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HomeMy WebLinkAboutBuilding Permit #809 - 89 MAYFLOWER DRIVE 6/18/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1po Date Issued: 6/1elll4 ANT: LOCATION Date Received must c/o_mplete all items on this PROPERTY OWNER�,S/ •h �, , Print MAP 210 %PARCEL: ZONING DISTRICT: M Historic District yes Machine Shop Village yes v�St`nc ;6,�0 0 \*\ I � Z.. �%i% TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New BuildingOne f it 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� WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: I<"�.� Asp, � Phone: 526� Address: 10 e: v CONTRACTOR Name: _21 ,9-M,4 0S G -VP d Phone: Address: &9 OZd d ., �Z1 rte' IPOe# 44 i ae e, 4Wo - v f Supervisor's Construction License: &S 74 310 2-- Exp. Date: 1--41411149 Home Improvement License: ARCHITECT/ENG IN EER��yi��yr� ���r�yrS Phone: 78/ -aW6 Address: Ste© �1?.¢.`n ��; Qt.•`ti 6-, Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ /a° �f 2 / Check No.: Receipt No.: �:3 ��%S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agerrt/Own Signature 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 COMMENTS U 40 Ajlvia-e e- clpm� H ALTH Reviewed on Signature s i t COMMENTS 4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation becision: Comments Water & Sewer Connection/Signature & Date briveway Permit x DPW Town Engineer: Signature: LOcateo 664 US ootl Street 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 21A —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 a 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 LocationT No. gU� Date TOWN OF NORTH ANDOVER a Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ f00— Other Permit Fee $ TOTAL $ Check # 250��, ilding Inspector 24 r m m m X m tl/ m _D y CA CD C � a Z y CD CL C. C. CL =' y n� -v CD CDCL 0 cr CD CD O CD C CD y CD CL C CO) � I CO CD CD to CA CD .0 CD Z a O CD 0 CD cn 2 Q� 0 z cn C 0 CA C) m T m CO) --1 _ o rrr G O m y :`l] O CD CL CD m C, my.: UP CD y O : y� O O m (� m O CD CD � V y O O C7 "r ..m .i yCD :\ M -O+� � CD m m CD ate. Go O .� � CD 0 d �. y C CS N OCLO ® C2C2 CL -j -� C y O .-r C �. O p1 fu CA rr .rt a =r n � O OO 0�o . O �x n o 0 =rcD CD 00� 0 O p O n ho ' d O m N'�; CA C) m T m CO) --1 _ o rrr G O m y :`l] O CD CL CD m C, my.: UP CD y O : y� O O m (� m O CD CD � V y O O C7 "r ..m .i yCD :\ M -O+� � CD m m CD ate. Go O .� � CD 0 cn o ro 0 O � O OO 0�o . j p �x n o 0 G �.. O o oo & � x 0 O p z H 0 0 c INlassachusetts - Department of Public SafetN Board of Building Regulations and Standards Construction Suliervisor License License: CS 75302 Restricted to: 00 BENJAMIN C OSGOOD 69 OLD VILLAGE LANE NO ANDOVER, MA 01845 Expiration: 12/4/2010 (' unmissiuncr 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 (No. Street ❑ Individual ❑ Partnership ® Corporation ❑ Other Other workplaces not shown above: POLICY NO. I WCC 5007581012009 PRIOR NO. I WCC 5007581012008 North Andover MA 01845 Town or City County State Zip Code FEIN 04-3311218 2. The policy period is from09/15/2009 to09/15/2010 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 policy limit Bodily Injury by Disease $ 1,000,000 each employee 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 EXT NSION OF INFORI 4ATION 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 KIND PLACING CLASS AUDIT OFFICE CLAIM OFFICE NAME CHECK SAFETY GROUP MA 5645 123 1505 WC 00 00 01 A (11-88) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. I otal Lstlmateo Annual Premium $ 2,846.00 Deposit Premium $ 755.00 MA Assessment Chg. $2,419.86 x 7.2000% $174.00 v,,W, 08/25/2009 Authorized Signature Date The Fairway Agency Inc 305 Forest Street Bridgewater, MA 02324