HomeMy WebLinkAboutBuilding Permit #810 - 87 MAYFLOWER DRIVE 6/18/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
D
Permit NO: ?I
Date Issued: 6Ille/lo
IMPORTANT:
LOCATION'_ A'76
Date Received
must complete all items on this page) �/
`J) 4p d 2, 04>�117
PROPERTY OWNER 46 Vie- J�c-.
Print
MAP 210 PARCEL: A` 7 ZONING DISTRICT: JkHistoric District
Machine ShoD Vil
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
ew Buildin
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
DESCRIPTION OF ORK T BE PREFORMED:
�047d�� e, ,�C4(1�.foi,. Dgcite a U..,oe k .
Identification Please Type or Print Clearly)
OWNER: Name:I w a- Y14, C- . Phone: 778-(PR3 -31(p3
Address: !,0 1+ e,10 %celQ>`Vvo Ajo e T't 1�K�0ge a wt+¢
CONTRACTOR Name: AU 644 * K Phone:
Address: lomat0/9
Supervisor's Construction License: G' S 7,'.3 01— Exp. Date: xA. 10
Home Improvement License: Exp. Date: 11
ARCHITECT/ENGINEER c�lSvI.L•iqn. 14ec�C. Phone: 7& --W& ` Aw67
Address: 68 WA.�,n. � d:K6 M4 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: $ A0,0
Check No.: wx,! - Receipt No.: ZOO �4
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
_.
Signature of AgentlOw � C- ignature of 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH. �, Reviewed on Siqnature
COMMENTS
Zoning Board"of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Sianature & Date Driveway Permit
DPW Town Engineer: Signature:
uocatea oo4 uS 000 aireet
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department 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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ 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
❑ 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
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 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 2008
Location
No. 710 Date 6111P110
Check # 7f,
2-3OV11 04•
B�iii ing Inspector
r
A.
TOWN OF NORTH ANDOVER
O` .•o • 1ti00
Certificate of Occupancy
$
,,SJACNUS t�
Building/Frame Permit Fee
$
Foundation Permit Fee
$ /Dy
Other Permit Fee
$
TOTAL
$
Check # 7f,
2-3OV11 04•
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INlassachusetts - Department of Public Safety
Board of Buildim, Re-ulations and Standards
Construction Sup'ervisor License
License: CS 75302
Restricted to: 00
BENJAMIN C OSGOOD
69 OLD VILLAGE LANE
NO ANDOVER, MA 01845
-- Expiration: 12/4/2010
( unuuis�inur Tr#: 6955
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts NCCI NO 40959
(800) 876-2765
ITEM
1. The Insured Key Lime Inc
Mailing Address: 10 Hepatica Drive North Andover
(No. Street Town or City
❑ Individual ❑ Partnership ® Corporation ❑ Other
Other workplaces not shown above:
POLICY NO. I WCC 5007581012009
PRIOR NO. I WCC 5007581012008
MA 01845
County State Zip Code
FEIN 04-3311218
2. The policy period is from09/15/2009 t009/15/2010 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 policylimit
Bodily Injury by Disease $ 1,000,000 eachemployee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
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
SEE EXTENSION
OF INFORI
IIATION PAGE
Minimum premium $ 500.00
As indicated, interim adjustments of premium shall be made:
❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly
This policy, including all endorsements, is hereby countersigned by
GOV
STATE
GOV
CLASS
15645
KIND PLACING
AUDIT OFFICE
CLAIM
OFFICE
NAME
CHECK
SAFETY
GROUP
MA
23 1505
WC 00 00 01 A (11-88)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
I oral tstlmateo Annual Premium $ 2,846.00
Deposit Premium $ 755.00
MA Assessment Chg.
$2,419.86 x 7.2000% $174.00
&,W, 08/25/2009
Authorized Signature Date
The Fairway Agency Inc
305 Forest Street
Bridgewater, MA 02324