HomeMy WebLinkAboutBuilding Permit #1296-2016 - 5 GREEN HILL AVENUE 6/10/2016 ` (� �J BUILDING PERMIT 3 NORTFr
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AMA `tom OF�T`eD
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION * ,�
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Permit No#• Date Received�1� l0 q
�s4°Rareo�e" �5
gSSAC HUS'(
Date Issued:
IMP TANT: Applicant must complete all items on this page
LOCATION S eA, r A�
Print
PROPERTY OWNER SGo±L S
Print 100 Year Structure yes
MAP �-2- PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yeso
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
r more family [I Industrial
❑Addition [I Two o y
❑ Alteration No. of units: ❑ Commercial
Q%Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
r]Water/Sewer --
DESCRIPTION OF WORK TO BE PERFORMED:
Rei kce_ i5k )t,.,er- n i + t cep a ;y- tea
Identification- Please Type or Print Clearly
OWNER: Name: 560 +-+ Ef i i S Phone:
Address: S Greer H ; << LIP, �J , 8n 0LQ\AeC'
Contractor Name:
eey, C_r►1I3`6c ic:✓I lo
- Phone: 978-691-'5z0 /
Email: eS tu c-4. cvL Co Go ,
Address PQ Go O �' G _e
Supervisor's Construction License: CS-U -7 60 t Exp. Date: l/6 I//7 f
Home Improvement License: /0? 30 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: $ 5 [ 35 ,
®O FEE: $ (P2_
Check No.: I �4b Receipt No.: e27 t)k4� 1" .17
NOTE: Persons contracting with unregistered contractors do not have access to th u n and
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
Certified Surveyed Plot Plan
4. Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/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
OTE: 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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Doe:Building Permit Revised 2014
i
r
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 Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
-oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
F`lanning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
,t Located 384 Osgood
Street _
A FIRE DEPARTiME 1Temp Durnp er q'-nr e�, 'e§ . . no`"
446cated at¢124 Main Streets T
h 4Fire.Department si .�- �-
r g=_natUurge/d°atb .
�GOIVMENI
Dimension
Number of Stories: Total square feet of floor area, based an Exterior dimensions.
Total land area, sq. ft.:
I
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 Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
r
,r
Location
No. �ZO1DateE ���
r
• - TOWN OF NORTH ANDOVER
r
Certificate.of Occupancy $
Building/Frame Permit Fee $In
Foundation Permit Fee $ `
Other Permit Fee $ _
`4
TOTAL $
Check# MID
/
3 0492 Building Inspect�'
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 59135.00 m
$ - $ 61.62
Plumbing Fee $ 7.70
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 7.70
Total fees collected $ 177.03
5 Green Hill Avenue
1296-2016 on 6/10/2016
Replace Shower Unit Repair Wall
r 1 NORT►y • -
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h ver, Mass, h,�l o �(
coc Mlc Ml MCC
�as RATED I'P�,`�5
1. IJ BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
•
THIS CERTIFIES THAT14 ,,, „4 BUILDING INSPECTOR �.
........................ .c.............. .. .............. ... ....................
... .. ........ . .. ..
has permission to erect .............. buildings on ..�..'t w4J �.....�C• Foundation
........ .... ............�... ................... Rough
to be occupied as ......�� .'�...showw...t*.O.k.... .. fir.. .......... Chimney
provided that the person accepting this permit shall in eve respect conform to 0e terms of the application p p p 9 p every p pp Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST Rough
Service
..... .... ........ ........ .......
Final
BUILDI INSPE OR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
57 ,
� f
KEEN 50NSTRUCTION O.)Jc 9 3 5 PROPOSAL
e
NORTH ANDOVER;MA 01845 All home improvement contractors and subcontractors
Tel: (978)691-5201 J engaged in home improvement contracting, unless
r
Fax:(978)682-3231 ! specifically exempt from registration by Provisions of
_ { i Chapter 142A of the general laws, must be registered
Submitted GG t #— ( 1 ;5 with the Commonwealth of Massachusetts. Inquiries
To: t IIII about registration and status should be made to the
JDirector,Home Improvement Contract Registration,10
Park Plaza, Room 5170, Boston, MA 02116 617-973-
�n /c 8787 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.
PHONE DATE REGISTRATION NO. EIN NO.
MA. H.I.C. 108383 46—3783401
> C/S=Customer Supplied S+I=Supply+Install C See Attached Appendix A
We hereby submit specifications and estimates for work to be performed and materials to be used:
1
Pr A
�v1 cel r k —
> Construction related permits:
_ ......._—._._...._....._._.....__..____.._.......................__.— ..._._.____............._............................,............................................................................................_............___.......................
_..WORK SCHEDULE —__._............_..____r_-__...._.._--.
Contra 'll 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 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 Contractor 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
-}
1 ;J,o,5A✓1J Cu L �1C� ,y all I I'1 i cl—1, ` �lf dollars($ �� 15.C)U ).
Payment to be made as follows:
% ($ ) upon signing Cotract; ROBERT A. KEEN
1 1\ Name of Contractor/Designated Registrant
_% ($ ) y, c c�nRl�tl n off -14g6
-T -Sr 7C; L X 925
) > Street Address
_p u�olr\t completion of. N. ANDOVER, MA 01845
City/State
($ ) shall be made forthwith upon (978)691-5201 (978)682-3231
completion of work under this contract. Ph o Fax
Notice: No agreement for home improvement contracting work shall require a M Le t i
>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
advance,to order and/or otherwise obtain delivery of special order materials and Authorized Signal&M
equipment,whichever amount Is greater. Note:This proposal may be withdrawn by us if not accepted within days.
Acceptance Of Proposal-1 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.
7
Signature Dale "' , �I�' Signature Date
IMPORTANT INFORMATION ON BACK ►
REMC)DELING SPECIALISTS
978-69-1-5207
KeenConstructionCo.com
Scott Ellis
5 Green Hill Ave.
N.Andover,MA 01845
Contract#5782; Appendix A May 24, 2016
Replace shower:
• Remove and dispose of existing tub and shower walls
• Supply& install Sterling shower unit,with full tub and three-piece walls
• Supply& install Symmons shower valve
• Patch plaster around shower
• Paint walls and trim in bathroom
Total Price: $5135 (five thousand one hundred thirty-five dollars)
Price does not include cost of permits or repairs to any unusual, unsafe or non-code compliant existing
conditions not addressed in this contract.
Payment Schedule: $1000 due upon signing contract
$1500 due when tub is removed (plus permit fee)
$1500 due when new shower is installed
F
$1135 due when contracted work is complete e`
i
Customer Robert Keen
9.
Date Date
PO Box 935 Page 1 of 1 P: 978-691-5201
N. Andover, MA 01845 F: 978-682-3231
CSL#076691 Sales@KeenConstructionCo.com HIC#108383
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
-
C11111t1 UCLIIIII JUIICI VI\111
License: CS-076691
ROBERT A KEElY
12 E WATER ST< IES
North Andover NfA 0
Yy'S �
� �:)rva' Expiration
Commissioner 08/16/2017
�1e�nn�auae�,�aea�l�
� o�UliLaa�ac�iu�leC�l
ice of Consumer Affairs&Business Regulation
E IMPROVEMENT CONTRACTOR
egistration:.;:
:Q 3 _� Type:
Expirab6n� 2r > Supplement Car
KEEN CONSTRUCTION ,. ,:.,;
ROBERT KEEN Ytr
1175 TURNPIKE ST
NO.ANDOVER, MA 01845
Undersecretary
ACORD® CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDD""")
11.1.1 10/23/2015
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(les)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 endorsements).
PRODUCER NAMEw Barbara McDonough
Gilbert Insurance.Agency, Inc. PHONE -2225 Fax o:(7e1>9d2-2226
137 Main Street pDIL .bmcdonough@gilbertinsurance.com
INSURERS AFFORDING COVERAGE MAIC N
Reading MA 01867-3922 INSURERA Norfolk 6 Dedham Insurance 23965
INSURED INSURERS:Safety Insurance Co=any 39454
Keen Construction Company INSURERC'Travelers Ins. Co. 0031
483 Chickering Road INSURERD:
INSURER II
North Andover MA 01845 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1552101779 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR I
TYPE OF INSURANCEPOLICY EFF POLICY EXP
Im POLICY NUMBER LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000
A CLAIMS-MADE a OCCUR
PREMISES currei 100,000
ND-P-010078/000 3/13/2015 3/13/2016 'MED EXP(Any one person $ 5,000
PERSONAL S ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X JECT �LOC PRODUCTS-COMPIOP AGO $ 2,000,000
POLICY O
OTHER: S
AUTOMOBILE LIABILITYBINEDSINuLt I
a $ 1,000,000
BANY AUTO BODILY INJURY(Per person) $
ALLOWNEO SCHEDULED -
AUTOS X AUTOS-O�� 6226807 COM 01 5/23/2015 5/23/2016 BODILY INJURY(Per accident) $
X HIRED AUTOS X NON PROPERTY DAMAGE $
H
Underkreured natodd S 100,000
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED I I RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y I NI STATUTE
ANY PROPRIETOWPPRTNERIEJECUTIVE ER
E.L.EACH ACCIDENT $ 100 000
C OFFICERIMEMBER EXCLUDED? a NIA
(Mandatary In NH) 6BUB-9997M5B-2-1S 10/8/2015 10/8/2016 E.L.DISEASE-EA EMPLOYEE S 100,000
0 yas,deealbe under
DESCRIPTION OF OPERATIONS bebw E.L.DISEASE•POLICY LIMIT 500.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddWonal Rarnarks Schedule,My be attached U mon spaca Is fegWnd)
CERTIFICATE HOLDER CANCELLATION
(978)623-8320
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
M Gilbert, CIC/BARBAR
®1988-2014ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025 notaon
The Commonwealth of Massachusetts
= Department of IndustrialACCidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
,••` www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le:sibly
Name(Business/Organization/Individual): 1t gen �(•VI 5�f-y
Address: 1935
G 1$P one#: 3— r`�r�� `b72,0
City/State/Zip:
Are you an employer?Check the appropriate box: Type Of project(required):
1.M I am a employer with Z-- employees(full and/or part-time).* 7. ❑New construction
2.n I am a sole proprietor or partnership and have no employees working for me in 8. WRemodeling
o workers'comp.insurance require .]
any capacity.[N required.] 9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole
11.0 Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insuranceJ
14.[]Other
6.[]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.]
*Any applicant that checks box 41 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.
TContractors 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. f
Insurance Company Name: �(��� '- I �5 15
Policy#or Self-ins.Lic.#: 14 U iJ 9/ 9 I j?, 2- Expiration Date:
Job Site Address: 'e eN t I �� City/State/Zip: A
g { 1
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration'date).
fine u to 1 500.00
fishable b a $ ,
2 is a criminal violation un y p
Failure to secure coverage as required under MGL c. 152,§25A P
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.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 ze p and penalties of perjury that the information provided above is true and correct.
Z/
Si ature: Date: tP
Phone#: 7
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#: