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HomeMy WebLinkAboutBuilding Permit #858-15 - 8 MAYFLOWER DRIVE 4/28/2015BUILDING PERMIT A��O N OF NORTH ANDOVER PLIC ION FOR PLAN p/— EXAMINATION Permit No#: J �'%S� ate R ccs e Date Issued: Dived IMPORTANT: Applicant must complete all items on this page LOCATION 6 �owre PROPERTY OWNER Print MAP lo PARCEL: 0�� Print 100 Year Structure ZONING DISTRICT: Historic District Machine Shop Village TYPE OF IMPROVEMENT KNew Building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Demolition ❑ Septic ❑ Well _-- - WatPr/TiM%A/cr PROPOSED USE Residntial 15HOne family ❑ Two or more family No. of units:_ ❑ Assessory Bldg ❑ Other Non- Residential ❑ Industrial ❑ Commercial ❑ Others: ❑ Floodplain ❑ Wetlands LESCRIPTION OWNER: Name:__ Address: /o Contractor Name: Ema-il��C'e�L;; Address: ZI�A� yes no yes no yes U Watershed District WORK TO BE PERFORMED: AT. (c2 7sy -A,� nIL cation - Please Type or Print Clearly s -t L- . `cam 50.• a 97883 3«� Supervisor's Construction License: CS-p�,y3p� Exp. Date: /a1i 1 Home Improvement License: L Exp. Date: ARCHITECT/ENGINEEROS�,��� 1�'ecA t / ' 7-S5 Phone: Address: Reg • No. FEE SCHEDULE: BOLDING PERMIT.- $12.00 PER $1000.00 OF THE �`' TOTAL EST/MATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ S"k , ?sa Check No.: Z-/2 ? NOT �Perons co ata Receipt No.: .��' 7o,6 ath unregistered contractors do not have access to the guaranty f za�— r— Plans Submitted 1�r Plans Waived ❑ Certified Plot Plan R Stamped Plans � TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swiumning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed o Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Q 7— Water & Sewer Connection/Si nature a Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street �F RE„DEP/OX R4TM,TtempitD jiLtocated at ,1�2.4�MainiSfleetF, - �Y �� �"""` "`-` `®- �F re Depa tment ignatur�i /date; 3�� i 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 Mr)T[=-q and BATA — (For denartrnent 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 Building 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 OTE: 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/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 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's 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 4 OTE: 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 No. �f Date -4 1 / 'n Check # 7 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee $ TOTAL Building Inspector CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 858-15 on 4/28/2015 Date: November 7, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 8 Mayflower Drive MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Key Lime Inc. 10 Hepatica Drive North Andover, MA 01845 uilding Inspector Fee: PrePaid $100.00 Receipt: 28706 Check: 7427 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 858-15 on 4/28/2015 Date: November 7, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 8 Mayflower Drive MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Key Lime Inc. 10 Hepatica Drive North Andover, MA 01845 uilding Inspector Fee: PrePaid $100.00 Receipt: 28706 Check: 7427 APPLICATION FOR CERTIFICATE OF OCCJPANCYANSPECTION �9 °Rwrc° 1e`yg5 SSACHUSE� BUILDING PERMIT ADDRESS/LOCATION OF PROPERTY:_ S /44 - Dou�ffre_ b iet` U iZ Map DParcel_____Zj, Lot Number / SUBDIVISION: ©kf 4 a4i V1, L DATE REQUESTED FILED/READy FOR INSPECTION: /j% CLOSING DATE ON PROPERTY:_ FIVE -(5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: Address: /D j/Pfl4f'C 4 1 p 'L) 1', ROUTING �,,// TOWN ENGINEER; SITE PL — DRIVE -WAY REVIEW u� 10 2-s-1 1 (0 CONSERVATION° PLANNING " 2g2cc5 _,RLb 11R) Ib DPW -WATER METER L' �`�J ly.y dg SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW SIGNATURE File: Application for OC form revised Jan 2007/2011 rA n M or- Mr- or - Cc y., O v ;F, • cC �a L� w CD Ec C� O• J • � L m COD t��`1► ., .� m 9 L O d• .� as > • \�_ O \t • a • .C2 `oO Qi O Z CL y N 2 O Bt � m 0 H v O O •� 0,0 N O m (D.2 m W C -0 2. O O uj cnLL N T ni N O t O CLW t0.� d v a O� N CD > N-0 O = F- EE t � O_ O V CL Ae t .2 m O c O N O t O Z O a O I Z m ccZ LU w IL W W a. iV E )E DIY C]e �0 ® O v J � U) Z ■w _c CL 0 It Q 0 LU v a LU O F- U c x LL z Q `n z U � uj — G eau ^, ,^L) CO C N E _ m V N, \ IVT ok-71ay LU uj O Y N U O O_ O cu LL N 'd N f L C' O O _ L_ D O p C_ LL U > O I d' N m p LL \�( L v co o O CC LL O z O ai O O v m E M or- Mr- or - Cc y., O v ;F, • cC �a L� w CD Ec C� O• J • � L m COD t��`1► ., .� m 9 L O d• .� as > • \�_ O \t • a • .C2 `oO Qi O Z CL y N 2 O Bt � m 0 H v O O •� 0,0 N O m (D.2 m W C -0 2. O O uj cnLL N T ni N O t O CLW t0.� d v a O� N CD > N-0 O = F- EE t � O_ O V CL Ae t .2 m O c O N O t O Z O a O I Z m ccZ LU w IL W W a. iV E )E DIY C]e �0 ® O v J � U) Z ■w _c CL 0 It (Rev. 01/16) ! CERTIFICATE OF COMPLIANCE M.G.L. CHAPTER 14, SECTIONS 26I=, Wv2 City or Town, . %��/% UO�f/t Cate: This cortifias that the properly located has been equipped with approved smoke detectors, and carbon monoxide alarms* and was found to be in compliance with Massachusetts General Law, Chapter 448 Sections 26F, 26F112 and 527 CMR 1.00 Section 13.7. lnspection/Testing completed on:� 16 By: . . (Inspector) Fee Paid: Head of Fire Department: 1 , a _ __ , f Noiet This certificate expires sixty (60) days after date of issue. SELLER'S COPY Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 343,750.00 m $ - $ 4,125.00 Plumbing Fee $ 515.63 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 515.63 Total fees collected $ 5,256.25 8 Mayflower Drive 858-15 on 4/28/2015 Single family home 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 three 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 becawc.of-such employment be,lieemed to be ail employer." MGL chapter 152, ;§25C(6) alsg4tates that ;;every state or local licensing agency shall witithold•th6 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 commonwealths or 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 confmi ation 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 w Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavitiar yo�fio fill out in the event the Office cif Tiiv6stigatloiis has `to icdritact y6u 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 that iriust submit rflhltiplol p6rhn Micense applications in any given year, need o$s i ubmit ofi6iffAdvit 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 ou 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; sieleph©ne acid fax number: =• •� _ •;, •� da. ,<.. The Co=40n ucalth of Massachusetts: • �}v - Department of I dustrial Accidents ' ... Office of Investigations 6.00 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727;7749 www.m.ass,govfdia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le:ribly Name (Business/Organization/Individual): Address: to City/State/Zip: kc, . V�" 4L✓ w v_o, Phone M '' &63 "3 /to S o an employer? Check the appropriate box• Are yo"' �� 1Iam a employer with 4. 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. ❑ 1 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 'ect (required): 6, ew construction 7. ❑ Remodeling S. ❑ 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. tContractors 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. r Insurance Company Name:_ _sGC. ,( melo wee, . ;f S . Policy # or Self -ins. Lic. #: WCC 500-3pp75�1 "gym/ Y Expiration Date: 7/j///sem Job Site Address: IP/J2 Wow Kloao&f City/State/Zip: 00, �o✓��� /¢ O(YYa 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. Ido hereby certo under thepains andpenalties ofpS,riury that the information provided above is true and correct 1_ v k - 33 A' — I/0A C. 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 #: ci4 O x J Q W 2 O oOC O IC -J V1 Z Z ~O CL (A Z Zu 0 �0 H z u W Z W 2 W m (A G m t :3 m c ° d U WJ (7 OC LL O 0 LL T u flto cu. N O 7 LL L c E U cp LL LC dA 0 _ LL as 0 a) U a1 N C LL C O C LL a) m Z '�"' Ll N a) O N CLT) U) U) GO L O 0) r_ O N d t O Z O H a O Z O m cc Z w w CL W LU CL O : W :a y C7 U) I-- I— O V U) 0 V Cl) J:D w N v O rM- L v 01- 0 2 mm a o o CL CL �a J O Z CL V+ c WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01603-0970 (800) 976-2765 NCCI NO 40959 POLICY NO. 81-2014APRIOR NO. [WW�&Cd­-!056-5-0075 -0-5007581-2013A 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 09115/2015 12:01 a.m. standard time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Pert One of the policy applies to tate 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 Past Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,0 0 000 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. i _.Classifications` Premium Basis -- Rates No. of Estimated Total Annual Remuneration Per $100 Of Remuneration j Estimated Annual Premium --- 'toe NTRA 285886 NTER SE CIMS 0:0E 5011EDiJ E ! MA 5645 MA Assessment Chg. Minimum Premium $575 Total Estimated Annual Premium -- $4.217 Gov GOV Deposit Premium $1,086 STATE CLASS. MA 5645 MA Assessment Chg. $3,778.00 x 3.4000% $128 This policy, including all endorsements, is hereby countersigned by L `-.-e-K Auttiorizadsignature — 07/31/2014 Dam Service Office: Third Avenue Aver M P Roberls Insurance Agency Buu Burlington MA 01803 1060 Osgood Street North Andover, MA 01845 WC 00 00 01 A (7-11) rnorudci Copyrighted msterfel of the Naliaeei COMM an Campenastlon 1nsvrBrx9, ueed with Its parmisston.