HomeMy WebLinkAboutBuilding Permit #709-13 - 50 MAYFLOWER DRIVE 4/26/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: —1 Date Received I
Date Issued: �)Alh
IMPORTANT: Applicant must complete all items on this page
LOCATION �fJl• &VIW -6b
w�J
/ Print
PROPERTY OWNER A"W 01L��, l =
Print 100 Year Old Structure yes C6Zo
MAP NO: /b? 6 PARCEL: ,P ZONING DISTRICT:Historic District yes aP
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Resi ntial
Non- Residential
ew Building
One family
❑ Addition
0 Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
El Water/Sewer
DESCRIPTIOti OF
/"Dl1�1di�T'r`D7 �2 S'iil�
OWNER: Name:
BE P.EKFUKMtU:
Identification Please Type or Print Clearly)
/. - -
Address: /D /te�is > -e4 --pe, � 'i (/ AoQ/D!/C� /¢ 0/,Fo
CONTRACTOR Name: G. &A t -P 00 Phone: SO* d-70 --'{d1ttd
Address:
%'/G��� �K Iva
Supervisor's Construction License: Exp: Date: ��//o7O,q/
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER We���'�`� ' (!�p Phone:
Address: /%/4,'2 ���� ����� �0 �'¢ Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ 1 M—
Check No.: ff5o Receipt No.: �5Z.
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Si nature of contract C-
Signature of Agent/Own err _ _g
Plans Submitted � P ns Waived Certified Plot Plan L� Sta ped Plans
4
W
Plans Submitted IJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans 1
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/MassageBody Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private'(septie;tank,,,etc.
Permanent`'Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
❑
CONSERVATION Reviewed on �{ f
7 7 -
COMMENTS,
HEALTH Reviewed on Signature
COMMENTS - -
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comme
Commen
Water & Sevver Connection/Signature &Date Driveway Permit
n DPW 'Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 MainStreet
Fire Depar#inerit signature/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
NOTES and DATA — (For department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li Building Permit Application
u Certified Surveyed Plot Plan
Li Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 Mass check Energy Compliance Report (If Applicable)
u 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
u 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
o 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 2012
10 Ha
Location y -k e �� n
No. tii Ql�i - k Date = i
I" 74
Ilo-
Check # -6M
.:.:.,26332
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ LDJb i
Other Permit Fee $
TOTAL $
f
uilding Inspector
Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
Construction Supervisor
=�
License: CS -075302
BENJANQN C OSOOOD
69 OLD VHI AGE LANE.
NO ANDOVER NIA 01$5
f
,
Expiration
Commissioner
12/04/2014
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
ITEM
1. The insured
Mail Address:
Key Lime Inc
10 Hepatica Drive
Street No.
POLICY NO. WCC 5007581012012
PRIOR NO.I WCC 5007581012011
North Andover
Town or City County
MA
FEIN xxxxx1218
01845
State Zip Code
❑Individual ❑Partnership ®Corporation ❑Joint Venture []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
AUDIT
Remuneration
Remuneration
Premium
INTRA 285896
MA
5645
14
SEE E
TENSION OF INFORMATIC
NPAGE
Minimum premium $ 500.00 Total Estimated Annual Premium $ 4,470.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 1,160.00
❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly
MA Assessment Chg.
$4,026.02 x 4.2000% $169.00
This policy, including all endorsements, is hereby countersigned by 07/10/2012
Authorized Signature Date
GOV
GOV
KIND
PLACING
I CLAIM
NAME
SAFETY
STATE
CLASS
AUDIT
OFFICE
.
OFFICE
CHECK
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
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