrac or,his subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above T� specifications,for the sum of:O `�`M�J e 5r� JPt/dollars($ 3�t 2- Payment to be made A follows: % ($ ) upon signing C ntract ROBERT A. KEEN Name of Contractor/Designated Registrant ($ o t of 1175 TURNPIKE ST. Street Address %� _.�.p.71 tion of N. ANDOVER, MA 01845 .. City/Stale % ($ ) shall be made forthwith upon (978)691-5201 (978)682-3231 completion of work under this contract. Phe„ 1 /� Fax Notice: No agreement for home improvement contracting work shall require a - fv {/P(— >down payment(advance deposit)of more than one-third of the total contract price Name or sate an or the total amount of all deposits or payments which the contractor must make,in advance,to order and/or otherwise obtain delivery of special order materials and Authon dSigns lure equipment,whichever amount is greater. Note:This proposal may be withdrawn by us it not accepted within days. Acceptance Of Proposal-I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done in writing. DDQ NQS SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. � Sign at ure eDate Signature Date IMPORTANT INFORMATION ON BACK Windsor Lane 12-22-15 ^jT'o J%. 1'q N.Andover M.A. 9:315am CS seam 4.1126.1 kmsearnSi&4.11.26.1 Materials Database 1516 Member Data Description: Member Type: Beam Application: Roof Top Lateral Bracing: Continuous Slope: 0.00/ 12 Bottom Lateral Bracing: Continuous Standard Load: Moisture Condition: Dry Building Code: IBC/IRC Snow Load: 55 PLF Deflection Criteria: 0240 live, L/180 total 1.000" max. LL Dead Load: 15 PLF Deck Connection: Nailed Member Weight: 15.6 PLP Filename: Beam1 Other Loads Type Trib. Other Dead (Description) Side Begin End Width Start End Start End Category Additional Uniform(PSF) Top 0' 0.00" 16' 5.50" 9 0,00" 55 15 Snow Point(LBS) Top 2' 0.00" 597 298 Snow Point(LBS) Top 4' 0.W' 597 298 Snow Point(LBS) Tap 7' 0.00" 597 298 Snow Point(LBS) Top 9' 0.00" 597 298 Snow Paint(LBS) Top 12' 0.00" 597 298 Snow Point LBS Too 14' 0.00" 597 298 Snow 1 10 16 5 a r 16 5 6 Bearings and Reactions Input Nin Gravity Gravity Location Type Material Length Required Reaction Uplift 1 0' 0.000" wall SPF Plate(425psi) 5.500" 3.754" 8376# -- 2 16' 5.500" wail SPF Plata 42 si 5.500" 3.684" 8220# - Maximum Load Case Reactions Used for applying point loads(or line loads)to Carrying members Snow Dead 1 6157# 2219# 2 6053!1 2167# Design spans 15' 8.250" Product: 2.0 i id rn LVL 1-3/4 x 11-7/8 3 ply PASSES DESIGN CI-IECKS Connect members with 2 rows of 16d common nails at 12.W oc NOTE:Nails must be applied from both sides Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. ,Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 33229.# 381734 87% 8.23' Total Load D+S Shear 76681 138614 550% 0.4' Total Load D+S Max.Reaction 83761 12272.# 68% U Total Load D+S TL Deflection 1.0045" 1.0458" U187 8.23' Total Load D+S LL Deflection 0.7376" 0.7844" 0255 8.23' Total Load S Control: TL Deflection g t13,,yr LDn,`dasU 100% Snow=115% Hoof=125% wind=160°1° pro es a repetitive member use increase in bung stress: 4% '� &ill18)V3 ' t r Ali produot names are tmdomarks of Uwir rewo"41 eowners Copyright(C)2013 by Simpson Sirongfiie Company Inc.ALL RIGHTS RESERVED, when the member,lloorjoist,beam or gifde4 shown on this drawing meetsapplicable design criteria for Loads,Loading Conditions,and Spans listed on this sheet.The d b a ualilied dei nor orded n fesslonai as Mquired for 819rova.Thisto the manufacturers arealffcations. Windsor Lane 12-22-15 Y K N.Andover,M.A. 9:42am 10fe l.tl'o' CS Bearin,4.11.2&1 kmBeamE*)e4.i1.2&J MaterialsDatabase 1516 Member Data Description: Member Type: Beam Application: Floor Window Header Top Lateral Bracing: Continuous Bottom Lateral Bracing: Continuous Standard Load: Moisture Condition: Dry Building Code: IBC/IRC Live Load: 40 PLF Deflection Criteria: 0360 live, U240 total 1.00011 max, LL Dead Load: 10 PLF Deck Connection: Nailed Member Weight: 12.5 PLF Filename: Beam2 Other Loads Type Trib. Other Dead (Description) Side Begin End Width Start End Start End Category Additional Tapered(PLF) TOP 9 0.001, 10' 0.00" 0 80 80 0 Live Point(LBS)-- To 5! 0.09' 6118 2219 Snow T% 0 10 0 0 Q, / 10 0 0 Bearings and Reactions Input Min Gravity Gravity Location Type Material Length Required Reaction Uplift 1 01 0.009, Wall SPF Plate(425psi) WA 2.042" 4557# 2 10' 0.000" wail SPF Plate(425psi) N/A 1,976' 4414# Maximum Load Case Reactions Used for applying point loads(or line loads)to carrying members Live Snow Dead 1 334# 3059# 14984 2 477# 3059# 1355# Design spans fly 1.750" Product: 2.0 RigidLarn LVL 1=3/4 x 9-1/2 3 ply PA,13SES DESIGN CHECKS Connect members with 2 rows of 16d common nails at 12.9'oc NOTE:Nails must be applied from both sides Minimum 2.04"bearing required at bearing#1 Minimum 1.98"bearing required at bearing#2 Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 21951.# 25122A 87% 5- Total Load D+S Shear 44764 11089.# 401/6 -0.06 Total Load D+S TL Deflection 0.4379' 0.5073' 0278 4.99 Total Load D+S LL Deflection 0.3065" 0.3382' U397 !Y Total Load S Control: LL Deflection DOLS: Uve=1000/o Snoriv=1150/6 Roof=125/o Wind=160'/o Design assumes.a repetitive member use Increase in bending stress: 4% A RUHR, All product names are trademarks of their requective o rmr Copyright(C)2013 by Simpson Strong-Tie Company InG.ALL RIGHTS RESERVED. "Passing ludefined asMan the member,11DOrlolst,beam orowei Mown on thisdrawing Ineels;applicable design Olean for Loads,Loading Condiliviz,and Spans listed on ilris sheet.The design must be ravIewedby a qualified desionerord"ark ornfirsdonal as mQuirad for acraeval.Thisdesinn assumes product Installation accordina to the manufacturers iflcations. }REAR ELEVATION 1/4 =1 -O EXISTING WINDOW F-1 VERIFY LOCATION IN"FIELD ,/ ADJUST ROOF fF NECESSARY r-EXISTING HO4.ISE EWYONDJ 4 F 12 E:l El E:1 NEW CONSTRUCTION DRAWN f37: NOV, 18, 2015 MARTHA MAGINNIS 55 RECiFNT AVE, PROPOSED NEW SUN ROOM 13RADFofRD, MA. 01535 h0 WINDSOR LANE (978)374-8719 NORTH ANDOVER, MA 24"X 24"SKYLIGHT F-1 F-1 E:l EXISTING DECK E:l L TO REMAIN---,l RIGHT SIDE ELEVATION L LEI=T SIDE ELEVATION 1/4"=1'-O 1/4'=1'-O DRAWN 13y: NOV. 16, 2015 MARTHA MACINNIS 55 REC-Tr--NT AVE, PROPOSED NEW SUN ROOM 2 BRADFORD, MA. 01835 60 W NDSOz LANE (978)374-8719 NORTH ,ANDOVER, MA EXISTING Hg1SE TO REMAIN UNCHANGED—� EXISTING DOOR TO REMAIN I POST TO FOUNDATION FOR RIDGE BEAM I I EMEND EXISTING DECK NOTE: TO NEW SUN ROOM DOOR RE NOM501 INAL TRANSOMSI ARE NOMINAL 36"WIDE Jd 15"TALL 16� 6X6 Posis E FLOOR PLAN DOOR UNItS,TYPICAL 1/4"4-0 /A =� ^ `t —0 I I POST TO(3)ZXIO I HE4DM I FULL LITE STORM DOOR SYSTEM WITH SCREEN INSERTS,TYP.ALL SIDES 19� DRAWN 13Y: NOV, 9, 2015 MARTHA MACINN15 55 REGENT AVE. PROPOSED NEW 5UN ROOM BRADFORD, MA, 01535 60 WINDSOR LANE (978)374-8719 NORTH ANDOVER, MA ALL WOOD USED FOR STRUCTURE SHALL BE PRESSURE TREATED USE 6X6 POSTS AT TUBES WITH SIMPSON ABU66 BASE WITH 1/2"ANCHOR BOLTS AND PAIR SIMPSON AC6 OR ACE6 CAPS EXISTING HOUSE TO REMAIN UNCHANGED FLOOR FRAMING „ F I/S11=11-0 I ' ' " ' 12®16" AllI (Di 3'1 t 1. ,� 4)2X12 FOUNDATION PLAN SIMFSON I-URRICANE CLIP END OF EACH RAFTER,TYP (5)16d NAILS CEILING JOIST 16' TO}RAFTER TYP.AT TOP PLATE POST TO FOUNDATION 12"CONC,FILLED SONOTUBE WITH C3)II-1/4"LVL RIDGEMS.YLIGHT-� -- ATTCHED 24' BIGFOOT"OR POSTED TO FOUNDATION EQUAL FOUNDATION,4'BELOW GRADE,TYPICAL FRAME FOR(3)24"X (3)2X10 HEADER 2X10 RAFTERS ®16"or- ROOF 1=R,4MINC (3)II-114"LVL RIDGE poSTED 1/811=11-0 T 2 HEADER 12EL011X10 PRAWN 13Y- MARTHA MAGINNIS NOV, S, 2015 58 REGrENT AVE, PROPOSED NEW SUN ROOM BRADFORD, MA, 01835 60 WINDSOR LANE (978)3748719 NORTH ANDOVER, MA 4 RIDGE VENT LVL RIDGE BEAM SHINGLES TO MATCH EXISITNG 1/2"EXT,PLYWD.SHEATHING 2X10 RAFTERS m 16"O.C. 4 IF12 24"x 24"SKYUGHT t-2x5 m 16 00-� (3)2X10 METAL DRIP EDGE CONT.SOFFIT VENT 216 STUD WALL 6X6 POST HOISEWRAP EO.TO"TYVEK" 1/2"EXT,PLYWD.SHEATHING- SIDING HEATHING SIDING TO MATCH EX15TI 2X12 m 16"OC 3/4"T 4 G PLYWD.SUEFLOOR (4)2X12--► 4� TYPICAL WALL SECTION ION 1/4"=]'-o DFZAUIN BY: NOV, 9, 2015 55REMARTHA T AVE,s PROF0j� NEW �jUN }ZOOM 58 R)=G�Nt AVE. BRADFORD, MA. 01835 roO WINDSOR LANE C978J374 8719 NORTH ANDOYIER, MA HOUSE SIDE DECK SIDE p ad o 6"OC PORCH DE I-}- AILS SIMPSON H2.SA 1/2"DIA,SIMPSON FOR LENGTH OF HURRICANE CLIP HDG-THREADED ROD FLOOR JOIST 12"PT PLYWD,SPACES TO WITH NUT AND WASHER MATCH WIDTH OF POST Bean PAIR OF LPCT CAPS - SEE PLAN DTT2 ALL CONNECTORS TO BE SIMPSON Z MAX USE ONLY FASTENERS SPECIFIED FOR THESE SIMPSON DTT2 CONNECTORS PECK POST WINDOW SILL ALL LUMBER TO BE CONNECTIONS NOTES: IF APPLICABLE PRESSUIME TREATED I, REF, 512.2.2.3 IRC 2009 SIMPSON 2. DTT2 TO BE CORROSION PROTECTED PER A-23 CLIP ANGLE SIMPSON AND PRESSURE TREATED LUMBER RECOMMENDATIONS GIRDER 3, SEE SEPERATE DECK LEDGER CONNECTION DETAIL SEE PLAN 4. FLASHING AND WATERPROOFING BY OTHERS SIMPSON CAP/BASE 5, MIN.2 CONNECTIONS-I EACH END OF DECK 12"PT PLYWD BC6 FOR 6X6 POST UNLESS OTHERWISE NOTED ON FRAMING PLANS SPACERS 5C4 FOR 4X4 POST OR REQUIRED BY DECK DESIGN SIMPSON LUS21055 J015T HANGER DECK LATERAL LOAD CONNECTION 6X6 POST SIMPSON A5U66 FOR 6X6 POST CONNECTORS: 3-518"FASTEN MASTER LEDGER I-OK 5/6"DIA,ANCHOR BOLT Of OfOOf O.0 60 PSF DECK LOAD Su 4" SPACING SPACING SPACING SPACING 4" (O.C,)ON CENTER SPACING S'WIDE DECK 6"Ov S'-I TO 10'WIDE 5"OC 10'-1 TO 12'WIDE 4"Or 3/4.. V-1 TO 14'WIDE 4"OC O O REFER TO FASTEN MASTBR 4� TECHNICAL BULLETIN DECK LEDGER TO RIM JOIST FOR 10"DIA,TUBE INSTALLATION PROCEDURES AND OTHER REOUIREMENTS O o TI-3/4" Li -�z24"DIA.BIG FOOT DECK LEDGER CONNECTION UNDISTURBED SOIL DRAWN BY: MARTHA MACINN16 NOV, 9, 2013 55 FREC+-NT AVE. PROPOSED NEW SLIN ROOM BRADFORD, MA, 01835 roO WINDSOR LANE (978)3748719 NORTH ANDOVER, MA -\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia SV• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY.A brant Information Please Print Lesibly Name(Business/Organization/Individual): en t,_yt Si CL)C Address: X 93 lqn CL, '42 r— � �f�'P one City/State/Zip: `� Are you an employer?Check the appropriate box: Type of project(required): 1.[Z I am a employer with Z 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. E]Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 W 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 11.F-1 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.FJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL o. 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 insurancefor my employees. Below is the policy and job site information. -�• Insurance Company Name: I (1�•�/� ' �� / -5 Policy#or Self-ins.Lie. N L) 1J - 99 9 I N5?, Expiration Date: 10 / l V ikl� I`7C l��l City/State/Zip:Alil Job Site Address:0 �' �' � 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 verification. I do hereby certify, dere pai s andpenalties of perjury that the information provided above is true and correct. Date:.ate: � � ature: Si i Phone#: 9� - 6 91 —6 zo 1 LLI]ff only. Do not write in this area,to be completed by city or town official. n' Permit/License# hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: ,acoRv® CERTIFICATE OF LIABILITY INSURANCE EATE(MMIDDN—) �/ 0/23/2015 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(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 EONTACT NAME: Barbara McDonough Gilbert Insurance Agency, Inc. PHCNE (781)942-2225 ac o:(701)992-2226 137 Main Street p"RIE D DSS:bmcdonough@gilbertinsurance.com INSURERS AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURERA Norfolk & Dedham Insurance 23965 INSURED INSURERB:Safety Insurance Company 39454 Keen Construction Company INSURER c:Travelers Ina. 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. INSR TYPE OF INSURANCE ADD B POLICY NUMBER MMN)CDYIYYrr POLICY P LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 1,000,000 A CLAIMS-MADE }{❑OCCUR PREMISES aoccurrenoa $ 100,000 ND-P-010078/000 3/13/2015 3/13/2016 MED EXP Anyoneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINEDSNGLE LIMIT e accident $ 1,000,000 _ ANY AUTO BODILY INJURY(Par person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS 6220807 COM 01 5/23/2015 5/23/2016 BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWMEO PROPERTY DAMAGE $ AUTOS (Per accident Underinsured motodst $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ , EXCESS LIAR CLAIMS-WADE AGGREGATE $ DED I RETENTION $ WORKERS COMPENSATION S TUE ETH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) GRUB-99911,158-2-15 10/8/2015 10/8/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 8 es,describe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached it more space Is 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(2014/01) The ACORD name and logo are registered marks of ACORD INS025(20140/) Massachusetts -Department of Public Safety Board of Building Regulations and Standards x--___.•__- 1.1111.161 Ul Ull 11.]U I/CI Vlll/1 License: CS-076691 ROBERT A KEEN-` 12 E WATER ST North Andover r&A 0 ?. ti Expiration Commissioner 08/16/2017 � 9971-2e wQO%77/Y 6vie4eamll,110I/GCOJdCGCf2ClQe 1 Office of Consumer Affairs&Business Regulation W'ME IMPROVEMENT CONTRACTOR gistration: 108383 Type: piration: 8L1k 16 DBA r , KEEN CONSTRUCTION GO Kenneth Keen 1175 TURNPIKE ST NO.ANDOVER,MA01845' =` Undersecretary