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HomeMy WebLinkAboutBuilding Permit #037-2016 - 40 MAYFLOWER DRIVE 7/7/2015 1 � BUILDING PERMIT,7t0 p10RTF1 o� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ''yyvim T �• h Permit No#: 0,3 7 2'x/6 Date Received 9 11 q°Rwre° gSSAC14US�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print j PROPERTY OWNER .Ke_,y r ✓ , c Print ' ; 100 Year Structure ;yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE 1-1 Residential Non- Residential ew Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain []'Wetlands ❑ Watershed District ❑Water/Sewer p/ DESCRIPTION OF WORK TO BE PERFORMED: Identification-_Please Type or Print Clearly OWNER: Name:_Xey �(+` Phone: 9'78 Address: Contractor Name&(It. hone:S-Oc6 -,:oO-0630 Address: ©),A Y,,1,L*,�Ce araC, D Supervisor's Construction License d '-s'07a Exp. -Date: 101/ A16 Home Improvement License: _Exp. 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. Y Total Project Cost: $ A&,0067 FEE: $ /Z/Y Check No.: 9Z// 62 7 Receipt No.: NOTE: Persons coma n wit ��eyed contractor dp not have ac o th aranty fund � ' 5 c� Signature_. Agent/Owner Sign a of contractor Plans Submitted ❑ Plans Waived Certified Plot Plan, ❑ Stamped Plans ❑ TYPE.' F SEWERAGE DISPOSSALL p��blic Sewer U Tanning/Massage/Body Art ❑ 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS . t HEALTH Reviewed on Signature COMMENTS 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 R DPW Town Engineer: Signature: Located 384 Osgood Street IRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street j Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based`,.on..;:Extdrior-dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service droptrequrres„ap"proval 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 i i Date Time Contact Name Doc.Building Permit Revised 2014 i s 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/Cross Section/Elevation Plan Of Proposed Work With-Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) o 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:Building Permit Revised 2014 ` I Location No. A/-, � / Date 2 . - TOWN OF NORTH ANDOVER nm� Certificate of Occupancy $ ma Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ a TOTAL $ Check#7,f Y/ 71 l/ r• F; r• n wilding Inspector Sr t� tAORTH J own of �._ ? Andover - ..�.. 0 No. ®31- 2aj � * - ,� o h ver, Mass, COC NI CNIWICK �� ��A�agTED ►'P�`�q5 S ll BOARD OF HEALTH Food/Kitchen PERMIT T LD - Septic System THIS CERTIFIES THAT ............:d('. .................................................................... BUILDING INSPECTOR . .�.l.D(:;�Ef. Foundation has permission to erect .......................... buildings on . .... .........................................� / Rough to be occupied as ......... 1.::`1 :.'��!... 1.! .: .f: ................................................................... chi X provided that the person accepting this permit shall in every respect conform to the terms of the application ,n 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 CONSTRUCTION STARTS R gh `� �'L "�" / � Service .. ..`�::�....................................... • ""�'��-.:::.:` mal BUILDING INSPECTOR 7 3LC 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. _ r/ Burner Street No. — � Smoke Det —�3 NORTH Town of �. E ., Andover No. 31_ * o�h ver, Mass, CO[MICNl WICK y�' A�R�TED %P�`�.(5 S V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ..............I.G.. .................................................................... BUILDING INSPECTOR has permission to erect buildings on ��7.1`eK .�k/ Foundation Rough to be occupied as ......... 1..`.`1�:. �+... s.�:. .(:% ................................................................... chi ey provided that the person accepting this permit shall in every respect conform to the terms of the application ,n 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 CONSTRUCTION STARTS Rough (G�'VL_ C1-. CVF_ UNLESS CONS Service ✓1.�.-�" • �"'��. ................................................. .. .. final � Zi BUILDING INSPECTOR 7 3 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. r/ Burner Street No. '' Smoke Det —�S Z Z NORTH Town Of _. EAn'dover O No. 031— 2oj � % h ver, Mass, COC NIC Nl W�CN �• ' �.9 A�RATEO ►'PP`,�'�y S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .C.� �C . - � ., has permission to erect .......................... buildings on . ......... .All4 17........................................ Foundation 1 Rough tobe occupied as ......... .................................................................... 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 CONSTRUCTION STARTS Rough fe, Service ..r/'/ r .... �... ..`��...................................... Final BUILDING INSPECTOR j 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. The Commonwealth of Massachusetts Department of Industrial Accidents a d 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/Individual): /<Q,/p(//ic .ne -!nC Address: /o /ICA/ T G 9 ]>,c, l90 �01142 City/State/Zip: & �.z��/BQ W4 Phone#: Are you an employer?Check the appropriate box: Type of roject(required): 1.D I am a employer with employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. [:]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [:]Building addition ensure that all contractors either have workers'compensation insurance or are sole ll.FJ Electrical repairs or additions pr netors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROOF repairs These sub-contractors have employees and have workers'comp.insurance) 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 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 that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:4-%P<• /G6 gews ..I.N S• C-(� Policy#or Self-ins.Lie.#: Wn:::-Son-SW 7A;461 ,76 Expiration Date:_ Job Site Address:_yg f�l,�yf,�Ow o2 �,Q City/State/Zip:NU #.,4'erg wo 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 under the pains and enaltie's of perjury that the information provided above is true and correct. Si nat /��0;�� / isn� �•- Date: 7 �� Phone#: �• G Official use only. Do not write in this area,to be completed by city or town official. 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#: I 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,constfuction 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(6)also 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. Cit Town City or 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 you to fill out in the event the Office of Investigations Lias to confact 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 pe'rmit/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 burn 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 i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction supei-vilsor License: CS-075302 BENJAMIN C OS 0OOD 69 Old Village Lade North Andover M-A Ofr ) 1 -" Expiration Commissioner 12/04/2010 WORKERS COMPENSATION AND EMPLOYERS LIABILIT'*-k'lt-iSURANCI-zRCI-ICY INFORMATION PAGE Associated Errployeers Insurance Company 54 Th"d Avenue, 9wr I ton, Mas.-tachuseft 01 0 (8 141 0)67~-2 NCC;i NO 40959 P oo-1 B 2014 PRIOR NO, 23 ITEM 1. The Insured: Key Lima Inc DBA: Mailing address: 10 Hepatica Drive FEIN.,"-***1218 Nufth Agdovar,IMA 0 i 845 Legal Entity Type: Corporation Other vioeeplaces not shown above: 2- The policy period is from 09/15/2014 to 09/15/2015 12:01 a,m.staridaid time at t i✓i=;gumd's rpa-',ann�-A-Irm 3. A. Weezer-s CoMPS113afion Insurance:Part One cO tt'c Pei'.0 Y aPPUS-2 tia the VVO,*Gm, Compensation Ldw ol the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in ca--h atata listed In itemn 33.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1 ftWOOU each P-Ccident 130diIY Injury by Disease $ ---- 1 000,000 policy limit Bodily injury by Disease $ ---- . 1,66-0--.000 each-employee C. Other States Insurp-rice. Guverage Replaced by Endorsenlari,ivu 20 03 06 B 0- This Polil-N inetudes these Endorsements and Schedulais-, SEE 31"'AHE-DULE 4. The premium for this 12011cy will be determined by our manuals of Rules,Clffssifli�-qtlns,ft-t-We-nnd�PIF_t*r- n a S Ali informafion required below is subject to verification and change by audit. 1 n Cla��fflca�.=s rnium Basis Fsaies Code Estimated -T—Per-S100- t! No. Toief Annual I Of Anrval R1 wrt-Ineration INTRA 285696 iNTER SEE�CLASS CODE SCHEDULE Minimum Premium $575 Anrua!Pramh,m 20V : GOV Denrosit Prem;urn $ ,217 STATECLASSi I Vo Ma 5645 MA Assessment Chg. $3,778.0()x 3.4000% $1128 This ooliev,including Pit endorsomer.i.,, kss uyc;n d 07/31/2014 Uale Service offlcow- 54 Third Avenue M P Roberts Insurance Agency Burlington MA 0-1803 WOW Osgood Street North Andover,MA U 1845 WC 00 00 01 A(7-11) InChidan cnpyrJghtL5d m�, !hn ,ie tar- used Walt He pqrmlssfl;�.