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Building Permit #176-13 - 25 CEDAR LANE 8/30/2012
NORT" BUILDING PERMIT TOWN OF NORTH ANDOVER i • . p APPLICATION FOR PLAN EXAMINATION Permit NO: 1 l0 I Date Received �ySSgCHus��<� Date Issued: ?S t) IMPORTANT Applicant must complete all items on this page -A y '";,. g, i _ � .8�, - � ,LOCAT�UN* . r t+#k r ti a s� r. 2 5 C 4kas r.. PRPERTYOIYIINER MAP�;NC�� � �PARCEL ���;Z®NlNG�D1SrtRIG� ` H�'storic�D�str�ct '� ���e4s� ,�{�� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building rOne family ❑ Addition ❑ Two or more family . ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other e _ lo�dpain x x: ❑❑rVlfafershedDisfirict DESCRIPTION OF WORK TO BE PREFORMED: Kav4rbCAL k dentific o Please�ypepr Pri t Clearly) / qZ 2,3 OWNER: Name: v Q��� 0V_\ Phone: 79' �P s) l Address � LA CONTRACTOR' Name �a a as',+, v i^ d+ di iess-;W r "�r z V` u gE, Lcen ., tionu z a 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: $ �� FEE: $ Check No.: -7 2M Receipt No.: 1,74ZPI L�_ NOTE: Persons contracting with unregistered contractors do not have access to a ua ty fund Signature of AgentfQwner Slgnafure ofi contractor BUILDING PERMIT 0 "O RT 6A+ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: l0 Date Received 7EO,•P��S SgACHUS@ Date Issued: 7� v IMPORTANT:Applicant must complete all items on this page `3z�':` 'p.,"�y. xr-r.y�" 'Ci 21�°T" *' ^""" P.. '� sem# "M 07' -on i _, 'M '' t k �,,;rk "•.*' r `:k r ,t'• ffia "'3-gm nn' "OPERT 0 NSR .4 -t3.y-rim .a r �s�:m� s�'�• s�� .�'Ss ',�� �� � �u"`� P n 3 �,g�--Ki� `'�•ays ,�.ss � �nK��5 x.�-.e4 �����y�-�dq� . ��'fs• t .�•.��'-�'��"'�'�y''"�R.tC�6,F� ��` F dt�7 ��"e{e`�'t'r"r � ]v� �'�. k L�-"�.�e 'x kK�� � 7�+;�'1 � � s r _ ,� lac nes hopage r � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ` One family ❑ Addition ❑ Two or more family . ❑ Industrial ikhAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 0 Other , tD2 141 Uel * pmv` t{a-n�d�ssx:��"4 "1$' `r '."`_�a't�e,F4'�rffs_..�9h•�eh"�C"'d�D,1gr§ Cct'lir ? u tA, 3m `7fig DESCRIPTION OF WORK TO BE PREFORMED: dentifico Please ypep�qr Pri t Clearly) // Z 2 OWNER: Name: C'- C�� Phone: 76' �P��" Address: ( �r— LA L , 4ac 1a'3�'j�a tl "MT.:"Yt �k� �mS 4._a3i• n � �R': 75 P '� Gr"S^# F S W yi"� — �ONTFiA��T�OR���l��arn�� 10-ima lfi� ffilffiT a t �9€e -t. k+..^ �' �v.n k'" a') " �' , ,#"�y 'yOn A e � ���� �� �� �.�� ��Y���E�X(����_atLrt 'Er ' s�a,au•�.'�"�� �'�yf+s'yr-`v ra^ �� "ix ._.t! � Ft 3s��'�� x�ic� �`-7`�' �''.3#SSti;,�i- 'ik.Sfi.:" .ri 4 s y. .,.��i� t".e..s'.t�"+.�Ms.•..3a1. M«Y:Y.....-b{ ��._•X-':•�^2`*tl aK.+w,"Y�. t�i_.e�Wn�. �'�.� 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: $ r7'\ FEE: $ Check No.: -? 2-� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to e ua ty fund Location 2,4 L i j L No. 1 1�P 3 Date . ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 2,W °3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ .,337.E Check#-7Z 25672 Building Inspector } r t . .,. :. - - -- .. ..y.' _ - ..: - - - - .. .. .. .:_ _ S. 1 % . .,.. - _ .. .. _ .. . ... — .. - - .. - .. .. - .. -. ' . � .. J ! F : . .' .'. : _ I I-..... -: .:• :: w y J g; - .. .,...i_ r_. ,. ... ...:y. ., - .. .. - 3 } 1 2 L Y r t -e iv.•.-a" [+:..r-^'s�i+t�2"".'�."y.+'i„�-r... .•.. i�L`..i'- •.,.e•T==, , +x•- ;. ' O-Av �r- -__. Location v� 1. y No. �1�P 3 Date '!0 `7� Y " • ' TOWN OF NORTH ANDOVER tion __ ���.. ` .. �� �,-_ ' `�. ,k1.1.11 Certificate of Occupancy $ r ` - Building/Frame Permit Fee $ ,C7b A 11 li1-1 : _ : Foundation Permit Fe1 Ie $ 1.5m: .. - I. f'-4 . ° � � Other Permit Fee $ �{' TOTAL $33'� - T: f�.ry w - h- —4 � Check#�Z 7 // .. --. _, ` ����� B{iing Inspector � ; v n i, R « 4.: ... .w =b .... '.. .:-i __.;fit: .1 ._:: <_ l.._. t : .._. - - _ -.,.. _ _ _ { v -..y. ... -:..:;: r ... ... - - 11 4 �.. S .•�: .... .... .. ..... _ . •- -. - , ' .. - . .: v . .. ... ... ; -.., •'' ., _ .. C, ' ... r... ,... .: - .. .. .. ... - . _.,. .... ._....-. .. . .::.. .... ,:..::.'.. ... ... ..,.... .. .. 11 .,.. _. .. - ..... ...t _... .. ,., . .: :.... ....::. ..... 1. - .. - - .`N { y [.r T •. .. '; X x E , ,.:z,: Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS II 1 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIW-ER RTMENT Temp Dumpster on slte yes a s 110Ya Sia u Located+a#124MainSfree# '{ A 4 vFxreDeparfinen signature/date 2- ,,,...3,: 4s„ .-a�..�.. '{,.. F id .� q., '*';.3 ,� ..` '" .xr '$a�4�..- ' t� �•. �hr � r ,+,t�. s a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Seng Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 1 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 L% Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street FIREhbit AR7MENT wTem' Duri1 set P P RaZ.3t' `'T,Krn 't:.'{ .x i.- ; �Fx•.2 §'S,.,.,,n"� .'t. # Locafecxa#x124Main S#ree# y � r ; :z.+-i7"::` ¢ rr T Ftre:DeparEmentsignature�date . ..t mss, �{W`: ... 1N � '4 - �� � ,fid �.a.Ja.j�7.'r KT$l+i �'`;�,•��•t x?"S.', y��,ri � yr.ss'.A�,ty,_ yt,�.x..Y .A+• �.,,�,_ut5�x�'si. ' ti COMMENTS r. 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.s100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date i 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 Li 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) s for Engineered products eered o Engineering Affidavit g 9 g NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler PlanAnd Hydraulic Calculations (If Applicable) o Copy of Contract o 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 NORTH Town o _ Andover 0 No. LAK2 h ver, Mass, I Z®a� A- coc«�cHew�c« ��• 7�AERATED S V BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System THIS CERTIFIES THAT x4Y-41 e.Y........................................................................... BUILDING INSPECTOR 1.�:".r: -' �. Foundation has permission to erect ... buildings on ... ?. ... tn' :. /W.t................. , �- - . . tobe occupied as ............. d � :' ..��................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application F. 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. PLIM,BIIN �� NG INSPECTOR VIOLATION of.the Zoning or Building Regulations Voids this Permit. Rough 7/S / Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA TS- = 7J- Service .................... .... .. .................................._ Final BUILDING INSPECTOR OOa_ D Z GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 8/15/2012.12:58 PH FROM:I Gilbert Gilbert Insurance Agency; Inc. TO: +1 (978) 68273231 PAGE: .001 OF 002 . DATE(MWDOIY"_ ACQBpM CERTIFICATE OF -LIABILITY INSURANCE 08/15/2012 PRODUCER (781)942-2225' FAX (781)942-22.26. 'THIS CERTIFICATE IS A,MATTER OFINFORMATION Gilbert Insurance Agency, Inc. ONLY AND CONFERS.NO RIGHTS UPON,THE;CERTIFI,CATE 137 Main Street HOLDER.THWCERTIFICATE DOES NOT AMEND,EXTEND OR. ALTER THE COVERAGE AFFORDED.BY THE POLICIES BELOW. Reading, MA 01867-3922 INSURERS AFFORDING COVERAGE NAIC# INSURED Kenneth Keen & Robert Keen INSLOFRa NORFOLK:& DEDHAM INSURANCE 23965 DBA: DBA Keen Construction Con iany "NsUZERe Travelers Insurance 21 Hewitt Ave.. INSURER C:" North Andover, MA 01845 iNsIzERD: ,INSURER E:. OVERAGES THE POLICIES OF INSURANCE LISTED BELOWHAVE;BEEN ISSUEDTO THE INSURED NAMED ABOVEFOR THE POLICYPER IOD INDICATE0.NOTWITHSTANDING ANY REQUIREMENT,TERM.OR:CQNDITION'OF_ANY CONTRACT OR OTHER DOCUMENT WITH:RESPECT-TO WHIGH•THIS CERTIFICATE,MAY BE ISSUED OR MAY PERTAIN;THE INSURANCE AFFORDED.BY THE:POLICIES DESCRIBED'HEREIN IS=SUBJECTTO ALL THE,TERMS,.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATEIIMITS'SHOWN MAYHAVE BEEN REDUCED BY-PAID,CLAIMS;: ILTR NSR ADD . TYPEOFTNSURANCE POLICYNUMBER POLICYEFFECTNE POLICY EXPIRATION LIMITS' :" GENERAL LIABILITY - - :ND-P-01007 _ EACH 8/000 03 '13 2012 '03 13';2013 occURliErvcl= $ 1`000,,00. X COMMERCIAL GENERAL LIABILITY 1DAMAGE TO RENTED" $. 100,00- PREMISS CLAIMS MADE OCCUR MED EXP(Any one person) S' 5"00( A _ PERSONAL 8 ADV INJURY $ 00( GENERAL AGGREGATE :$:. 2,000,.00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,•OQO QQ X `POLICY PROPRODUCT LOC AUTOMOBILE-LIABILITY COMBINED,SINGLE LIMIT $- ANY AUTO l (Ea accident) ALL OWNED AUTOS .80DILY4NJURY SCHEDULED AUTOS (Par.person) $ HIRED AUTOS BODILY INJURY $_ NON-OWNED AUTOS _ (Per accident) - PROPERTY"DAMAGE (Per accident) $ .GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 3 r ANY AUTO OTHERJHAN FA-ACC..$ :. AUTO ONLY: AGG $ EXCESSIUMB RELLALIABlUTY; EACH.00CURRENCE OCCUR a CLAIMS MADE AGGREGATE $ DEDUCTIBLE. S RETENTION $ ;.. - . WORKERS COMPENSATIONAND 6KU8'-58407267A-:12 O8'/ 20 03' 12' 08/03/2013 .WC;STATLL 0TH / „ TORYLIMITS FR EMPLOYERS'LIABILITY Eli EACH ACCIDENT $ "1'00 00 B my PROPRIETORtPARTNERIEJ(ECUfIVE -"OFFICER/MEMBER FXCLUDED7 - -E L.DISEASE EA EMPLOYE tS' 100,000 It yes.describe under - - SPECIAL PROVISIONS below E:L DISEASE-POLICY LIMIT $ SQ.O,00_ OTHER .. . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES)EXCLUSIONS.ADDED BY ENDORSEMENT I SPECIAL PROVISIONS vidence.of Coverage CERTIFICATE HOLDER 0 - 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 NAMEDTO'THE LEFT, BUT FAILURE TO'MAIL SUCH'NOTICE SHALL IMPOSE NorOBUGATIONOR'"LIABILRY. OF ANY KIND UPON THE INSURER,ITS,AGENTS'OR REPRESENTATIVES. I, Evidence. of Coverage [AUM11ORIZEDREPRESENLATIYE rk Gilbert. CIC ACORD 25(2001/08) ©ACORD CORPORATION 1988 Board of Buildin- Re-ulations and Standards ` Constructirom Supervisor License License: CS 76691 ROBERT A .;KEEN 12 E WATER ST ` N ANDOVER, MA 01845 �- - -� Expiration: 8/16/2013 ('ununissiuix r Tr#: 3772 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SuperA icor ` License: CS-058245 `fir,r 's „ KENNETHBI&EN 21 HEWITT AVE 0 N ANDOVER M01845R 71 Expiration Commissioner 03/24/2014 c72,�pomvinaruuea o�C acufrcaeC Office of Consumer Affairs&Busifibess Regulation OME IMPROVEMENT CONTRACTOR egistration: ;.�'Q8383 Type: xpiration :8/1812014 DBA KEEN CONSTRUCTIOF1-C' Kenneth Keen ; 21 Hewitt Ave t No.Andover,MA 018 Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ke--f L,-7 1 't l 1(Lfc4lon Address: +4 City/State/Zip: f lf Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.P I am a employer with l 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 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.]f employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 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. :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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. _1� ff Insurance Company Name: Policy#or Self-ins.Lic. KV �— 5 6 L402 6-A l z Expiration Date: �J / Job Site Address: g5 CccPr- ta 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 verage verification. I do hereby certify u e the p ins a penalties `of perjury that the information provideed`ab is tru and correct. Si nature: v Date: U �J 1 2 Phone#: �T9 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 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 Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia KEEN CONST2UCT.ON Ccs. 21 If t1ITT AVE. N. ANDOVER, MA 01845 978X691-5201 rrCc�:esi Pashayan,:David,: Betsy . .25 Cedar Lane N..Andover MA01845° 97&973-2685 Contract#5040 Appendix A bate:8/30/12 Create master bath. • Remove existi.ng carpet in master b-ed.rb6rn ® Remove;-wall board from ceiling imrnasterjijedroom and_walls where bathroom will be • .,Build will approx47'•fron� rear wall tri create bathroom • Create vuall next_to shower to accept ca& eery ® Removo and replace sub-floor as needed far piumb►ng • Insulate textenor walls to:code . 1 ` • Supply&install"blueboardion walls-a'nd ceii.:ing and;.skimcoat plaster to smooth finish • Supply,-.&install;ceramic tile,on bathroom f,fdor,"shower flaor-and shower walls($3:00 per foot i material allowance • Supply&�instaii flour F.eiia,Architect.series reptacementwindows with.removable;grids • Supply&instalt-pockefAoor unit into bathroom • Supply&install:unit pair(French style}doors in.master cl.aset • Su:pp1 &install.stew tr€m to.rnatch existing; • Install customer supplied vanity and `linen slcset`cabinetry • Install.custom of supplied vanity in rtiain bathroom(plu -bi fees{fixtures or countertops and . patching of floor or walls is extra) • Dispose of alf debris Electrical Supply&install.bath.room vent • Supply,&.install.seven recessed ceiling fixtures(four in.bedreiom three in baths . • Supply&-install outlets and switching to code, plus one outlet near'linen' cabinet and one behind TV area • . Supply&install cable outlet behind TV area • .. Supply l &install 4 fluorescent light fixture in closet Pc t oft XEE CONSMUMON Co, gfWqrA WANDOVE, MA 01845 97$-691-5201 Ks� ar�ecci o�t��"cam c Plumbrna. . . Sb,,pply&ihstali plumbing drains)vents and feed p[iaes as rieedecl;to install customer supplied . fixtures • Relocate..existirng bas'e'board heat in bedroom and bath o Supply&instaH'eopper shower pan s Instal(customer supplied fixtures in bath Extras: t o Supply.&install 21/4" reel Oak prefinished,hardwood flooring in bedrdom and closet $2056.00 Total Pricer 2$ 1110.00 twee $ { tY e:ght.thousand one hundred dollars} . v : This price does-not include thecost of any perm€tfees,painting,flaortng: r bedroam,,cabinetryr plumbing fixtures,,shower enclosure;or problem found when Walls and floor is'open. Payment schedule: $1000.00 clue upon signing contact $5000:06 due-the-first day oil°work.{plus permitf, �pprox..$337}. $4t El€.-00:due when tough plumbing-is comp€ete $3000.00 due when rough electrical is complete, $5Q00 00 due when framing is:complete $3000:00-due when plaster is:cornplete` $3000.00.when the work_is complete :. $3 000. when windows are installed $3IOO.06 due wtien-contracted:work is eamplete'` Cusco er Kenneth B.Keen' Date' Date 1 a a P W2 O2 KEEN CONSTRUCTION CO. GP ffiPhR'0""""" Afig& 21 HEWITT AVENUE ��L 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 Chapter 142A of the general laws,must be registered with Submitted TO 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. rm� I n s �- Owners who secure their own construction related g _ ' �� :�v (�3 ......j permits or deal with unregistered contractors will — - ._�� ..- T .. ........ .._.__�_ be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE JJDA]EREGISTRATION NO. (V;0 _? EIN NO. )0 ( _ MA. H.I.C. 108383 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: .................... ....__ -- I sA I i _._.__-___.,-._. z X ............ .......... __.. .__..._.-.__.,.,..._.,.___...._._..... _...___� ------------ ......... ............... ------- r .........._... ............... .......... _ -__ __. ,. ._._..... ----- _ _ ............... -- -- _...............................__._ -_....... _ ..........------.__-...______-_.,.___...... ..................... .......... .......... ......... ----------- ........................ E ------- > Construction related permits: ---------- _........-......__....................................................................................................-......................,..............,........_........................................................................................._.... .................._..........._.... __.............................____...._______.............._...........__............_,.................__...._..................-..........................................................................................................................................,..........................................._......................._._. WORK SC ED LE Contractor 'ij'not eg)�i the work or order the materials before the third day following the signing of this Agreement,unless specified herg in fiting. ontractor will begin the work on or about '! ` (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by r f 7 2-- (date). The Owner hereby acknowle es anA 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 ~ 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 Contracto,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- I in accor ance with ab ve specifications,for the sum of dollars($ MN eclPayment to be mad as follows: )• ($ ) upon signing Contrl ct; KENNETH B. KEEN / ROBERT A. KEEN Name of Contractor/Designated Registrant % ($ ) u o ` t J 'idn of 21 HEWITT AVE. ^I , Street Address up n cdmpletion of_ , MA'01845 N. ANDOVER- City/State "$ ) shall be made forthwith upon (978) 691-5201 (978) 682-3231 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 Sal smanor 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 Au�rWnf Signature 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 time prior to midnight of the third business day after the date of this transpeti Cancelfa ion must be done in writing. `�<_. :� O 6T SIGN THIS CONTRACT IF.THERE ARE ANY BLANK SPACES. Signature ✓r %�i t�. Date Signature Date IMPORTANT INFORMATION ON BACK ' NORTH own of E : ., ndover O _ No. h ver, Mass ZnIZ cocM�cMewKw �1 A04ATED ►PP,�,�y S u BOARD OF HEALTH PERMI�T T D Food/Kitchen Septic System J BUILDING INSPECTOR THIS CERTIFIES THAT ...6G6.,5. .... .. /Ir. . . . Foundation has permission to erect .......................... buildings on ..a. ,$... .(: 4:::. .................................. Rough to be occupied as ............../0. , 44'c1 zn46W.t/1 . ................................................................................. 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 VONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION VSTATS Rough Service .................... ... ....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 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 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 ❑ 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 2.2007 _ 25 CEDAR LANE 210/106.A-0147-0000.0 �/ /ate LOT E� C 5O4P� LANE '- i�; M ► L.L\/!F—W ✓ �s ,lOP-iTN 2 Antes,E L 74 13GAL E= III LOT 1 � ' (G .e' . 4 �u nti�{ 200 ` 96 `�U ► �l \ i , FcT Lc.T Co C E CDAFR L.4N5 '� To # "A WT C L-MAR. LkS, ,. .,, a2"Mw.T,apsflw COvf-R 3"WA5%WPeA9Tot+tE �"yam 3j8" " • ��� ��t� �/�' � ABSORPT10t� A6Lt3A 3, i ABSORPTION BED END SECTION ' a 0 --...,. o o a ay c+OALUOK • SEP'i'1C 0 cr TANK 0 ell's Lo„ DISPOSAL SYSTEM PROFILE. r ?6 , � ABsoRt�no�c ►� `��� ABSORPTION BED PLAN 9 rIJ Tr, C-]"'i r%r AL, 086.HOLE PERC. HOLE PERC RATE TEST DATE Jt 1,7y. r O PERC TEST T . H. Iva Commonwealth of Massachusetts = City/Town of _ System Pumping Record NORTH ANDD �E.l Form 4 DEP has provided this form for use by local Boards of Health. Other foLing y be used, but the information must be substantially the same as that provided here. QKis rfb t k witf�r your local Board of Health to determine the form they use.The System Pumecord must be submitted to the local Board of Health or other approving authority within 14 days frT�MpidgdateJOVER accordance with 310 CMR 15.351. LTH DEPARTMENT _.ENT A. Facility Information Important: When filling out 1. System Location. forms on the — � /'1„ j computer,useonly the tab key Address to move your cursor-do notiuse the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) - — --- City/Town State 'Zip CCe, 70�� �-- Telephone'Number B. Pumping Record /eq C'W 1. Date of Pumping Date 2. Quantity Pumped: Gall ns 3. Type of system: ❑ Cesspool(s) Aeptic Tank El Tight Tank F1 Grease Trap ❑ Other(describe): --- —"" -- - - - 4. Effluent Tee Filter present? ❑ Yes 4No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: rrc>c) 6. System Pumped By: s Name � 1 \ w Vehicle License Number Company G&L.S.D. 7. Location where contents were disposed: 14or*Andmet- MA. Siign rreofgnatauler Date f7- Seceiving Facility Date l t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record ,i ' Form 4 DEP has provided this form for use by local Boards of Health. The System P-Tm i ord must be submitted to the local Board of Health or other approving a JE C-—E1� D A. Facility Information JUL 1 U 2008 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the computer,use ed ►� HEALTH DEPARTMENT only the tab key Address to move your >yo T'\h And over G ©I $4S cursor-do not - use the return City/Town State Zip Code key. 2. System Owner: 'ab sh G qn Name — Address(if different from location) City/Town tate Zip Code elephone Number B. Pumping Record 1. Date of Pumping Date 7-0g 2. Quantity Pumped: -1430 Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Jm Name 1 Vehicle License Number �inG�ty_et �.n ►rOnMen�( Company 7. Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM IFS Address of property 25 Cedar Lane , N . Andover M . Owner ' s name Bruce & Laura Shook Date of Inspection June 8 , 1995 PART A CHECKLIST Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health . X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period . Large volumes of water have not been introduced into the system recently or as part of this inspection . X As built plans have been obtained and examined . Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. _ X The site was inspected for signs of breakout. i _ All system components , excluding the SAS , have been located on the site . X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge , depth of scum. X The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential } I _ number of bedrooms --4_ number of current residents y,Q.� garbage grinder, yes or no *e.p,_ laundry connected to system, yes or no Nn seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available : Privete well n/a Last date of occupancy GENERAL INFORMATION Pumping records and source of information: _ System pumped as part of inspection, yes or no if yes , volume pumped Reason for pumping : Type of system X_ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records , if any) Other (explain) Approximate age of all components . Date installed, if known. Source of information : 1974 No Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` SYSTEM INFORMATION continued ) SEPTIC TkNK: (locate on site plan) depth below grade : material of construction: —X—concrete metal FRP other(explain) dimensions : 51V2l _414peer sludge depth distance from top of sludge to bottom of outlet tee or baffle �_ scum thickness 41L distance from top of scum to top of outlet tee or baffle ----1-511distance from bottom of scum to bottom of outlet tee or baffle Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles , depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) Tank is parbieiiy eevered by stairs to decit. DISTRIBUTION BOX: (locate on site plan) 0 depth of licuid level above outlet invert Comments : (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) Wag same tai 1 et paper in l)nx , rl eanerd out. and worki na T rn?arl y PUMP CHAMBER: (locate on site plan) N'44— pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc . ) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOS PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields , number, dimensions 1_f I e I d 5.1X36 , overflow cesspool , number Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) C and lawn , noonding . CESSPOOLS (locate on site plan) : number and configuration N/A depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY : ( locate on site plan) materials of construction dimensions �T/n depth of solids Comments : (note condition of soil , signs of hydraulic failure, level of ponding condition of vegetation, recommendations for maintenance or repairs , etc. )( 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 3 � � - DEPTH TO GROUNDWATER Nomeber depth to groundwater method of determination or approximation: Rarrnr,ic show no water table in 8 ' deep test hole on lot . 1� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C FAILURE CRITERIA Indicate yes , no, or not determined (Y, N, or ND) . Describe basis f determination in all instances . If "not determined" , explain why not) Nn Backup of sewage into facility? Ne Discharge or ponding of effluent to the surface of the ground or surface waters? -No Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? No Required pumping 4 times or more in the last year? number of times pumped Pie Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? No Is any portion of the SAS , cesspool or privy: below the high groundwater elevation? No within 50 feet of a surface water? No within 100 feet of a surface water supply or tributary to a surface water supply? NT n within a Zone I of a public well? _ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? N-a— within 50 feet of a private water supply well? No less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria , volatile organic compounds, ammonia nitrogen4 and nitrate nitrogen . 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Robert L, Innis Company Name RLI Corp. Company Address 475 Boston Rmad Billerica , Ma . 01821 Certification Statement I certify that I have personally inspected the sewage disposal system at this .address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems . Check one : x I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature Date June 8 , 1995 Original to system owner Copies to : Buyer (if applicable) Approving authority Address Title of Fide Page of Date File Open: Gate file closed: Doc Document/Action Title IDOcurnent/;d0curnent/ of fer to other Purpose of document/Action and notes; action IWum' on artment i Board of Appeals - Board of Health - Planniin•g Board - Conservation Commission - Building Department �- G_