The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #140 - 115 SOUTH BRADFORD STREET 8/26/2008 BUILDING PERMITo�"°RT b qti TOWN OF NORTH ANDOVER c? 6y. ' - •6 O� APPLICATION FOR PLAN EXAMINATION Permit NO: / U Date Received gSSACHUSE� Date Issued: OP• MPORTANT:Applicant must complete all items on this page LOCATION / S. y..1 tz y 4D... S Print PROPERTY OWNER i Eri• Print ' MAP NO: ZLW PARCEL: / f ZONING DISTRICT_ : Histor'ic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family v- Addition Two or more family Industrial Alteration No. of units: Commercial Repair; replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TOPREFORM n� CV 1 eL `N 1&-) Ki b rt! o N g 2 ate, -C;I!po n• -J T Identification Please Type or Print Clearly) OWNER: Name: 0 0A RNW Phonce'2q- 6Z-a --X73 Address: its A � Jr— rk �1J CONTRACTOR Name: k$,rl NC•f� JJy Phone'' Ss- 6Cy> t - ,Sr c11 Address: 0'2 t 13 t.lJ i 11 qN 4,0 usi.-- 04x4 Supervisor's Construction License: 5S a Y•S Exp. Date: Home Improvement License: / 69371 Exp. Date: q '/D i 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: $ 43(96c) 00— FEE: $ �14 Check No.: 'Sir's Receipt No.: c9l x/9/7 NOTE: Persons contracting with unregistered contractors do not have access to the gu my 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.OFF ICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT 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 j FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 1 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 - Date L.....-............................_.................................._..._............................-- ..__..__......................._..---...._................................_.—_............__. --............_.............— ................................ —._.................... _._._ Doc.Building Permit Revised 2008 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 ❑ 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 ❑ Floor/Crossection/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 ❑ 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:INSPECTIONAL SERVICES DEPARTMENTMITORM07 Revised 2.2008 ` NORTH TO'" of tAndover No. 0 LA/�o dower Mass. o > COC MIC KE WICK � ORATED pPG �y 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System � BUILDING.INSPECTOR THIS CERTIFIES THAT........ 0...... ...c4ee"qE.. .....::..........................................:.............................................. Foundation has permission to erect........................................ buildings on ...... ..... dr ...................... Rough QLi^ d0/ ` Chimney to be occupied as......:................... /Lf......... ...... ........................................... ..1................,............... provided that the person accepting this perm4hall in every 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 PERMIT' EXPIRES IN b MONTHS ELECTRICAL INSPECTOR UNLESS CO V S 1 RUC 1 ON TS Rough ............................... Service BUILDING IN CTOR Final Occupancy Permit Required t® Occupy 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.. KEEN CONSTRUCTION CO.. 21 HEWITT AVE: NORTH ANDOVER,MA 01845 (978) 691-5201 Dianne&John Carney 115.South Bradford Street North Andover MA 01845 Date 6/25/08 (978)682=0731 New Entry Front Door • Supply&install.(1)Therma-Tru:smooth star door unit, -C)w/satin.nickel hinges. Supply&install Schlage Plymouth thumb latch w/dead bolt in a satin nickel finish. Exterior trim to be fluted PVC boards (Kleer brand) • Supply& install house numbers{11:5) to match finish of lock sets • Dispose of old door&trim Total Pr-ice :$2200:00(two thousand two hundred dollars) Price does not include cost of permit,.repairing.any rotten..wood or damaged siding. Payment'schedule:$1000.00 due upon singing.contract C t�,.q O 73 $ 1200.00 when job is complete(.plus permit fee) Customer Kenneth B. Keen Date Date �✓ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 T" S www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n ,t Please Print Legibly Name(Business/Organization/Individual): ( /Z CA O•✓ Address: p2 ( j4Lc t TC Ay f City/State/Zip: afido,aaA &e 8 ys Phone. #: Are you an employer?Check the appropriate box: Type of project(required):, 1.[g—i am a employer with 2 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 7 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. amodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. $ 9. Building addition required.] 5. We are a corporation and its 10..0 Electrical repairs or additions . 3.El officers I am a homeowner doing all work have exercised their 11.[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 131other 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 anal then hire outside contr`ctors 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 insurance for my employees. Below is the policy and job site information. 11 Insurance Company Name: �'(7-P 0. 4- E T r4 f C Policy#or Self-ins. Lic.#: (,�1 cC 7 L/ 31 V 7 n Expiration Date: Q Job Site Address: l S J (z ►a SL-�n 1Z c`t . t "j City/State/Zip: 10" , J' N JO 0Zv". cn) ��'YJ Attach a copy of the workerscompensation 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. I do hereby certify under the pa' and enalties of perjury that the information provided above is true and correct Signature: Date: 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#: 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"ever 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 conf rrnation 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 permittlicense 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 bum 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. # 6.17-7274900 ext 406 or 1.877-MASSAFE ` Fax# 617-727-7749 Revised 11,22-06 www.mass.gov/dia 8/11/2008 12:18 PM FRONT: Gilbert Insurance Ag Gilbert Insurance Aq TO: +1 (978) 682-3231 PAGE: 002 OF 003 ACORL�, CERTIFICATE OF LIABILITY INSURANCE 08/11/?8 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Reading., MA 01867-3922 INSURERS AFFORDING COVERAGE NAIC# INSURED Kenneth B. Keen IN—ERA: NORFOLK & DEDHAM INSURANCE 23965 DBA: Keen Construction Company INSURERB: Granite State Ins, Co. 0077 21 Hewitt Ave. INSURER C: North Andover, MA 01845 INSURER D: INSURER E: OVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TVPEOFINSURANCE POLICY NUMBER POUCYEFFECTNE POLICY EXPIRATION LIMITS DATE fMMIDD1YYI GENERAL LIABILITY ND-P-010078/000 03/13/2008 03/13/2009 EACH OCCURRENCE $ 11000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISIFS(FA !1 $ 50,00 CLAIMS MADE F�]OCCUR MED EXP(Any one person) $ 5,00 A PERSONAL d ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,001 GEHL AGGREGATE LIMIT APPLIES PER: ' PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY JEC LOC - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS - BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ALRO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE - AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND WC7431477 08/03/2008 08/03/2009 X I WcsTATu- I I OTH- EMPLOYERS'LIABILITY ER B ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVIGNS riginal workers compensation certificates to be issued by company. Evidence of Insurance only. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. evidence AUTHORIZED REPRESENTATIVE Mark Gilbert CIC ACORD 25(2001108) OACORD CORPORATION 1988 ---- _7le 6anvrre�mcuea�� o�✓ 'QOa`/au°elta Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration 108383 Expiration 8118/2010 Tr# 272473 Viz,sTYpe D+BA KEEN CONSTRUCTION Kenneth Keen k r ` 21 Hewitt Ave „.>' No.Andover,MA 01845`; Administrator fie Vomvrnaruaea oy✓VGaddaclu�6e�4 { Board of Building Regulatidhs and Standards t: Construction Supervisor License a a a License: CS 58245 Expiration 3'/24/2010 Tr# 17840 Restr coon OQ': ,,, � KENNETH B KEEN L i 21 HEWITT AVE N ANDOVER,MA 01845 a Commissioner 1 �`il, `Y ✓� VdI79///7.Q�IZL(�P,QUAL 6�;�u(.aaQa,C�2U�7A.0' . Board:of Building:Regulations and-Standards Construction Supervisor License License: CS 76691 Birthdate =:'8/16/1;968 s Expirafion g/16%2'009 Tr# 3859 t Restnction OQr ROBERT A KEEN 12 E WATER ST i N ANDOVER,-MA 01'845 Commissioner I Location No. Date HQRTM TOWN OF NORTH ANDOVER F ; 9 ` Certificate of Occupancy $ s•�"' ESQ' Building/Frame Permit Fee $ +cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 1 447 Building Inspector