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HomeMy WebLinkAboutBuilding Permit #1023-15 - 18 HEPATICA DRIVE 6/8/2015 T A4WBUILDING PERMIT - ogtio TOWN OF NORTH ANDOVER 3 - ��'�� 1 " � �F APPLICATION FOR PLAN EXAMINATION .y Permit No#: Date ReceivedA° `.ArD �.y Rreo�Pa�•(9 LAC HUSfc Date Issued: �6% IMPORTANT: Applicant must complete all items on this page LOCATION X9 Gt¢ b f. 10193 _ Print PROPERTY OWNER {�e���` E', Z;4C Print 100 Year Structure yes no MAP /07-3 PARCEL:10493 ZONING DISTRICT: !i'iP Historic District yes Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building kOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain 0-,Wetlands a�Watershed District 0 WatetjSewer. DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Ke!{ �--"e- Zic, Phone: 9��•(D�,�-31�� Address: /0 ,4 "floe1401-oi-ee't 4y. Contractor Name: ge mi (f a&OD D Phone:', a6-39&- `f630 Email: ;•ne d L''o•�e T Address &!1 01-, l:11"tG a '140tz, Ifio'eik Aldo 9 mi8ys' Supervisor's.Construction License: CS- 07S3oa Exp. Date: /d fll& Home Improvement License: Exp., Date: ARCH ITECT/ENGINEER0:W4,y* ec • c� Phone: S )- cGpe7 16n:W-ye s2 Address: rIw,i Sf. �e�dt•�6-. OR4 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:]d�A Check No.: i Receipt No.: � NOTE: Persons contractingAith unre ' tered contractors do ofhave acc ss the gu my fund nature _ . J 1 i i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i TYPE OF SEWERAGE DISPOSAL . i Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ ❑ Well Tobacco Sales Food Packaging/Stiles.` 0 Private(septic tank,etc. ❑ Permanent Dmnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 'x/ COMMENTS ��— CONSERVATION Reviewed on 6 Si nature 3 COMMENTS i i HEALTH.. . Reviewed on Signature COMMENTS %� �.,,L, Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes ."lanning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si na e,& D Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Durnps,�t�e��ron site es Lo�"ca'ted at 12 Main S rf`et' Fire Depart em nt gig atur dates;® yw 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I 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 OTE: All durnpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4 Building Permit Application 4, Certified Surveyed Plot Plan 4 Workers Comp Affidavit .6 Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4, Mass check Energy Compliance Report (If Applicable) 4 Engineering Affidavits for Engineered products OTE: All dum stet permits require sign off from Fire Department prior to issuance ce of Bldg Permit New Construction (Single and Two Family) /4, Building Permit Application 4, Certified Proposed Plot Plan � . Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 4, Engineering Affidavits for Engineered products OTE: 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:Building Permit Revised 2014 Location a No. Z Date 4% 1 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $i 4/ Other Permit Fee $ - TOTAL $ s; Check.# Building Inspector °k ?.t � � yy s F� v € s , �� � , �T �,' k D yq :�• � + ,� <: ,k- r � k � �� � � tr{� !��� � i'W �� i 1 ^ 1 t �a ', r��f o- s, � ,�;-: t. rt�,� � 9"-,.. ��_ "� ,,��� Y. + h ji9+�" � ` ,d - ,�. �. � � �� � �� �: },�� s� � , �� '� 4�� r a. NORTH own of s E ndove.r /oIL h ver, Mass, Wit j COCHICNl WICK RATED PPP�.(5 U BOARD OF HEALTH Food/Kitchen I _T _ T LD .. PER Septic System THIS CERTIFIES THAT .......................... W - _ BUILDING INSPECTOR _ � �. ... Foundation has permission to erect... �...... ....:.. buildings on ... ..... .. __ _ ._- _• _ w_ _ __ -- -— - -- Rough to be occupied as ...............�.t .l �,11�. : . A. .. ....................................................... Chimney provided that the person accepting this permit shall in every respect coit•Form to the terms of the applicaton 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 Rough VIOLATION of the Zoning or Building Regulations.Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR - UNLESS CONSTRUCTI STARTS Rough ----- - Service .�r••�•�:'- ................................... . 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. *��r�,. �ti Dolo/Tiol Dn7fting ti yAttdC- r .. 74 l<Bjy z-N)7Elers a fill Rte, 114 No Un/t HMod iea tli©rl 2r>s9 _..• . SC,9 !V»It H drowings .... for padAutlranou rnrarrfnatfian m re.u :w..uw�.�i .,.�u. �r.r ree !knit H g6,,!4.e;•FrFrol7tt Ell- -o' tbodnp auea Apel �9 "201,'B .Alan Carroll �4edGfsnM7J OVsvfflrty 978•-902-0131 for f4ot�cv+a!tDu9dtrrR E�=e�C,�.°Wvnpll�ha1{i�u:m 24'-0• t2'-07 7-7' 12 ' Colonial - Drafting I' I 11 , 1 Luing Breakfast Kitchen q AdNai CAYn>iof layout m b II _ mwy xory op I ` I Key Lime Sul/ders I II , �I I - - - -0/0f So%m VI-1loge . . N Y II lav �„"1 ••-^- _ Rte. 114 North Andover . II Unit H Modlfioo tion ?V?----------------- dere Unit Hdtok,7gs p I Gl q for oddItIonal informotlon of - -'----- � If Dining 11 II � 1 Rc+ Ras 6'-415• rn try Office Garage - - F - - ..................... .......... H®ase , 15-22 -a-� DRewWsed-81st floor Plan � I 3/16-a J=p• A Q, D-PM%,g daft Apt* os .2015 I '-9' ,Q•-B' 8"-10' ,2'-6' P7uo Palo= axr7nq „'_s- s•-4• Alan Como# for wnre�olold 8 .+a X064mer. ss-•o• 978-902-0131 GonhvafD•s and D+.olcpc+re - - £- o7�CrdfoPJ .aorrl Au qq J 92 IU 1 u - L; nq Breakfast7 LCitchen Lltrin , 19r�olr�vst 'o IYh41W ePW.0 bpu.r 6 Ib 01 b Wit IErr' G y � �` _ _ •_ n I II VI ,1 t _ AoV I1 lov II 1 � II _ 11 _ ..........o—_«.a.� I ILL _.. ..-. ---------- ..,------- 161 -"-__ 9 EnPry ;; lining p �I En try /1 II 11 t � 5'-1 P ta'- • Garage (Porch � � Garage i - ............................................... _........................................... - 2,'-B' ib Horse 15'-22 9oue. in/t-M Unit //�' +7r<Cino.� t"irs+� Flvor Plort R sed F PZo—Or.felon_ Key Lime Builders C1010nicr/ 6 2 Old Salem Village !?rat't/ng Rte. 114 /Worth Andover r2 Unit H .Mlodifrcotion 6� See Unit H d►awJnga Tar a�a'dltdancsl lnfarmah'an 41 m,n .� Noor FnmJnj . �.�. Bedroom 3 ,�.���� Hall hph 60-•6 Gc.peN. 41 4yr rrew - - 7f/ice DiningKitchen � Entry Lav Breakfi F t ji ft r10Yfor Noll - � E.fRriaf AtrH _ - t dxBArb ac. 't. 2x6016`o.c. �a _ 62" - Sneff"W"7 60=5 0•o pq�F - : Nob 80-6'0.0. Y 36'-6' House If 15-22 15-22 Cross Section 1-1 Cross Section 2- D1c• J"V,a P-0" .7/16 = P-0 APIYI 09, 201 �I mid"t m nwrrrng Alen Corroll 978-902-01'31 oerore o„n dna Z-HW o tb<Emm { . 2 ' 1 Colonial 17 ©rafting ♦t ................... .... ............. �•r 'S Key Lime welders s - - ®!d �So%m !/aye Rte. 114 North Andover Unit H Mlodfflcatfon ♦' F - See Unit H drawings .................................................... far oddlfional Infarn7otvon n -- i House _-15-22 Unit--H ' ' 1 Remised Foundation Plan : •i ��.�. rM ePr8a. prOalaaemAsstrDJanr waS/eenB�tur�Osds e� .-.:........_. .__......�......�..�.............................3.D. ------- � • Owmw hv c.d�.a.ow.a. : - ----------------- 4pr11 09, 2015. r o .. ............ ..........'.........................10"2'-D. Alan Carroll l 978: IJ l Cortfrorfaa and Obi i 1 The Commonwealth of Massachusetts Department of IndustrialAccidents a 1 Congress Street;Suite 100 Boston,'MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly � Name (Business/Organization/Iridividual): Atwey)Ic we _ .l�T�9V. Address: /D-q beivll , 4 City/State/Zip: o j�� olrfo 1-7 m� Phone#: 9?c-68 3-3 X61 3P J �. .q Are you an employer?Check the appropr►ate box: T e of Iwo'ect re aired): LF-1 I am a employer with. „, employees(full and/or part-time).* , ], blew construction 2.❑I am a sole proprietor or partnership and have no employees working forme in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself,lNo'workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and'will be hiring contractors to conduct all work on my property. I will . ensure that all contractors either have workers'compensation insurance or are sole t 11.❑Electrical repairs or additions proprietors with no employees. 1 12. ]Plumbing repairs or additions 5.24am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t [ 6.F-1Weare a corporation and its officers have exercised their right of exemption per MGL c.- i• 14.❑Other 152,§1(4),and we have no employees.*'workere comp.insurance required.] 1 E *Any applicant that checks box 41 must also fill:out the 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer thai is providing workers'compensation insurance for my employees. Below is the policy and job site information. �ge�G• _ Insurance Company Name: /.fir ejoYoe fir!5 uQi�4Ki�i� Policy#or Self-ins.Lia#: (ba C'-6OG-$007S*t _ ;*#dl 4 Expiration Date: ?1/3/ID^ j Job Site Address: City/State/Zip: Attach a copy of the workers'compensation'policy declaration page(showing the policy.number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undq the pains and penalties of perjury that the information provided above is true and correct Signature- Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# 1 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other 1 Contact Person: Phone#: r ' : Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments,and.'who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such.,employment be deemed to be an employer." MGL chapter 152,§25C(6Yals6.states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials - •' Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for"ybu"Z fill out in the event the Office of Investigations.has'to`contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address;telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia WORKERS COMPENSATION,INFORMATION EMPL OY ON PAGE LIABILITY INSURANCE POLICY gseoi>Cited Employers Insurance Company 54 Third Avai nue; Burlington, Massachusetts a1 f3fl3_p NCCI NO 40959 (8co)878-2765 POLICY NO. WGG-540-5007581-2014A, PRIOR NO. I WGC-500-50 .7581-20i3A ITEM l 1. The Insured: Key Lime Inc DBA: FEIN: Mailing address: North Andover,MA 01845 i Legal Entity Type: Corporation I Other workplaces not shown abuiw. 2. The policy period is from 09115!2(}14 to 09/15/2015 12-01 a. $�the Workers s Compensation Law of tthe insured's mailing hderess. 3. A. Workers Compensation Insurance.Part One of the policy app lies states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. Accident $ X1,000,000 each accident The limits of liability under Part Two a're: Bodily Injury by 1,000,000 policy limit Bodily Injury by disease $ _ Bodily Injury by Disease $ _ 1,400,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WG 20 03 06 B 1 D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 1 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications --- _ — _Premium Basis Rates fEstimated Code Estimated Per$10ti j Annual No. j Total Annual � Premium Remneration —1 Remuneration — I INTRA 285896 INTER SEE CLASS CODE SCHEDULE Minimum Premium $575 Total Estimated Annual Premium $4.217 Deposit Premium $1,068 GOV GOV STATE CLASS MA Assessment Chg, I MA 5645 $3,778.00 z 3.4000% $128 07/31!2014 This policy,including all endorsements,is hereby countersigned by Authorized Signature Date Service Office: M P Roberts Insurance Agency 54 Third Avenue 1060 Osgood Street Burlinglon MA 01803 North Andover.MA 01845, WC 00 00 01 A(7-11) Includes copyrighted material of the National council on compensation insurance, „and With ria osrmisalon. i { i t i i I 3 Massachusetts -Department of Public Safety Board of Building Regulations and Standards WWRONOW %-onstruction Super-Yisor i License: CS-075302 BENJAMIN C OSOOO. 69 Old Village Lae North Andover ba 084' Expiration 12/04/2016 Commissioner f ' t 1 i 1 k 1