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HomeMy WebLinkAboutBuilding Permit #395-13 - 120 WEYLAND CIRCLE 5/1/2018 RT BUILDING PERMIT TOWN OF NORTH ANDOVER 0 io APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page I I'T 7N-5�:�TtiT EtOGATIONc- r '4- wrint 57. ;Y T- -Hi9t 'Di§trict, IN&DISTRI( , -AP P, - Machinno A. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building P"One family Addition Two or more family Industrial 1/Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other " 4�- Floodplain Wetland eptic, -7, A:r;-;A VV­t6f/ DESCRIPTION OF WORK TO BE PREFORMED: � y;tc\ 60 , W4 its AJ Identification Please Type or Print Clearly) OWNER: Name: a- jC.-� Phone: Address: O W LA .-J ICQ NT RA TOPR _6.? x cen . up y Y�i�h rUbOr'Li ;Date ./Y_-35" gr.Lsgf n' b Diite!, ft,!Ift��Nfi[I)iq e s 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: S-'b 71) FEE: $ (51.60 Check No.: 7--Z 3 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gua my fund re:of-A"g7-q6n t/O of c6ntebbt6')-4- 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 II THE FOLLOWING SECTIONS FOR OFFICE 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 'FIRE'DEPARTMENT,�`,�T}emp Dumpster on site yes . 5. irr : e 7 " i p 'f `L ocated,%U,1241 irrStreet, . ,. Fife Depaitmen t'signature/elate;: '�'�� ''a ` ,'�' �,( .. �S 4 G";-.s . t r nti• .a t-,,..r .{ v-.1 > "''?• a y, t 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 I ❑ Notified for pickup - Date 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 DEPARTMENT:BPFORM07 Revised 2.2008 Locations No. T Date/ /Z • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ D1J Foundation Permit Fee $ Other Permit Fee $ .14 . TOTAL $ Check# 3�-? 25940 Buliilding Inspector NORTH own o ndover O - .:;. 1 No. t = z h ver, Mass COC NIC Nl WICK � S U BOARD OF HEALTH I-T T D Food/Kitchen Septic System PERM ,' THISCERTIFIES THAT .. G .......:4. c:�G'..ar1.�. ............................................................................ Foundation BUILDING INSPECTOR has permission to erect .......................... buildings on / a...�G!.� ��?! �Ci��� ........................................... Rough to be occupied as ............... '.o......��'.�.,1....5'......../'�r... „srf �............................ 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough ............... 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. SEE REVERSE SIDE °' '` fi$"7't' } q�br .�, .' -Fs ``�•�°' 'tr.: �+{8' a >i *'T"�, 1P.'- a. p ,kf^'. �P Z4 �.y. ���.,,�"'�{ if?*, RK' �r ,y ��� �- `�' r�'d�.nV.,��",,', r `''r�p k'�Ft°, ' v�m•'we+y ¢n�ti •"`;?�'�. re's«-n,k.�°. I KEEN CONSTRUCTION CO. GP a 21 HEWITT AVENUE PROPOSAL o 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 Chapter 142A of the general laws,must be registered with Submitted � �� r d� :) e ! � , the Commonwealth of Massachusetts. Inquiries about ! To: _............._.______-......_..._....................__....__......__...__.._ registration and status should be made to the Director, 0 � � iq k C 3 Home Improvement Contract Registration,One Ashburton _..._...._._.......... _. __ _ _ --_-__. -_.._. Place, Room 1301, Boston, MA 02108 (617) 727-8598. l -iOwners who secure their own construction related !`-`CU <yi /9 permits or deal with unregistered contractors will v_..------ ..................................__.._ -_ r _..._..-..................._.._.... —. be excluded from the Guaranty Fund Provision of I� MGL c. 142A. f PHONE C 1 DATE REGISTRATION NO. EIN NO. 6�w''�- -- d r ~` i MA. H.I.C. 108383 7 .� .,� d L:.�� /r' f r� � �,� 26-0462904 > C/S= Customer Supplied S + I =Supply + Install ❑ See Attached Appendix A I We hereby submit specifications and estimates for work to.be performed and materials to be used: IV, ----_---_,_ -_..----....._...___.._ - - - ._ .._.._. --—_—_ .........................-_.......__.._..._ l r , 11. w /n k vt l(I i�z v�vj, �.L) ��}m i;.: _---.__..........._.... -_............ Ln+ C �1� . LDWt (�j'I()N (-� �z.x.� , vY>�Nz:,l ( r Nf ���, I I ................ i I ........------------_._____ _ _____._.._.._.._.._................._......___.____ � > Construction related permits: E _ _....._..._......__.__...._............._._.._..._.,....._......_._-.,_., ..._......_.._...._...,............................_............................................................................................._...................................................................................................................................................._... WOR_,.._,..K " . _.K,__.S,CHE.__ D,,._._.,,UL_._,.,_................. _.... ..... ......... _........ .. I Contra ort not �pgin the work or order the materials before the third day following the signing of this Agreement,unless specified her i wn Cofttr ctor will begin the work on or about3's_(date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed b _ /_r i p y (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 j comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,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 t f i �� �- / h C, I-) �r�-N�� h J U . 1J / _�_.------�__v_ __ dollars($ Payment to be made as follows )' % ($ upon signing Contract; KENNETH B. KEEN / ROBERT A. KEEN Name of Contractor/Designated Registrant ! % ($ �© w) upon completion of �' .j f t�r� �� � 21 HEWITT AVE. .. ,�.' FJ.\. Street Address ($ �) upon completion of �L '``i�' N. ANDOVER, M�►01845 _ _ . ._.._ l tol 9( % ($ upon City/State /p 7o r) shall be made forthwith (978) 691-5201 (978) 682-3231 i completion of work under this contract. Phone Fax Notice: No agreement for home improvement contracting work shall require a >down payment(advance deposit)of more than one-third of the total contract price Name of Salesm , 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 _Auth5,felsignalure �--�~- equipment,whichever amount IS greater. Note: This proposal may be withdrawn by us if not accepted within days. f 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. < DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature / ` Date Signature Date IMPORTANT INFORMATION 04 BACK 110 The Commonwealth of Massachusetts Department of Industrial Accidents TIM Office of Investigations 600 Washington Street Boston,MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name (Business/Organization/Individual): ��(� �_ N Ste Address: el ( O f-w : fu 406- City/State/Zip: 0t-City/State/Zip: _ A NCS O d44L 6/g y$Phone#: �'Z� (c�'/ - 5-o7 a 1 Are you an employer?Check the appropriate box: Type of project(required): 1.P'11 am a employer with ( 4. ❑ I am a general contractor and I 6. ❑New 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. $ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and*ob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 1-4 U 513 487 a� /9 lot Expiration Date: /3 Job Site Address: fie;z) w F y L p•rc Ci 2 City/State/Zip: N ,09ph 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 pa' and enalties of perjury that the information provided above is true and correct. Si nature: Date: 3 r` Phone#: 7" S 01 D 1 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 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(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 5-26-05 Fax#617-727-7749 www,mass.gov/dia r 8/15/2012 12:58 PH FRON:� Gilbert Gilbert Insurance Agency, Inc. TO: +1 (978) 682-3231 PAGE:. 001 OF 002 ACORDM CERTIFICATE OF LIABILITY INSURANCE OBAV2012 PRODUCER (781)9422225 FAX (781)942-2226. THISCERTIFICAT.E IS'ISSUED AS A;MATTER OFiNFORMATION Gilbert Insurance Agency, Inc. ONLY. ENAND CONFERS NO-RIGHTS UPON THE CERTIFICATE 137 Main Street HOLDER.THIS''CERTIFICATE DOES<NOT AMEND,EXTD.OR ALTER THE COVERAGE-AFFORDED BY THE POLICIES BELOW:' Reading, MA 01867-3922 INSURERS AFFORDING COVERAGE NAIC# INSURED Kenneth Keen &. Robert Keen INSURERA NORFOLK & DEDHAM INSURANCE 23965 DBA: DBA, Keen Construction Company INsURERs: Travelers Insurance 21 Hewitt Ave. INSURER C: North Andover, MA 01845 INSURERP: INSURER:E COVERAGES . THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED T.6THE INSURED NAMED:ABOVE FOR THE POLIbY PERIOD INDICA7E0 NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH;RESPECTTO WHICH THIS;CERTIFICATE'.MAY BE ISSUED OR MAY PERTAIN ;THE.INSURANCE AFFORDED;BY THE POLICIES DESCRIBED'HEREIN IS SUEJECT TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATEtIMITS.SHOWN'MAYHAVE`:BEEN REDUCED BY PAID:CLAIMS. INSRDD'' - POLICYEFFECTIVE POLICY EXPIRATIOW - LTR NSTYPE OF INSURANCE POLICY NUMBER DATE IMMOONY1 LIMITS GENERALLIABILITY ND=P-010078/000 03/13/2012 03/13/2013 EACH OCCURRENCE $ 0 00. X COMMERCIAL GENERAL LIABILITY DAMAGE-TORENTED $. 100,00, CLAIMS MADE a OCCUR MED EXP(Any,one person) ; 5.00 A - PERSONAL&'ADV INJURY $ 1,0.00 00,' GENERAL AGGREGATE $ 2 i 000,OO GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-.COMP/OP AGG $ 2,OQQ,00, NJ POLIOY PRO- JECT L.00 AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED ALTOS BODILYiNJLIRY SCHEDULED AUTOS (Perp'erson) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) ..GARAGE.LIABILRY AUTO ONLY-EAACcpm •$ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG .$ I E EXCESSIUMBRELLALIABILf1Y EACH OCCURRENCE $ OCCUR a_CLAIMSMADE AGGREGATE S $ DEDUCTIBLE $ RETENTION $ S WORKERS COMPENSATION AND 6KU8-5840726-A-12 :08/03/2012 08 03 2013 WCSRy TATU-` 0TH- EMPLOYERS'LIABILIT/ E.L. EIL EACH ACCIDENT $ 100 OO .8 ANY PRoPR1ETOR/PARTNER/EXECUTWE OFFICER/MEMBEREXCLUDED7 E.1.01SFASE-EA EMPLOYE $ 100,00 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT ,$ 500',00. OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY EN06RSEMENTI SPECIAL PROVISIONS Evidence of Coverage CERTIFICATE HOLDER O . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF;THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEDTO'THE LEFT, BUT FAILURETO`MAIL SUCH-NOTICE SHALL IMPOSE NO OBLIGATION'OR•LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Evidence of Coverage AUTHORIZED REPRESENTATIVE Mark.Gilbert CIC ACORD 25(2001108) OACORD CORPORATION 1989 Board of Building- Re-tilations and Standards -- Construction Supervisor License License: CS 76691 ROBERT A KEEN 12 E WATER ST P. N ANDOVER, MA 01845 --�— -! Expiration: 8/16/2013 ( onunissiuner Tr#: 3772 I Massachusetts -Department of Public Safety Board bf Building Regulations and Standards Construction Super�ism- License: CS-058245 KENNETH B IdEN 21 HEWITT A-VE,A N ANDOVER MA '018 5 Expiration Commissioner 03/24/2014 Vlze Cpa'.ecr"o�C oac�ivaetla Office of Consumer Affairs&Busi ess Regulation OME IMPROVEMENT CONTRACTOR egistration: 1108383 Type: xpiration:. $/1812014., DBA KEEN CONSTRUCl`iON Cad _----- `" �r. Kenneth Keen 21 Hewitt Ave No.Andover, MA 01845 Undersecretary