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HomeMy WebLinkAboutBuilding Permit #74-15 - 46 MAYFLOWER DRIVE 7/23/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: '" Date Received —7/�2 Date Issued: ` Z3 1�4 IM R ANT: Applicant must complete all items on this page ,r /_ A ll LOCATION .f C> t52 (//62 (r' �+'��-�/F�owec ZJ+�; u 0ea &1ti oyeoe I Print. PROPERTY OWNER D,C• Print 100 Year Old Structure yes MAP NO: /&7 PARCEL: & ZONING DISTRICT: Historic District yes Machine Shop Villaqe ves 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 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF 1JVORK TO BE PERFORMED: O tet. a Gr -t a cq-7 D4 f -e a.c ® Its L st Identification Please Type or Print Clearly) OWNER: Name: �� �.�.ti,e� f4c. Phone: Address: ---LO o -DZoe✓a f A/o M4 &i8*s CONTRACTOR Name:Zt;a j n C'_ Goa o Phone: 5a8 3 -x(030 Address: Goy( ©IJ Y'4L46e 4,, m. bo #--LL leQ. �►2 e�8 5 Supervisor's Construction License: S 02 Exp. Date: Home Improvement License: =xp. Date: ARCH ITECT/ENGINEER.6&xgoZ�. Devi F. 1,�—; Phone: Address: 1P9ow*J- , iYI Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: 23��- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/O_r SQg �atureof contra r _ Plans Submitted LJ P s Waived Certified Plot Plan ❑ St ped Plans Plans Submitted ❑ 'Plans Waived ❑ Certified Plot Plan ❑ . Stamped Plans ❑ :TI'PE_OI�;S)✓WERAGE_DISP.OSAL = _. _ - Public Sewer ❑ Tanning/Massage/Body Art ❑ .. .Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc._ ❑ Permanent D mpster on Site ❑ .-THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _:,..'DATE REJECTED . DA -APPROVED PLANNING & DEVELOPMENT ❑ 7-2- 3-� f COMMENTS COMMENTS f) �47 — `' - COMMENTS zbninq Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 4 Planning Board Decision: Comments Conservation Decision: :Comments Water & Selmer Connection/Signature & Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTM,r NT. =Temp Dumpsfer on site yes no Located at 124 Mair Street - - Fire Department signatu"reldate Y HEALTH' Reviewed on Siqnature COMMENTS zbninq Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 4 Planning Board Decision: Comments Conservation Decision: :Comments Water & Selmer Connection/Signature & Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTM,r NT. =Temp Dumpsfer on site yes no Located at 124 Mair Street - - Fire Department signatu"reldate Y Dimension Number of Stories: Total land area, -.sq. ft.: Total square feet of floor area, based on Exterior dimensions._ iELECTRICAL: Movement of Meter location-, rust or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: Yes No MGL.Chapter166.Section 21A -F and G min.$10041000:fine NOTES and DATA — (For de LI Notified for pickup - Date Doc.Building Permit Revised 2010 ent use Building Department --The following is'a list of the re quired.forms to be=filied out for the appropriate. permit to be obtained. Roofipg, Siding, Interior Rehabilitation Permits - ❑ Bailding 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 apw, 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: Doe.Building Permit Revised 2012 Location C ftoaQvj-le/L No. Date 2 TOWN OF NORTH ANDOVER Certificate of Occupancy $ il,di.n 8 -Perri Fee $" oundation Permit Fee $ TOTAL Check # f `� Building Inspector Massachusetts - Department of Public Safety Board of Building Regulations and Standards Constructiu❑ Supen icor- , License: CS -075302 ' BENJAMIN C OSGOOD 69 OLD ViL LLAGE LANE 'z ' NO ANDOVER ASA Ot8;15 Expiration Commissioner 12/04/2014 P w 0 M r6 cow = GZ Oou'C 00 w U +' O O LL E °j N u O. N N p U z Z m c O Y a 7 O LL r 7 O W T c E t U LL 0 W CL Z J -j t 3 O 0' c LL p aui Z Q Uui w r W p v N C LL oc p a Z r CO p C LL ~ Z w' a. LL m O z OJ { j a+ N Y O {n D J _ _ O lC a a� a¢ o NcD Q L 0 • ; ( _ � yam.+ � YZ _s O +r <u W E 0 C V N d � O' J t/1 , i �a , m aD r • L =y O d > O O = _ UME Q 4: o m O Z _.rte H O O .a L 7• Q ui y-+ rO+ ui I— V O = _ Q L L d Q d . M Cl)A0- N O 2 m W -a -- O O !i '� - M . N = Q. s O u L s 0 w E L v � s � N Q O y y .O O = I— .OL- r- 0 - O. 0 0 G Z Cl) CL W H /W A U Z 0 t� J The Commonwealth of Massachusetts Department of IndustrialAccidiiits Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print ULibl_y Name (Business/Organization/Individual): K 41 C- G . Address: 1D ge_f#�, ca bdc: City/State/Zip: IJCP 464 d ayi%e, M 4 &MSfhone #: Wf—&f t -814>t, Are yo}i an employer? Check the appropriate box: 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. 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 3. ❑ I 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.] t 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. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:.Gi9�� Policy # or Self -ins. Lie. #S:4 :"wG rC. -5D8J 00 ^.Sp75'-070!311 Expiration Date: /� D •- ,* Job Site Address: t��o�14LOW e,*41.#&43 City/State/Zip:_AD h�jc ee-oe, ws 0/fts Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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. Ido hereby certtry under thepains andpen Ities ofper'ury that the information provided above is true and correct. �iunafimP �./�1Os�/ ��• Lam _ n �e. 7/!71 At/ 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. PIumbing 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 tbree apartments and whq resides therein, or the occupant of the dwelling house of another who employs persons ft4d mainte"rianc6, '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 bean employer." MGL chapter 152;, 25C(6),alsq states that,".every state of local licensing agent _shad withhold the issuance or renewal of a license or permit to operate a business or to construct liuildirigs n 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 affi4#it;1br you.to Pili out in the event the Ork& afinvestigations Lias: to' coni' et you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant fiat inust'submit tnultipleapermiVlicense applications in any given year, need odf '`subfiiit on�af idavitindicating 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, telepli6he and fax number:, The C o mmonwoalth ofMassachUsetts.; k Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tei, # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mtass,govfdia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WCC -500-5007581-2013A PRIOR NO. I WCC5007581012012 ITEM 1. The Insured: Key Lime Inc DBA: Maiiing address: 10 Hepatica Drive FEIN: ""-'""1218 North Andover, MA 01845 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 09115/2013_ 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 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 Remuneration Remuneration Premium INTRA 285896 ' INTER SEE CLASS CODE SCHEDU E Minimum Premium $575 Total Estimated Annual Premium $4,470 GOV GOV I Deposit Premium STATE CLASS MA 5645 MA Assessment Chg. $169 f This policy, including all endorsements, is hereby countersigned by " 6 07/23/2013 Authorized Signature Date Service Office: 54 Third Avenue Burlington MA 01803 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 1060 Osgood Street North Andover, MA 01845