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HomeMy WebLinkAboutBuilding Permit #488-14 - 29 HEPATICA DRIVE 12/10/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: V / Date Received Date Issued: �U IMPORTANT: Applicant must complete all items on this page LOCATION o� ejPO¢� `Co ���O. / Print PROPERTY OWNER i�t . t, 0 , - c� Print 100 Year Old Structure yes MAP NO: PARCEL: ZONING DISTRICT:Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building ❑ One family ❑ Addition ❑ Two or more family �''� ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer _DESCRIPTION OF /WORK TO BE PERFORMED: iS�,.lG-eonSJ- 4Qee01:-� tf--a/7- ntification Please Type or Print Clearly) OWNER: Name: Address: /o Me jg,p 78 -699 3l6, CONTRACTOR Name::�ft,lwn'. K C- a6 -00p Phone:,9483 Address: C01? C.4 Vt'�t#-C-r- Supervisor's Construction License: 4 � Exp. Date: Home Improvement License: . Date: 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: $� lo't. FEE: $ Check No.: Receipt No.: %/ G NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF-SEWERAGE.DiSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ .. Swimming Pools ❑ Well ❑. Tobacco.Sales . ❑ Food Packaging/Sales ❑ Private (septic tank, etc... ❑ _ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED- - DATE.APPROVED PLANNING & DEVELOPMENT ❑ COMMENTS -CONSERVATION COMMENTS HEALTH L. COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;-, Engineer: Signature: Located 384 Osgood Street FIRE -Df PARTMENt -'Temp Dup ter on site yes no Fire"Department"s`ignatu'r"e/date"'� ' . ,.�* , . • ;,. .- . , ` .. . COMMENTS 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 Doe.Building Permit Revised 2010 Building Department The fol?-3wing is -a -list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits u Building Permit Application Li Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract u Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application u Certified Surveyed Plot Plan Li Workers Comp Affidavit a Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) u Building Permit Application a Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report u 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 apr),,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:tted with the building application Doc: Doc.Building Permit Revised 2012 Location No. Date Check # 21 1 %S TOWN OF NORTH ANDOVER Certificate of Occupancy $ a Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 14 Building Inspector Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 123000.00 m $ - $ 144.00 Plumbing Fee $ 18.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 18.00 Total fees collected $ 280.00 29 Hepatica Drive 488-14 on 11/10/2013 Finish Basement m m m m X m y m 10 CD � z CD O �r >CQ 'o O 00 C� O. Cr CD o �G O U) 'a 0 0 LU CD r+ CD M CD 9. U) CD U) O O CD 0 CD 0 c� Z m cn0 cnn 0 z TDT 0. J cn c Z, Z m cn z a� 0 Cl) ...mmo * * W. Ln 7 o N p N !-,t m — Z W C 3 A T °' S O ago 3 T °—' (Am M 2 N O ago S T > °—' w O ago S T > °—' ii T 7 7o O aro S T O m Q �. to N = r! L T O m � r* (D f+ O M m m HW ZD to m O m m r N V m C M N fl m p C p N m El m 3 n m 3 O O 2 D zl O O 0 _ ,qm Imw 0 C rD01 r ik� HIML assachusetts Cepart °arq of Builgin9' Re meRt of 9ulatio public Safety on uction S pen-isor License: CS -07 s anq construction Stan 9EpNy��COS�302args � �"` N V&1-4cO r U A1V� VERflit, o ,184NO * .•c 1 i Corerni ssioner #io 12/Oq/2'On WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC 5007581012012 PRIOR NO. WCC 5007581012011 ITEM 1. The insured Mail Address: Key Lime Inc 10 Hepatica Drive Street No. North Andover Town or City County MA 01845 State Zip Code FEIN xxxxx1218 ❑Individual ❑Partnership ®Corporation []JointVenture ❑Association []Other Other workplaces not shown above: 2. The policy period is from 09/15/2012 to 09/15/2013 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 Law of the states listed here; MA B. 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 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 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 Code Estimated Per $100 Estimated No. Total Annual Of Annual 14 Remuneration Remuneration Premium INTRA 285896 SEE TENSION OF INFORMATIC N PAGE Minimum premium $ 500.00 As indicated interim adjustments of premium shall be made: ❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly This policy, including all endorsements, is hereby countersigned by Total Estimated Annual Premium $ Deposit Premium $ MA Assessment Chg. $4,026.02 x 4.2000% Authorized Signature GOV STATE GOV CLASS KIND AUDIT PLACING OFFICE CLAIM OFFICE NAME CHECK SAFETY GROUP . MA 5645 14 505 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its ,permission. M P Roberts Insurance Agency Inc 1060 Osgood Street North Andover, MA 01845 4,470.00 1,160.00 $169.00 07/10/2012 Date /ACOR�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY) 6�24/zo13 THIS CERTIFICATE 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 OR PRODUCER, AND 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorseme0s). PRODUCER CONTACT NAME` M P ROBERTS INS AGCY INC A/C.No Ele: (978) 683-8073 MC No:(978) 683-3147 1060 Osgood Street North Andover, MA 01845 ADDRESS: - - INSURER(S) AFFORDING COVERAGE NAIC# DAMAGE I L) RLNTEU— PREMISES Ea occurrence $ 50,000 INSURER A: ESSEX INSURANCE CO INSURED KEY LIME INC INSURER B: 10 HEPATICA DRIVE INSURER C: HANOVER NORTH ANDOVER, MA 01645 INSURER D: 978-683-3163 INSURER E: INSURER F ;• A L:UVFK/At-iFl CFH 11"r -ATF M1111ARFR• - orcnerner ♦u uanfifn. THIS IS TO 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. ISR TYPE OF INSURANCE ADDL 1Nso SUBR vnrD ; POLICY NUMBER P LI Y EF MM/DD/YYYY P I Y EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY- CLAIMS -MADE OCCUR - EACH OCCURRENCE $ 1,000,000 DAMAGE I L) RLNTEU— PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ EXCLUDED PERSONAL &ADV INJURY $ 1,000,000 A 3DD9812 06/15/13 06/15/14 GEN'L AGGREGATE. LIMIT APPLIES PER: POLICY I JES L—T CI LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ EXCLUDED $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE$ Ea accident BODILY INJURY (Per person) $ ANYAUTO ALL AUTOS SCHEDULED AUTOS BODILY INJURY (Pet accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY —DAMAGE--$ Per accident $ UMBRELLA LIAR �_J OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNIER/EXECuiNE OFFICER/MEMBER EXCLUDED? ❑ NIA 1PER FF X STATUTE I ER E.L. EACH ACCIDENT ` $ EL. DISEASE - EA EMPLOYE $ (ManAatory in NN) If yes, describe under - E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS below C HANOVER INSURANCE IHN221411405 11/16/13 11/16/14 Fire Builders Risk DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PROPERTY LOCATION: 8+ & 10+ ACRES ON TURNPIKE STREET NORTH ANDOVER, MA 01845. PROPERTY LOCATED MAYFLOWER & HEPATICA DRIVE NORTH ANDOVER, MA 01845. NOTE 400,000 EACH HOUSE TOTAL VALUE 1.2 MILLION/ ENTERPRISE BANK LISTED AS MORTAGEE AND CERTIFICATE HOLDER. vin i Or 1%1^ 1 Enterprise Bank 6 Trust PO Boa 5203 Norwell, MA 02061 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988-2013 ACORD CORPORATION. All rights reserved. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD