HomeMy WebLinkAboutBuilding Permit #507 - 3 LINDEN AVENUE 3/30/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received
Date Issued: 'S
-A 0 0"
IMPORTANT: Applicant must complete all items on this page
LOCATION 1, €bu 1Q u '
Print
PROPERTY OWNER_ Ct,;,(#qdY H1 J',44-
Print
ii94-Print
MAP NO: I PARGEL:46_ ZONING DISTRICT: Historic District
02
PROPOSED USE
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Non- Residential
New Building
9_
yesno,
yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
ane family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
L. -Repair, replacement
Assessory Bldg
Others:
bemolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
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OWNER: Name: 12
Please Type or Print Clearly)
Address: 3 N d 1--i (� v
Pho
CONTRACTOR Name: i E. N 0D vJ S 120 cf Phone' "? • C� '1 tit � a
Address c L 91"J-6 14 c) lam, y
Supervisor's Construction License: ,Sr dv`� `� � Exp. Dater
Home Improvement License: /b 13 g -V :Exp. Date:
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: $ / 9 �O �� FEE: $ 20 �
Check No.: � 67B Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the zuara ty fund
Sianature of contractor, `
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
L.Aafiic Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
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THE FOLLOWING SECTIONS -FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH_ > ,, Reviewed on Signature
COMMENTS
A '
. 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
DPW Town Engineer: Signature:
Located. 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no (
Located at -124 MainStreet—"—
Fire Department 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)
❑ 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
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 2.2008
(.- h tit 14ve-
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NORTH
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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 ' A
To:
R
IT
PHONEGATE`
C/S = Customer Supplied
We hereby submit specifications and estimates
Construction related permits:
work to be
S + I = Supply + Install
med and materials to be used:
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. 108383 26-0462904
See Attached Appendix A
_ _...
..................................-...........................................................................1........
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 (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (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 1 4 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 Contras r, 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 accordancewith a ove specifications, for the sum of
C14 cvA dollars ($
Payment to be made as follows:
% ($ ) upon sig�n\of ning Contract;
,J�completlon of
shall be made forthwith upon
completion-of:work-urider -this _contract.
. -
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
or 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
equipment, whichever amount is greater.
KENNETH B. KEEN / ROBERT A. KEEN
Name of Contractor / Designated Registrant
21 HEWITT AVE.
street Address
N. ANDOVER, MA 01845
City / State
(978) 691-5201 (978) 682-3231
Phone. _Fax _ ._ ..
-'-
---------------
Name of ales�n
/
Authohzigffgldre
Nole: his proposal may be withdrawn by us if not acceoted within d—
Acceptance Of Proposal - I have read both sides of this document and all attached documents avid 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.
DO, NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
l�
Signature Date
KEEN CONSTRUCTION CO
21 HEWITT AVE.
N. ANDOVER, NIA 01845
(978) 691-5201
r
d , (
r t..i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
ensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): N
T
Address: ' V e--
City/State/Zip: 1� . tt 0A6 d Cot q Phone #: 9 7W , b ✓ —S^o�� 1 _
Are you an employer? Check the appropriate box:
[G am a employer with 9_ 4. ❑ I am a general contractor and I
employees (hill and/or part-time).* have hired the sub -contractors
'. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.t
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.]
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. l -Other W i lu t C t,-*
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: G rL A aJ ; f E S_
Policy # or Self -ins. Lic. #: WIG 'j [ Expiration Date: p
Job Site Address:_ 3 !� AJ ALJ 6- City/State/Zip: , � sy D
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.
Ido hereby certify under the painyand penalties of perjury that the information provided above is true and correct.
Phone #: v 7. 0 • (fl C1(' S O
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 #:
6/16/2008 11:13 AM FROM: Gilbert Insurance A❑ Gilbert Insuranna An Tn- +l rg7AI 5Aq-tq-ii pnrF. nno nv nn -z
AC , CERTIFICATE OF LIABILITY INSURANCE
06/16/2008
PRODUCER (781)942-2225 FAX (781)942-2226
Gilbert Insurance Agency, Inc.
137 Main Street
Reading, MA 01867-3922
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED Kenneth B. Keen & Robert Keen
DBA: Keen Construction Company
21 Hewitt Ave.
North Andover, MA 01845
INSURERA: NORFOLK & DEDHAM INSURANCE 23965
INSURERS: Granite State (A I G)
INSURER C:
INSURER D:
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
?NSR
MD
TYPE OF INSURANCE
POLICY NUMBER
POLICYEFFECTNE
POLICYEXPIRATION
LIMITS
GENERAL LIABILITY
ND -P-010078/000
03/13/2008
03/13/2009
EACH OCCURRENCE $ 1,000.00
X COMMERCIAL GENERAL LIABILITY
DAMAGE 70 RENTED $SES ,00
(FA occurence) 50
CLAIMS MADE a OCCUR
MED EXP (Any one person) $ 5,0(0)
A
PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,00
X POLICY jEa LOC
AUTOMOBILE
LIABILITY
-
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS
(Per person)
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
.
GARAGE LIABILITY
-
-
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC - $
AUTO ONLY: AGG S
EXCESSIUM13RELLA LIABILITY
EACH OCCURRENCE $
OCCUR ❑ CLAIMS MADE
_
AGGREGATE S
4 F DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATION AND
X WC STATU- OjH-
B
EMPLOYERS'LABILITY
ANY PROPRIETOR/PARPAf2TNER/EXECUTIVE
WC6380688
08/03/2007
08/03/2008
IQRY LIMITS FR
E.L. EACH $ 100,00
OFFICERIMEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE $ 100, 00
II yes, describe under
-
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $ 500 00
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
riginal Workers Compensation coverage certificate to be forthcoming from Granite State Insurance.
Evidence of Insurance
ACORD 25 (2001/08)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
OACORD CORPORATION 1988
T� 1°ommwruuea�ii ������
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration; 108383
Etrat��la $718/2010 Tr# 272473
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TYPe DBA°
KEEN CONSTR66*6 CO `
Kenneth Keen
21 Hewitt Ave
No. Andover, MA 01845'". Administrator
_ ✓fie "loaavaao��zu�eaC� ay,/i'�aQar,�c�u�aeC�S
Board of Building Regi lati, s and Standards
Construction Supervisor License
i License: CS 58245
Expiration 3x/2412010 Tr# 17840
,�' Restriction.:"00`,.
KENNETH B KEEN
21 HEWITT AVE
N ANDOVER, MA 01845 Commissioner