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HomeMy WebLinkAboutBuilding Permit #908-14 - 28 PHILLIPS COMMON 6/12/2014Permit N 9ouq TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 11 Addition El Two or more family 11 Industrial 11 Alteration No. of units: 0 Commercial ,kRepair, replacement El Assessory Bldg El Others: OlDemolition El Other , S D1. Wei . . . . . . 1P, N as OF. i� R. alp) - : 'T. -N-5- f 51 W. 1-1 Wa r , " . rp- "'i �kDESC(�I�IPTION OF WORI� TO BE PERFORIVIE�, orT6G,76�_ t Y\ 0- Y, I IS, I Identification Please Type or Print Clearly) OWNER: Name: &)`lo k::, Gia rke_oZ, Cc)( -:b(-, Phone: 9%? -6'U-(<:,�2-i Address: P i S COMV(cm RANG 2!M _xs VIA) 1, cm, K �n n j T. —7-7 Add 7 LW__ uona '"rlvis C A-5 p -rov ben 1) 101I.N5 ,ern_ 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.: -k v9c) Receipt No.: 2-1(-P J4 A A NOTE: Persons contracting with unregistered contractors do not have access to On.-ildran d7i Plans Submitted ❑ R,lans Waived ❑ 'Certified Plot Plan ❑ Stamped Plans ❑ d 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 CONSERVATION COMMENTS HEALTH COMMENTS i Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: s Com Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tbvvp_ Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster onsite yes. no Located 6t'l24 Main Street {` Fire De`partinent 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 strop 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 2010 Building Department The foEowing 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 submAted with the building application Doe: Doc.Bui?ding permit Revised 2012 Location No. Check # 27674 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector J 40 d 2 loon Eq__* _ Q Uj _ LL O ® Q O m v u , O LL N ? N u O. V) p W Q z Z 0ccQ J m c -a 7 LL t 7 Q' ? U — LL O W CL LA Z z J d 7� w LL O d N1 Z cc v J LL -C 2' i to N LL a V LL Z s CD d' c6 LL Z CW LL LL oc LL i m O z N N N N 0 ) N _ _ O�O : Cc _ 40:.2..- �: ^f M d a: a �_ �. 0.- 0 E o. L U) Nrep LE U. _ 0 cC O IL a o a •8 O �oa > t i E o zo �• N = O d O = o :a co � a m as s .«. m 0 LA CD a i L � � •o NO °' 2 m °' LU = '0— c o LL O -;5 N = O LLI I-- U) gs :EO Z LU E v 7o... 0 O d 0-0 N S = J to .O 04-- ®_ F� - � o Ci > 2 z m to _z LLI a. W 5I-- L W CL N LS iii V N E Z .E L O CL m .CL U w N s 0 o ® AL CL i }r • V J O a9 Z U) a Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS -058245 KENNETH B KEEJ4 21 HEWITT AVE N ANDOVER MA 0184 Expiration Commissioner 03/24/2016 IfMI Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -076691 ROBERT A KEEN-` 12 E WATER ST . x1� North Andover WA 0184 y Expiration 1 Commissioner 08/16/2015 Tj L 0-914o rn rrca�ztuP a�<,/ Office -of Consumer Affairs & Busiss Regi j OUlt IMPROVEMENT CONTRACTOR. egistration: Tb8383 Type: e xpiration ,-_ 8/18/20:] , CBA KEEN CONSTRUCT10i1 Kenneth Keen 21 Hewitt Ave No. Andover, MA 01:845 UndersecretWry r AI O® CERTIFICATE OF LIABILITY INSURANCE 4/15/2014Yv) 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 Gilbert Insurance Agency, Inc. 137 Main Street Reading MA 01867-3922 CONTACT Barbara McDonough NAME: g IPAHONE . (781) 942-2225 FAX o: (781)942-2226 E-MAIL ADDRESS: gcg bmdonou h@ ilbertin surance.com INSURERS AFFORDING COVERAGE NAIC If INSURERA:NORFOLK & DEDHAM INSURANCE 23965 INSURED Keen Construction Company 1175 Turnpike Street North Andover MA 01845 INSURER B :Hartford Fire Insurance Com an INSURERC:Travelers Insurance 0022 INSURER D: INSURER E: 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 ORC:ONDLTION_OF._AN_Y__CONTRACT_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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER LICY EFF POLICY EXP MM DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE aOCCUR D -P-010078/000 r3/13/2014 3/13/2015 EACH OCCURRENCE $ 1,000,000 DAMAGES ( TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS 08UECAA6432 12/3/2013 12/3/2014 BIINEeDtSINGLE LIMIT COMaccident) Ed1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ Underinsured motorist $ 100,000 UMBRELLA LAB EXCESS LIAB d OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ C WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? [:]N (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below I A 6HUB-9991M58-2-13 10/8/2013 10/8/2014 STATU- OTH- EACH ACCIDENT $ 100,000 E.L. DISEASE • EA EMPLOYEH $ 100,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 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) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 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): Address: 1 ') TU 1_. 21 617T5 Phone #: Are you an employer? Check the appropriate box: 1. [P 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 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] —6-91— Type 6-9f— 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 *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: J r—not;', I e r 5 I Y1.5,(,j f-0, l,� G Policy # or Self -ins. Lie. #: �: N O - /199 2 -1 Expiration Date: G' % t - Job Site Address: 25- Nl 1 �I 1 Q S 6CY0 McA) City/State/Zip: I 1 TL 0 Ver, © l $yr, 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 er tye painAnd penalties ofperjury that the information provided above is true and correct Phone 91 5 ZO l 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): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: