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Home My WebLink AboutBuilding Permit #745-14 - 21 HEWITT AVENUE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATIONS o? t 1-t —tN, TR. Oq ✓ c � �' PROPERTY OWNER hi N t-2,z Print 100 Year Old Structure yes no MAP NO: PARCEL: 5 ZONING DISTRICT: Historic District yes no Machine Shop Village 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 epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District R 1�11ater/Sewer / DESCRIPTION OF WORK TO BE PERFORMED: 4 �1,��t 1�2o Booz t2�PI�c� �,� �5 Ina V nrvt L w PCujyi ►jA (- Sl iii Identification 'Please Type or Print Clearly) o OWNER: Name: g NPL d " (t £ ►� Phone: Address: l ��W i r( y of �. Acid MA- ,n / hVS �. V CONTRACTOR Name: KtNsT Phone.9 7 ' Ge/( ' .)v-?o l Address: ( L7S -'y ape,' i< �f • �- � E Supervisor's Construction License: D � 2 is Exp. Date: 3 - 16 Home Improvement License: In3 Exp. Date: ' /4 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ��-J OU FEE: $ Check No.: // Receipt No.: , ` --- NOTE: Persons contracting with unregistered contractors do not have access to the guaran fu d SI nature of�A ent/�Owner �� '^ r Si riature:of contrac Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sta ped Plans 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 I i CONSERVATION Reviewed on Signature i COMMENTS HEALTH Reviewed on Signature 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 DPW'Towp- Engineer:,Signature: Located 384 Os ood Street FIRE DEPARTMENT' -.Temp Dumpster on site yes no Located at"124.Mairi Street , ; Fire Dep9ft.merit-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 El Notified for pickup - Date Doe.Building Permit Revised 2010 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) ,4 ❑ 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 submated with the building application Doc: Doc.Building Permit Revised 2012 Location No. ' < Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee 's v 'r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# � �� Building Inspector I Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-058245 +. T,, KENNETH B KEEfli --- 21 HEWITT AVE: It N ANDOVER Mk 019 Expiration Commissioner 03/24/2016 10 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-076691 ROBERT A KEEN-` ' 12 E WATER ST North Andover WDA 01 Expiration Commissioner 08/16/2015 } � F�efie�¢o�zimaaacuea�r�C>r�Oaa Office.of Consumer Affairs&_Busi ess Re`g�ta OME IMPROVEMENT CONTRACTOR <. egistration: 108383 Type: xpiration:-,8t18/207,4a DBA KEEN CONSTRUCTION C0 Kenneth Keen 21.Hewitt Ave No.Andover,MA 01845 a Undersecretary i � NORTF� Town of t E : 1, ndover to o - - No. � Ilk LK : - �oh ver, Mass, ,/ COCHI[HtwICK _ S U BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THAT ........... ...... .. BUILDING INSPECTOR ........... ..... ................. ................... has permission to erect ... buildings on 1.1....... .. .. . ...!�w ......�!�■................. Foundation ......................: ...... Rough to be occupied as... ..r.�lti ...... V~...... ..... ... ..... 5 .�.... ........................ Chimney provided that the person accepting this permit shall in every respect orm to the terms 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. x/6 � � � PLUMBING INSPECTOR � " � Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONT S ELECTRICAL INSPECTOR UNLESS CONSTRU N S TS Rough Service .......... .... ...... .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinje 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. A E) DATE® CERTIFICATE OF LIABILITY INSURANCE 4/15/2014 Y) 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 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 policy(ies) 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 endorsement(s). PRODUCER CONTACT Barbara McDonough NAME: g Gilbert Insurance Agency, Inc. FHGNE (781)942-2225 FAQ o. (781)962-2226 137 Main Street EMAIL bmcdonoh@ ilbertinsurance.com ADDRE S: u 5 4 INSURERS AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURERA:NORFOLK & DEDHAM INSURANCE 23965 INSURED INSURER B:Hartford Fire Insurance Coln an Keen Construction Company INSURER C:Travel ers Insurance 0022 1175 Turnpike Street INSURER D: INSURER E: North Andover MA 01845 INSURER F: 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. NOTWITHSTANDING:ANY REQUIREMENT,-TERM OR.CONDMOi OF-ANY__CONTRACL.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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ � A CLAIMS-MADE ❑X OCCUR D-P-010078/000 /13/2014 3/13/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JFCTPRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNEDSCHEDULED OSUECAA6432 12/3/2013 12/3/2014 AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ Underinsured motorist $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N I ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBEREXCLUDED7 6HUB-9991M58-2-13 10/8/2013 10/8/2014 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD 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/Organization/Individual): � P�� ( L�jT(Z/�;f f CIVI Address: 1179 Tornod�e City/State/Zip: J (^ 617Y5 Phone#: 9 2,7—6 91-5 Za Are you an employer? Check the appropriate box: Type of project(required): 1.[0 I am a employer with Z 4. ❑ 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, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers 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' 13.0 Other comp. insurance required.] P q ] *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. $Contractors that check this box must attached an additional sheet showingthe name of the sub-contractors c� actors ant state whether or not these 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. Insurance Company Name: 7rajt e r5 n,j ii rr,_i,1 C e, Policy#or Self-ins.Lic.#: �{, U�' 9JJ I I'15 2 — Expiration Date: 10 Job Site Address: 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 ascivil 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 er t e par nd penalties of perjury that the information provided above is true and correct Si nature: ' 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#: