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HomeMy WebLinkAboutBuilding Permit #73-15 - 40 MAYFLOWER DRIVE 7/23/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ?`; Date Issued: I 6 IMPORTANT: Applicant must complete all items on this Daae I .•.A� LOCATI D Print. PROPERTY OWNER_Aes/ Print 100 Year Old Structure yes MAP NO: /O% _ PARCEL: __ ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential 1rhew Building ❑ One 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/Sev►er O DESCRIPTION 9F WORK TO BE PERFORMED: FOC -fro? Identification Please Type or Print Clearly) OWNER: Name:Phone: 97W-663-310Address: /19 4weKkC.4 6l/ll , JJ0 A -1-L 4ot/B4e, *14 0I7YS ,Sb� 338..- yflo$O CONTRACTOR Name:iA�C-- Phone:y� - Address: CO 1 ©t� V).,_�64e X e> 9,-clsve,e. 49/74(s Supervisor's Construction License: G5 - Exp. Date: /2,191J// Home Improvement License: :xp. Date: ARCH ITECT/ENGINEERWQvpo Phone: Address: iEG��''�i Mor Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $__(W6 FEE: $ Check No.: :� dD: ( Receipt No.:a­:4� 1 , - --- - NOTE: Persons contracting with unregiste d contractors do not have access to the guaranty fund Signature of Agent)Ow 4 _ gnature of contract Plans Submitted F] moans Waived 0 Certified Plot Plan ❑l Nkped Plans Plans -Submitted ❑ 'Plans Waived `..Certified Plot Plan ❑ Stamped Plans ❑ - ;TY'PE OYSEWERAGEDiSP.OSAL = DATEAPPROVED Public Sewer Tanning/Massage/Body Art Fl. .Swimming Pools ❑ Well -Tobacco.Sales Food Packaging/Sales ❑ Private (septic tank, etc_-. -` Permanent D"iiinpster on Site THE -.FOLLOWING SECTIONS FOROFFICE USE ONLY _ INTERDEPARTMENTAL SIGN OFF U FORM PLANNING & DEVELOPMENT COMMENTS ,:-.."DATE. REJECTED DATEAPPROVED COMMENTS0 0-4 S ®v I �1 Q 100 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 'Consgrvation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tovv '&engineer: Signa FIRE DEPARTII ENt `Temp Dumpster on site yes Located -at ,124 Mair, Street - --Fire DepartFn-e►it•signatu're/date�Y a COMMENTS Locaiea ots4 usgooa Street no -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 Z®NE LITERATURE: Yes No MGL -Chapter 166. Section 21A -F and G min.$100-$1000fine MOTES and DAJA — (1 -or department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol .awing is alist of:the require&forms to be filled out'for:the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ B'gilding 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 cans .if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn;�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:?ted with the building application Doc: Doc.Bui?ding Permit Revised 2012 T Location No. l Check # 703- 1 G I ti IL'! J Date -712.&)I� TOWN OF NORTH ANDOVER Certificate of Occupancy $ �— Building/Frame Permit Fee $ Foundation Permit Fee $(00 Other Permit Fee $ TOTAL 1 t uilding Inspector Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super, icor License: CS-075302 BENJAMIN C OSG'OOD.._- 69 OLD VILLAGE LANE NO ANDOVER NTA 01845 y Expiration Commissioner 12/04/2014 The Commonwealth of Massachusetts Department of IndustrialAccidents Off ice of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): L& #ft t:— d-yJ Address: 10 14-64,'C4 �D ety t j City/State/Zip: No 4,+ I o0e e (M 0177"Phone #: `17 Co 17 s ^ S/b--f- Are -f- A,reeyyou an employer? Check the appropriate box: 1. L-1 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. , Insurance Company N Policy # or Self -ins. Lic. #: W9C.40 —S00 — 6007S$/ —0013V Expiration Date: ?11:5_1A01,1 Job Site Address: DSL 0 .5A tLotrt �%r pit#& City/State/Zip: P% h4JO&V _ dJ# -0lPits Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under thee pains and penaltieesss ofperjury that the information provided above is true and correct, Siunafirra C, �/�rstJ� n..4 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than$htee 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 deemedxo be an employer." ,. MGL chapter 152, §.25C(6iJ also states that ",overy 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 -contractors) 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 Ar yoti'to M out in the event the Officio of Taveit�galions�lias �o'coniact 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 twt m, u*st'p:bmit �mdtiple,perml#/license applications in any given year,need'ibnl� submit ore a�fid�vit 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, tele hire and fax number: r,.�#z ,.>.,+ ► _:- - >_ . . The Commonwealth ofMassachvsetts Department o:f industrial Accidents Office of Investigations 600 Washington Street Boston} MA. 02111 Tel, # 617-727,4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax # 61.7-727;7749 www.mass,goV1dia WORKERS COMPENSATION INFORMION PLOYER ABILITY INSURANCE POLICY Associated Employers insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. IWCC-500-5007581-2013A PRIOR NO. I WCC5007581012012 ITEM 1. The Insured: Key Lime Inc DBA: FEIN: ««_«««1218 Mailing address: 10 Hepatica Drive North Andover, AIA 01845 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 09/15/2(113_ to 09/15/2014 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 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: D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for ,his 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. r Classifications Premium Basis Rates Code Estimated Per $100 Estimated No. Total Annual Of Anrual Remuneration Remuneration Framium INTRA 285896 INTER SEE CLASS CODE SCHEDU E Minimum Premium $575 Total Estimated Annual Premium $4,470 GOV ' GOV I Deposit Premium STATEiCLASS MA ' 5545 MA Assessment Chg. $169 This policy, including all endorsements, Is hereby countersigned by 07/23/2013 07/23/2013 Authorized signature Date Service Office: 54 Third Avenue Burlington MA 01803 WC 00 00 01 A (7-11) lnciddes copyrighted material of the National Council on Compensation Insurance, used udth U perm)selon. M P Roberts Insurance Agency 1060 Osgood Street North Andover, MA 01845 J Y LL OZQ ac Q m v \ O O LL E v Ln U O. N N p �= (A Z Z J m c ° m "6 7 O LL t D O OC a cu C i U _ C LL O W N Z m a t � O d' _ N O LL O aW H Z U U W w t O d' u O In _ t9 C LL O U W Z Q t 7 O K _ N C LL Z ce CLW o W LL Y. 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