HomeMy WebLinkAboutBuilding Permit #81-11 - 45 CHESTNUT STREET 7/23/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: / s/ / Date Received
Date Issued:
-0g, 0
IMPORTANT: Applicant must complete all items on this page
LOCATION I'C Y1 Z S N o'T` -
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Print
MAP NO:a 10 PARCEL: S ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
impair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
ut;,l.K1r i IUK Ur VIIUKK I U
L
PERFORMED:
119 IV S v/
IZA NI (!I rl C "4e i J
2 v►� d 1-2 a -iT V F�_ Le -
Identification Please Type or Print Clearly)
OWNER: Name:
Address:
Pho
CONTRACTOR Name: K -a- IJ Phoneme]'? ' 1 / l rc�?cti1
Address: C1...s i ` _ ✓ t bq NA. t .;
Supervisor's Construction License: c' ` Exp. Date:
Home Improvement"License, D 1i 3 3 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: $ f -13- 7 FEE: $ �_6*
Check No.:��'j Receipt No.: a s I (Q
NOTE: Persons con ratting with unregistered contractors do not have access to the gil4iranty fund
re of contra
Location
No. % Date
^TM TOWN OF NORTH ANDOVER
16
+ ; , Certificate of Occupancy $
CNUS t� BuildinglFrame Permit Fee $
Foundation Permit Fee $
V-.
Other Permit Fee $
TOTAL $
Check # .& -
2326 Ij
Building Inspector
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
K
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 724 Main Street
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 6n.$100-$1000 fine
Doc:.Building Permit Revised 2008
r -
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: Doc.Building Permit Revised 2008
'
The CommonWea&k of Massachusetts
j (
Department of Industrial Accidents
Office Investigations
of
iva�t ;'
f
600 Washington Street
Boston, IwL4 02111
www_mass.gov/din .
Workers' Compensation Insurance Affidavit. Builders/Con
Applicant Information tractors/Eieatriciaas/Piam6ers
Please Print Leg -
Name (Business/oTSmizationnndividual);
Address: oZ f i F w i
$�S Phone A:.
•Sao
Are you an employer? Check the appropriate box:
[. �I am a employer with -L_ 4, g T
ypef project (required):
❑ 1 am a general
employees (full and/or part-time).*
❑ I am.a.sole proprietor or
contractor and I
have .Izii ed the sub.aorihactorsew construction2.
partner_
and have no employeesThese
listed on the attached sheet !emodelingship
sub -contractors haveworking
far me in any capacity,
worltErs' comp. insurance
workers' comp. insurance. emolition[No
5.❑We arc a corporation and its uilding additionregtnred
]
l din a homeowner doing all workright
officers have exercised their lectrical3•❑
repairs or additionsmyself.
of exemption MGL
[T10 workers' comp.
per iumbin
c t5 grep ' oradditionsinsurance
Z' § 1(4), attd we have noq
re aired t
]
employees. (No workers' oof repairs r(comp.
insurance required.] ther til t Nd••e)W j' .•Any applicarrt thatchecks bolt I must also fill out the sectionbelowshowing their:workets'compensationynrmation
Homeowne F who submit this affidavit indicating they ars loin an work
Contract°ts that end hire
check this box muatettache an aacs,•-tional sheaf show
outside cvnuactots must submit anew affidavit indicating such.
am
tng the name of the sub -contractors and their worimm,
r..
• _••• — crrw-.PUr raw is' rot�/i Worke ' . -- r •. , liau nnau0n.
infornurfinn p : g rs contperrsaYion ins'urancefor dry. employees; Below is thep �'o1' and job site .
Insurance Company Name: ' iJ 2#q N �- E '
�-N S
Policy # or Self. -ins. Lie. #: *7
3
Expiration Date.
Job Site Address: C S�'ry .V� C fi
Attach a copy of the workers' compensation Policy declaration Crit'/State/Ltp. N(�
Pa y la ratSon page (showing the policy number and expiration date). .
Failure to secure coverage as required under Section 25A of
fine up to S`1,500,00 ad/or on ear im MGL c. 152 can lead to the imposition of criminal pena]tics of a•
n
Y prisonment; 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
Investigations of the DIA for insurance coverage verification. may be forwarded to the Office of
I do hereb3
me pat7,;�
d enaldes of perju y that the information provided above is tine and correct
7PA � ..
Date:
Phone 4-
0
- ,
ficial USE only. Do not write Ln this area, tv be complezed by city or town o�cia[
City or Town:
Permit/License #
Issuing. Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PlumbingIns
6. Other
pector
Contact Person:
Phone #:
072/ -
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Reglst�.*_tip 108383
E-�-X' -btibjlf��,87118/2010 Tr# 272473
gir
KEEN CONS] Ky,,
Kenneth Keen
21 Hewitt Ave
No. Andover, MA 0 1 E
Administrator
N/1 Department (A Public SlIfet.
�, Board of Building ReaulatiohS and Stilildlit-ds
at
Construction Supervisor License
License: CS 58245
Restricted to: 00
KENNETH KEEN
21 HEWITT AVE
N ANDOVER, MA 01845
Expiration: 3/24/2012
T r#: 20523
V1 ass IcDepartmentPublic �S.Jfel-
lusettS - .oj
Boat*(] of Building Re,,Uj�jtjo "S ;,')(I Standai .
Construction Supervisor Supervisor License
License: CS
76691
Restricted to: 00
ROBERT A KEEN
12 E WATER- ST
N ANDOVER; MA 01845
Expiration: 8/16/2011
Tr#: 1690
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3/30/9011) 9.30 AM FRr1M- Ci Iho t T---- ri Iho. Trvnn n ---- 1, ...,-
gC�,,M CERTIFICATE OF LIABILITY INSURANCE
DATE (MMMON"
03/30/2010
PRODUCER (781)942-2225 FAX (781)942-2226
Gilbert Insurance Agency, In'c.
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 Keen & Robert Keen
DBA: DBA Keen Construction Company
21 Hewitt Ave.
North Andover, MA 01845
INSURERS NORFOLK & DEDHAM INSURANCE 23965
INSURERB: Granite State Ins. Co. 0077
INSURER C:
INSURER D:
INSURER E:
irw�w.�nsti
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.
INSR
LTR
DD'
R
TY PE OF INSURANCE
POLICYNUMBER
POLICY EFFECTIVE
M
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
ND -P-010078/000,
03/13/2010
03/13/2011
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITYDAMAGE
TO RENTED $ 50. 000
CLAIMS MADE fl OCCUR
MED EXP (Any one person) $ 5,000
A
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $ 2,000,000
POLICY PRO- LOC
JECT
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 $
EXCESSAIMBRELLALIABILITY
EACH OCCURRENCE S
OCCUR ❑ CLAIMS MADE
AGGREGATE $
$
DEDUCTI8LE
RETENTION $
$
WORKERS COMPENSATION AND
-W0006371378
08/03/2009
08/03/2010
1WC STATU-OTH-
I TORY LIMITS
B
EMPLOYERS'LIABILITY
ORI
ANY PROPRIETOR/PARTNER/EXECUTIVE
INAL TO BE MAILED VIA
E.L. EACH ACCIDENT $ 100,00
OFF ICEPJMEMBER EXCLUDED?
MASS WORK COMP BUREAU
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 I LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT[ SPECIAL PROVISIONS
Evidence of Coverage
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRrrTEN 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
AUTHORIZED REPRESENTATIVE
Mark
ACORD 25 (2001108) rax: ky(a)tb[s-ss[u OACORD CORPORATION 1988
Jul 22 10 06:00a Millwork Sales
Jackson
LUMBER & MILLWORK
97.8-689-1>097
Billing Fax: 978-687-5841
215 Market Street 234 Primrose Street 10 IndustrialDrive 145 Temple Street
Lawrence, MA 01843 Haverhill, MA 01830 Raymond, NH 03077 Nashua, NH 03060
Phone: (978) 686-4141. Phone: (918) 372-7727 Phone: (603) 895-5151 - Phone: (603) 883=7777
Fax: (978) 589-1023 Fax: (978) 373-7443 Fax: (503) 895-5152 Fax: (603)•883-7778`
MAIL TO: Jackson Lumber & Millwork Co. Inc.
PO. Box 449, Lawrence, MA 81842
KEEN CONSTRUCTION
KENNETH B KEEN
21 HEWITT AVE .(978)691-5201
NOANDOVER, MA. 018455215
Customer # Quote # Quote Date ..-
4676 224241 07122/2010 1'36 1.
P.1
Quote
This Quotation is valid t. ru 7119/2010. :After that it is subject to review
by Jackson Lumberan Millwork. Special Order and Manufactured
merchandise is Non -Returnable.
Page 1 of 1 7/2212010 9:26:24AM
TaM
QTotal
Lmul
Ct
C� qSc%,
Item Number
OrderedLN#
..
1
SOARC.HMILL
1
310 X 6/8 S-262 GBG W112"
EA
1,033.10
1033:10
MODEL # TRP30BGL TRANSOM
- 4 518 FRAMESAVER
- TT4X4 YZ BUTT
- ADJ ALUM SILL W/EXTEND. HORN
- PVC CONCORD HEAD PC
- 514 X 6 FLUTED PILASTERS PER
SKETCH; DOUBLE.BO'RE
- LH INSWING
This Quotation is valid t. ru 7119/2010. :After that it is subject to review
by Jackson Lumberan Millwork. Special Order and Manufactured
merchandise is Non -Returnable.
Page 1 of 1 7/2212010 9:26:24AM
TaM
QTotal
Lmul
Ct
C� qSc%,
KEEN CONSTRUCTION CO. GP
a 21 HEWITT AVENUE
NORTH ANDOVER. MA 01845
Tel: (978) 691-5201
Fax: (978) 682-3231
Submitted
1 _rt
jj
..._.... _.._..._...r:.. . . ................ .._1�.....-�..............._c'%_r_
PHONE DATE
b2J6
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
> C/S = Customer Supplied S + I = Supply + Install ❑ See Attached Appendix A
We hereby submit specifications and estimates for work to be performed and materials to be used:
.._.
......... �1 _r� �- -�G r_-. �N L,
.., -
I r2 ;
jC• lr t �> 17 r!
> tt�ll
r`'i1lc. Construction related permits: __ -----
6
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WORK SCHEDULE
Contract r 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 rfr . (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 _ % Y l 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 Contracto , 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 with above specifications. for the sum of :
I--- � — `�
—F k)ny >`;. t�� C` 1" r'�yc�t/L1l) dollars ($ y% %t� l ..
Payment to be made as follows: )
($ Q A ) upon signing Contract; C KENNETH B. KEEN / ROBERT A. KEEN
Name of Contractor / Designated Registrant
4Q
% ($ ) upon completion of _ J L L 0 j 1/ .z 21 HEWITT AVE.
Street Address
i° $n I: ANDOVER
( �� upon completion of �� r t �. n �--�•1--w ���'r�)� :z�, , MA 0185 '
"S- E'�', •-) * r Z , y) City / State
% ($ �� T b) 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 i
down payment (advance deposit) of more than one-third of the total contract price Name o! Sales an -�
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 Auth ri igriature r/
equipment, whichever amount is greater. Note: n s proposal may be withdrawn by us it 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.