HomeMy WebLinkAboutBuilding Permit # 9/3/2015 BUILT%ORTH DING PERMIT Q-0 IISD '6
16
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#:,„)�!; Date Received -Ar.ED PPayRy
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 9 5,
IPrint
PROPERTY OWNER Q
POM 100 Year Structure yes n-ol
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
Li New Building Li One family
Li Addition Li Two or more family 11 Industrial
Li Alteration No. of units: L1 Commercial
XRepair, replacement 11 Assessory Bldg [I Others:
El Demolition 11 Other
0 -
0 Wetlands A i
!
DESCRIPTION OF WORK TO BE PERFORMED:
V\ e
1,q C_e_ 0
Identification- Please Type or Print Clearly
OWNER: Name: R- C L K-,A-�� C-In Phone:
Address: '7,9 LJ L
Contractor Name: JC---Co Phone: 72- 6 9
Email:
Address:
Supervisor's Construction License: G —Exp. Date: I ( /i
Home Improvement License: Exp. Date:
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$1000-00 OF THE TOTAL ESTIMATED COST BA DON$125.00PER S.F.
FEE: $ 7
Total Project Cost: $ (,C) , C) (D — — C) I
� �- ') (z) 2— Receipt No.: 2)6)
Check No.:
NOTE: Persons contracting with unregistered contractors do not have access to the ra
nf contractor
%40)R H
-Townof
_E 1}
Andover
0 .
No.
0 LANE h ver, Mass,
COCNIc"t—CK .-
�� C5
S u
BOARD OF HEALTH
PER
Food/Kitchen T LD
Septic System
THIS CERTIFIES THAT ................ .... . BUILDING INSPECTOR
4.I�P ................... ...................................................................
Foundation
has permission to ere .......................... buildings on-..71.4....... .. ..............................
..A.4
Rough
to be occupied as ..% s .r 4��,...•—�.....�.°.`.......5�..... ......�...... .. ... ��....... . ...... Chimney
provided that the person accepting this permit s all in every respect conform t3 the terms of the application Final
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
q. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT S Rough
Service
........................................ .................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
KEEN CONSTRUCTION CO.
° 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
Chapter 142A of the general laws, must be registered
Submitteduiries
To: with the Commonwealth of Massachusetts. In 1C_ �\ �G 1-� -�ct c q
about registration and status should be made to the
9 6) Director,Home Improvement Contract Registration,10
(CI Park Plaza, Room 5170, Boston, MA 02116 617-973-
8787 Owners who secure their own construction
Gam(/ fVI j j G related permits or deal with unregistered contractors
will be excluded from the Guaranty Fund Provision
Of MGL c.142A.
PHONE DATE REGISTRATION NO, EIN NO.
MA. H.I.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:
> Construction related permits:
WORK SCHEDULE - - --
Contractor will not begin the work or order the materials before the third day lot[owing 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 Contractors 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 C
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of ., 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 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
J2 ul, (IUU.S � 1,1 i —
dollars($
Payment lobe made as follows
/e ($ ) upon signing Contr ct; In ROBERT A. KEEN
1( Name or--n—lo,/Designated negistrant
/a ($ ) po cFple
n cL l 1175 TURNPIKE ST.
lStreet Address
($ ) yip r cn of N. ANDOVER, MA 01845
city/stale
shall be made forthwith upon (978)691-5201 (978)682-3231
completion of work under this contract. IN �Ilesrna
Fax
Notice: agreement for home improvement contracting work shall require a A '1
>down payment(advance deposit)of more than one-third of the total contract price n
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 Aulhodx a
equipment,whichever amount is greater. Note:This Signature
proposal may be withdrawn by 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.
/�o DSO NOT
_SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature [ mow""'"?�` ,+^ Date / Signature Dale
IMPORTANT INFORMATION ON BACK
-7
C041ruc6on Co.
RfMOUFI_IIVc SPFCUALII FS
978—F9"1-52®'/
KeenConstructionCo_com
Halbach, Rick& Kathy
79 Gray St.
N. Andover, MA 01845
Contract#5551;Appendix A August 25, 2015
Gable end siding: $6240
• Remove existing siding on southern gable end
• Supply& install Tyvek house wrap and %"x 6"clear cedar clapboards to be stained
• Repair damaged front rake board
• Remove& re-secure electrical service and post as needed
• Replace misc.siding around house(50 lineal feet allowance)
• Replace misc.trim board around house (32 lineal feet allowance)
Replace Bulkhead: $1620
• Remove existing top of bulkhead
• Create wall with 6"x 6" pressure treated wood
• Supply& install Bilco 0 series bulkhead
Total Price: $7860.00 (seven thousand eight hundred sixty dollars)
Payment Schedule: $1000.00 due upon signing contract
$2000.00 due the first day of work (plus permit fee)
$2000.00 due when siding is done
$2860.00 due at completion of contracted work
ALr
c
Customer Robert A. Keen
/15
Date Date
1175 Turnpike St. Page 1 of 1 P: 978-691-5201
N. Andover, MA 01845 F: 978-682-3231
CSL#076691 Sales@KeenConstructionCo.com HIC#108383
The Commonwealth of Massachusetts -
-' Department of IndtfstriglAecWd is
Office of Investigations
600 Washington Street
Boston,MA 02111
Uf www.mass gov/ilia
Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectriciansfRIumbers
Applicant Xnformation Please Print Legibly
Name(Business/Organization/individual): Ke-eV) CM 5 +ru
Address: e. -
City/State/Zip: 4A a- E�1 9$6 Phone M 9? ? _ 6�4/ 2_0
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with — 4. El am.a general contractor and I 6. []New construction
employees(fall and/or part time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7• Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance, g $uilding addition
[No workers' comp.insurance 5. El We are a corporation and its
required.]
officers have exercised their 10.[(Electrical repairs or additions
3.[] I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),andwohaveno 12.QRoofrepairs
insurance required.] employees.[No workers'
q ] 1311 Other
comp.insurance required.]
'Any applicantthat checks box#t mustalso fill outthe section below showing their workers'compensation policy information.
7-Homeowners who submit this affidavit indicating they b're doing all worle and then hire outside contractors must submit a new affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
fain an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name% -a Vfj ,V) C
Policy#or Self ins.Lic.#l: (o 9Expiration Date: + 15 r
�' . y i /State/Zi C1 � t
Job Site Address. ty p
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration.date).
Failure to secure coverage as requiredunder Section 25A of MOL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as wallas civil:penalties in the form of a STOP.WORK ORDER and a fine
of up to$250.00 a day against the violator. De advised that a copy of this statement maybe forwarded to the Office-of
investigations of the DIA for insurance coverage verification.
X do liereby eerti de lie p ins andpenaltles ofperjury tliat the information provided above l true and correct. -
signature: Date:
Phone#'
Official use only. Do not write in this area,to be completed by city or town of-tial.
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#:
11
RightFax C3-1 3/24/2015 9:51 : 03 AM PAGE 2/002 Fax Server
DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
T. 1'IFICATE IS ISSUED AS A MATTER 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 INSURER(S),AUTHORIZED REPRESENTATIVE
O PRODUCER. D THE CERTIFICATE HOLDER.
IMPORTANT:if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the
certificate holder in Ileu of such endorsement(s).
PRODUCER CONTACT
NAME:
GILBERT INS AGCY INC PHONE FAX
137 MAIN STREET (AJC,No,Ext): (A/C,No):
E-MAIL
READING,MA 01867 ADDRESS:
246WY INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS INDEMNPI Y COMPANY OF AMERICA
KEEN CONSTRUCTION CO INSURER B:
INSURER C:
INSURER D:
1175 TURNPIKE STREET INSURER E:
NORTH ANDOVER,MA 01845 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS ITTO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMkDD\YYYY) LIMITS
GENERAL LIABILITY =-ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
CLAIMS MADE [—]OCCUR. 71REMISES(Ea occurrence)
ED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $
POLICY Q PROJECT[:]LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)PROPERTY DAMAGE $
771 (Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION ANDY We STATUTORY oTI IER
EMPLOYER'S LIABILITY YM I
UB-9991M582-14 10/08/2014 10/08/2015 LIMITS
ANY PROPERITOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION -.....n nti n n
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTlVE ;
NORTH ANDOVER,MA 01845
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
-�--
Lt/11.111 11 I.LIU11 JII ICI Vl,ll/1 �®
License: CS-076691
ROBERT A KEEN-W' '
12 E WATER ST; t$
North Andover NfA 0
wIilExpiration
Commissioner 08/16/2017
U l2e1p0��77�72aaeulelLGGl21/bAlul��cclicule Q
Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration: 1108383 Type:
xpiration 8/4b/20--16-, DBA
KEEN CONSTRUCTION CO.
Kenneth Keen
1175 TURNPIKE ST
NO.ANDOVER,MA 01845 - Undersecretary