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HomeMy WebLinkAboutBuilding Permit #743-2016 - 66 HERRICK ROAD 12/18/2015Ard,M BUILDING PERMIT TOWN OF NORTH ANDOVER (APPLICATION FOR PLAN EXAMINATION M_2 Permit No#: _ /__J lto Date Received (� tt LED 16♦�NO o A Date Issued: 12AI 115 IMPORTANT: Applicant must complete all items on this page LOCATION �e r- r + -c k PROPERTY OWNER 1 �t r'e� Print 100 Year.Structure - yes n MAP Qt PARCEL �� ZONING DISTRICT: Historic District yes Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 00 Repair,. replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer N OF WORK TO BE PERFORMED: Identificati n - Ple se Type or Print Clearly OWNER: Name: �� r 0. i s G 10,1,/— Phone:922' 77 3 3(93 Address: 9 Supervisor's Construction License: �$ �� 67& � t —Exp Date s kc, Home Improvement License: t Q,; .3F3 Exp. Date:`i� //'g I , 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: $ F06 ®t dy FEE: $ I te — Check No.:' v] � 'I Receipt No.: 2.5;ts ?I 10 NOTE: Persons contracting with unregistered contractors do not have access to the ran furl ;Signature of Agent/Owner - Signature of contractor 1�J__/G_ �11 4 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 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments tx Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Gated 384 Osgood Street FIREVE PARTMENT =Temp Dumpster on site yes,no Located: at 124 Main Street Fire-Departmentsignature/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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Nu i is ana UA I A — (I -or department use ❑ Notified for pickup Call Ema Date Time Contact Name Doc.Building Penuit Revised 2014 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 o 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/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 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 VOTE: 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 Location 4eq 2 t Nrt No. Date ws Check # 1-114 2`"' 39 .0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $! TOTAL $ Building Inspector v C � — N n M p CD 0 Z CO CDo �o CL —• _ >(o y vCD CD CL Cr _ CD (1) o �oCDo� N� CL 0 5.0 N CO C o N z 0 70 CD C CD 0 O Z m rn Cl) Cl)� nm Ox z -cn v �m C in ME —W-21 zic z cn h CD co O W CD co 0 2. O CA rt o�%v _ N =� < mU) MU rn ccD, CD n CD n 5Q m c � v► a; (D -n O O .+C m W 0 'a y p CD CD 2 � C n � to 0- U) NO W � O CD - � O O O c � O°N�h (D o 0 3 _� ...p CD U) Q. =C.) =r: 0 0 U2Q In N o 0 Wr 6F �C cn!Z to 0 O O CD C CD CD N O O W C.) W CCD -0 p1 � fl1 O O O CL N N W T m T N po -nm T (� m T VI T c N N T, fD Z UO Oq 00 Oq 3 = Q Z (D v N O < rr .0 rr O r 3 rD N m ��.. W 3 :3 C C W mO H v v 00 n z CA) o n N N a m m m m m . Z� 70 O 2 0 O 0 O W � W O KEEN CONSTRUCTION CO. PROPOSAL e 1175 TURNPIKE STREET 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: \ r '�\� G I I i r - with the Commonwealth of Massachusetts. Inquiries Toabout registration and status should be made to the Director, Home Improvement Contract Registration, 10 - G "I! ` `�'I " Park Plaza, Room 5170, Boston, MA 02116 617-973- !� ( 8787 Owners who secure their own construction o 1_6 5 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. o-42-11. 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: 4�- etNQ,-elS�;��� �C' C� �('G C.> j > Construction related permits: `___. ....... _.._... _....... ... ... _........ __.......... .._............. __....,.....,,._.._.._.... __........................... :... ..... ....... .... .... ........ .............................................. ........ ... ..... . WORKSCHEDULE _...__......__...._.............._._....._...._ _.._.__.......... Contra for wll not gi he work or order the materials before the third day following the signing of this Agreement, unless specified her i rlti s o tr or will begin the work on or about (date). Bardng delay caused by circumstances beyond Contractor's control, the work will be completed by G_ -- - I date). The Owner hereby acknowledge and groes 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 \ PSC 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 damontractorT age caused by the Cubcontractors, 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 dollars ($ ) 00 ), Payment to be made as follows: ($ ) 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 ($ tliy�) shall be made forthwith upon (978) 691-5201 (978) 682-3231 completion of work under this contract.Pht° <1 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 n! 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 Authorizbb Signature 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. OT SIGN THIS CONTRA FT IF THERE ARE ANY BLANK SPACES. I I' j C� Sig ah lure / / % l / Dale I1) Signature Date IMPORTANT INFORMATION ON BACK ► The Commonwealth of Massachusetts Department of Industrial Accidents a d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia ti I rance Affidavit: Builders/Contractors/Electricians/Plumbers- Workers Compensa on nsu TO BE FILED WITH THE PERMITTING AUTHORITY. A_ pphcant Information Please Print Legibly Name (Business/Organization/Individual): 0&1 Sj f -y L 1 Ca/1 Address: k i V—)0 X 7_ C';tv/Mate/7,in: � ��� vC7�►��IC � � 6r Are you an employer? Check the appropriate box: #: 9?3- (e -r 94 r 572n 1 1. 21 I am a employer with 2-- employees (full and/or part-time).* 2.Q I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.1 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) 6. Q 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 11.0 Electrical repairs or additions 12._1 Plumbing repairs or additions 13. N Roof repairs 14. ❑ 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: J_rc, ve f r5 In -5 — Policy # or Self -ins. Lic. #:6 11 U rB 99 91 2- Expiration Date: 10 L -F ZI C�'/ i State/Zi fioj, � ` Job Site Address: E (G Attach a copy of the workers' compensation policy 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 certify uhd r th pai . dpenalties ofperjury that the information provided above is true and correct. natP• 12—/7 / ��.io 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 #: ACOR 7 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MIWDD/YYYY) 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 CONTACT Barbara McDonough NAME: g FAX AHC N Ext): (781) 942-2225 AIC No: (781)942-2226 ADDRESS,bmcdonough@gilbertinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA Norfolk & Dedham Insurance 23965 INSURED Keen Construction Company 483 Chickering Road ' North Andover MA 01845 INSURER B:Safety Insurance Company 39454 INSURERC:Travelers Ins. Co. 0031 INSURER D: INSURER E: 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 LTR TYPE OF INSURANCE DDLSUBR POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE a OCCUR DAMAGE TO RENTEU-- PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 ND -P-010078/000 3/13/2015 3/13/2016 PERSONAL & ADV INJURY $ 1, 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ JET F-1LOCPRODUCTS - CCMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS 6228807 COM 01 5/23/2015 5/23/2016 BODILYINJURY(Peraccident) $ PROPERTY DAMAGE $ (Pe accident X HIRED AUTOS NON OWNED AUTOS Ix Underinsured motorist $ 100,000 UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 C OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A 6HUB-9991M58-2-15 10/8/2015 10/8/2016 E.L. DISEASE - EA EMPLOYE9 $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) ) 623 - Town of North Andover ACORD 25 (2014/01) INS025 (2014011 I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gilbert, CIC/BARBAR ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Safety Board of Building Regulations and Standards q-I/II.ILI Ulllllll au'r1ei-VISOF License: CS -076691 ROBERT A KEET�-, 12 E WATER ST 4 North Andover WA 0 Al '-wig", Expiration Commissioner 08/16/2017 Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR .elgistratilDn: ;;J08383 Type: xA/-f i xpiration: DBA KEEN CONSTRudi"Off"No- 15' Kenneth Keen` 1 V-- 1175 TURNPIKE ST \ NO. ANDOVER, MA 01 84V---5` Undersecretary