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HomeMy WebLinkAboutBuilding Permit #828-16 - 632 CHICKERING ROAD 1/21/2016A414 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: I IMPORTANT: ADDlicant must comblete all items on this baize I LOCATION �� Z �hr'G�Q.('i✓t� 4J _ r . int PROPERTY OWNER e,G4C(1 ,� Print 100 Year Structure yes anoMAP �PARCEL:ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer IDESCRIPTION OF WORK TO BE PERFORMED: b /,' h04kx(o/+ i pe; ,-n + L)fl ► Identification - Please Type or Print Clearly OWNER: Name: -T add; t Phone: Address: 19 30X Evrd k) , 4VI dGt1-�(— 0/31,51 Contractor Name: kat9il 6 U cr (�o Phone: Email: -,Ie-5 & CCAS cv nA Address: Po &x 9r35' t ✓t e— Supervisor's Construction License: 6 L2/ Exp. Date: !( (2�� Home Improvement License: fog3'93 Exp. Date: I ARCHITECT/ENGINEER Phone: Address: Rea. 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: $ On FEE: $_ /I ---- /21 Check No.: S Receipt No.: C�ZT�6r—zn NOTE: Persons cont acting with unregistered contractors do not have access to the ". Ir d Location " �� tG —lx, No. ( Date %9 Check # 1 --)- i TOWN OF NORTH ANDOVER Certificate of Occupancy $, Building/Frame Permit Fee $ + Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnnining P0013 ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING c& DEVELOPMENT COMMENTS CONSERVATION COMMENTS r HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comments Water & Sewer Connection/Sic nature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE .DE RAR)TMENT -:Temp Dumpster onsite ,yes I Loeatedjat ,124tWinrStteet Fire, Department�signature/date; .._ COMMENTS r 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA -- (For department use ❑ Notified for pickup Call Emai Date Doc.Building Pennit Revised 2014 Time Contact Name M 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 Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract r< 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 E: 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 TOTE: 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 F- n O u CO o Ln •Q. 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RM I REMC3DELING SPECIALISTS 978-697-520' Kee nConstructionCo.com Hunt, Teddie & Gene 19 Boxford St. N. Andover, MA 01845 Contract #5571; Appendix A Remodel 632 Chickering Rd.: January 21, 2016 • Remove existing tub and wallboard around it • Supply & install Sterling Ensemble fiberglass tub/shower unit, re -using existing shower valve • Disconnect power to code • Patch walls around new shower unit where needed • Secure dishwasher to cabinetry • Replace all smoke detector batteries • Qrganize electrical work (work to be billed separately) • Prep and paint all walls, trim, heat casing and ceilings in unit Total Price: $9750 (nine thousand seven hundred fifty dollars) Price does not include cost of permits or repairs to any unusual, unsafe or non -code compliant existing conditions not addressed in this quote. Payment Schedule: $1000 due upon signing contract $2000 due when shower unit is installed $2000 due when plaster is complete $2000 due when painters begin $2750 due at completion of contracted work Customer Robert A. Keen /2-1 Date Date PO Box 935 Page 1 of 1 P: 978-691-5201 N. Andover, MA 01845 F: 978-682-3231 C5L #076691 Sales@KeenConstructionCo.com HIC #108383 r L C`p �j •OCy �a; .0NOLod C7O O p N O^>M� m C N (0 N C O O Q> > C p 1- c v m' m d ti �ua`� 0 � oM O d N N Y T N N O C LL Z' Gl Z_ O C E L >'p v y w N U O C o d N U Y 0 E •� p 17 m '� a Y m u co p c �, N E o M m •E o y c o N y o O a>>1 E E w o o E o 3 or 0 CL m Q E � E U E d X Z N Q U EO m ICU. c Y O a. O .p N -j O a N U C 7 U sU+ 'n _ QI N N a•C+ O it W t9 _ 2 t . QdNU3�o(L 0 3o N cu Lu U C) W co � w 0 Cr- QCM �7 L C4 W ll > o ^, Y w0t0 M+�1 > — .� 0 co 0 ' 0 Q °z � 0 LO F- U- z�z W a i E J X a C: 4) CL Q Q L U co Q N U) El m rn c CL CL M •n OL U) a� O 7 U 11 U) U d CL m c 0 U 2 41 C O U IN 3 The Commonwealth of Massachusetts Department of IndustrialAccidents i d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia yv Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): L{/AeV, 5 fit) C C7 Address: C'.ity/State/Zin: lqn C16 11�e Are you an employer? Check the appropriate box: #: 973- (In 94 - 572n 1 1.M I am a employer with ___?:!:_employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 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.] Type of project (required): 7. ❑ New construction 8. Remodeling 9. Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12..Plumbing repairs or additions 13. ❑ Roof repairs 14.E] Other *Any 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. Insurance Company Name:/<37 /I I t' �5 / PI -5 — Policy # or Self -ins. Lic. #: (� /4 0 3 - 99 9E� 1 M5� - 2 _ Expiration Date: 17 Job Site Address: 2-l c,` rt q City/State/Zip: , /1! �l Attach a copy of the workers' compensation pol y declaration page (showing the policy number and expiration date). 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 certifytn er t pa's and penalties of perjury that the information provided above is true and correct. =PWV� 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 Aco O® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 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(ies) 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 endorsement(s). PRODUCER Gilbert Insurance Agency, Inc. 137 Main Street Reading MA 01867-3922 CNNT AC Barbara McDonough PHONE (781) 942-2225 FAX No: (781)942-2226 nDDRIESS:bmcdonough@gilbertinsurance.com INSURERS AFFORDING COVERAGE NAIC 0 INSURERA Norfolk 6 Dedham Insurance 23965 INSURED Keen Construction Company 483 Chickering Road North Andover MA 01845 INSURERS:Safetv Insurance Company 39454 INsuRERc.Travelers Ins. Co. 0031 INSURERD: INSURERE: INSURER F: GUVtKAGt5 CERTIFICATE NIIMRFRCL1552101779 RFVIRIAIU NI I"Mcc. 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 LTRPOLICY I TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NUMBER POLICY EFF POLICY EXP LIMBS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,000 PREMISES aoccurrence $ 100,000 MED EXP (Any oneperson) f 5,000 ND -P-010078/000 3/13/2015 3/13/2016 PERSONALE ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: X POLICY❑ JECT F1 LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGO $ 2,000,000 $ OTHER: AUTOMOBILE UA131 ITY COMBINED SI I $ 1,000,000 a acct em BODILY INJURY (Per person) $ E•ANY AUTO ALLOWNED X SCHEDULED AUAUTOS 6228807 COM 01 5/23/2015 5/23/2016 BODILY INJURY (Per accident) $ X HIRED AUTOS X AN�OO MED PROPERTY DAMAGE $ Underinsured motorist $ 100,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION -7- C AND EMPLOYERS'LIABILITY YINA ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If Yes, describe under N I A 6HUa-99911458-2-15 10/8/2015 10/8/2016 TE I ER ISERTU E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE - POLICY UMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CEK 111'ICATE HOLDER CANCFI I ATIAN (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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025nouDn Massacnusetts - Uepartment of w.ublic Satety Board of Building Regulations and Standards LI/II\LI VL111111 aurlei V1\111 License: CS -076691 ROBERT A KEEr1- 12 E WATER ST �¢ North Andover NSA 0 S '�� Expiration Commissioner 08/16/2017 &14 Office of Consumer Affairs & Business Regulation Vel,,ME IMPROVEMENT CONTRACTOR gistration: pp8383 Type: iration:DBA KEEN CONSTRUCTIOhIN a Kenneth Keen 1175 TURNPIKE ST NO. ANDOVER, MA 01845` i Undersecretary