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HomeMy WebLinkAboutBuilding Permit #5 - 114 SPRING HILL ROAD 7/2/2007 %40RT1i BUILDING PERMIT oFtt�eo ,°�tio F?ABS: . ap TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION qq Permit NO: Date Received 39 �RArgo SSAC HU`�� Date Issued: IMPORTANT: Applicant must complete all items on this page R. LOCATION Print w . PROPERTY OWNER 400, J zF, Print _. MAP NO: PARCEL ZONING DISTRICT HISTORIC LUST ICT ,. yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ) One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 7f-Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other .Septic 'a-Well ,RFIoodpIa1n`% aW. etlands atershedr'l istri 0 Wates"/Sewer DESCRIPTION OF WORK TO BE PREFORMED: a L 7—i ,4 /i- '00-91-4 00 Identification Please Type or Print Clearly) OWNER: Name:^Sb0 rh ; ` 2n1 b1,-J Phone:g�•6�z- Address: J �' l' ll 1? • 14 CONTIAC OR Name: KSZO rFu hor Address: j i 14 a ' w,a Supervsar s Construction Liconse: d Exp. Date=�. H©me`'Imprpyement Licens a Exp.;bate,. 0 ' 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: $ Z z hs 0,6 FEE: $ 3 2 6 Check No.: 7o�U Receipt No.: w �� NOTE: Persons contracting with unregistered contractors do not have access to the guara ty fund Signature of Agent/Owner Signature of contractor �� Plans Submitted ❑ Plans Waived ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE DEPARTMENT_o. TempDurtpster o`n site yes i rib Located at 424 Maim Street Fire department signaturetdate COMMENTS I Dimension 1 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I ❑ Notified for pickup - Date ..................................................................................................................................................................................... Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) L3 Building Permit Application Li Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract a Mass check Energy Compliance Report o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. t Date -O MORT1y TOWN OF NORTH ANDOVER 3�O•t,`•u I•,hOOL � 9 + Certificate of Occupancy $ + a� . ..�_.. +•' • to SSACHU Building/Frame Permit Fee $ Foundation Permit Fee $ I Other Permit Fee $ TOTAL $ Check # 206 %1dU Building Inspector p� ✓rie i�an�nzaruuecz o0 J!/tzaatcclucac�ta Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:, 108383 icpiratiori 818/2008 �Tjrpe t�A' K€EWCONSTRIlIrTkON Q14;. Kenneth Keen - 21 Hewitt Ave • No.Andover, MA 01845` Deputy Administrator j ✓�fl�[Y��L'r1.7.017.UMi� �/U(Q{1G�LClQP.�6 l`. BOARD OF IUILDIN' RE'GUQATI.b 8 k I¢ensq: CONSTRUCTION SUPERVISOR N, inber+ S 058245 ir�h`date 03/24fa;943 p ;a 1�8I47408 Tr;no 13436 3 ; I innc�'�uH 'Z'Fcn r."}ai��t v t �Rasi to� Op 1 I�FIV �ICBE13 '7 �jU EWI'�TiAY = r7 4 T1,AhIJQOVR SAA 0114 :r �` I ` Gw)nisaiyoner r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i d 600 Washington Street W` Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � Please Print Legibly / / Name(Business/Organization/Individual): �1. ecti `o,05`,,(aV.c.�)oN �o . Address:—7,1 Heu' j i 7 - A ✓E City/State/Zip: A( . R N d oy Zrz f& Phone#: 979 691 -S z 0 1 Are you an employer?Check the appropriate box: Type of project(required):. 1.[3 I am a employer with ?-., 4. E] I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, F]Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance. # required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.[1 Other 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. tContractors 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. /y Insurance Company Name: 2 A u i'�-E S�A f& _�$ , C." p Policy#or Self-ins.Lic.#: tU (2 Expiration Date: Job Site Address: l I`� SP2 j n r, -� ( lty p.N . .4 t�c IV S_�✓ .4 Ci /State/Zi 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 of the DIA for insurance coverage verification Ido hereby certify under the pain nd Xpenalties of perjury that the information provided above is true and correct. Signature: Date: /_ Phone#: 6/ 7 G <0/ 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#: Information and Instructions 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 the boxes that apply to your situation and,if necessary,supply sub-contractor(s)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 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(if necessary)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. A new affidavit must be filled 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 and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 wwFw.mass.gov/dia ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE /DD 03/2222/2000707 PRODUCER (781)942-2225 FAX (781)942-2226 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gilbert Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 137 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Reading, MA 01867-3922 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Kenneth B. Keen INSURER A: NORFOLK & DEDHAM INSURANCE 23965 DBA: Keen Construction Company INSURER B: Granite State Ins. CO. 0077 21 Hewitt Ave. INSURER C: North Andover, MA 01845 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INLT R DD' TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBERDATE(MMIDD[YYI DME iMM/DDfYY) LIMITS GENERAL LIABILITY ND-P-010078/000 03/13/2007 '-03/13/2008 EACH OCCURRENCE $ 1,000,00f X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00( CLAIMS MADE OCCUR PRFMISFS(Fa MED EXP(Any one person) $ 5,00( A PERSONAL&ADV INJURY $ 1 1 000 1 00( GENERAL AGGREGATE $ 2,000,00( GEN 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00( POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ RAUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F CLAIMS MADE AGGREGATE $ _R DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND WC8855053 01/09/2007 01/09/2008 wCSTATu- $ orH- EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, KEEN CONSTRUCTION CO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 21 HEWITT AVENUE OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE IDOREEN M DONOHUE ACORD 25(2001108) FAX: (978)682-3231 ©ACORD CORPORATION 1988 KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER,MA 01845 (978) 691-5201 Dolben, Sumi 114 Spring Hill Rd. N.Andover,MA 01845 (978)682-1456 Contract# 1663;Appendix A Date: 6/28/07 Remodel Master Bath: • Remove and dispose of existing bath fixtures • Remove existing tile floor • Create knee wall for end of tub • Create burm for shower • Supply&install fixtures selected on quote#116286(dated 4/19/07)from Peabody Supply • Supply&install tile on shower floor and walls as.selected from National Tile(approx. area 4' x 5' x 80") • Supply& install ceramic tile floor as selected from National Tile(standard installation) • Install customer supplied vanity and top • Upgrade electrical to code as necessary • Supply& install three recessed light fixtures • Supply& install customer supplied vanity lights • Electrical allowance$1600.00 Total Price:$27,135.00 -Price does not include cost of permits, remote exhaust fan,vanity,top, other tile(backsplash on `vanity and bubble tub or baby V2 rounds for shower), shower enclosure or changes required by inspectors. Payment schedule:$8000.00 due upon signing contract-Pd $2000.00 due the 1"day of work Pd $5000.00 due when bath is demolished except toilet and sink=pd $2000.00 due when toilet and sink are removed,pd ' $5000.00 due when bath fixtures are installed $4000.00 due when tile is installed $1135.00 due upon completion of contracted work Cu Omer R . Ke n Date Date KEEN CONSTRUCTION CO. . 1563 21 HEWITT AVENUE PROPOSAL *'lot" NORTH ANDOVER. MA 01845 Tel: (978) 691-5201 All home improvement contractors and subcontractors engaged in home improvement contracting, unless Fax: (978) 682-3231 specifically exempt from registration by Provisions of - ) f Chapter 142A of the general laws, must be registered with Submitted „�l.`(�1 ��� 1 (� ) the Commonwealth of Massachusetts. Inquiries about To. _ — " ---- registration and status should be made to the Director, _ --\ t-_ =� C 1v ! ) t+ Home Improvement Contract Registration,One Ashburton _ .._._ }m.}� ....1.1\_: �5 Place, Room 1301, Boston, MA 02108 (617) 727-8598. 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. F.I.D.NO. � 41} MA. H.I.C. 108383 04-325-8052 > C/S = Customer Supplied S + I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: EF C"A (t �I r` / _ ._. > 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 wci'ng. CQpjractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractor's 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 \/ �' 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 Contractoir,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 wit above specifications, for the sum of 7 C)��, i) j `l '!'r F� 1� dollars($ I '-j t-fit <���. Payment to be made follows:✓ % ($ ) upon signing Contract; KENNETH B. KEEN Name of Contractor/Designated Registrant ($ ) utp.��/yy fo I ti_ bf�e. 21 HEWITT AVE. C l` it J Street Address % $_ �` ) flop JJJn���co...,,,mpletion of_ N. ANDOVER, MA 01845 1 - P City/State ($ ) shall be made forthwith upon (978) 691-5201 (978) 682-3231 completion of work under this contract. Phot Fax Notice: No agreement for home improvement contracting work shall require ay� �Q V >down payment(advance deposit) of more than one-third of the total contract price Name of safes a 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 Authori ed s na 'e 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. j DO NOT..SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature Date Signature Date IMPORTANT INFORMATION ON BACK ► NORrIy Town of And Oiaiilv 1 No. **yy _ Z .o dover, Mass.,, T Q C I COC MICCHE NE WICK V A0RATED S BOARD OF HEALTH PERMIT .. T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......45. rrik.I...........................j...... .... .. .................. �.......... ......... ..... Foundation has permission to erect........................................ buildings on...11%(......'S. ...rl................ I.....a............. Rough to be occupied as......&-M-0.40%41.,.......I&x4..1'.�. .. &, Chimney ...... . ....... ..................................................................... provided that the person accepting this permit shall in obry respect conform to the terms of the application on file in Final 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 32 6W0'0 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TLT Rough .................. ......... Service BUILDING INSPE M'OR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det.