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HomeMy WebLinkAboutBuilding Permit #629 - 412 MAIN STREET 3/29/2007Permit NO: IP Date Issued: • ' TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received ? •dq • 0-;L- IMPORTANT: Applicant must complete all items on this Dap -e LOCATION Print / PROPERTY OWNER E Z R W &2 ;e- S i C1 i%L Print MAP NO.: A) PARCEL: TYPE AND USE OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration L� One family ❑ Two or more family No. of units: ❑ Industrial Jii,Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED / z .1)14-.- r' W I i do w I Identification Please Type or Print Clearly) OWNER: Name: 4Ncr E Z4 i d E /Z; Phone -97i • 6 S" SM Address: �(/ Z ;-.4 CONTRACTOR Name: ICEEEld 609.10-s TfZ cJ c, T� / Q •d Phonel %� ' C��}! -S-20 Address: 4 Supervisor's Construction License: Lf Exp. Date: 3 Home Improvement License: /0 g Exp. Date: ARCHITECT/ENGINEER Name: 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 S 2 0 e_ �o FEES -�o Check No.:—!z-, 7 ,� Receipt No.: ;L o 0 4 Page 1 of 4 TYPE OF SEWERAGE DISPOSAL Art ❑ Swimming Pools El g Public Sewer Well r .V ❑ Tobacco Sales ::-•.� Food Packaging/Sales ❑, Private El - ermar�ent Dumpster on Site ❑ _ � (septic tank, etc. Electric Metgr loeat qn toy, project INV I L: Persons contracting with unregistered contractors do not have access to the guaranty f d Signature of Agent/Owner vSignature of contract_ - 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 ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH, - ❑ - COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes d Fire Department signature/date Ilk COMMENTS - Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments - Water & Sewer connection/Sianature & Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Require Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 1V V 1 Lb and VAI A — (r or department use Page 3 of 4 Doc: INSPECTIONAL Created JMC. Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:BPFORM05 Page 4 of 4 ///-7 ",f Locauon 7/i:r No. Date TOWN OF NORTH ANDOVER 41 Certificate of Occupancy $ CHU A Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # t/0 Uilding Inspector N m. m m m y m y m o� s Ewa Q s __ 1 S_ =30 0 1 0 ca t C Mm 2 CrIc di -4 ro oma.°.t m d° T CL o' m o��� o y C � �. r m • _ O� o�0�O d m �, a y C') Lo• O ►-b 2r CD Z CO) R r �' CL CD �. CTi m o CL C/) �•� �. C. O cc cc Om a Z n° Icr cn C5 CD CL POO CD C% Er tv ma ,C CD y cn CD C. co `� '"� o 0 m . W (n CO) Oc CSD Z 0q o O aRCD R. o � 's CD cs W AL � C� � �'' O � �' � O rte., OV �'' O 4Q��.. "'t7 r L.- a- ` O qa�.r' O � `C', M n The Commonwealth of Massachusetts. Department of Industrial Accidents W Office of Investigations W ' d 600 Washington Street ,Wt Boston, MA 02111 , y www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ! Please Print Legibly l"�- Name (Business/OrganizatiorAndividual): eeri Address:—Z 1 77- Ay' E City/State/Zip: Q. R N d o l/ t rz. IXA Phone. #: 97$ 69Y - S Z 0 1 Are you an employer? Check the appropriate box: 1.0 I am a employer with 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- 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. ❑ 1 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' 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. V1 Other W i e- d a w S fAny 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. 1 Insurance Company Name: G R. A u i + S 7 A ] 6_ ZXI $ . C, - /� o Policy # or Self -ins. Lic. M CV C9 3 Expiration Date: l^ Q 9 O Job Site Address:_ �i/Z iw City/State/Zip: ef 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 pain,,;I�end penalties ofperjury that the information provided above is true and correct. use only. Do not write in this area, to City or Town: or town official Permit/License # 29 +o 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-contiactor(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 maybe 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-$77-MASSAFE Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia ACIORQ CERTIFICATE OF LIABILITY INSURANCE 03/22/2007 PRODUCER (781)942-2225 FAX (781)942-2226 Gilbert Insurance Agency, Inc. 137 Main Street Reading, MA 01867-3922 THIS CERTIFICATE IS ISSUED AS A 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 DBA: Keen Construction Company 21 Hewitt Ave. North Andover, MA 01845 INSURERA: NORFOLK & DEDHAM INSURANCE 23965 INSURERB: Granite State Ins. Co. 0077 INSURER C: INSURER D: INSURER E: I9181NO'T±TC12W THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN 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. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDfYYI POLICY EXPIRATION LIMITS NORTH ANDOVER, MA 01845 GENERAL LIABILITY ND -P-010078/000 03/13/2007 03/13/2008 EACH OCCURRENCE $ 1,000,00-0 r000,000 X COMMERCIAL GENERAL LIABILITY O R DAMAGE TENTED $ 100,000 CLAIMS MADE M OCCUR MED EXP (Any one person) $ S,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICYF_j PROECT LOC J 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 $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F] CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC8855053 01/09/2007 01/09/2008 WCSLIMIT OTH- EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CFRTIFICATF Hn1 DFR f AKIrPI I ATInKI ACORD 25 (2001/08) FAX: (978)682-3231 ©ACORD CORPORATION 1988 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 NAMED TO THE LEFT, KEEN CONSTRUCTION CO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 21 HEWITT AVENUE OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 DOREEN M DONOHUE ACORD 25 (2001/08) FAX: (978)682-3231 ©ACORD CORPORATION 1988 67/ �'� a�✓�%aaaccc/u�aetfa Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registr.44— 108383 Ex t-[-- $118/2008 _ w KEEN CONSTRUC�10'N Q� Kenneth Keen i 21 Hewitt Ave ..eC a •� No Andover, MA 01845' ' Deputy Administrator j < C�Jo�rvnwmur�ea�� cd4ura6 {{rr BbARD-OF BUILDIN zR G04 ULAT ONS s ir[n.aaie-u�i14/�yR3 !iP t�4�08 Tr: no 51 1:3436 es "I I TIiET I OR°AHEWI M� h z rlOV R ��IA.tYl4Py+a I i KEEN CONSTRUCTION CO. n 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978) 691-5201 Fax: (978) 682-3231 Submitted f L=, PHONE DATE C/S = Customer Supplied S + I_= Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: 1657) 0 P 0. 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 N0. F.I.D. NO. MA. H.I.C. 108383 04-325-8052 i rJ -