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HomeMy WebLinkAboutBuilding Permit #492-16 - 71 MAYFLOWER DRIVE 10/19/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION f_ Permit No#: Date Received Date Issued: 1611 9/1< TANT: Applicant must complete all items on this 0 �t LEU Ibx�i�C LOCATION 7/ )04V - l E�PUJ6 4 r j�71 Print PROPERTY OWNER .!_ :etc. Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic Q Well ❑ Floodplain 0 Wetlands » Waterah-e stnct DESCRIPTION OF WORK TO BE PERFORMED: _ Identification - Please Type or Print Clearly OWNER: Name: Ke,//,s-ftr- 1.c, • Phone: 17* -&83 Address:_JO yr -e 1t e'A; bei Ulf - Contractor Name: TevL 0—c- -om Phone: Email ( e IL,`.+a w: klbee C&"1C-4r L s Address: har442 test Q24,4 IIc, IL*c-,- r,.Aawiffl, JlJo ik o#,e e2- RU Supervisor's Construction License: -(3 S - ©753 0.1 Exp. Date: lal ylI& Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 4 �14 11, &R9, O LL Phone: 7! 7B , 90;. - 013 t Address: .oA Sulo(. 11,14o1Jeie. t'1'lb� 6,1810 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: $ )5, ooV FEE: $ A Check No.: NOTE: Persons M Receipt No.: contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL F Public Sewer TanningWassage/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 1060 Signature_ brf*e COMMENTS 2-i'vtwt�l� �\d SINC�P i}�G Maddhchmr- CONSERVATION Reviewed on /6 /1 q11 COMMENTS_ HEALTH i COMMENTS Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Conservation Decision: Comments Zoning Decision/receipt submitted yes Wafter & Seaver Connection/Signature & Date Driveway Permit ' DPW Town Engineer: Signature: Locatea :it54 Usgooa Street FhF�ZEDEP'-.}pysteon 'i L�ocate�at12`'4�Main�S�trneet• .z .. �FireerDe artment�i �- .�.�pa. gnafure/dafe 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use LJ Notified for pickup Call Ema Date Time Contact Name Doc.Building Permit Revised 2014 M 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 4- Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products E: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. Building Permit Application Certified Surveyed Plot Plan ,4. 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) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products . TE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 Location � r No. i�� - Check # �?,q�( Date /(l /g TOWN OF NORTH ANDOVER Certificate of Occupancy $ ' Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ Building Inspector v, C � 57 O N n 0 O n Z N CD CL Q. :• N > c � O � vCD < o CrCL � — c� CD O ou CDW o y CO CID I � v O n O O CD O m X v m C/) Z Z V//2/� Iq O D 0 z Oh S CD N (O W Q (O CD co _ 0 N 0 N S cn CD o='a 0 __ o ai - CD y 0 CLO CD C7 CD r�0-0 3 "' o 2:�-a O N N CD 0 O O Q N OU D. CD CD N O O CD C. O N CD C O Q'O ,nom (Q O N O D) S CD •CD . CD •a ._ 0 O to O 0 N z CD ;O cD �rt� <D y Q- �- = n�:l: o Q 0 IN < CD �' O CD N O CD CL W ID U) O y 0 (n O (D N rr W j fD m Z rt C 70 O S H m TV1 O d to :' 0 c T N =r CD v C W � Z 0 T j v ii S 7 N � T O 7Q N O W C O G1 Z M In fD L (D 3 O /\ O -O•w ' Q n0 CD -0 0 ar 0 � 0 CL , O y 0 (n O (D N rr W j fD m Z T v 70 O S H m TV1 O d (D < M Z7 O S m m A Z A 0 T N � O c S v C W � Z 0 T j v ii S 7 Z7 O pOq S T O 7Q N O W C O G1 Z M In fD L (D 3 T O m ' W > O T y x 0 Q C V VORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers insurance Company 54 Third Avenue, Burlington, Massachusetts 018OM970 (800) 876'2765 NCCt NO 40959 POLICY NO. i WCC -500-51007581-2015A PRIOR NO. WCC -500-500758.1-2014A! ITEM 1. The Insured: ''Key Urne inc DBA: Mailing address: 10 Hepatica Drive FEIN: **-***l 218 North Andover, MA 01848 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 09/15/2015 to 09./15!2016 12:01 a.m. standard time at the lnsursd's ,mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed Isere: RAA e. Employers' Llability 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: Coverage Replaced by Endorsement WC 20 03 06 8 D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for thle polies 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. Glassitications Premium Basis Rates Erode Estimated Per $100 Estimated No. Total Annual Of Annual I Remuneration Remuneration Premium INTRA 285896 INTER SE CLASS uiaut SGIIEDU _ Minimum Premium $575 Total Estimated Annual Premium $575 GOV GOV Deposit Premium $578 STATE CLASS MA 5645 State Assessments/Surcharges $48.00 x 5.7500% $3 This policy, including all endorsements, is hereby countersigned 9 by "'s°a'�'4- 07/30/2015 Authorized Sigrasture Date Service Office: 54 Third Avsnus Burlington MA 01803 WC 00 00 01 A (7.11) Includes copyrlgMed ntatottal Of the Netlanal council on Compenaetion Insurance, uled with IN permission. 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