HomeMy WebLinkAboutBuilding Permit #620-14 - 80 SETTLERS RIDGE ROAD 3/6/2014Permit N0: L
,i
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
ANT: Applicant must complete all items on this
LOCATION . _/0 F.)
PROPERTY OWNER 'e -_� eel + e, Ke vi t
Print 100 Year Old Structure yes
MAP NO: 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
X Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
OWNER: Name:
Address: de.'
CONTRACTOR Name:
DESCRIPTION!�F WORK TQ BE PERFORMED:
Type or Print Clearly)
Phone: 579 -
16 Phone:
Address: i % `7 ) u� 'il. p ( �P_ )t AlI &Vern , INH
Supervisor's Construction License: ) 9( _ Exp. Date: F I
Home Improvement License: %� �J Exp. Date: r
ARCHITECT/ENGINEER
Phone:
-190y
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: $ d 0 FEE: $ / '_
Check No.: aa, Receipt No.: cZ3 Z
NOTE: Persons contracting with unregistered contractors do not have acc7=aMf)nd
:Signature�of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted -0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
.TYPE OR-SEWERAGEDISPDSAL
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
COMMENTS
-CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATEAPPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Co
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Toiw Engineer: Signature:
FIRE -DEPARTMENT Temp Dumpster on site yes
Located -at 124 Main Street
-Fire Department signatureldate --'
{
COMMENTS
Located 384
no
Street
-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 2010
Building Department
• The fol( -)wing 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
o 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doe: Doc.Bui?ding permit Revised 2012
"KA
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $-
TOTAL $
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KEEN CONSTRUCTION CO.O'f
21--H-EW4-T:T-A7V-ENUE- 105 -PrrP f �,E
NORTH ANDOVER. MA 01845 F
Tel: (978) 691-5201
Fax: (978) 682-3231
Submitted
...... ot--a
PHONE DATE
96
52U::a
All home improvement contractors and subcontractors
engaged in home improvement contracting, unless
specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108 (617) 727-8598.
Owners who secure their own construction related
permits or deal with unregistered contractors will
be excluded from the Guaranty Fund Provision of
MGL c. 142A.
REGISTRATION NO. I EIN NO,
MA. H.I.C. 108383 1 26-046-2904-
> C/S = Customer Supplied S + I = Supply + Install Ifl See Attached Appendix A
We hereby submit specifications and estimates for work to be performed and materials to be used:
Construction related permits:
1X .........c!._Wee`_A+:2......' �......_•:is'�d' C��(„i_�4' � C/t'"el"I
OR SCHEDULE � �...................fi_...._._.......,_....
Contractor wi I of begin the work or order the materials before the third day following the signing of this Agreement, unless specified herit Contractor will begin the work on or
about (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed byre in w .. (date). The Owner hereby
acknowledge 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 a i, r— 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 Contract r, his subcontractors, employees of 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
`7 X � ., itch r 1_.L n Afe d r P ✓� -- — — (,� ~l/� �) D
Payment to b6 made as follows:
% ($ ) upon signing Contract; KENNETH B. KEEN / ROBERT A. KEEN
Name of Contractor / Designated Registrant
% ($ ) upon cc leti n of t .2a_HEWtFT Aw �� �J ""Fort)
. Fo r) f) r �: L,.
��� Street Address
% ($ dmpletion of N. ANDOVER, MA 01845
Cit / stale
{-;`l($�, ) hall be made forthwith upon (978) 691-5201 (978) 682-3231
'y completion of work under this contract. Phe a Fax
Notice: No agreement for home iimprovement contracting work shall require a
Name n! Sale man
down payment (advance deposit) of more than ane -third of the total contract price
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 Authorized Signature
equipment, whichever amount is greater.
Note: This proposal may be withdrawn by us if not accepted within days.
Acceptance Of PrOpOsaI - 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 NPT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Dale Signature Dale
IMPORTANT INFORMATION ON BACK ►
iaeMo��ra.rnc. srre:�n�.tsrs
en
XeenConstructionCo.com a
Kent, Jerry & Kellie
80 Settlers Ridge Rd.
N. Andover, MA 01845
978-975-1004
Contract # 5285; Appendix A
January 2, 2014
Front door replacement:
Supply & install Masonite door unit (BMT -106-725-2) with two sidelights (BMT -129-725-1) as
selected by customer. Door will be factory pre -finished and frame of unit will be primed, ready
for paint.
• Supply & install standard Schlage Plymouth lockset and deadbolt, keyed alike
• Supply & install Larson storm door to match existing with almond finish and brass hardware
• Supply & install new exterior PVC trim to match existing as close as possible
• Supply & install new interior trim
• Dispose of all debris
Total Price: $6410.00 (sixty four hundred ten dollars)
Price does not include cost of permit, painting or any unusual, inadequate or unsafe existing conditions.
Payment Schedule:l due upon signing contract
$2800.00 due when door is delivered
$1410.00 due when contracted work is complepe
Customer Robert A. Keen
f/g11_7
Date
Date
1175 Turnpike St. R: 978-691-5201
N. Andover, MA 01845 F: 978-682-3231
Sales@KeenConstructionCo.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): r� �`G� i/l r_n1,5+fyc� (on_
Address: W_)15 � v
City/State/Zip: fiAJ"r-
Phone #: ,92 g— (04(— 5z�Q /
Are you an employer? Check the appropriate box:
1. P I am a employer with z
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ® Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
-Any appncant tnat checks box IN must also till out the section below showing their workers' compensation policy information.
I 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:V 1 6�G N.
Policy # or Self -ins. Lic. #: � i 1 U (3 -- 99 % 1 M 5 0 — 2 ' (3 Expiration Date: %Q , h y
Job Site Address: VU c e,:Hd e r s 4JU PA City/State/Zip: i1 � Ueoo, #7 f O /Bq5
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.
Ido hereby certify un the ins penalties of perjury that the information provided above is true and correct
Signature: Date: t9 `7
Phone #:
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 #•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
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."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, 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 may be 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 line.
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 number 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 proof that 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction SuperAisor
, License: CS -076691
ROBERT A KEEN.t',
12 E WATER ST
4] North Andover WA 018
)I J,x Expiration
Commissioner
08/1612015
Massachusetts - Department of Public Safety
Boardof Building Regulations and Standards
Construction Supers isol-
License: CS -058245
KENNETH B IdEN
21 HEWITT AVE
N ANDOVER ;�V01845`7r
Expiration
Commissioner 03/24/2014
G9Z W,11-1tveallli, Off' fssjaCk,6&M
Office of Consumer Affairs & Busi e.Regulatioir
OME IMPROVEMENT CONTRACTOR
egistration: • 108383 Type:
xpiration: 8/f8/2014 DBA
KEEN CONSTRUCTION CO
Kenn6th Keen
21 Hewitt Ave
No. Andover, MA 01845 Undersecretary
11/18/2013
11:50 FAX 781 942 2226 GILBERT
!
16 001
.4C —
CERTIFICATE OF
I
LIABILITY INSURANCE
E 5,000
I
DATE (MM/DDIYYYY)
10/29/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON ITHE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS M U I E 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 pollcypes) 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 Iconfer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER Basbara xwonou
NAME:
Gilbert Insurance Agency, InC. gas Ig PHONE , (781) 942-2225
137 Main Street E -MN )donough@gilt
iA 01867-3922 1 INSURERANORFOLK 6
INSURED
Keen Construction Company
1175 Turnpike Street
Orth Andover MA 01845 1 INSURERF:
DVERAGES CERTIFICATE NUMEJER-.CL13102900618
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURI
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM;
LTR TYPE OF INSURANCE
GENERAL LIABILITY
�17CLAIMSAIIADE
MERCIAL GENERAL LIABILITY
A ❑X OCCUR
J
GEN'L AGGREGATE LIMIT APPLIES PER:
AUTOMOBILE LIA131UTY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON.OWNED
HIRED AUTOS AUTOS
UMBRELLA LIAe OCCUR
EXCESS UAe CIAM6
-2-13
AND EMFLOYERS LIABWTY Y I N
ANY PROPRIETOWPARYNERMXECUTIVE❑ N I A
OFFICER/MEMBER EXCLUDED?
(Mluldalnry In NN)
It vee. dawrDsunder
13/2013
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Ramerlta Sdwdule, h Moira space Is requtrad)
Evidence of Coverage
(978)623-8320
Town of Andover
Building Department
360 Bartlett Street
Andover, MA 01610
(1811942-2726
cam
Dcvlelnki NI IMRFIa•:
ID NAMED ABOVE FOR ITHE POLICY PERIOD
)OCUMENT WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT ITO ALL THE TERMS.
LIMrr$
EACH OCCURRENCE
S 11000,000
D RENTED
s 100,000
MED EXP (Any are person -
E 5,000
PERSONAL It ADV INJURY I
E 11000,000
GENERAL AGGREGATE
S 2,000,000
PRODUCTS - COMP_F- AGG
S 2,000,000
comoiN90 $ NGLE LIMIT
a xeidenn
9
BODILY IN.tURY (Per person)
6
BODILY INJURY (Paratddenl)
PROPERTY DAMAGE
IPQr amidenl
9
EACH OCCURRENCE
S
E
AGGREGATE
E
WC STATUS0T -
s
E.LEACH ACCIDENT I
S 100,000
E.L. 016CME - EA GMPLOKEE
9 100,000
E.L DISEASE - POLICY LIMB
S 500,000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELTYERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZM REPRESENTATIVE
Gilbert, CIC/BARBAR
ACORD 25 (2010105) ®1988.2010 AGORD CORPORATION. All rights reserved.
INS025 (2DItlo6)m The ACORD name and logo are registered marks of ACORD