HomeMy WebLinkAboutBuilding Permit # 10/24/2016 a�
BUILDING PERMITS
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION -
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Permit i�lta: bate Received ______--
Date Issued: ® �
IMPORTANT: Applicant must complete all items on this_..ai5e_.,_.,..
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l TYPE OF IMPROVEMENT PROP05ED USE
ResidentialNon- Residential
_W New Building ---_- --...__One farrtily__-..��.._�._ .._-.._._._ �
Addition parking lot Two or more family l ': Industrial
Alteration No, of units: lx Commercial
I- Repair, replacement Asse.ssory Bldg, lW Others:.
Demolition Other
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Project consists of the construction of a neve auto perking area and associated site work to
accommodate a new building expansion at 351 Willow Street South, North Andover, MA.
- - IdentificationPlease Type or Print Clearly)
OWNER: Name: Bake N Joy Phone. 800-666-4937
Address: 351 Willow Street South, North Andover, MA 01845
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ARCHITECT/ENGINEER The Morin-Cameron Group, Inc Phone: (978) 887-8586
Address: 447 Boston St# 12, To sfield, MA 01983 Reg. No. Civil No. 39836
FEE SCHEDULE.BULDING PERMIT_$12.00 PER$1000,00 OF THE TOTAL EVIMA MD COST BASED ON$725. 0 PER SIF
Total Project Cost: ` �_---FEE: $
Check No.: _ Receipt No., _
NOTE; Persons conlracfirkg with unregistered contractors do not have aecess to the gita ty.10nd
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---------------------- ........................ ........ ................ .......
T%ORT11
Town . o a q 'A'.. 6
n over
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3No. Rwe R Ii.-
ver, Mass, _/� Z� �/&
cocs��cMewrc« 1'
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
P PWA::
THIS CERTIFIES THAT ....._.7o/ 019.9....A? . ............................ 13UILDING INSPECTOR
Foundation
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has permission to erect .......................... buildin s on . .....
to be occupied as 4.W.Jq........................ ..................................... Rough
- V..........;A;..-- - Chimney
provided that the person accepting this permit shall in every respect conform to 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS ION S Rough
Service
..... . .. ............ Final
BUIEI)IiNG��[ �
GAS INSPECTOR
Occypaney Permit Required to Occupy Buildin 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.
The Cvntinonivealth vf'Maysachusetts
N P Department of'Industrial Accidents
l` Office of'Invewigettions
t', rTZ 6001. Washington Street
Boston, MA 0211.1
www.maass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (13asitTesslOrganizatioii/lndividual): � evr ' ' , I Inc
Address: '
City/Statc/Zip: ( p.holle#: b, 17, 32 1 1
Are you an employer:' Check th appropriate box: Type of project(required}:
l.❑ I ani a employer with 4. E] T am a general contractor and T
employees.(full and/or part-time),* Have fired. the sub-contractors 6• ❑New construction
2.❑ t ata a sole proprietor or partner- listed on the attached sheet. 7. ❑Rernodeling
ship and have no employees These sub-contractors have 8• Demolition
working for mein any capacity. employees and have workers'
[No workers' comp, insurance comp. insurance.t 9. F1 Building addition
requit•ed
' oration and its 10.❑ Electrical repairs or additions
.] 5, � We are a corp
3,❑ I ann a hotmowner doing all work officers have exercised their I I,❑ Plumbing repairs or additions
trtyself., [No workers' comp• right of exemption per MOL 12,❑ Roof repairs
insurance required.]1' c. 1.52, §1(4), and we have no
employees. [No workers' 13.[l Other: parking lot
cornp. insurance required.]
"Any applicant that checks box 41 tiinst also fill Out the section Below showing their workers'compensation policy information.
I loincowners who submit this affidavit itidicating they arc doing all work and then hire outside contractors triust.subrnira new affidavit indicating such,
(,'ontractnrs that cheek this box nutst attached an additional slicer showing the narne of the sub-contractors.and:state whether or not those entities linve
,imploycs. If`tlie sub-contractors.have employees,they nnrst.provide their workers'comp.policy ntrntber.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
iii frrrmatiarr.
Insurance Company Name, J: �pi C-2-C iU)n.. l,1(2
Policy#or Self-ins. Lic. #: We-(, ;L i I 2 Expiration Datta: (1 1-`
351 Willow Street South
,tali-Site Address: City/State/Zip: North Andover, MA 01845
: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
line tip 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 ftp to$250.40 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
Ido hereby certify u ler thepa' s urtdp6nallies of'perjury that the infarrnation provided above is true and correct.;
Signature: r � __. - _ Wt .t Date: , October 21, 2016
Phone 9:
O,ffrcial use only. Do not write in this area, to be completed by city or town offtciaz
City or Town: Permit/License#
Issuing Authority(circle one):
1.. Board of Health 2. wilding Department 3. City/Town Clerk 4. Eleetrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Massachusetts Department of public safety~�
Board of Building Regulations and Standards.
License: CS-094656
Construction Supervisor
KAREN F CURRAN ;
70 UNION ST .p
MARSHFIELD MA 02'
Expiration:
�:arrimissioner
- 10109120/7