Loading...
HomeMy WebLinkAboutBuilding Permit #239-2016 - 571 FOREST STREET 8/26/2015 BUILDING PERMIT 0 NORTkf q (t LEO 6 -y o TOWN OF NORTH ANDOVER A APPLICATION FOR PLAN EXAMINATION APPLIC Permit No#: ` r Date Received J sSgcHuse Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 5'l 1 Fo res fi 6t 6,A , � L,L C-, P avPROPERTYOWNER Print 100 Year Structure yes o MAP _PARCEL: �� ZONING DISTRICT: Historic District yes Lfio 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 $Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other flfSeptic ❑ FT, afWetlands l ' UVateeshedl*Dstnct; fl INate�/Sewer ' �n K DESCRIPTItO�N OF W/ de-e- TOBEPERFORMED: / iSG �t'r1M �4 r-r Do1, j am'+ e- QEr �t' V'e vtl0 d e— Identification- Please Type or Print Clearly OWNER: Name: Afar{- Qi r-c k LrLC Pau( bn2o �`JVhone: Address: P6 box g'B ( k , findothe f' 0 Contractor Name: Kwo � Sf� r Co Phone: Email 56,to 5 6-- .ems- S r (J all CC , Co rx Address: U 2 5 Tu ike 51 At o O /- Supervisor's Construction License: CS` 0`7 Exp. Date: Home Improvement License: CO 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. a Total Project Cost: $ L(500 . 00 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wid unregistered contractors do not have access to th ua `nty and �. r 4- Location �J No. �. �1 `� Date • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ ,. Check# ti Building InApector 25 2 4 Y Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiimning Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Q-nservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit s DPW Town Engineer: Signature: Located 384 Osgood Street „o.. y�-., �.�.e+++.� yYw 7r?:"fi °-�1. C#a T e� "�3wcp- FIRE D,AMM - , Ternp�Dumpsfer on site=yres ,� no� �' 3 4MC-2ted at 124 Main Streets y �-sr..-... a wt.S:*. ,. �-l�v ;�:*ts[�,"�#i4 ���t�=• :s.,L,}�tyc s �y :, 'Y %�• 4 �•, Fire Depa mentsignature/dat�e " ' dr i 7� �� i..7' ; •� 1 '� r r¢ $b�sft %- rC'1 3 - 1 K,� ver w. L+c.&#.�. £ ..{�. 4�� a �, �„4. iF�.,, = J^ a t'je.+tt�c •� u=�4 f� � Ja�i4 �t .;�, �.�.e}r �'�v - :{ COMIVIENT,�S;» A � 1 =�"'� §'• C � •� ` ���'ra ��f4 ,t% �i x ...� ��e �� t t = : F :.- � t:,ti s 4• •.,a � _<..S.z.�.Y, ,.....:�..i...s...aw.. .�_�,r.,.�e.h aa+�..�w>.,.-+.� .=.e+i «....:�,�»:.t._+-w.,....«..t`.e:�. -+a.y��. 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 4. Building Permit Application 6 Workers Comp Affidavit 4, Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4. Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign offrom 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/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 IECC 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 Doc:Building Permit Revised 2014 r , 1 NORTH - 0 Von No. � a h , ver, Mass, COCNIc"t WICK y1. �.9 ADR�ITED I' 05 S u BOARD OF HEALTH Food/Kitchen PER . T T LD Septic System THIS CERTIFIES THAT ......... ...............1 L1 J A w'A�'� BUILDING INSPECTOR 1... ... has permission to erect .......................... buildings on . ..\...... .............................`........ Foundation .... .. I 6:0tojRough to be occupied as .;461& ftL �in.! �� .�. R1... N Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspect' Alteration nd d, 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 I0,NTHq ELECTRICAL INSPECTOR UNLESS CONSTR TA S Rough Service ......... .......... ........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy 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. 1 KEEN CONSTRUCTION CO. rp:r&cmr&AOM4L P e%Alb, i A a 1175 TURNPIKE STREET rmu wbAL I NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax: (978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted No( - �G"' rU r-� (_,.l.�l__. with the Commonwealth of Massachusetts. Inquiries To: I I about registration and status should be made to the ( Director, Home Improvement Contract Registration, 10 l LI �c, S SCJ 6{r4 � Park Plaza, Room 5170, Boston, MA 02116 617-973- i G 8787 Owners who secure their own construction Q B©X D related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision 9(4 of MGL c.142A. PHONE DATE REGISTRATION NO. EIN NO. c Z MA. H.I.C. 108383 46— 3783401 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: bc, 'k [,P-' a'\\r- 'b (E o I 54c, I ,rte ID Jec,. R,E\vIOVp— �x i j '1 c ^ ) � �cti�� � ��� ,� J S ( 711 wc,,AP cL Prd I f•er +� 4 rc �p�f d k J Ck J Ld a J � S�Q C0 31. e-r- \_c1 i �� be I V1 C) C': 1 , Construction related permits: > i ..............._........................................_.................................._......... WORK SCHEDULEor Contra ll,qof-be in a work or order the materials before the third day following the signing of this Agreement,unless specified her 'n r'ng. o tractor will begin the work re y about L"�� ( (date). Barring delay causer 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 Q following completion and shall The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 9 com P 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 onyear 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. e We Proposehereby to furnish materialandlabor-complete in accordance with above specifications,for the sum of dollars($ L4 5C)0 , 00 ). Payment to be made as follows: ($ ��G ) upon signing Contract; ROBERT A. KEEN Name of Contractor!Designated Registrant ($ ) upon completion of 1175 TURNPIKE ST. Street'Address ($ ) upon 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. Phone Fax � Notice: No agreement for home improvement contracting work shall require a C)be f > advance deposit)of more than one-third of the total contract price Name o'Salesm down payment ( p ) 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 Autho ed Si atur i equipment,whichever amount is greater. Note: This proposal may be withdrawn by us if not accepted within days. I Acceptance of Proposal -l 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 J this transaction. Cancellation must be done in writing. O NOT SIGN THIS CONTRACT I THERE ARE ANY BLANK SPACES. Signature Dale 2-'i Signature Date f IMPORTANT INFORMATION ON BACK ® i The Commonwealth of Massaehusefis Department of Indiust� ialAccidents 1 Congress Street,Suite 100 Foston,MA 02114-2017 -t www mass.gov1dia Sy Workers'Compensation Insurance Affidavit:BuRders/Contractors/Electricians/Plumbers. TO BE FILED Vff TH THE PERMTTTING AUTHORITY- Applicant UTHORITY.A licant Information Please Print Le IV Name(Businesslorganization&dividual): Gf/1 r1J�- rCJ✓l Address: `l -25 Iy r-Y, City/State/Zip: done##: Areyou an employer?C&e'ktlie appropriate box: Type of project(required): 1.[0 1 am a employer withemployees(full and/oz part time).* 7. E]New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In 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. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors withno 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.insurance.1 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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. ?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-confir-6s fiave employees,they must provide their workers'comp.policy number. am an employer that is pfoviding workers'compensation insurance for my employees'Below is the policy and job site information. Insurance Company Name: Ce — Policy#or S elf-ins,Lic.#: U Q- 9 9 ��5 Z "' Expiration Date: Job Site Address: 57 + Fi��fi S City/State/Zip: Attach a copy of the workers'eoinpensation-policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify u the ins penalties of perjury that the information provided above is true and correct Si nature: Date: 2 6 j 5 Phone# 9 $ 9l 5 Z 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): i 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 empYoyees. 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." Auemployer is defined as an individual,partnership,association,corporation or other Iegal entity,or any two or more of the foregoing engaged in a joint enferprise,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=contractor(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 Hue. 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 numb or 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 proofthat 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-"SAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia RightFax C3-1 3/24/2015 9:51 : 03 AM PAGE 2/002 Fax Server DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE TU4001FICATE 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 PRODUCER.OR E 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 and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: GILBERT INS AGCY INC PHONE FAX 137 MAIN STREET (A/C,No,Ext): (A/C,No)- E-MAI L READING,MA 01867 ADDRESS: 246WY INSURER(S)AFFORDING COVERAGE MAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA KEEN CONSTRUCTION CO INSURER B: INSURER C. INSURER D: 1175 TURNPIKE STREET INSURER E: NORTH ANDOVER,MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEAMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMtDD\YYYY) (MMOD\YYYY) LIMITS GENERAL LIABILITY =ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F-1 OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY E]PROJECT❑LOC DRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON OWNED AUTOS (Per accident)PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-999IM582-14 10/08/2014 10/08/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N WA E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT VE NORTH ANDOVER,MA 0184526 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. Massachusetts -Department of Public Safety Board of Building Regulations and Standards �.11111L1 Ultlll 11 JUIIGI VI,1111 License: CS-076691 til TT.� ROBERT A KEE = 12EWATER ST North Andover NrA 0 Y `L Expiration Commissioner 08/16/2017 Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Vx, .egistration: x.1,08383 Type: piration:;�-81*12016,; DBA KEEN CONSTRUCYION CD:. Kenneth Keen } >r 1175 TURNPIKE ST N0.ANDOVER,MA 0184$ -�'r Undersecretary