HomeMy WebLinkAboutBuilding Permit #469-15 - 114 ROSEMONT DRIVE 11/13/2014 I e
BUILDING PERMIT :wl` M'�•�°a
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received ",1 lK,�n��.y�,. •A
Date Issued: 1� +�4lrla/�1�
IMPORTANT:A licant must complete all items on this page
LOCATION
PROPERTY OWNER,. print
in a l._
Print
MAP NCS:3 PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village ' yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family C Industrial
Alteration No. of units: C Commercial
❑ Repair, replacement ❑Assessory Bldg C Others:
Li Demolition_ u Other
n Septic n Well n Floodplain ._. F1 Wetlands n Watershed District
0 Water/sfiwer M
Re-ft dL\ E X 1t
Identification Please Type or Print Clearly)
OWNER: Name: �v`fln 'b , 00 Lac�--a se- Phone: 92?— 952`52-9j
Address: y KO fl,1CV) " f i ft✓ld
CONTRAGTOR Name: Phone, 925:1f Z-6 f ;
Ket-n, cxn c
Address:
i !"' ,a,
Supervisors ConstructionLicense: Exp. Date:
Home Improvement Ucense: Exp. Date-
` 1
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: O 20 FEE: $ 3 6a1--�
Check No.: \Z�o Receipt No.: -z
NOTE: Persons contracting with unregistered contractors do not have accesmm
Signature Ql ►gentlOwne_r SWnature of contractor �
t ' �
J
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
TYPE'OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on 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 yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
I
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
Location
`.`� �,, US2 M o ..;� 1)-e r V r—
No. �V, Date 1 1 11,4
. - TOWN OF NORTH ANDOVER
• s� b jam`
.
,r Certificate of Occupancy $
Building/Frame Permit Fee $ W
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
-'7 C
Check# 4
J
Building Inspector
Enter construction cost for fee cal - North Andover Fee Cakulaf►on
Construction Cost
$ 255020.00 m
$ - $ 300.24
Plumbing Fee $ 37.53
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 37.53
Total fees collected $ 475.30
Foundation 100
114 Rosemont Drive
469-15 on 11/13/14
Remodel Kitchen
� `yORTh
Town Of ndover
No.
h ver, Mass, 1� 2A Iq
o
coc C"IwIc
R'Oo P`y
S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LID Septic System
THIS CERTIFIES THAT ..................... BUILDING INSPECTOR
........ ....... ... ......... .. .... .. .. ................
........ . ..... ......
has permission to erect buildings on ...�.� �� Foundation
.......................... .................................................................
Rough
to be occupied as .....! Vheo�.��,. �........
..... ' ..................................................... 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 WNTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT S- S Rough
i Service
............. . ....... ..... .... ............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
The Commonwealth of Massachusetts -
- Department of Indusfrig1 Accidents
Office ofInvestigations
600 Washington Street
Boston,MA.02111
11 www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contrractors/FIectricians/Plumbers
Applicant Information l Please Print Legibly
Name(Business/Organization/In.dividual): �eOJA c
Address: I J i 6+ -
UV/State/Zip: [� n �' U a4hone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. El am a general contractor and I 6. E]Now construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.'I
7• E]Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g. ❑Building addition
workers'comp.insurance 5. ❑ We area corporation and its
o w pan additions
� 10. Electrical repairs or addxty.
required.] officers have exercised their p
3.❑ I am a homeowner doing all work right of exemption per MGL 1 LE]Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roofrepairs
insurance required.] employees.[No workers'
�' l 13.❑Other
comp.insurance required.]
'Any applicant that checks box must also fill out the section below showing their workers'compensation policy information.
('Homeowners who submit this affidavit indicating they 2-re doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. i
Insurance Company Name: ( yL 12(`� 1 Y1 S Ufr.-Y1&e
Policy#or S elf-ins.Lic.#:(qExpiration Date: If 5
Iob Site Address: Pity/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 Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations o£the D1A-f&uranoo' coverage verification.
X do hereby cert n er td,pen�alties offpperjury that the information provided above is true and
jd correct. -
Signature: v Date: Ix 13
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#•
L
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,•
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking tfie boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be fil gd out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone anal fax number:
The CoR 0UW0ajthofIVrassao—tts
Depat tme,u.t dZndwWal.A,ccldenta
Offleo offavestigatitom
60 Wa gtoa Street
Boston,MA 021 Z 1
Tel,#617-7.27-4900 eyt 406 ox 1-877 MASS.AFE
Revised 5-26-05 Fax#617-727-7749
�t�.�a�s,g0vfdza
V-HIS—C-ERTIFICATE
14 09:58 FAX 781 942 2226 GILBERT 0 001
® I DATE(MMIDDNYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/13/2014
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 pollcy(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 endomement(5).
PRODUCER Co'eCT Barbara McDonough
Gilbert Irisurence Agerioy, Inc. PHONE (781)942-2225 FAx N,,.!1781)942-2226
137 Main Street E"MAIL .bmcdonough@gilbertinavrance.com
INSURER(S)AFFORDING COVERAGE NAIC tI
Reading Imo, 01667-3922 INSURERA:NORFOLK & DEDHAM INSURANCE 23965
INSURED INSURER B:Hartford F1re Ins=ance Cola �n
Keen Construction Company INSURERC:7.'ravelera Insurance 0022
1175 Turnpike Street INSURER D:
INSURER E
North Andover MA 01645 INSURBRF:
COVERAGES CERTIFICATE NUMBER:CL1441500922 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, NOTW)THSTANDING 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 ADOL U POLICY NUMBER POLICY EFF POLICY EXP
LIMITS
LTR
GENERALLIABILITY EACH OCCURRENCE 3 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES( RENTED 3 100,000
Pi CLAIMS-MAGE D OCCUR -P-010079/000 /13/2014 /13/2015 MED EXP(Anyone arson $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREOATELIMIT APPLIES PER: PRODUCTS-COMPIOPAGO $ 2,000,000
X POLICY PRO- LOC $
AUTOMOBILE LIABILITY COMBINIE�D SINGLE LIMIT 1, 00,000
ANY AUTO BODILY INJURY(Per person) $
$ ALL OWNED X SCHEDULED OBUECAA6432 12/3/2013 12/3/2014 BODILY INJURY(Per scdarint)I $
X AUTOS X NON OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS
Undorinsured molorisl 3 100 000
UMBRELLA LIAR OCCUR EACH OCCURRENCE I I
EXCESS LIAR CLAIMS-MADE AGGREGATE 3
DED-F I RETENTIONS 3
C WORKERS COMPENSATION o Be Provided directly OR IWIT 0TH
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE YIN is the otirr±er_ E.L.EACH ACCIDENT $ 100 000
OFFICER/M(Mandatory InNH�EXCLUDE07 N/A 10/8/2014 10/8/2015 E.L.DISEASE-EA EMPLOYE 3 100,000
Ir yes,Gesaibo under
DESCRIPTION Or OPERATIONS below EL DISEASE-POLICY LIMIT' S 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VENICLEES(Attach ACORD 101,Addlllunal Remarks Schedulo,If morn space Is required)
Evidence of Coverage
CERTIFICATE HOLDER CANCELLATION
(978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE IANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood Street
North Andover, Va 01945 AUTHORIZED REPRESENTATIVE
X Gilbert, CINEARBAR
ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(201005),01 The ACORD name and logo are registered marks of ACORD
KEEN CONSTRUCTION CO.
° 1175 TURNPIKE STREET PROPOSAL
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
Submitted
Chapter 142A of the general laws, must be registered
,I��
To: c c, r G �j Vg. with the Commonwealth of Massachusetts. Inquiries
about registration and status should be made to the
2 Director,Home Improvement Contract Registration,10
Park Plaza, Room 5170, Boston, MA 02116 617-973-
8787 Owners who secure their own construction
r related permits or deal with unregistered contractors
will be excluded from the Guaranty Fund Provision
of MGL c.142A.
PHONE DATE REGISTRATION N0.
r'- 1522
EIN N0.
97 ZS- 5 Z 3 ((; O�' MA. H.I.C. 108383 46-3783401
C/S=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:
--- flee
Construction related permits:
_CH E____....�LE____......._.
..._.--........
._
. _.........._.. .
_._........__...._...__.....................
......
............................................................................................_..........
....•.....................
.__.....
.........................
.._.._....._.....---...........
.....
_.....
............
._..............
........
..__..__.
WORK
Contractor w'I not egin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. C tractor will begin the work on or
about (date). Barring delay causedby circumstances beyond Contractor's control,the work will be completed by�_(date).The Owner hereby
acknowledg s an agrees that the scheduling dales 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 C, r 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 Contract r,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 specifications,for the sum of
y" P L(P>� r�G L� f� � I�IJI��� � I ( T `7 dollars($- 1 , 250,UCJ ).
Pa mens to be made as follows.
% ($ ) upon signing Contract; ROBERT A. KEEN
Name of Contractor/Designated Registrant
($ upo tt ntof� 1175 TURNPIKE ST.
Street Address
% ($ 1. in ompletion of N. ANDOVER, MA 01845
Cny r State
shall be made forthwith upon (978)691-5201 (978)682-3231
completion of work under this contract. Phos
Fax
Notice: No agreement for home improvement contracting work shall require a Vr� -D
down payment(advance deposit)of more than one-third of the total contract price Name nl Sales
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 Authonzed Signalure
equipment,whichever amount is greater.
Note:This proposal maybe withdrawn by us it not accepted within days.
Acceptance Of Proposal-1 have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated.
I understand that un 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 Buye may cancel this transaction at any time prior to midnight of the third business day after the date of
this,trans,ct o `Cancellation must be done in writing.
- \\\ DO N-,-.- IGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature -7 1
Date �I 1(If
Signature Date
�`� IMPORTANT INFORMATION ON BACK ►
Canstrucfian 4.
REMC�Ot_I.1M4 SPECGI/�LISTS
978-697-520'1
Keen ConstructionCo.com
Lagasse,Soo&John
114 Rosemont Dr.
N.Andover, MA 01845
Contract#5513;Appendix A October 30, 2014
Remodel Kitchen:
• Remove and dispose of all existing cabinetry
• Upgrade electrical to code
• Relocate lighting as needed (four recessed lights)
• Relocate electrical outlet for new range location (total electrical allowance$1000)
• Upgrade plumbing as needed
• Install customer supplied appliances and fixtures(total plumbing allowance$1000)
• Patch and re-finish existing Oak flooring (approx. 360 sq.ft.)
• Install customer supplied cabinets and related trim as designed by Jackson Kitchen
• Patch walls and ceiling as needed
• Paint walls,ceiling and trim (two neutral colors,two coat finish)
Total Price: $11,850.00(Eleven thousand eight hundred fifty dollars)
Price does not include cost of permits, cabinets,counters,appliances, plumbing or electrical fixtures, or
any repairs to unsafe, inadequate or non-code compliant existing conditions.
Payment schedule: $1000.00 due upon signing contract
$3000.00 due the first day of work(plus permit fee)
$2500.00 due when rough electrical and plumbing is complete
$3000.00 due when cabinets are installed
due when contracted work is complet
AV$2350.00
Robert A. Keen
to-31 ` -t V ie ;30 ,
Date Date
1175 Turnpike St. P: 978-691-5201
N. Andover, MA 01845 F: 978-682-3231
CSL#076691 Sales@KeenConstructionCo.com HIC#108383
T� I - -
Jac sQnosai�soea�er of the Yea" Order
' KITCHEN, DESIGNS 2014-
Transaction
o�fti�fe#_
1093 Osgood Street, North Andover,MA 01845 I 482628
Phone: (978)685.7770 Ship Date Pcd
Fax (978)685-7771 L 11/01/2014
Billing Fax:978-687-5841Location
A E `1
MAIL TO: Jackson Lumber& Millwork Co. Inc. Sales Representative
PO Box 449, Lawrence, MA 01842 JE ALA-SY RA
Bill To: Ship To:
SOO LAGASSE SAME **CASH ACCOUNT**
**CASH ACCOUNT** 114 ROSEMONT DRIVE
114 ROSEMONT DRIVE (703)961-8255 NORTH ANDOVER, MA 01845
NORTH ANDOVER, MA 01845
Customer# Order# I Order Date Oper Purchase Order Terms Ship Via
54578 482628 1 11/01/2014 073 CUST PIU
N# Item Number OrderedDescription UMI Price/ nit Extension
1 SOSCHROCK 1 SCHROCKTRADEMARK
EA 12,200.00 12200.00
FLETCHER DOOR MAPLE WITH
COCONUT PAINT FOR PERIMETER
MAPLE CHOCOLATE FOR ISLAND
PER KITCHEN PLAN
2 SOWILSONART 23 BP29340AS KNOBS FOR DOORS EA 5.00 115.00
3 SOWILSONART 16 BP29349AS HANDLES FOR DRAWERS EA 5.00 80.00
Amount: 12.UYOQ
Special order and manufactured merchandise is non-returnable. Tax: 774.69*
Customer agrees that any amount not paid within 30 days of a) Total: 3,169.69*
invoice date will carry interest at the rate of 1.5% per month U Paid: ,10 .0
and further agrees to pay all costs incurred in collection, Due' 7,06F69
including reasonable attorney's fees.
Page 1 of 1 11/1/2014 1:03:41PM
t Massachusetts - Department of Public Safety
�J Board of Building Regulations and Standards
Construction Supervisor
License: CS-058245
KENNETH B KEE,& A ,
21 HEWITT AVE=
N ANDOVER MA 018 1
i'Srw+'�C/�► Expiration
Commissioner 03/24/2016
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-076691
ROBERT A KEEN-` VIA 7. ...
12 E WATER ST
u* _
North Andover WA Ole" t
)' "' \ Expiration
Commissioner 08/16/2015
/fie ip'om�nw�uraP,a,:!�o�C/�Ga�J�uae�
P-\ Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration: pg383
�_. , Type:
xpiration:, 8/�g/2016 DBA
KEEN CONSTRUCTIOtit�p •� ;.•
c �
Kenneth Keen ,
1175 TURNPIKE ST
NO.ANDOVER, MA 01845
Undersecretary
i'
w,
11/13/g014 10:00 FAX 781 942 2226 GILBERT 001/p01
DATE1MMro01YYYY)
ACOORU CERTIFICATE OF LIABILITY INSURANC �11/11/2014
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 aY 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. i I
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
eertlflcate holder in lieu of such endorsemen 6).
PRODUCER DO Barbara McDonough
Gilbert Insurance Agency, Ino. o a (781)942-2225 r •I(791)a42-2226
137 Main Street E.MAIL .bmadonough@gilbortinsurance.aom I'
WSU ER AT-FORD140 COVERAftG MAIC
Reading MAL 01667-3922 iNSUKRA'1qORPOLK-j DEDHAM 23965
INSURED fNsupMeLHAEtford Fire I>1 =anoe CozoiLn
Keen Construction Comp"y INSURER C ITravelers Insu=wice 0029
1175 Turnpike Street IN89mc
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North Andover MA 01845 INSU FIFA F:
COVERAGES CERTIFICATE NUMBER-CL1441500922 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BE=LOW 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.
AIMX rA
TR TYPE OF INSURANCE 9 POLICY MB Marr/ EFF Y EXP LIMTT5
OENERALLIABILITY EACHO URREN09 S 1 000,000
X COMMERCIAL GENERAL LIABILITY I S REN hu x,00,000
CLAIMS44ME ❑X OCCUR -P-010070/000 /18/3014 /38/2015 MED EXP vIw on $ MOO
PERSONAL A ADV INJURY � 000,000
GENERAL AGG TE I 3 2 0,000
GE 'L AGGREGATE LIMIT APPLIES PER; PROD CTS-COMF/OP AGG! S 2,000,000
rxi POLICY PRO LOC $
AUTOMOBILE LIABILITY 9 Y LIMIT _�.c000
H ANY AUTO BODILY INJURY(Per POMM)( 9
ULO ED AC19SULED 6VF,CAA6432 2/3/2013 2/3/2014 BODILY INJURY(Perawdonl) s
OP TY AUTAGE
N NOWNED S
K HIRED euros X Aures � s -100,090
ndenm"d mo
UMBRELLA UAB OCCUR EACH 0 RRENCE ! S
-! "SS I" CLAIMS-MADE AGGREGA-eL•—
NA S
C WORKSMCOMFENSATION To to Previded directly O .
AND EMPLOYERS.UAeIU7Y YIN
ANY PROPRIETOR/PARTNERIEXECVTIV9 NIA is the carrier. E CH ACCIDENT' 9 100190
OFFICEWMEM@ER EXCLUDED? 0/0/2014 0/9/2015
Ilba„ x"In NH) E.L, ISEASE-EA EMPLOYE' 100 00
IfYn 02WAN Under
E CRIPNFOETIO
&L DISEASE-POLI Y LIMIT S 5Q0.000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Altaoll ACORD 101,AddWonal RwW a Schedule,K morn space to raspdred)
Evidence of coverage
CERTIFIC&M HOLDER CANCELLA ON
(978)686-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BI:ICANCELI.ED BEFORE
THE EXPIRATION DATH THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood Street AUTHORIZED REPRE56NTATIVB
North Andover, MA 01845
M Gilbert, CIC/BAPIM
ACORD 26(2010/06) ®1988.2010 ACORD CORPORATION. All rights reserved.
,�,o��� ��. �,�• Tha ACORD name and Iosco are registered marks of ACORD I