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Home My WebLink AboutBuilding Permit # 4/28/2015 BUILDING PERMIT o�N°D , qti TOWN OF NORTH ANDOVER 3� 5 '. _.,,646 0 APPLICATION FOR PLAN EXAMINATION Permit No#: r�S ` " Date Received �gSSgcHED USE��y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Ile Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other J "y3 r51f L< rj^,"",��, r ey id ''`A,R',r',"r `r` f .-rr / fr" - r > r .. .' fixi y^r ,� r`1`r' �,,vz k, x+ n ✓ U rSe tt(`r Wella rr f `aFlood lainWeflands r r❑ Watershed,Dis ric , p 4 pi '' t. .r t t,' r r >�rr :Srk ',,,,,EJ! ,.3 i'r:t` .r,rw.. 7.r � 1:�,t �.. ,,r�i%`s.�l'� .,,,,.`••. r,.r...i r �y b r,�;,, �,z,:y ,lr r x,.,�� n r � ✓, rr �. � r rr5 � .��n £ l her% ( ✓pr r�ry r ..ry! rq�t�".r rr r krr._.�r` 2 r � . T'.;.. � N ff.'s �. ,:.� �� 1 ..k ,/�v5'1 F'<.r�.. x.f,,"a `r,,Y :r%..✓,n.r,�c,., rye` � .....�"r<ar `zJ s.�,r` �� , e a c „s. r:L°.�..�-.F.<.�r„ .,_.;e,.r t�.h_, ,,.:-. rF�,....,✓.,,...z?:r-rirr rs rr..r...1„nrar.,,t`s,r,�rrr., .rf,:r`,.r�r,r a�� d�sl;:.� ..,�9,: '.^'n.,,'!o-rYr3_: ,.r, rt,;,;:€,: ,r, ✓ ESCRIPTION Of WORK TO BE PERFORMED: 7U, �t Ide7p,we! fication- Please Type or Print Clearly OWNER: Name: ey Phone: Address: /® fy�P�-�-C+ Contractor Name:� d-lw,`-i C- O 4;;gPo6Phone: Email: iLe of :J460e-S C® (Z4-S� Pe 4- Address:._'Z A,c*- fie,•v12 Supervisor's Construction License: C�-> -07,g-3®A _ Exp. Date: Home Improvement License: y� / �,4 Exp. Date: ARCHITECT/ENGINEER rc,/ 1d*K llecZ, Phone: Address:_ _ �¢¢�'��}, Iy119 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: $ ,4 - � FEE: $ i 12 1 Check No.: 2 7 Receipt No.: 4, NOT Persons co a ti ith unregistered contractors do not have access to the guaranty f I' Plans Submitted PT'� Plans Waived ❑ Certified Plot Plan R"' Stamped Plans �I 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 ❑ � I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF 4 U FORM II PLANNING & DEVELOPMENT Reviewed On Signature_ A COMMENTS GC 6 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer C®nnecti®n/sr nature&^°Ia ZDriveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street r r FIREoDEPAR�TMENTr ,Tem !D stet p r p 'z !,, n: G• r "/r! /// Located at;,124 Main,Street !r% ,,,,, r /ir! ✓ '//kyr/r'ir rr it i,orr ///,it/ F�,reaD�e artment so nature/date „ ,,r ,rr„, ,//1/ar ,rr r, irllr , „� it r r r COMMENTS' ' r � 'r' F t4ORTH Town of ndover ® = No. ��KE h h ver, ass, 11;OX1,5 COCHIC"9 WICK �.ys RATED ►•P�`��,�5 U BOARD OF HEALTH PERMIT T Food/Kitchen LD Septic System THIS CERTIFIES THAT � a BUILDING INSPECTOR . ... ............................................. .............................................. has permission to erect buildings on � Foundation ... .. ................................. .......... to be occupied as ....} l..�y. .,/ ... G� l� Rough ..... ...... ........... ............ .......................... :�.r ... ............... Chimney provided that the person acceptlnhis permit shall in a ery respec nfor_m to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final 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 CONSTRUCTIONT T Rough Service .. .. .' .c' -.�,................ BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required t® 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. 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 POLICY NO. WCC-500-5007581-2014A]' PRIOR NO. WCC-500-5007581-2013A ITEM 1. The Insured: Key Lima Inc DBA: Mailing address; 10 Hepatica Drive FEW: .....1218 North Andover,MA 01845 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 09115/2014 to 0911512015 12.011 a.m,standard time at the insured's mailing address. 3. A. Workers Compensation Insurance,Part One of the policy applies to the Workers Cornpansation Low of the states listed here: MA B. Employers'Liability Insurance:Part Twv 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 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 the3e Endor-sements and Schedule*: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans, All information mquired below Is subject to verification and change by audit. Classifications Premium Basis Cads Estimated Per$100 j Estimated a No. Total Annual Of II Annuat Remuneration RBrnunerallon I Premlurn INTRA 285896 INTER SECLASSCODE SCHED" Minimum Prornfuni $575 Total Estimated Annual Premium 94,217 GOV G6V- Deposit Premium $1,086 STATE CLASS. MA 5645 MA Assessment Chg. $3,778.00 is 3.4000% $128 This policy,including all endorsements,is hemby countersigned by 07/3112014 —Data — Servfca Office: M P Roberts Insurance Agency 54 Third Avenue 8urlington MA 01803 1060 Osgood Street North Andover,MA 01845 WC 00 00 01 A(7-11) Includor"ayrighted material of the National Counull on Carnponsallon tnourence, usod w1th Ili paymla#lon. The Commonwealth of Massachusetts Department of IndustrialAccWhts Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Address: to ((ee& -'CO _s Jeb U11_ City/State/Zip: Nv . ,,, ��e, � Phone#: 649 Are yowan employer?Check the appropriate box- Type of 'ect(required): 1.Eal am a employer with 4. am a general contractor and I 6, aKew construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]f employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name:. A /Zi 6C. tZ o yges. J;15. _ // Policy#or Self-ins.Lic.#: MCC 549,0—.SOO72S gt—a m 1Y t$ Expiration Date: 7!3///s� Job Site Address: 4e4 5 ��, i'i•` ,0&,e City/State/Zip: Aya,ht', ✓B�� /� 0.1,FV � 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 DTA for insurance coverage verification. I do hereby certify under the pains andpenatiles of per'uty that the information provided above is true and correct. i Si afore. Date: Phone#: 3 "3s 8r 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#: