HomeMy WebLinkAboutBuilding Permit #731 - 54 SPRING HILL ROAD 6/25/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: J J31 Date Received
Date Issued: C -) I
IMPORTANT: Applicant must complete all items on this page
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LOCATION (� t h ! 1 Ra
f/ Print (
PROPERTY OWNER W ' i aM 'b L. r) -Q, (le(�
Print
MAP NO;Ib 7 PARCEL:2- L ZONING DISTRICT: Historic District yes no
Machine Shoo Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Re air, rep acemen
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESC PTION OF WORK TO E PREFORMED:
0. --Me
e �°In Z Wi pw
Identification Please Type �olr Print Cle rly) Phone:972-622- 7 / 7
OWNER: Name: r' -b - 2
Address: 5L� �S D r i ng� Mt Kol N.firK6-tr
CONTRACTOR Name: Keevl CGYkS'fUC'�'1AC Phone -573-9/- 5524 % `
Address:21 ew f kte t AAc ave(` M4
Supervisor's Construction License:C5 5E,92'f5 Exp. Date: 3/Z� 26/
Home Improvement License: fC> 9 33 Exp. Date: J gl2oi 6
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: $ 2 9,, g7/PEFEE: $ !g0
Check No.:rJ 92Q Receipt No.: a l �3
NOTE: Persons contracting with unregistered contractors do not have access to tkjg ra t y fqn
§ignature of Agent/Owner Signature of cor
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
ZPrniv:at�e(�septic�et .
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed o
COMMENTS
.HEALTH'
COMMENTS
a
r
Signature
Reviewed on Signature
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 §treet
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 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 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: Building Permit Revised 2008
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ADDlicant Informat
The Commonwealth ofMassachitsetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
ensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
�1
Please
Address: % f,ew i A
City/State/Zip: Jk) r Af?d6Tf_ r; Nh o1845Phone #: 97Y'69),5201
Are you an employer? Check the appropriate box:
1. X1 I am a employer with % 4. ❑ I am a general contractor and I
employees (hill and/or part-time).* have hired the sub -contractors
. 2. ❑ 1 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.t
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] 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. r71 Remodeling
8. ❑ Demolition
.9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #t 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.
In Company Name: t n rr n i ie 45z i ,o In s , Co _
Policy # or Self -ins. Lic. #: IAC. 793 1 Lf 7 7 Expiration Date: /09
Job Site Address: 1(' ) rku City/State/Zip: I v i �AQOVtr //I � 01
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
I do hereby certify i r th Ypain nd penalties of perjury that the information provided above is true and correct.
Signature: Date: �_2 5"d 9
Phone #: 9? 13'- (1-9.1- 52- 6 1
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 #:
4/8/2009 4:15 PM FROM: Gilbert Insurance Aq Gilbert Insurance Aq TO: +1 (918) 682-3231 PAGE: 002 OF 003
QCORQ. CERTIFICATE OF LIABILITY INSURANCE
MM
04/09/" 2°2009
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.
Porth Andover, MA 01845
INSURERA: NORFOLK & DEDHAM INSURANCE 23965
INSURERB: Granite State Ins. Co. 0077
INSURER C:
INSURER O:
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.
TYPE OF INSURANCE
POLICY NUMBER
OLICYEFFECTNE
PDATE IMMIDDIYYI
POUCYEXPIRATION
DATE immIDDIM
LIMITS
GENERAL LIABILITY
PID -P-010078/000
03/13/2009
03/13/2010
EACH OCCURRENCE $ 11000,00
rA
X COMMERCIAL GENERAL LIABILITY
DAMAPREMGE TO RENTED $ SO,
Sr
CLAIMS MADE ®OCCUR
MED EXP (Any one person) $ S'00
PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,1
GERL AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COAPIOPAGG $ 2,000,000
X1 POLICY PRO LOC
AUTOMOBILE
LIAMLIT/
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 acciderd)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESSAIMBRELLALUIBLITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR ❑ CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION S
WORKERS COMPENSATION AND
WC7431477
08/03/2008
08/03/2009
XI TORY R WCSTATU- oTr+
EAPLOYEPS' LIABLITY
E.L. EACH ACCIDENT $ 100 QO
B
ANY PROPRIEZOR7PARTNERlFJ(ECllT1VE
E.L. DISEASE - EA EMPLOYEd $ 100,00
OFFICER/MEMBER EXCLUDED?
II yes. describe under
E.L. DISEASE - POLICY LIMIT 13 500,00
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
riginal workers compensation certificates to be issued by company. Evidence of Insurance only.
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KING UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
NONE - EVIDENCE ONLY AUTHORREDREPRESENTATIVE
CIC
ACORD 25 (2001108) OACORD CORPORATION 1986
Aw too�nmaoouuea,�Cii o''✓�1dd1rc�ivael�a
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration,: 108383
Expiration 8(18/2010 Tr# 272473
YP
e DBA F
KEEN CONSTRUCTION C 0
Kenneth Keen
} 21 Hewitt Ave
No. Andover, MA 01845". ` Administrator
67
Board of Building Regulati sand Standards
w Construction Supervisor License
t
q License: CS 68245
Expiration! -3/24/201 0 Tr# 17840
C> # -
.4
Restric#ion 00`:
r
KENNETH B KEENJ
4 21 HEWITT AVE
N ANDOVER, MA 01W'-..' Commissioner ! I
- ---
✓iie �anvrrzoruoec��i a�'�; �,aa�crc�zuaeiGi
Board:of Buildinge.Regulations"aad,'Standards
Construction Supervisor License
License: CS 76691
�..
Blithdate "8/16/1968
Ex irat�on 162009 Tr# 3859
1 p
f'i2estnctifin >OQ.
ROBERT A KEEN
12 E` W. ATER' ST'G
N ANDOVE.:R, MA 01845 Commissioner
- 5013
KEEN CONSTRUCTION CO. GP
e 21 HEWITT AVENUE
®P®�A L
NORTH ANDOVER. MA 01845
Tel: (978) 691-5201
All home improvement contractors and subcontractors
Fax: (978) 682-3231
engaged in home improvement contracting, unless
specifically exempt from registration by Provisions of
Submitted f //
To: _...L� C/_..'.
Chapter
Chapter 142A of the general laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about
_..._
__._-........._._........�_✓............_ t
registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108
------- ................
��..j._.......---_......_........................__.....
(617) 727-8598.
Owners who secure their own construction related
Permits or deal with unregistered
... .... ............:....1.- ----_--_. _ ..
contractors will
be excluded from the Guaranty Fund Provision of
MGL c. 142A.
PHONE DATE
GJ
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:
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V ► �%' I C.` v. ` .61,L)
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.... ... _ _ _...._. _
C..�.t3 ►__)_� { to �° �l)��, C,U' �l U'
�i`�!^i11 , D 1 )[ti 1 r't 1 ) 17 �'i r'
> Construction related permits:
_................
.............
..............................-.................,..........,............................,...,......................._..........._._...
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 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 inaccordancewith above specifications for the sum of
y:
Ct.? " r,;n Cly' t, CI' ' \' , ."V4 J 7�vz / 15 / 9 .
Payment to be mahe as follows:
dollars ($ 7).
% ($ f�Q ) upon signing Contract; KENNETH B. KEEN 1 ROBERT A. KEEN
�. % ($ ) upon completion
o --
% (s5ir— '1 shall be made forthwith upon
completion of work under this contract.
Name of Contractor / Designated Registrant
21 HEWITT AVE.
mreetAddress
N. ANDOVER, MA 01845
City / State
(978) 691-5201 (978) 682-3231
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
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 tgnature
equipment, whichever amount is greater. Note: This proposal may be withdrawn by us if 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.
_Signature Date Signature Date
IMPORTANT INFORMATION ON BACK
Location
No. Date v D
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Permit Fee $
r
Other Permit Fee $
TOTAL $
Check # t5 D�
22*1'03
Building Inspector