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Home My WebLink AboutBuilding Permit #464 - 261 HICKORY HILL ROAD 1/22/2008BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: y!°y Date Received /pORTM\ / O`�t�[o �6• tid 0 DESCRIPTION OF WUKK I U tst t-KtrVr1v1cu: ILS.I®InGF FRoriT Woc9e-yNi OWNER: Name J *I Please Type Print Clearly) 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: $ Z O Z = FEE: $ �a dD Check No.: 4/ Receipt No.: -90 ;5�O b"� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL t , Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales 11 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS c - • ;,' DATE REJECTED'_ DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Commen Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street:. - , t , 4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Commen Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street:. - , 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 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 o 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 Location, 6?6/ .o/'y �"T� �� eV No.� y Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �6•..— s t Foundation Permit Fee $ Other Permit Fee $ �- TOTAL $ Check #�` G 20905 SKU ding Inspector �1/ze�mvmauuec�t/�.tztela t} BDARD OF BUILDINRE`G"1�Lt4*TIONS ieens� CONSTRUCTIONSUPERVISCSR Ad- ly, S 058245 �rthd to -03724/1,943 rxte�0�470 Tr no. 13436' ` tom n sloner� } The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street ' `Wt Boston, MA 02111 wM y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �l9i�J b%?IzoL E Address: Z ( / gi C �en by City/State/Zip: P. & i- CIdy Phone #: 5'? F_ 4� 4?0�6 —4515S-3 Are you an employer? Check the appropriate box: 1. Lam' 1 am a employer with Tj 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. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' insurance 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. Ekbther jQo& J Tp cot"Ll "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 showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: a 2yq N> ; (<-C Policy # or Self -ins. Lic. M 6 3., 6 t) (9 f Expiration Date: O ".3 — d T Job Site Address: Z % l okQ<< /tOVLc/ At I( ARt, City/State/Zip:/J • IQNG. 6197Y,% 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 certify_!�nder theAains and penalties of perjury that the information provided above is true and correct. Phone #: Vi b !�? % ` 5 i n use only. Do not City or Town: area, to or town official. Permit/License # z z -0Y Issuing Authority (circle one): I. 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 dwellMg.house having, — t 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 becaiise 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 11-22-06 Fax # 617-727-7749 www.mass.gov/dia /4VV! 11.JV fnA IVL 044 f.4LV .p;Jvvr PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Gilbert Insurance Agency Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 137 Main St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Reading, MA 01867.3922 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Kenneth Keen 8 Robert Keen 21 Hewitt Ave North Andover, MA 01845-x000 I Erg -THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. I40T WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER `DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PIA D CLAIMS. oD LTR I TYPE OF INSURANCE POLK 'NUVHDE POLICY EFFE CTIVE DAME PGLfOVEXPRA710N DA A RK TDN EIman MPLOYERS'LIABILITY LIMITS PROPRFTOFV PART'NERSIEXECUTNE OFFICERS ARE: NCL 0 EXCL ❑ 63EI0888 8/03/2007 8/03/2.006 ATUTORY LIMITS THER erepeMalesIaVAOpwotlmaOltt . ACCmEN7 s 100,00 ISEASE POLICY LIMrT $ 500,00 ISEASE-EACH EMPLOYEE $ 10010% ESCRIPTtON OF OPERATIONTAV C GAL ITEMS ROBERT KEEN IS COVERED BY THE WORKERS COMPENSATION POLICY AND KENNETH B KEEN IS NOT COVERED BY THE RKERS COMPENSATION P=tLICY. ,!CERTIFICATE HOLDER CANCELLAMON JOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLCIESHECANCELLED BEFORE THB EX7RAT10M DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAX -19 -',.1GD0 OSGOOD ST DAYS VWRRTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT ` NORTH ANDOVER. MA 01845 FAILURE TO MAR SUCH NOTICE SHALL HOSE NO OBLIGATION OR LVSBILrrY OF ANY KNO UPON THE COMPANY, IFS AGENTS OR REPREBENTAT NES. AUTHORIZED REPRESENTATIVE e ��V �V/ YVVI LV, �1 •(lel I VL V9Y YYYV -ma V - 1 / �7 THE POLICIES OF INSURANCE LISTED 9ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN ANY REQUIREMENT. TERM OR CONDII QN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOFtbED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN:MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR IDWg - TYPE OF INSURANCE POLICY NUMBERPO CYE C VE P UCY EXPIRATION LIMITS GENERAL LIABILITY ND -P-010078/000 03/13/2007 03/13/2008 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S S0,0001 PwcwiQGS IF, . _ - - CLAIMS MADE a OCCL R MED EXP (Any one person) S 5,0001 A PERSONAL t( ADV INJURY S 11000,000 - - GENERAL AGGREGATE S 2,000,000 GEN'L ACGREGATE LIMIT APPLIES FER; PRODUCTS • COMP/OP AGO $ 2,000.000 POLICY P UA' AUTOMOBILE LIABILITY COMBINED SINGLE LIMN 5 ANY AUTO (EB ecc dent) BODILY INJURY S ALL OWNED AUTOS SCNEOULEDAUTOS - (Pet person) BODILY INJURY S HIRED AUTOS - (Per eccideM) NON -OWNED AUTOS PROPERTY DAMAGE S '— (PeracadeM) GARAGE LIABILITY AUTO ON 6V - [A ACCIDENY $ OTHER THAN EA ACC S ANY AUTO AUTO ONLY! AGO S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE i OCCUR F] CLAIMS MADE i S DEDUCTIBLE RETENTION T W C STATV• OTH- WORKERS COMPENSATION AND E,l, EACH ACCIDENT S EMPLOYERS' LIABILITY , ANY PROPRIETORIPARTNEWEXECUTWE E.L. DISEASE • EA EMPLOYEE E OFFICERIMEMBER CXCLUDED't K ycs describe under SPECIIAL PROVISIONS below E.L. DISEASE • POLICY LIMB 5 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VM41CLES I EXCLUSIONS A130ED BY ENDORSEMENT I SPECIAL PROVISIONS Town of North Andover,' 1600 Osgood Street North Andover, MA 018:45 SHOULD ANY OF TME ABOVE DESCRIBED POLICIES BE CANC ELLED BEfORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICESMALLIMPOSE NO OBLIGATION OR LIABILITY OFANY KIND UPON THE INSURER SAGENTS AUTHORIZED REPRESENTATIVE ACORD 25 ( 001/08) FAX; (9719)682-3231 OACORO CORPORATION 1988 KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER, MA 01845 (978)691-5201 KEEN CONSTRUCTION CO. a 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978) 691-5201 Fax: (978) 682-3231 Submitted 7 To:. _fit f V t....If Rd 6.1 All home improvement contractors and subcontractors .engaged in home improvement contracting, unless specifically exempt from .registration by Provisions of Chapter 142A of`tte'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. PHONE DATE REGISTRATION NO.. F.I.D. N0. i %i C _ _. � 2. 7 MA. H.J.C. 108383 04-325--8,052 > C/S = Customer Supplied S +'I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: __..._ . .. .. > Construction related permits: (i..t.,..�.....!:s...(. ........................................... .....,....... WORK SCHEDULE ['1...,.r..l..........�Y..:....,:=r _��....�... .1,.. .; .L.. / ........ <..-�...�, rel r'l..i............... / ......l�j-- c..i....i.. .,r.. 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 (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (date). The Owner hereby ackno Me ges 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 �I 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 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 :nt to be made as follows: % ($ ) upon signing Contract; ($ ) upon leti, n�of�__ % ($ 0, `p kn completion of r� shall be made forthwith upon completion ofwork under this -contract. specifications, for the sum of : �.,,,_�..._.._....._--_..dollars ($ KENNETH B. KEEN Name of Contractor / Designated Registrant 21 HEWITT AVE. Street Address N. ANDOVER City / State (978) 691-5201 MA 01845 (978) 682-3231 ... Fax-- Notice: ax 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 nt sales an / or the total amount of all deposits or payments which the contractor must make, in advance, .o order and/or otherwise obtain delivery of special order materials and Autn6& -ignatu� equipment, whichever amount isgreater. Note: This proposal maybe 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 transaction. Cancellation must be done in writing. 1\ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK( SPACES. `Signature /:/!,....�.:._.r�.G-'i' /�-c.�;s�.. 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