HomeMy WebLinkAboutBuilding Permit #769-12 - 19 HOLLY RIDGE ROAD 4/25/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: O l Date Received
Date
;2
must complete all items on this
— - Print
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- -- - Prifit
MAP NO: J"b- PARCEL. � ZONING DISTRICT: Historic District yes no
Machine Shop Village yes - no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential '
❑ New Building
ne family
0 Addition
0 Two or more family
❑ Industrial
Iteration
No. of units:
❑ Commercial
❑ Others:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
'``
Ik®,Sep well tt
_
❑ Floodlam f Wetlands �* sj
r p .s
��Waters edDistr`ict
- - 7)F�('.RTPTI0N
OF WORK TO BE PERFORMED:
• 13"O
Kit % c1<S,Rth •. F.1 rn-I, (3 KV"k
Identification Please Type or Print Clearly) 7y
✓illa !1I J /V1 S I 1 to hone- f� �$ -1
Address: 1 a too icy 2 `S y6- 71
CONTRACTOR Name: Phone:
Address: l W � ✓L
Supervisor's Construction License: CC a Ll S Exp. Date: 3
Home Improvement License: /D 3 Exp. Date: d�
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PIVFMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. >'
Total Project Cost: FEE: $ 6,
Check No.: Receipt No.: ;Z4� 21
NOTE: Persons contracting with unregistered contractog t have � guaranty fund
Si nure
of:contracfor~::_
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Tanning/Massage/Body Art ❑
Tobacco Sales ❑
Permanent Dumpster on Site ' ❑
1 � i
Swimming Pools ❑
Food Packaging/Sales ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U -FORM -
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENT
CONSERVATION Reviewed on Siq.nature
COMMENTS
HEALTH Reviewed on ` ~ rSimature •' ' �`'k
COMMENTS'
i
i L a
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
{r,- - _
Wattirr' & Sewer Connection/Sianature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -'Temp Dumpster on site yes no +.' t
Located at 124 Main Street
Fire Department signature/date
COA4NMNTS
Dimension
Number of Stories: Total square feet of -floor area, based on Exterior dimensions.
Total land area, sq. ft.:,
k
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
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
DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording .
gust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location
J
No. _. r2 Date
Check #—Z/4 -I-
25229 25229
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
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4)25/2012',9 55 AM; FROP:.Gilbert';Gilbertjnsurance Agency, Inc.;.:TO::+1,(978) 68.2-3231 PAGE:.:001 OF ..002
TM: CERTIFICATE. OF LIAB:LLITY
!NS_URANCE
DATE (MMIDD 11 ,
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THIS CERT.IFICATEIS ISSUED AS A?MATTE - INFORMATION
Gi 1 beet Insurance A'gency,.. Inc.
`ONLY ANDCONFERS NO RIGHTS UPON THE•CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR
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137 Marin Street "`
ALTER'THE.COVERAGE�AFFORDED`sBYTHEs;POLICIES BELOW
Reading MA;01867-3922
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INSURERS AFFORDING COVERAGE. NAIC #
inlsuRED :Kenneth;: Keen .& Robert Keen'
INSURERA NORFOL•K:;& DEDHAM INSURANCE: ` I2396- }
DBA. DBA Keen';Construc T. 'Company
WNSURERB Granite' State Ins. Co'. :0077
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INSURER c.
North Andover„' MA '01845
IRISURERD.
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THE POLICIES OF INSURANCE LiSTED;;BELOW HAVE BEEN. ISSUED TO THE• INSURED NAMED A80VE F.6k,' E POLICY PERIOD INDICATED NOTWITHS M - -
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License: CS 76691
ROBERT A KEEN
12 E WATER ST
N,ANDOVER, MA 01845
Expiration: 8/16/2013
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KENNETH B 19EN
21 HEWITT AVE
NANDOVER 0-,' 845
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Type:
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21 Hewitt Ave
No. Andover, MA 018x6.:
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KEEN CONSTRUCTION CO. GP
a 21 HEWITT.AVENUE -
NORTH ANDOVER. MA 01845
Tel: (978) 691-5201
Fax: (978) 682-3231
Submitted
rr
l �l �t [.. ti l t <. r k t/ d 1....._ ..1_ ...... ......
We
PHONE DATE
`
C/S = Customer Supplied S + I =Supply + Install
lby submit specifications and estimates for work to be performed and materials to be used:
f
V
> Construction related permits:
PROPOWS"AL
All home improvement contractors and subcontractors
engaged in home improvement contracting, unless
specifically exempt from registration by Provisions of
Chapter 142A of the general .laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
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.
REGISTRATION -NO. - - EIN NO.
MA. H.I.C. 106383 26-0462904
❑ See Attached Appendix A
_.................. ................_.................... ............. ............... ......... ..... .......... ... ..... ._._.......................................................... ...............................,....................................................... ............................................ ............,,..:.,:..,......................... ........ _............... ....._..........................
..........
WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or
about r ' "' (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by �> " j={]L (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 j 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 Contra tor, 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
Payment to be made as follows:
- % ($ ) upon signing
'' Contract;
- % ($ ) upo�a ompletion of
_% ($ %') upon completion of
shall be made forthwith upon
($ ) completion of work under this contract.
dollars ($
KENNETH B. KEEN / ROBERT A. KEEN
Name of Contractor / Designated Registrant
21 HEWITT AVE.
Street Address
N. ANDOVER, M_.A 011845 _.
City / State
(978) 691-5201 (978) 682-31231
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 n! alesman 1,
-
or the total amount of all deposits or payments which the contractor must make, in
r1 r �
advance, to order and/or otherwise obtain delivery of special order materials and AuthB j�°`SiOature r'� �•�
equipment, whichever amount is greater. Note:' This proposal may be withdrawn by us if 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 prior to midnight of the third business day after the date of
this transaction. Cancellation must be done in writing.
PP. -NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature'''-2-"�"'"�"%•"-Dale- !�-�..Signalure - - Dale
4 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorAndividual): �y f1 �c� A-,
Address: (9 t t4L .i l t IT lqy C
City/State/Zip: j-) . fi f -J , YV i R D A'W' Phone #: 0/ 7 2 - 6 9 f - ,? p I
Are you an employer? Check the appropriate box:
1. E7am a employer with. (
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ['Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
r...y appucam uia, cnecxs oox 371 must also till out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: G R 11 P", 4--e ��� �` e S. C
Policy # or Self -ins. Lie. #: W e, a 6 4 & 4 6 ( 4 _ Expiration Date: a
Job Site Address:___ �� D �/ ZZi 112A City/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 of the DIA for insurance coverage verification.
I do hereby certi& under the pain d p9nalties of perjury that the information provided above is true and correct
Phone #: I Cl -7'6 • & 9 ( —,5 o7Q I
Official use only. Do not write in this area, to be completed by city or town officiab
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 #•