HomeMy WebLinkAboutBuilding Permit #841 - 33 WALKER ROAD 6/23/2016f HOFTI{
p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
CHUSE4 -
Pei -III it NO: /
Date Received:
Date Issued: 16,(
IMPORTANT: Applicant nulst complete all items on this nage
LOCATION, 53 _w 19 111.5r, JZt�.
Print
PROPERTY OWNER K3jQNc4
Print
MAP NO.: S PARCEL: ZONING DISTRICT:
TVPF ANi) i1CF. OF RiliUMNI !`_ Z nJ-/I- uir•rrin,n t%iroly ,..,.
TYPE OF IMPROVEMENT
PROPOSED USE
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Residential
Non- Residential
New Building
E One family
J Addition
;= Two or more family
7—Industrial
--Alteration
No. of units:
'_. Commercial
Wr-Repair, replacement
C. Assessory Bldg
C? Demolition
C Moving (relocation)
' Other
F, Others:
Foundation only
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OWNER: Name:
Address:
CONTRACTOR Name:
Address:
ion Please Type or Print
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Supervisor's Construction License: __ ,C'b Z 4S Exp. Date: i—
It
Home Improvement License:- �(' �S Exp. Date: V,6
ARCI-II'i'E-CT./FNGiNEIR Name: Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDLVG PERMIT. • 4'10.00 PER $1000.00 OF THE TOTAL ESTTVIA TED COST BASED ON
$1 ZS. 00 PER S.F.
Total Project Cost :$—.7 Z Z S �� xI0.007=FEES -77----
Check No.: "i Receipt No.:�
FTYPE OF SEWARGE DISPOSAL
I
-
TanninglMassage;Body Ail
Swimnlin- Pools
lic Sewer -
I
-
-
Tobacco Sales
Food Packaging/Sales _..
Well
_
Permanent Dempster on Site
!
Private (septic tank, etc. L..
i
i
i
NOTE: Persons contracting with unregistered contractors du not have access to fire gnarantp.jui!
Signature of ,,kgentiOwner ` `Signature of Contractor
Plans Submitted ❑ Plans Waived ❑. Certified Plot Plan ❑ Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ U
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS _
DATE REJECTED DATE APPROVED
CONSERVATION ❑ -_- ❑
COMMENTS
t
DATE REJECTED DATE APPROVED
HEALTH.
f.
CIVINIENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision,'receipt submitted yes
Plannln'u, Board Decision:-0111111ents"
F
Conservation Decision:_ Comments.
\ iter &: Sewer conncction signature & date
Temp Dempster on site yes_— no Fire Department signature/date
Buildin" Permit A pproved and Issued by:
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
..Required
Provides
Required
Provided
DIMENSION
Number of Stories:
Total land. area, sq. ft.:
NOTF,S and DATA —(For department use)
Total square feet of floor area,. based on Exterior dimensions.
i
Building Department
I
The following is a list of the required forms to befilled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Debris Removal Form
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
❑ Fonn U
❑ Surveyed Plot Plan
❑ Debris Removal Form
❑ 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)
New Construction (Single and Two Family)
❑ Building Pen -nit Application
❑ Form U
• 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
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 cope and proof
of recording must be submitted with the building application
Doc: I\SPECHONAL SERV ICES DEP.IRTMEYr:111'FORN105
Location
No. D a t e, AZz-4
97 7
TOWN OF NORTH ANDOVER
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10
Certificate of Occupancy $
C" Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
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—�----- /A,f'ar�ainzoozusea c o�✓�aa ccaefta
n\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 108383
Expirations 8718/2008
Type D,BA
i.
KEEWCONSTRUCTIONCO'.
Kenneth Keen
21 Hewitt Ave
No. Andover, MA 01845 Deputy Administrator j
✓ize: �am�r�m�ueal�
i BOARD OF BUILDING. REGULATIONS F
d—yhicense: CONSTRUCTION 'SUPERVISOR
i Number:t-S 058245
I 1
3irthdate 03%24/:1943
a I'Ex'`.pite3 03/2412008 Tr. no: 13436
"`ne+aii+w►inn _!`C f a
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Restricted 00 /
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KENNETH B KEEk)3 '7
21 HEWITT AVE
N ANDOVER MA '0145 J
Commissioner] ./ .
- _ -
ell,
Y� 77_ The Commonwealth of Massachusetts
Department o Industrial Accidents
�. .
=. Office oflnyestigatfons
''Vi� 600 Washington Street, 7tl' Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit Building/Plummbing/l+.'.lectr ical Contractors
Applicant infiirmati6i Please:PRINT:Iearbly `
name
addresss:��� eJ�
city Ni�Rl N (1 :J ��' state: i� ziu:4V/2YJ phone #972 • ��
work site location (full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑ New Constniction ❑Remodel
] am a sole proprietor and have no one working in any capacity. ❑ Building Addition ('4 1 NC�t�w,5
❑ I am an employer providing workers' compensation for my employees working on this job.
company name:
city: phone #•
insurance co. policy #
❑ 1 atm a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
city: phone #
insurance co. policy #
r
company name:'
city
phone #•
insurance co. policy #
Attach.addihonal sheet ifneeessary r „ ',7777777
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cern i the pains 4d pe i ht! es of perjury that the information provided above is trite and correct.
G - Z> 2 -o6-
Print name ,U NL� �(� � } Phone # /
n:.3S":.SLv.>:"s,•!,''!.1...J.,e.ax#. ., Wa1.1,...6':..M,..t„sse.
official use only do not write in this area to be completed by city or town official
city or town:
permit/license #
P ❑Building Department
❑Licensing Board
❑ check if immediate response is required
❑Selectmen's Office
❑Health Department
contact person: phone #; ❑Other
(revised Sep. 2003)
KEEN CONSTRUCTION CO.
a 21 HEWITT AVENUE
NORTH ANDOVER. MA 01845
Tel: (978) 691-5201
Fax: (978) 682-3231
Submitted
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To:
1�
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C I C:, v t . //7,
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-.-_._.._ _ _._.._..__ ... _._............ ...... ..............__..A.___._ � �, ___..._ ..
PHONE TZZ
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C/S = Customer Supplied S + I = Supply + Install
We hereby submit specifications and estimates for work to be performed and materials to be used:
• A
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. F.I.D. NO.
MA. H.I.C. 108383 04-325-8052
�. % ...l..V ----- . ............... ......... .V.� l i_�'� ✓1'�._` n n c !`•) t J C1 Cl, a C�� t�(� � )
?i......................_ `L
j I �.
Construction related permits:
(tI 1L I C- h l
........Sf�.!/l)
t�:................... .:.......................4�. ....._ <.:.......::.....,.... ._ :'.!.:J...............(.....,......................,-... r. .....0 Q !...... r:..,..1....:....,...,....!....t.............................................
WORK SCHEDULE ..........
Contract r will not rgin the. work or order the materials before the third day following the signing of this Agreement, unless specified here --in writing Cont r ctor will begin the work on or
about -
4date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by 2 -- - 4) � (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 n 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, 4 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 with above specifications, for the sum of
t a 1 :/ p" i rJ C dollars ($ ).
Payment to be made as follovrb
($yj��) upon signing Contract; �� 4v ?; `er ` KENNETH B. KEEN
b � Name of Contractor /,,Designated Registrant
($ �� j upon completion of tf f / w c�pt--'�,�_ V('� � 5
%21;HEWITT AVE.
Street Address
N: ANDOVER, MA�'017845.
($ )upon completion of s
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 Salesman //��
or the total amount of all deposits or payments which the contractor must make, in ( // , l/ , /f'I :51� ?
advance, to order and/or otherwise obtain delivery of special order materials and Author d' ignature ---
equipment, whichever amount is greater. ole: This proposal may be withdrawn by us ii 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.
/DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signaturer '--1.1 )L/ / Date t1'%, I V W Signature Date
11VIKUM IAN I INI-UHMA 11UN UN UA(;K PW-