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Home My WebLink AboutBuilding Permit #606-12 - 27 HEPATICA DRIVE 2/21/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: / Z Date Issued: -2 -,/// z IlORTANT: Applicant must �;ca -0 2;v Date Received all items on this �or A0 Prild, v PROPERTY OWNER KaV k" ON e- -L-" c • Unit # 30 Print MAP NO: /V7 6 PARCEL:34 ZONING DISTRICT: L/C Historic District yesno Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Fflew Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑Other {❑ SS' tic ❑ Well' 0 Floodplain Ef Wetlands. ❑ WatersfiediDistrict ["Water/Sewer � _ _ rmo-M,I M. DESCRIPTION OF WORK TO BE PERFO D: ee-c leoowt ,y n, t�,A.Sew�.v u.: r� ! (Identification Please Type or Print Clearly) � Q OWNER: Name: 1<&-!Zt'.&�na� �+G • Phone: ?cg-co�,3-31i'3 Address: /O Hof 416 cVJk"j. K L cJscr-e�o�� CONTRACTOR Name: K9 t %� e- x� mi0 • Phone: Sv6 - 3X 8 - HioZv J Address: �� d v�L�i #0iii N'Pie Gdcei wt OI YY Supervisor's Construction License: 7,3, E Exp. Date: 1 cP I -q 4zor-�- Home Improvement License: ARCH ITECT/ENGINEE Exp. Date: Phone: a Address: Reg. No FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. 19 Total Project Cost: $ 2 �, 900FEE: $ /�� Check No.: 3 yJ Receipt No.: 9-03 2 -- NOTE: Persons contracting with unregister contractors do not have access to the guaranty fund nature of Agent/OW ✓ gnature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPO,SALL Public Sewer u Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ TobaccoSales ❑ -,. � Food Packaging/Sales' ❑_ Private (septic tank, etc. El � _ permanent Dumpster on Site ❑ _ THE FOLLOWING SECTIONS FOR OFFICE USL ONLY 0 C �, INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMEN CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature w- 'i COMMENTS ' t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments A Conservation Decision: Comments Water & Sewer Connection/Sianature &Date Driveway Permit DPW Town Engineer: Signature: t Located 384 Osgood,Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMME&T-S' 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 2011 June/mi 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 ❑ Photo 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: Doc.Building Permit Revised 2008mi Location Z�- / "/� No. (�2626- I Check �22�/ 25032 Date /12 /j TOWN OF NORTH ANDOVER Certificate of Occupancy 00 Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL .Efd-ildih-g Inspector Q CD =0 Q O C v j •� A v yrCc •- CDm Q a o 4D 0 Z 1 V +O" o V as m a U o ` a = cf) ti m (n a = c C ECA m U m o a� m U m CD ac m Ci:. � a C s ►-� CD c •C m 0cc H Z O • d t•" OCD . t LL J O cc 'a y.. •V! R c s O. H N •dZC 01 = Z LU •E c'., o C •y o ci 10 cm 5 co _ � ..� N •= t- z �m m 5. CDE MMCD c b4 Z M ` � CD CM p ,I CD ._ O H w CD 40. CD U w O ca C cc Q •o •Qr y 0 H V C O c C y o O w r o z Q o o CO w cn w w U rE w w w cn ti. ci: w CC1. v) U) Q CD =0 Q O C v j •� A v yrCc •- CDm Q a o 4D 0 Z 1 V +O" o V as m a U o ` a = cf) ti m (n a = c C ECA m U m o a� m U m CD ac m Ci:. � a C s ►-� CD c •C m 0cc H Z O • d t•" OCD . t LL J O cc 'a y.. •V! R c s O. H N •dZC 01 = Z LU •E c'., o C •y o ci 10 cm 5 co _ � ..� N •= t- z �m m 5. 0 II�w Y/ U) w W LU 19 W w w CDE MMCD c b4 Z M ` � CD CM p ,I CD ._ CD CD 40. CD GQ o O ca C cc Q •o •Qr y 0 Z v V C O c C y 0 II�w Y/ U) w W LU 19 W w w Massachusetts - Department of public Safetl Board of Building Regulations and Standards Construction Supervisor License License: CS 75302 BENJAMIN C.- OSGOOD 69 OLD VILLAGE LANE NO ANDOVER; MA 01845 ` Jam- �y Expiration: 12/4/2012 Commissioner Tr#: 6267 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 64 Third Avenue, Burlington, Massachusetts 0803 (800) 676.2765 NCCI NO 40859 ITEM 1. The insured Mall Address: Key Lime Inc 10 Hepatica Drive Street No. North Andover Town or City POLICY NO I WCC 5007581012011 PRIOR NO. WCC 5007581012010 MA 01845 County state Zip Code FEIN xxxxx1218 ®Individual []Partnership gCorporation []Joint Venture OAssociatlon [30ther Other workplaces not shown above: 2. The policy period Is from 09115/2011 to 09/15/2012 12:01 a.m. standard time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation taw of the states listed here; MA S. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in item 3.A. The limits of our liability under Part TWo are: Bodily Injury by Accident $ 1:000.000 each accident Bodily injury by Disease $ 1.000.000 policy limit Bodily Injury by Disease $ 1.000.000 each employee C. Other States insurance: Coverage Replaced By Endorsement WC 20 03 05A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be (letermined 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 Coda Estlraatad Persim Estimated No. Total Annual Of Annual 14 ReminerMbn Remuneration Prerrtlum INTRA 285896 SEE E ENSION OF INFOPMATIC N PAGE Minimum premium $ 500.00 Total Estirnated Annual Premium $ 4,426.00 As indicated interim adjustments ofremium shall be made: Deposit Premium $ 1,165.00 ® Annually [ISemi Annually I8 Quarterly ,E3 Monthly MA Assessment Chg. $3.983.19 x 5.9000% $235.00 This policy, Including all endorsements, is hereby courdelsigned by 07108/2011 Autlmrt edSwtatxxt oate GOV STATE GOV CLASS KIND AUDIT PLACING OFFICE CLAIM OFFICE NAME CHECK SAFETY GROUP MA 5545 14 505 WC 00 00 01 A (7-11) Includes copyrighted material of the National Councti on compensation Insrawrea, used with Its permission. M P Roberts Insurance Agency Inc 1480 Osgood Street North Andoverr, ARA 01845