HomeMy WebLinkAboutBuilding Permit # 5/11/2015 BUILDING PERMIT C
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:90 Date Received ILI Z/��'
Date Issued: �i 44i-T—ANT,,Applicant mt completeall items on oris page
Us'comp
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",Imm/�ilsis
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
(I New Building[din 0 One family
Ei Addition 0 Two or more family I 1 Industrial
D Alteration No.of units: ❑Commercial
--
KRelpair,—replacement D Assessory BldgOthers:
Ei Demolition 0 Other
C?IPTI�N +
OF WORK TO BE PEPFORrED:
oc, �
UVI C-0 L>P/\-
11 t,fi at'
,7,",-,P1C,,�'jyr,wv,P�iwt Clearly
7
OWNER: Name: Phone:
Address:
ARCHITECT/ENGINEER Phone:
Address: Reg.No.
FEE SCHEDULE.BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost:$ _FEE:$
Check No.: —Receipt No.:
I :a
NOTE: Persons contracting with unregistered contractors do not have access to or fund
'8]664 'ofAgenfIibwnei,,,,`,, Signature of con I tractor
KEEN CONSTRUCTION CO.
175 TURNPIKE STREET PROPOSAL
NORTH ANDOVER,MA 01845 All home at...nn-
Tel::�978�T-5201
I :P9191d in rhp-llt.
belt no..ong, unless
Fe. 978 6.2-323 spec'(
of
chblo,142A If flhbrol..,m.1t b,11gilt-d
Sri -th"I C--eblth of lbq.i,,bo
To about g't ' a tl h,,Id bI --t.the
4D,,,,t,,11-b Improvement 0,,t,.bt Rey suet.,10
'-!-
Plo-,m—5170,Sold,-02116 617-973
8787 C-11 who s 0,6, 1— rhi-,st,bbron
gnnagmrs
,,If be b.b[bd.d from the Guaranty Fund P,,,i,i,,
If G1 c 1 12A.
Em r.
IATE H.I.C.108383 _j 46-3783401
til
C/S=Customer Supplied S+I supply hastafl 11 See Attached Appendix A
Weh by sub for-k to rfl—d -en-ie b.-L
cr�
o;T J
b
l :zX r
109K SCHEDULE
I b but-th,third dry 1h. f I-AgIll-L.�11-f,d roar, r,
ri hi
-Ir b,
aanow ed ea oaf me schetlan of this A,11-11
ARRANTY
Thentl shall
e.mply"'ffi,bq.--n&nb,,Ag,,,-b ig,bo,is
ct1--,-t-r-bdId
b_,"d
We Propose hereby totri'mah mod'ej one labor complete in accordance with above specifications,for the atim of
96dollars($ '7
% ),ijpon signing i ROBERTA.KEEN
N�; f f sae edema
5 Td9RNPIKE ST.
Up co hen
f
x, $ upon completion of MA 01845
% (s—)
completion
be made foithwith open (978)691-5201 (978)682-3231
of work Under this co, F-
NdOWn payment(advance deposit)of more the,one-third of the retail contract-1 no.
otice No agreement for home mpm,—nt contracting work shall JTe a
or the total amount Of all deposits or payments which the contractor—t make
.dc.,",to older and/or otherwise obtain di of spheral order materials end
e,aild-ot d
Acceptance of Proposal-I h-bohd b,thsciesoffis d,c,,,,[,,d atallso"ddot- 1, -11and 1111pt the P, spa l-lon,and corionero sed
,
I understand hot 11 signing,this proposal becomes,binding contract. —IonY11 11,authorized to do the
ochr,specified.Payment will be.1d,as outlined 11In...
I. the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of
this transact
u, e
Non.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
IMPORTANT INFORMATION ON BACK W-
Town of NI I gLCIr¢7y Andover
O
$ " h�
� ver,Mass,
H"A
o
'tiy QORare°rer`S�g
S �
BOARD OF HEALTH
PELERMIT T ILD Food/Kitchen
y�y, Septic System
THIS CERTIFIES THAT... .tel...... °! l.clL SI1q,. .................................... BUILDING INSPECTOR
.., _1 Foundation
has permission to erect..........................buildings on...... ............. .................
Rough
to be occupied aske.06M...lrl!.�i!�.....Qo.,,�.....�.....T1.Y..Q.li.}. ,p.�q�^ �Isa.�:��!.'.{J.�7.1W cnimneY
provided that the person accepting this permit shin every respect conform toftfe terms of the application Finai
on file in 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 9..
ELECTRICAL INSPECTOR
.UNLESS CONSTRUCT[ S Rough
se��me
.............. ................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BuRough
Display in a Conspicuous Place on the Premises—Do Not Remove I'm]
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Se,
Street No.
Smoke Det.
The Commonwealth ofMassaehusehs
Department oflndustrialAccidents
Z CongressStreet,Suite 100
Boston,
MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insnra ce AftidxvlC:Builders/CenWactors/lilectricions/Plumbers.
TO BE FILED wITD TBE PERMITTING AUTHORITY.
Applicant Information / I Pinusepnitit Leeibly
Name(B,rasness/organ;zari<�wlnaiv[anaq: 2°Cvt t5"f✓v T12%"`
Address:
City/State/Zip: Phone#:_
�UD
a you an omploy,,?Char the appropriam box: Type of project(required):
lam aempmyerwim e eyaes(nalarmorpas-hmo).= 7.❑New 000shvotiontarn asota pmpriator or pvNram}tip andhave no empleyeesworkiog forma in 8.❑Remodeling
any capacity.[Noworkers'comp.ivaunmc ragoimd] 9.❑Demolition
3.❑I wn a homwwner doing vll work myself.lYo workers'comp.insurancerequired.)t
10❑Building addition
4.❑[am ahomeowrrer and wpl be hiring conheotors ec covdnctall work on my Property.twill 11. P.lcot[ical r'epaixs or additions
we Nat all contractors either bave worker,compe�reation irvsurance or are solo ❑
propderom with no employee:. 12. Plumbing repairs ox additions
5.❑[err agenervl--'sad I have hired the anbcmhaotora listed on the attached shat[. 13.❑Roof repairs
Dc,_ub-conhactore have emplyecs sad have esedd e'comp.insomnce.i 14.E]Other
- 6.❑We are aeorporuvehaveno ftl`emh— wmkccsmaoughtasoreoeratgoirc,MGL c.
15:;¢I(4),ao emP oyecs.l a
"ArtyapplicanP that uhecks box Ml mus[also fillanttheaeo[ion iseeolmwingtheir workera'emnpansatiov policy irriormation.
i Bomcownem who submit this affidavit indicating firq am doing all work end then hire outside contracture must subaffidavit mit a new iadheigadoh.
tConhacmrs Yhvt checkthis box mus[attachedan additional sheatshowing the name of a,soh-contractors and state whether or not[hoso an[hicv hove
emPloyees.Ifthe subconhactore have employees,Nay must I--their workers'comp.policy number. -
Zamanenployerthaiisprovidingworlrers'compensation tnsm,for illy en>ployeev.Believ is tLepolicy andjob site
informattnn. _ "Iumce Co , /
Id
' (1 �,C� M z l Expir'atinnDate: /� �/5
Yolicy dt or Self ins.Ltifo.#:/�v k/—L9, 9 1� 5�y �. �j rt,�i�-
Job Site Address:? I LLr'pQ s'lUc,�c �.,:.i 4tT City/Sure/7,ile N, Asa, Ve%/ttl'
Attach a copy of theworkers'compensation policy declm inures page(showing the policy..rube,and expiration date).
Failure to secure coverage as required under MOL c.152,§25A is a criminal violation putishable by,fine up to$1,500.00
and/or one-ycm imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office offavestigntums ofthe DIA for insurance
coverage verification.
Ida hereby certify nears pair undpenahtes ofperjury then the informatiouprovi-acoinve is rue and correct
Date:
s'nature:
Phone#: 91 7�
ofpeiat use only.Do notwrite in this mea,to be conioleted by city or tarn aff+cia.
CityorTowm - eennit/License#
issuing Autlrm'ity(rirele one):
1.Board of Health 2.Building Department 3.City/Tmvn Clerk 4.Eketrkal Impactor 5.Plumbing Inspector
6,Other
Coronet Persmn Phone th
RightFax (73-1 3/24/2015 9:51:03 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE I
DATEIMMIDD/YYYY)
T IFICATE IS ISSUED AS AMATTER 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 INRURERIS),AUTHORIZED BEPRESENTATIVE
E CE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the
terms antl contlltlons of fhe policy,certain policies may require and entlmsemenL A statement-I'll c101111t,does Rot confer rights to[he
certificate holder IR". I_
such endorsements.
PRODUCER CONTACT
NAME:
GILB13 T WS AGCY INC PHONE FA%
137 MAIN STREET I—,No,Ext): (AlC,No):
E-MAIL
READING,MA 01867 ADDRESS:
246WY INSURERS)AFFORDING COVERAGE NAIC#
INSURED INSURER A: R
'f
KEEN CONSTRUCTION CO INSURER B:
NSURER C:
NSURER 0:
11]S TURNPIKE STREET uRER E:
NORTHANDOVER,MA 01845 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
11 IN ATIMAY11111UEDIIIA-CUTAII
RAIV
PIMA YYIE PIMMDmYVYY)E
L1.GENERALUABILITY N&I ACHOCCURRENCEmrt $
COMMERCIAL GENERAL LIABILITY AMAGETORENTED $
CLAIMSMADE OCCUR. P REMISES(Es occurrence)
ED ENP(AUY(AU--,L $
ERSONAL B ADV INJURY $
GENT AGGREGATELIMRAPFLIES PER ENERALAGGREGATE $
POLICY OPROJEGTOLO ODUCTS-COMPIOPAGG $
ULCOMOBILE LIABILITY -1 EDSINGLE $
ANY AUTO LIMB(Ea—H-)
ALLOWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Pe Verso.)
HIRED AtROG BODILY INJURY $
NON-OWNED AIROS (Per accideM)
PROPERTY DAMAGE $
(Pw accident)
UMBflELLA LIAR OCCUR URRENCE $
E%CESS LIAR CLAIMS-MADE GGREGATE $
BL= $
RETENTION$ $
A WORKER'S COMPENSATION AND Y TO
EMPLOYER'S LIABILITY YM UBBB9IM$B2-14 10/CW2014 IGGVVOUS
AUY cLUC[nx IVE ICA
L EACH ACCIDENT $ 100,000
.'H___
MxH)=x EL DISEASE-EA EMPLOYEE g 100,000
E L.DISEASE POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONSILOCATIDNSNEHICLESIRESTRICTIDNS/SPECIAL ITEMS
THIS R6T'[.ACES ANY PRIOR CERTIFICATE ISSUED TO TRA CEPIRRCATENOLDFR AR'ECHNG WORKERS COMP COVERAGE.
CERTIFICATE HOLDER I CANCELLATION
TOWN OF NORTH ANDOVERSHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED
BEFORETHE EXPIflATiON GATE THEREOF,NOTICE WILL BE DELIVERED
1600 OSGOOD STREET IN ACCORDANCE WITH THE POLICY PROVISIONS.
A-1111ED R EPRESENT VE
NORTH ANDOVER,MA 01845
ACORD 25(21110105) The ACORD name antl logo are registered marks of ACORO M 1908-201nORD CORPORATION.Ait rights reurved.
BOJ B tl FB iildi q R g tons 13tcJs
c Yn¢li s p a
L ense'CS-076691
ROBERT AKEEN
12E WATER ST _
North Andover MA 0183
j,/—
06/16/2015
Off fCo Aff M R gulelion
frIAE IMPROVEMENT CONTRACTOR
g [e[ion 108383 Type:
p ton: 8/16/2016 DEA
KEEN CONSTRUCTION CO
Kenneth Keen
1175TURNPIKE STa---,F:.L'�
NO.ANDOVER,MA 01845 U��Oersecretrry