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HomeMy WebLinkAboutBuilding Permit #787-11 - 85 LACONIA CIRCLE 5/23/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0•JeP7- // Date Issued: IMPORTANT: Date Received must complete all items on this LOCATION �r i9 Ca •u A (, //2 C l G= Print / PROPERTY OWNER �►�y A I/C ?i9 1; d �.7 rZ (� �y K o Print MAP NO: 21 D PARCEL -10-5- ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N -One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial C�rR'epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other SeticWell'2's-- mt6 DWetlan 43 r ` *77r- .z a x e�ra'1i, ®Water�SewerG� 5i,_a - ---�- �«.. r OWNER: N rolm"IN 0;r1iLt J OF WORK TO BE PERFORMED: i 4-n uvi S fi. 9 r] IPP i ►' e cl Identification Please Tkpe or Print Clearly) M Address: S"- L Vq CD w i .g ILI 4 't IF CONTRACTOR Name: K-4 t4 r- t� i�- K ��tj Phone: (9 I-Sa e I Address:t HSwilL.f/`t ✓ C Supervisor's Construction License: .� `f S Exp. Date: 3 a Home Improvement License: / o q 3 (� 3 Exp. Date: 9 — I ARCHITECT/ENGINEER Phone: Address: �-- Reg. No. �— FEE SCHEDULE. BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ Do FEE: $ Check No.: 6 6 1 do Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _ s inna re'ofi c`'tractor _ g1 X19 s Plans Submitted ❑ • Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Taming/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dumpster on Site ❑ Swimming Pools ❑ Food Packaging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ 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: Conservation Decisio Comments Comme Water & 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 No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc:.Building Permit Revised 2008 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 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 o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording !ust be submitted with the building application Doe: Doc.Building permit Revised 2008mi Location No.Date a3 1 Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ BuHding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 2474 -4 wilding Inspector NN W M Cd w x in 42 'a4 w �! cn 0 w iJ 00 cz w 03 c cc 0 a g AG O. �, U) cz O v c z C/) _. O0. c n 90 2 O O Q L Q O v Z.. CD CL O CO) � C w+W — cm i Q W � - * O 'O 'E m m 0 CD � O � O � CO 0 Q L cc O o- rma y C c � c Q Q v Q. Q � C Z Q V h cc c c— '- c ev � fl. A �. Im C " CD 03 c g o � :.0 H O c is O � t Cc A t0 (.: w cc I O L �VCD • L c �. ca J N � Ec 0.0 O O u C ®c E N O m • � L o N JV L 3 A mcm 40 r �. V: A 'C N w o r:aUL: 4 y m ; = � co C C to CO m tel; •C�y L cO o c o, cm CD :gam ca CD o. o CD COD�z~m LU c .. •o s � •N oRea •a O �N 'E o= c v v Z W w o '102 � g COD Fc -gm d m O �O O CL.,.CIO � 90 2 O O Q L Q O v Z.. CD CL O CO) � C w+W — cm i Q W � - * O 'O 'E m m 0 CD � O � O � CO 0 Q L cc O o- rma y C c � c Q Q v Q. Q � C Z Q V h cc c c— '- c ev � fl. A �. Im -Boston DeslgnS 215 South Main Street Middleton, MA 01949 Phone 978-750-1403 Fax 978-642-9595 Bili To Barby Kodys 85 Laconia Circle N. Andover, MA 01845 978.208.7495 Invoice # 4698 Job/Tag # Kodys-J-R-104-3896 SIs.Ord. # 3896 Date 3/30/2011 Ship To Barby Kodys 85 Laconia Circle N. Andover, MA 01845 978.208.7495 Designer J -R; Store Loc 104 Terms C.O.D. Item QtK, Mfr. Description Price Amount Cabinet I Ultracraft Ca... Kitchen Design - Ultracraft Cabinetry 15,000.00 15,000.00T -This is an estimated total amount for the kitchen cabinetry only - per existing layout discussed during consultation meeting in showroom - Saturday 3/26/11. Final measurements and pictures will be taken at site visit and a new revised design will be created for clients. At that time, clients will be presented with the new pricing. Any increase over this amount, will be added to the balance due. ***All final cabinetry selections to be made.*** -Site Visit: 4/1/11 @ 1:00 -Presentation Meeting: 4/9/11 @ 10:00 3/29/11: Paid 1/2 Estimated Amount - $7,500.00 w/ Visa h� Subtotal $15,000.00 We Appreciate Your Business! Sales Tax (6.25%) $937.50 Total $15,937.50 www.bostonkitchen.com Payments/Credits $-7,500.00 Balance Due $8,437.50 OfficAo>merrsiuess egu a. i HOME IMPROVEMENT CONTRACTOR Registration: 4`08383 Type: Expiration: $0W 012 DBA K CONSTRUciT1-Y _ ,,, Kenneth Keen A-wq 21 Hewitt Ave�e No. Andover, MA 018'x5 Undersecretary "� �9assachusetts Department of Public Safety Board of Buildin�, Ro�ulations ant) Standards Construction Supervisor License License: CS 58245 Restricted to: 00 KENNETH B KEEN 21 HEWITT AVE N ANDOVER, MA 01845 Expiration: 3/24/2012 ( niunis�iuncr Tr#: 20523 - Massachusetts - Department of Public Sato,: Board of Building Regulations andStiundaeds Construction Supervisor License License: CS 76691 Restricted to: 00 ROBERT A KEEN 12 E WATER ST N ANDOVER, MA 01845 Expiration: 8/16/2011 ('unuui.�iuncr Tr#: 1690 The Commonwealth of Massachusetts QUIP Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: ruC. Are you an employer? Check the appropriate box: L Q I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. [9 -remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ] Other --•,-rr---• Wa• uwna vx rr, muse also rrtl out We 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. lContractors 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: Policy # or Self -ins. Lic. #: VWL+ Q Q % 3 -7/,3 7 Expiration Date:—V,3 3 I Job Site Address: L fl C O !u r W ti, City/State/Zip: 4 If j/S^ 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 under the gins ayd penalties of perjury that the information provided above is true and correct % -000i t^J .7o 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 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 5/23/2011 9!41 AM. FRENA! Gilh—t Cilh—t A........., t., "' — 11 ro-ro% coo A -COR T. CERTIFICATE OF LIABILITY INSURANCE DATE (MM(DDNYYY) 05/2.3/2011 PRODUCER (781)942-2225 FAX (.781)942-2226 GiT•bert Insurance Agency, Inc. 137 137` Main Street Reading, MA101867-3922 THIS'CERTIFICAT.EIS`IS.SUED.AS-AMATT.EROFINFORMATION ONLYAND CON FERS'N.O'RIG HTS UPONTHE'CERTIFICATE' HOLDER. THIS;CERTIFICATE DOES NOME .:ALTER THE CO'VERAGE AFFO,RDED.BY THE POLICIES BELOW. INSURERS AFFORDING: COVERAGE NAIC # INSURED Kenneth Keen. & Robert Keen - DBA: DBA Keen Construction Company 21 Hewitt Ave. North Andover, MA 01845 ANSURERA: NORFOLK & DEDHAM INSURANCE - -23965 INSURER B: :Granite State Ins. ;Co. 007.7 INSURER C: INsuRER"D: INSURER E: THE'POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO.THE INSURED NAMED ABOVE FOR THE POLICY PERIOD. INDICATED`. NOTWITHSTANDING ANY REQUIREMENT TERMOR CONDITION .OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO. WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY'P.ERTAIN, THE INSURANCE AFFORDED DED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANUCONDITIONS OF SUCH -POLICIES. AGGREGATE LIMITS SHOWN MAY: HAVE BEEN REDUCED BY PAID CLAIMS. - INSR ADO!L TYPEOFINSURANCE _ POLICYNUMBER pOtIGYEFFECTIVE:. M -POLICY EXPIRATION LIMITS GENERAL LIABILITY ND -P-010078/000 03/13/2011 03/13/2012: EACH OCCURRENCE $ 1,000,000X' COMMERCIAL GENERAL LIABILITY DAMAGE -TO RENTED $ 0, 00 CIAIMS,MAI3E a OCCUR MED EXP (any one person) $ 100"000 A PERSONAL &,ADV INJURY $ 1 000.:00 GENERAL AGGREGATE $ 2 000, 00 GENL AGGREGATEtPIMIT APPLIES PER: , PRODUCTS - COMPlOP AGG $ 2, 000 ,.00 X..POLICY. JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea'eccident) ALL OWNED AUTOS 80DILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS - - BODa .$ NON -OWNED AUTOS (Pereccident) - accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR a CLAIMS MADE AGGREGATE $ DEDLICT18LE $ RETENTION $ WORKERS COMPENSATION AND W0009646942O8'�03/201008/03/2011 - WC STATU- OTH? EMPLOYERS'N WC CERT TO BE MAILED ElEACH ACCIDENT $ 100 00 B PRIETORILRY ANY PROPRIETOR/PARTNER/E)CECUTIVE OFFICERIMEMBEREXCLUDED? DIRECTLY VIA: GRANITE INS . If: yes, describeunder E.L. DISEASE - EAEMRLOYE $ 100, 000 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER. DESCRIPTION OFOPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS' ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS - - vidence of Coverage SHOULD ANY OF THE` ABOVE'' DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION .DATE THEREOF,: THEISSUING INSURER WILL : ENDEAVOR TO MAIL TO DAYS -WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL -IMPOSE NOOBLIGATIONOR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES: Evidence Of Coverage AUTHORIZED REPRESENTATIVE Mark Gilbert` CIC ©ACORD CORPORATION 1988