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HomeMy WebLinkAboutBuilding Permit #222-15 - 73 MAYFLOWER DRIVE 9/2/2014 BUILDING PERMIT of N°DT 6 qti TOWN OF NORTH ANDOVER 03 APPLICATION FOR PLAN EXAMINATION ~ �4 OH T Permit No#: - Date Received �9SSACHUS�`�� Date Issued: --9zallzl I ORTANT: Applicant must complete all items on this page LOCATION Q1� Print PROPERTY OWNERkeq t m e, .�c - Print 100 Year Structure yes n MAP/P7 PARCEL: le�e ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Plqew 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 f `DES RIPTIO OF WORK TO BEP RFOFMED: 1 ©vn 0 . OKE u.s i Ari. Pwi1. O eL Identification- Please Type or Print Clearly OWNER: Name: e� Li M&- c . Phone: Address: !D #e 4PC4 U44 Contractor Name: �6-6of Phone: SOS - 301a —1i(off b Address: L02 �� �/; ( •d-6-G �,,�-wl�.. Supervisor's Construction License: &7.6-,3 02, Exp. Date: IA1411`( Home Improvement License: Exp. Date: ARCHITECT/ENGINEER�W.�e"cjp -('-4L-;-be`V —�rl & Phone: Address:_ giwz&e. © c.4 A n(4 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: $ FEE: $ /OC) Check No.: �� 7--� Receipt No.: NOTE: Psods contracti ith re ' tered contractors d not have access totguar unci Signature of gent/OwnerSignature contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer 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 e Signature Aay COMMENTS CONSERVATION Reviewed on 2 Si nature ,--" COMMENTS '( `�3� (� I(0 C)1.) HEALTH Reviewed on Signature COMMENTS a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date i 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) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 Li Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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 ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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:Building Permit Revised 2014 Location ? /��a V &4--)fr No. -? 2 Date ® - TOWN OF NORTH ANDOVER 0 © Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ 4 Check# �7Y r % Building Inspector NORTH .. Town of ? t .''AY ndover No. 7e*12F i115i o It ver, Mass, 2zz COC L Kl MACK �1. - 77 V BOARD OF HEALTH Food/Kitchen PERMI-T T LD Septic System THIS CERTIFIES THAT .... ........................................ ............................... BUILDING INSPECTOR has permission to erect ............ buildings on .7,5...!�2g Foundation Rough ...,.. to be occupied as / , y 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 Service . .................... BUILDING. INSPECTOR.. Final 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. Massachuse is - Dei)artrr ent Ot puY;+lc Board of Buil ling Regu ati-•ns arcs 5tan-jarc:s COnstri,li.m 5upen isnr ..icense CS-075302 BENJAMIN C f►S OOIb 69 OTi,1D . ' VILI.A-sF'.LAI ���,:. v NO 4 ANDOVER NLA Oz4?��s; C-n-Ift-il ss over 12/04/2014 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 _._._..............._—.-- OLICY NO. !WCC_500-5007581--20146# PRIOR NO. i WCC-600-5007581-2013A] ITEM 1. The Insured: Key Lime Inc DBA: Mailing 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 09/15/2014 to 09/15/2015 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: Coverage Replaced by Endorsement WC 20 03 06 B 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 Annul Remuneration Remuneration Premiuril I INTRA 285896 INTER SEE CLASS CODE:SCHEDULE 1 Minimum Premium $575 Total Estimated Annual Premium $4,217 GOV GOV Doposit Premium $1,086 STATEICLASS MA 5645 MA Assessment Chg. ----- $3,778.00 x 3.4000% �)) $128 J. /21ru This policy, including all endorsements,is hereby countersigned by __= - `y` _ _____ 07/31/2014 Authorized Signature Date Service Office: M P Roberts Insurance Agency 54 Third Avenue 1060 Osgood Street Burlington MA 01803 North Andover, MA 01845 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permisslon.