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HomeMy WebLinkAboutMiscellaneous - 40 HITCHING POST ROAD 4/30/2018 (2) 4 TH O�?ORA S 16NOOL C o p�NG PERN�pVER .�\ON *"'gssA�N°��� BVL NORTN A ESM\NP WN OF P�PN ti. CA1\ON FOR Date ReceNed 1 PPP son this page ust coal etc all ;tezn 1 pe�m�t NO• ©• 9 R�ANT yes 10 O es -� Date`Slued ICY �►1'r" �� Pn�t r7E'$ st°ric Dish p vi1\a9� y n„tadhme S t Ll ra L `OCNI\ON �� M1 ZON\tAG D\� � Res�dent�a\ N° PERli{ OW RCE\' \a\ PRO O•��' POSED USE \ndus�erdja\ AP N �v PRO �a\ C°m M rt s'. 1 ode then ,. MENS Res e\am�1y m�\y O litF \MPROVE ✓�e °r m se\a ters�.ed D\str\c S E O N° °{unit W a Assess°N g\d9 ' ew gu\\d\n9 N et\aids Addi�or Other EFORMED: (Lo \oodP �� K SO BE p cR2 �P n OV)NOIR pJterat\o� \acement \a � �R'i.W,rep e\\ Ill aseo� 75hOQ6 C1eaT Phone � � 5 eoYp Ylease e' 1� P er,�,n�t OWNER Nam d '� ► � G �¢,,S't` d p��'�`' .) v �e o�g\dg pate 0 1. nssuar Addr Name• EXP. C6 -- 1 N�RAC�OR y `�.' ; � '� � ExP• pate• 1 t�dress uctQr Lrce�se Phone: P rstr '3 SUPe'NrsoI s Go t ytcer'se. C D Reg N°' ON$125.00 PER s.F er gASFV iC Pian Pnd Nome\mPr°gem EER TAS ES•riMA•rEp c°l SPCink�e S IENG\N 0°F•fNE TO E•.� � � and to �Ctc�ude PRGN\SEG PER$1000 0 FE ,n my f iJd l SS' PING PERMIt:$12 00 �� Rece\Pt a°e access t°the S dd B� do of „ N... P e�mit A rF E SCNEpp�E• L b tractors n c .0 arse o� g\d9 a s `Pr°�e°t Cost ung eg�steyed cvn �a, e o{ co tca uC�s ,�\pt to \5SU °and°f Ap oratvg °ta tl/ acting with - Si9 crert P om the-J °o{o{to No• s contr ePat the a'0II De�Opy and pr Check Person Ova? s OD OTE' O`Nnet must s Agent " S°f5�eheRegistCy°f �auYe Q _ — aea a J ✓ r i Sub I P/ahs mitt� ��T d YPE OF SE wE� P4bnic Sew GE DIS Plans VVaived er p�SAL pn en Certified Plot P/c ate(septic tam,I etc. ranning�assageBo in Star'%Tobacco dY A-t d Pla Saves ns , Permanent DumPst Swing Pools °n Site Food packaging/Sa / /IV `COWING nes. PtgOEPgRTM ECriON 1 IV'V//VG 4& DEV Nlq� SiGOpF OPP /C� - I COMEMNTS OpReNl OA TE RE P. U FOr•U ea, JEecr eostia V � Q CONSERe TiVA �� o�t`ae a c ON eQ aQQ C Reviewed o ' �� Akre t WO / ae` � Qe� a�C,e o`�ea `*1 `Gem Cp Review, 4.e Q`e �• �G,�S�`e�� �. NO MMFNTS 5<°��r e``oc �`o� `G5• `� `0 Qat i c`017 �°��° ec�Q�`G�. eat�Q'�����oo �Q,��< . , nin9 Board ofgppe ire 0����" �d`��SGo�G� aG� Qdc� 0 ���o Plannin als. Variance Q.� Qj`�`°`met G°� off\ tQ�-Z,,a, °�`�vv o opo °�G �O Q ` Boa AA`` 9 Board Decision. �5e'� e�Vv Ne 1 cense \� O o Qr oQ��Q�a � �6\ �. •:oe o5 :oa ��o n'atlo ``Gel Q�rD �, Q P Q� o n Decis� o �\°° •\,�e �Qe �• Water Sew on: O �� Qe�e eG�y �PQQ Quo J`� 0- �0 e1 �Q\ Dpi, er COhne O\`aJ Ott eta``eke��da Q,�`a Q�a°°"o� -- et Town Eaglbe �tioniSn nate comm'• �C:• P . �°� o,Q ��� Q P �G �'�`°� QQ\` Gem lea�te� oiRF DEp er' Sjgaatur re$Date �O� aa` J��` �e� Cp 01 Ox- g,�eJ ��P`:a� `fieo�F 1 e at 1,24 MTIyF e: P e : e�5 oQ� ���a.oma\ °�G°�Q V oeo Fir De an NT Te O G o�� G Go °�� �a'�` �o a Co parthent S19n mp dUmpster O r°'�° p� °55e��°� et���:'�e e5`°�� �oQ MMENTS atvre/date °h site yes Coc O O Q G°�� t\G���oG��C'� `d eo`��� ,�6 .``_ ° \o �<z\,y°re•:�`°'P�'`�� �e a See o ��`e'Q5'`o N°� P,QQ Q\o'`��' �e ,p\e1 t;- P C,°� �o,Q Q� G ` PGtie, �A P`•�5� �0S{ewoms S{ etibka, e4' a °�NG toe �`G o�` �eJ5" � za �\g am okGG� <el °Q�G �•5 5 e 5 rets �. O J e°i set• Ja` '�� oars �9�4 0��• GF. tbd'JS'�`o .�544,G .,Seal BUILDING PERMIT o`"O RT 6;�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Z ` O 1e Permit NO: Y Date Received �SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Y© lr � c Com© T tz C' Pint PROPERTY OWNER (1i 4 A L a C i� y ffF'S PrInt ` MAP NO:D`Z /0 PARCEL:39 ZONING DISTRICT: Historic District yes no, r Machine Shop Village yes do TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building t--Ohe family Addition Two or more family Industrial Alteration No. of units: Commercial t,—Repair, replacement Assessory Bldg Others: Demolition ' Other Well Floodplain Wetlands Watershed District a er Sewer DEC IPTION OF WORK TO BE PREFORMED: P t,� �� 3 _P002y Ts 2 % �- rmit Identification Please Type or Print Clearly) OWNER: Name: K a a-L-* cl ;.,,d y 94S5 i Ni g PhoneA 71'644' Address: y c5 0 i 4 c-t-x irx ?o f T Ra` CONTRACTOR Name: 1411pi C'z�w 57 Phone4'7i6 9'l • 5 a o 1 Address: t F F w i �"{ v E 1�-� , N d 0 �£,'� Mp'S S . in And � Supervisor's Construction License: .S q;2 IS Exp. Date: Home Improvement License: 1 D 9-37 -25 Exp. Date: ARCHITECT/ENGINEER Phone: ,dg Permit Address: Reg. No. ,rd of Appeals FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. sof of recording Total Project Cost: $ x 12. °1'6 g. b FEE: Check No.: i/f Receipt No.:� �� NOTE: Persons contracting with unregistered contractors do not have access to the gu my fund Signature of Agent/Owner Signature of contract r r i J Plans Submitted Plans Waived Certified Plot Plan Stpw- TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBo,4-- W ellTobar-- - t2ioed- ttmer�, `ttObeob Private(septic tank,etc. Oepa `ate petro o be%\ed°Jt{oc 5 tans t C��t o{t"e`eQU`<ed{° ```tat` r p g O 1 ��r9�s a�st 0� Rehaa e{o"° Arte P �t '�� p\\oa&.`°� L�cerses °{069 erm V-oo�\r9 Pec \t P `davit rdl Or G S to issoarGe ° 6u�\dyes G°�{\A\G' P \oC�IoCK ro&Gk ,��ert NN GOO ter ed p act ° phot° o Gor\.c PCoposeao�Erg`{eo,m Fire peP o G°pyr P\ar pt P�`dav�\se s`gr oA o F\°° eec`r9 \ts ce- o Ergpster Peck tr d P\\du s r Pr N���. . •or Ov i)eGy city\eV P\a — P►dd�t� P ec��t ea P\ot?\a\'\ �\Gerses otySP ° ?v� {\ed sko pgV�da\j\NV\ 05�'• Coposed� d9 Pe HES o GeoCyecs GOO')N�G� p\ar�{e p��°ab\el suan°e °{�\ \N GOO Gk \,nor b\ ) \f P9 .s COMti o Ph°N° O{ G°rtC���orlE\ev l\� PpP\Ge InE, �OduG�s ertV0 to ° 000 IGcoSSe \Gv\at�°rGoogP gar\reered e pepa\to ° F\°acao\�G GK ErOTO its dor Ero\cow F\c \�y ss Gree P�\dav e S`gr Ma ecirg eao�c ° ire c, \0 c Q�oning Boarc r9 ec 9 and \� p,\\ cwloq t .On lg*V% SpC\ry\er P PlanningBoard, t e Np'� Gorst,�uG p``Gat`o;ar es to\rG\ud Nevi r9 P eC�`os d P\�S L L\Gers Retocredl Conservation Dec. d� G• e ° 6 \{\ed Pr G. P.ra davit Gre g { Water & Sewer k o Ge hot° °{ Go P��r9 P\ar Ppp\`Gab\ 1 SSUar°e o DPW Town Engine o \N ovy evs S °1i8V'{\ at`°r5 l\� �e\Ok TO rt Pc`°C to ` tbe'VO o ��° ao\`G Ga\tact �p\`arGeeeTed prOepa�cre aecis�o�fco4 a�a4ti FIRE DEPARTME Nydc Gortt y Go �rg`r F\Ce statr►ptbeeas Ore Located at 124 Main Strep Gopy °{ eGy Erec avis i°c o voo sof`ce`e�e�;str`J of D Fire Department sig a asS IG r9 P `d u�re S`9 nC1e1Ck attbeR ° M eec\ ;ts ceq tbe10 re�Otaea COMMENTS o &o steC PeCm Vq%Stegttben�ettbs r�P �t 'a aU ice oT s4ec�be a4,PFi vca o 1 N a,,aria is o�eY' Faio�a4p o� s kf 'Oa tb b'v 6e o i In aU casappeal4 aw�tb e : F tb?;bbe sUb tte Rv10ESDEY� �- 0 SE �' 1�S4�C,t1p13P+L 'i_ RQV,Sea 2 2p08 - 1 BUILDING PERMIT Of "ORT" A �t"LIC 0 6t r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ✓Y Date Received 9q �SSACHU`��� Date Issued: ��`�� IMPORTANT:Applicant must complete all items on this page LOCATION Yo C� l'{C i Fps 7- 2 c-�- l Print PROPERTY OWNER (moi Aft L a 01#,dj Print " MAP NO:9 w PARCEL;3 fS ZONING DISTRICT: Historic District yes no. ; Machine Shop Village yes po TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building t--Ohe family Addition Two or more family Industrial Alteration No. of units: Commercial i,—Repair, replacement Assessory Bldg Others: Demolition Other Well Floodplain Wetlands Watershed District a er Sewer DEC IPTION OF WORK TO BE PREFORMED: i2o lyt 6 •.� R R• I s A T (2) �- Identification Please Type or Print Clearly) OWNER: Name: w 2 L-� ;Nd u t�1SS iNi g Phone: 644'. 3'` ? Address: Ll o i 4 c-1-% i n loos T G` CONTRACTOR Name: l 111i Oma- .S7 Phone(?Ii- 69t • ;Zt o ) Address: tl t F w i T7 �9 0 C P N d(6 j/£K dot S . Supervisor's Construction License: S` `f5 Exp. Date: ly Home Improvement License: f D 3 3 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: $ x 12 'to9. 6 FEE: Check No.: Receipt No.: ��C� 1Z� NOTE: Persons contracting with unregistered contractors do not have access to the gu my fund OF Signature of Agent/Owner Signature of contract r �� 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 LiPhoto 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 2008 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 OFFICEE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS —oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes / Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384.Os ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no x Located at 124 Main Street Fire Department signature/date COMMENTS 9 A LocationV-10 � � No. 3lO Date NORTH TOWN OF NORTH ANDOVER * ipow- at ; . Certificate of Occupancy $ _ s�CMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2r6 � :' Building Inspector c OR , Town of NTH Andover 0 No..? LAKE o �, dover, Mass.,// O COC HIC HE WICK V DRATE D 5 77 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �� THIS CERTIFIES THAT........ '. . ............................................................... ..... .._ BUILDING INSPECTOR . .. ...................................................... Foundation has permission to erect........................................ buildings on .. �....... . . .....I. T....... ... Rough to be occupied as..... .� ..... O �' �� j� 40.41 ��`/ Chimney provided that the person ccepting this shall in eve res ct conform to the terms of the a -permitevery cation on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ! Final PERMIT EXPIRES IN 6 THS ELECTRICAL INSPECTOR UNLESS CONSTRU O Rough .................. ....... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. i SEE REVERSE SIDE Smoke Det. KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER, MA 01845 978-691-5201 Pessinis, Karl&Cindy 40 Hitching Post Rd. N.Andover, MA 01845 978-686-5349 Contract#5020;Appendix A Date: 10/28/2009 Exterior Upgrades: • Supply& install one Thermatru S-214(A)door unit with brass caning and Schlage Plymouth thumb-latch with deadbolt • Supply&install one Thermatru 5-210(A)door unit with two S-155SL(A)sidelites with brass caning and Schlage Plymouth lockset with deadbolt • Supply&install one Harvey vinyl triple sliding door unit(left hand operating from inside) • All door units to be trimmed with PVC stock on the exterior to match existing and 3%"Jalco casing on the interior • Cover three sides of eight existing railing.posts on front of house with PVC trim to match existing • Supply&install panel molding on front side of six railing posts •. Repair gutters as needed and install leaf guards on entire gutter system • Dispose of all debris Total Price:$12,696.46(twelve thousand six hundred ninety six and 46/100 dollars) Price does not include cost of permits, painting, portico roof repairs,excessive rot or repairs to the;,: floors adjacent to the new doors. Payment schedule:$2000.00 due upon signing contract $4000.00 due when doors are delivered $3500.00 due the V day of work(plus permit fees) $3196.46 due when contracted work is complete ustorner Keh B. Keen io a4 Date Date U8/11/ZUUB U1111:41 rAA yol U49 ZZZO b1LPLAI 1AZ)L1AAAII1 W-jVVO ACDI�f? CERTIFICATE OF LIABILITY INSURANCE 08/11/2 09' PRODUCER (781)942-2225 FAX (781)942-2226 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gilbert Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 137 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Reading, MA 01867-3922 INSURERS AFFORDING COVERAGE NAIC# INsumm Kenneth B. Keen INSURERA: NORFOLK & DEDHAM INSURANCE 23965 DBA: Keen Construction Company INSURERS: Granite State Ins. Co. 0077 21 Hewitt Ave. INSURER C: North Andover, NIA 0184S INSURER D: INSURER E: COMERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !a MIL Type OF WSURANCE POLICY NUMBER POLICY EFFECTIYE POLICY EXPIRATION LIMBS GENERAL LIABILITY ND-P-010078/000 03/13/2009 03/13/2010 EAcH OCCURRENCE S 1,000.000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED a �.,.a s 50.000 CLAIMS MADE �OCCUR MED EXP(Any one person) S 51000 A PERSONAL A ADV INJURY S 1,000,000 GENERAL AGGREGATE f 21000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 21000,000 I-Xj POLICY j&OT f7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s ANY AUTO Me owdent) ALL OWNED AUTOS BODILY PIJURY SCHEDULED AUTOS (Perperson) s HIRED AUTOS BODILY WJURY NON-OWNEDAUTOS (Peracddent) S PROPERTY DAMAGE S (Por accidw) GARAGE UABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY. AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION i S WORKERS COMPENSATION AND 6371378 08/03/2009 08/03/2010 X I wCsTATU- OTH- EMPLOYERS'LIABILITY B ANY PROPRIETORMARTNEWEXECUTIVE E.L.EACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDE07 E.L.DISEASE-EA EMPLOYEE S 100,000 it yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT S 500.000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSQN3 ADOED BY ENDORSEMENT I SPECIAL PROVISIONS riginal workers compensation certificates to be issued by company forthcoming. ertificate holder is included as additional insured on the general liability with respect to Aerations of the Named Insured. CERTIFICATE HOLDER CANCELLATMN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MRL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of North Andover BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 120 Main Street OF ANY KIND UPON THE INSURER ITS AOENTS OR REPRESENTATIVES. North Andover, NA 01945 AvnIORIZEDREPRESENTATIYE Mark Gilbert CIC ACORD 25(2001108) ©ACORD CORPORATION 1988 ;lie yr arrrn�zonuiea� ��/�aa°ac�zuae�.d �< "x Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registton5 108383 Eiratton-8718/2010 Tr# 272473 KEEN CONSTRi7CT4JN CQ Kenneth Keen 21 Hewitt Ave No.Andover,MA 01845 Administrator r. _. Bei"_. `'.�w�+.� ---- -- ----- ------------ —�— -- Board of Building Reg.ulati s and$tandards Construction Supervisor License Licer.Lse: CS 5824.5 Expirataon x/24/2090 Tr# 17840 KENNETH B KEE-t4; 21 HEWITT AVE C�-7_-- - N ANDOVER,MA 09845-- Commissioner glee owvmwm.wezM4 of'�Awdac/� Board of Building Reg,,ulationsxaad Standar.-ds Construc.01 n-S. perui"sor License Licen9se CS 766:91 8r htlafe 8f16/T968 xp a inn $lrjf6/2;0:0:9 Ti# 3859 �' Res action ©E?? ROBERT A KEEN: 12 E WATER ST - N ANDOVER,MA'.0.1845 Commissioner The CommonrueaUk of Massachusetts i Department of Industrial Accidents Office of Investigations iiiI 600 Mashingrion Street tiU ll Boston MA 02.111 www&=s gov/dia . Workers' Compensation Insiu-ance Affidavit. Builders/Contractors/Ele Applicant nformation ctriciaQs/piumbers I Please Print LeQibl Name(Business/OrganizafiorAndividual): 6 L 7-2 u c I-C) Address: 02 w , City/<State/Zip , o f•z ✓�l R /$�S Phone#: . g_7$ _y FE3 employer?Check.the appropriate box: employer with 4, 'Type of project(required):� ❑ I am a genera)contractoa�, Iees(full and/or part-time).* havo hired the sub-aotttr6. ❑New coristivctionole proprietor or partner- listed on the attached sh7. []Remodeling ship and have no employees These sub-contractors have working for me in any capacity, workers' comp.insurance. 8. ❑Demo' [No workers'comp, insurance 5. ❑ We are a corporation and its 9 ❑Building addition 3•❑ required.] officers have exercised their 10•❑Eiecfrical repairs or additions i ain s homeowner doing all work right of exemption per MGL 11.❑ Plumbin myself [Novorkers$comp. t~ 152, §1(4),and we have no g��or additions insurance required.]t 12.❑Roof repairs -employees.[No workers' comp. insursn=required.] 13.❑.Other 'Any eowniq that Checks bo>L ti t mutt also fill out the section WDw showing their workers'oompensation policy information, t homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such ;Contractors that check this box mustattachd an additional shear show' Phe Harm of the sub-contractors and their work='co m,-.Policy irfom�ation. I ant.an ert�lnyer that is providing workers'compensadron crnsurance for illy employees; Blow is the o infornzado2 p yier and job site . Insurance Company Name: G r2,9 Iv Policy#or Self-ins Lic. Expiration Date: Job Site Address: . 40 .14c�� ----------- '.me -y (� Attach a copy of the workers' tomI City/Stats/Zip; lU, IQ_ lg�� peusa#ots policy declaration page(showing the policy number and--ex—piratio dao ted. 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 its civil penalties in the form of a STOP WORK ORDER and a fine Of tip 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 cert under the pains enalties o .e Sr . fP duly tthat the information provided above Lure: L is true and toured Date: L! - ► D c� Phone#: Cd A, Official use only. Do not write in this area,to be complej�j%d by city or town.officiaL City or Town: Issuing Authority(circle one): Permit/License# 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: KEEN CONSTRUCTION CO. GP PROPOSAL 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978)691-5201 All home improvement contractors and subcontractors 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 with Submitted the Commonwealth of Massachusetts. Inquiries about To: E:.__.t : ' .. . registration and status should be made to the Director, ' f Home Improvement Contract Registration,One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. �1� 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. PHONEDW2_9169 REGISTRATION NO. EIN NO. 9 MA. H.I.C. 108'%' 26-0462904 > 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 d /L'? _> Constructionrelaid perm ..... Ce/�_.(/(�C. _JC. ............-©- �ll ._ . 4 L....`La..I. .El .._..... ......... —–--- .. _ _...._..._........_...,w_..__.__ ........................._.._........_...._....,,.........__................,..............,.........,..........,.....................,..........................................,.,........,.......,..,..........................................................,..................................._....................................... WORK SCHEDULE w..._._...............__.._._. 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 T � _(date)._Parring delay caused by circumstances beyond Contractor's control,the work will be completed by (�a (date). The Owner hereby acknowledges and agrees that the schecyling dates krre approximate and that such delays that are not avoidable by the Contractor shall not 8e 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-complete in accordance with above specifications,for the sum of ` r / :`�� s f "r :3e 5 r\ - f ���j CoA J. f dollars($_12o(nn ,1'1 , Payment to be mad as follows: )' % ($ ) upon signing C ntract; KENNETH B. KEEN / ROBERT A. KEEN Name of Contractor/Designated Registrant ($ u I' i - off_ 21 HEWITT AVE. Street Address on completion of N. ANDOVER, MA 01845 City/State -I- City �$ ) shall be made forthwith upon (978) 691-5201 (978) 682-3231 compfetion.of work under this contract. _. _- Phone 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 of sat7ma� or the total amount of all deposits or payments which the contractor must make, in rf/1- J.. advance, to order and/or otherwise obtain delivery of special order materials and AulhOr ed ignawre r _: • equipment,whichever amount is greater. Note: This proposal may be withdrawn y 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. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature _ Date Signature Date IMPORTANT INFORMATION ON BACK1111111-