HomeMy WebLinkAboutBuilding Permit #856-15 - 79 GRAY STREET 4/27/20156177. �.[
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111 BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit ge - T -
Date Received
Date Issued: 11157-
.
IMP RTANT: Applicant must complete all items on this
11
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LOCATION' ? 9 —
PROPERTY OWNER 9-f C.k 'b �,n t h :I ci -'-
Print100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yeso
Machine Shop Village yes o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
[)CRepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition[IOther
Septic q Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
Q Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please TypeAU-I'MccV�
PClearly
OWNER: Name: P � ,. c -b �c. �. -� Phone: -
Address: .7 9 C-) Cry 5 t ItA
5AV(,i Co
Contractor Name. Phone: ? 7- (91- 52.0 1
Address:
1mox
Supervisor's Construction License: (f5- 677 &L-91 Exp. Date: 1_ I to II
Home Improvement License:._ 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: $ % % 0 00 FEE: $ -
Check No Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to guar ty d
gnature of Agent/Owner Signature of contractor
2-67
Location
N o. �-_S Date is'
4 If
Check # "
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ W2,
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
11
1z
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
TYPE -OF SEWERAGE DISPOSAL
_ fD
Public Sewer ❑Swimming
Tanning/Massage/Body Art ❑
Pools . _ �'❑ ' ' -
Well ❑
Tobacco Sales11
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
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Wp ter & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NU I t5 and DATA — (For department use
❑ Notified for pickup Call Emai
No
Date Time Contact Name !
Doc.Building Permit Revised 2014
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
a 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
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 2014
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5 5,'
KEEN CONSTRUCTION CO. �O ���
° 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
n 1 + Chapter 142A of the general laws, must be registered
Submitteodf� G { K< 1 �Cf G C "1 with the Commonwealth of Massachusetts. Inquiries
about registration and status should be made to the
-)9(/_ Director, Home Improvement Contract Registration, 10
y rGut Park Plaza, Room 5170, Boston, MA 02116 617-973-
) DI �� 8787 Owners who secure their own construction
dCV,\-- 4r �r I I related permits or deal with unregistered contractors
will be excluded from the Guaranty Fund Provision
of MGL c. 142A.
PO7 E / DATE REGISTRATION NO. EIN No.
7 g. �j 96 — %z b 7 y /J5 / MA. H.1 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:
r fr
Qo�f b M t '5 .
> 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 - compl to in accordance with above specifications, for the sum of (: �1
r _P_ 1y�L l) Jr CyM� � dollars ($ � 0 7 , Qy ).
Payment to be made as follows:
\
($ )upon sign g Contract; ROBERT A. KEEN
\\ Name of Contractor / Designated Registrant
($ Ion of 1175 TURNPIKE ST.
Street Address
up n 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. a Fax
Notice: No agreement for home improvement contracting work shall require a �v
> down payment (advance deposit) of more than one-third of the total contract price a "I a an
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 Authbrized signature
equipment, whichever amount is greater. Note: This Proposal may be withdrawn by us it 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
thi tnsaction. Cancellation must be done in writing.
rm)S,4�
GN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
.Signet Dale / 6 � J Signature Date
IMPORTANT INFORMATION ON BACK
*:0uc�ion,. Co,
RFJNC3DFI.INC: SPECl/aLISTS
9,;rla -5207
\eenConstructionCo.coT...'00
Halbach, Rick & Kathy
79 Gray St.
N. Andover, MA 01845
Contract #5529; Appendix A
Office tile floor: $550
• Cut existing floor in office adjacent to rear door (approx.12 sq. ft.)
• Supply & install underlayment and install customer supplied ceramic tile
Office roof: $1066
• Remove top 2' of roof and bottom 1' of siding
• Supply & install one layer of Grace Ice & Water Shield on roof and wall sheathing
• Re -install siding
• Supply & install new roofing where removed
Master bedroom: $680
• Paint walls and ceiling
Mid front bedroom: $640
• Paint walls and ceiling
Rear bedroom: $640
• Paint walls and ceiling
April 15, 2015
All prices include disposal of all construction related debris, but do not include cost of permits or repairs
to any unusual, unsafe or non -code compliant existing conditions that have not been addressed in this
contract.
Total Price: $3576.00 (three thousand five hundred seventy six dollars)
1175 Turnpike St.
N. Andover, MA 01845
CSL #076691
Page 1 of 2
Sales@KeenConstructionCo.com
P: 978-691-5201
F: 978-682-3231
HIC #108383
yen,
- i�t; Cons�truaiiarr:Ca;.
REMC�I)EI:ING SPECUILISTS
Keen Construction Co. corn
Payment Schedule: $1600.00 due when office roof and tile floor is complete (plus permit fees)
$1976.00 due at completion of contract work
Customer
Date
1175 Turnpike St.
N. Andover, MA 01845
CSL #076691
Robert A. Keen
i
l� r
Date
Page 2 of 2
Sales@KeenConstructionCo.com
P: 978-691-5201
F: 978-682-3231
HIC #108383
The Commonwealth of Massachusetts
d Department of Industrial Accidents
s 1 Congress Street, Suite 100
ti< Boston, MA 02114-2017
www mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information Please Print Le2ibl
Business/Organization Name: KQP,4 � DY) c5 �"iry G�' (\ CNl
Address: - l C) T�u r n pi - 5t
City/State/Zip:
Are you an employer? Check the appropriate box:
1. I am a employer with 3 employees (full and/
or part-time). *
2. ❑ lam a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
#: 5�
Business Type (required):
5. E] Retail
6. F�RestaurantBar/EatingEstablishment
7. E] Office and/or Sales (incl. real estate, auto, etc.)
8. E] Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11. ❑ Health Care
12. M Other 16M`2i NCJ 1C,-\
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box # 1.
I am an employer that is providing workersjj' compensatio `n insurance for my employees. Below is thepolicy information.
Insurance Company Name: I �a V�.1 'er 5 15
Insurer's Address: 'N) �3 c x 1_3"5'56
City/State/Zip: 0-,(—\ C,�, ay , F �L_ —5 Z SO Z
Policy # or Self -ins. Lic. # u G J )9 Jq1 � \'5 9 Z- " A Lk Expiration Date: 10 /1 5
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, "r the
of perjury that the information provided above is true and correct
Simiatur�(/`_ / G� Date: `� Z -7 Z 5
Phone #: % 6o9 I — 'J ZO
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia
03/23/2015 08:56 FAX 781 042 222.8 GILBERT
10 001/001
® DATE(MMIDDfYYYY)
ACORa► CERTIFICATE OF LIABILITY INSUR�AN E 4/15/2014E(MDW
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$ NO RIGHTS UPbN THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NECaATIVELY AMEND, EXTEND OR ALTER THE COVERAG5 AFFO.RDEDISY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WUREl ($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, I
IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements ._
PRODUCER
Gilbert Insurance Agency, Inc.
137 Main Street
Reading MA 01867-3922
C MT: C Barbara McDonough
NA
P ONE (781) 942-2225 1 Pax (701)941-22 6
E -MAI bmadonough@gilbartinsurance.cold
b
INS RB 5 AFF RDINO C ERAOrE NAIL N
1NSu ERA:NOPTOLK 6 DEDHAM INSURANCE 23965
INSURED
Keen Construction Company
1175 Turnpike Street
North Andover MA 0184$
INSURER a :$OL:6*t Tn$%IranO
INSURERC:Travelers Insurance 0022
INSURER D I
INSURER E!
INSURER F:
VU VI-RHl1 f'w4 LFK I1F1r-_A 1 F NI IMF2F6d rC"Lia.a l_�11114%J OGl /f-1-1 w„Iwweeef.:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR �HE POLICY PERIOD
INDICATED, NQTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESP CT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CTR
TYPE OF INSURANCE
A
POLIC NUMBER
MMIDO
PO%!� EXP
v
LIMITS
A
6ENERALA6IUTY
LI
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE QOCCUR
-P-010078/0003/13/2016
/13/2015MJP
EACH OCCURRENCE 13 1,000,000
D=MA E REN
a 100,000
EXP An one nrsan S� 5,000
PERSONAL & ADV INJURY I 1,000,000
GENERAL AGGREGATE I 8 2,000,000
GEN't,AGGREGATEIIMRAPP41ESPER;
7 POLICY F7 PRO OC
PRODUCTS - COMPIOP AGG a 2,000,004
$
B
AUTOM401LELIAOIUTYLgA
x
ANY AUTO
ALLOMED X SCHEDULED
AUTOS AUl'OS
HIRED AUTOS X AUT 3E0
6228807
5/23/20145/23/2015
a�c U SINGLE LIMIT11000,000
ROOILY INJURY (Per person) $
BODILY INJURY (Per yrcldern) S
P PER Y DAMAUI: $
e
Undarmaured mdt4rlst I S 100,000
UMBRELLA LIAR
EXGESB UAB
OCCUR
CLAIM$ -MADE
EACH OCCURRENCE S
AGGREGATE I S
DEO I I RE7 TION $
I $
C
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY
ANY PROPRIETONPARTNERI6XECUTIVII YIN
OFFICERIMEMBER EXCLUDED? ❑
(Mandatory In NH)
if 0Yas,oesonbeundor
DESCRIPTION OF OPERATIONS 1:010W
NIA
o Be Provided directly
is the tTlrri*r.
0/0/2011
0/0/2035
I STA 0 -
_
E.L. EACH ACCIDENT 1 100,000
E.L DISEASE - FA EMPLOYEE $ 100,000
8,L DISEASE.P LICYLIMIT S 50 000
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attadl ACORD 101, Addl(lonal RoMo is Sdwdulo, Ir mono Apaao la roqulrod)
Evidence of Coverage
(978)682-3231
Evidence of coverage
ACORD 25 (2010/05)
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
Gilbartr CZC/BAZAR
01988.2010 ACORD CORPORATION.I All rights reserved.
INS026 (niooa).o1 The ACORD name and logo are registered marks of ACORD
' U19 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor�-
License- CS -076691G
ROBERT A KEEN-` 'r
12 E WATER ST -f 0 �
North Andover MA 01845,
ny
Expiration
Commissioner
08/16/201.5'
Office of Consumer Affairs & Business Regulation
rI
ME IMPROVEMENT CONTRACTOR
gistration: .=j&383 Type:
iration:_811;8%2QF6:.; DBA
KEEN CONSTRUCT'Ib -00
Kenneth Keen x•
1175 TURNPIKE ST
NO. ANDOVER, MA 01845-- Undersecretary