HomeMy WebLinkAboutBuilding Permit # 6/11/2015 BUILDING PERMITof No oT b�tio
TOWN OF NORTH ANDOVER o? h�;:il .:_ .46
APPLICATION FOR PLAN EXAMINATION
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Permit No#: f Date Received �RAOR,,Eo PPa"R5
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Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 10193
/ _ Print
PROPERTY OWNER kQ-v x`41 e, �c t
T—� Print 100 Year Structure yes no
MAP /102-3 PARCEL: ,Pw3 ZONING DISTRICT: !/°/� Historic District yes
Machine Shop Village yes n
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
ew Building *-One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
1,2"014 JWv1,'o&4 Feie leo iwe
Identification- Please Type or Print Clearly
OWNER: Name: k�--v .1,-,"e-
,,re- j-is, Phone:
Address: 104 /1'!oe A i�overa
Contractor Name: 8ea 3#m ' C, 616--oo n Phone: O-3 �&- 11630
Email: ke�/�,a,e f .'�dces�c�C®•rrrc.¢s A.-lor
Address: J4yzg- �fioa��t tido va P, 9 �i8sts' /
Supervisor's Construction Licenser CS- o75S&A - Exp. Date: Id 1f,!/lo
Home Improvement License: f, Exp. Date:
ARCH ITECT/ENGINEERQiy��/Y,Qe�J�d-C`lS Phone:
,�. c:�/Jen bhGty��2
Address: � ',i �¢r ��, �.��-, 1h t4 Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE:
Check No.: Receipt No.:
NOTE: Persons contractin ith unretered contractors do of have acqeess the gu my fund
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools i]
well ❑ Tobacco Sales ❑
Food Pacicaging/Mes ❑
Private(septic tank,etc. ❑ Permanent Dumpster 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 . — > .w. ... ?, j C':
. .
HEALTH Reviewed on Siqnature
COMMENTS � itn-�r
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Si na re)&DaDriveway Permit
DPW Town Engineer: Signature: s -
"' Located 384 Osgood Street
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urn SterOn°si e" es
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COMMENTS
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AM t4ORTH
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fown of All
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iT h Ver Mass,J1Ar4
O LAKE
COCKICNEWICK
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BOARD OF HEALTH
LD Food/Kitchen
P �E R Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
.......................... .......... ..... .. . ..AlEp6tiA
........................... ............
... .. ....... ..
.. Foundation
has permission to erect ... ,,,.----- buildings on ......0.'P4.Ax
......... . �..33
Rough
to be occupied as ............... ... .X�1R 4'M�.l.. .... .... .. ..................................................... Chimney
p
provided that the person accepting this permit shall in every respect co or
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
IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTPSTARTS Rough
!/ l` Service
......... ...... Final............................
BUILDING INSPECTOR
GAS INSPECTOR
ccupancV Permit Required t® Occupy Puildin 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.
_._.----- —..-----— _ ._.—_._.— ---------------
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2'{07 22p z0' 15-22 'Mase
iQr,�Tli?' fEtIlsed Rij ft floor Plan
Key Lime Builders
Colonial
e2 DrUltfJ7g
Old' SOj(eM Kllagi-
Rta. 114 North Andlover,
Unit H Modficotion
,dee unit h, drawings,
for addfdona)Inibrmoeon
' Raaf Fro
2, TO.In-
Bedroom 3 Holt'
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7
Dining Kitchen E7 try Lay sreakf55t
kill
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House W 15-22 House A� 15-22
Cross Section 1-1 Cross- Sectaxon 2--.2'
Apr# 0.9, 2075
Alan Corroll
-=w 928--902-0131
Vtcmp md
------------------------------------------------- ------- .. . Coloniol
......
...... Drafting I
J-
. ................................ ......... ................................ ....... .... ............
Ke
y Lime Builders
Old Salem Village
Rte. 114 North Andover
Unit H Modification
F Tlt� . ........ ... ....
See Unit H drawings
4 .............................. .................. f-CdOitlana/information
............ ...........
House f 15=,22
.......................-..
------------ -2n1t—H
21
Revised Foundction Plan
----------------------------
--------------- w April 09, 2015
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116�n�C rroll
978—!90�2—o1ji
The Commonwealth of Massachusetts
f Department of IndustrialAccidents
i d 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): kw_�K /i1'1C
Address: /d•R �e���.a bei V/2 4
City/State/Zip: o ol'k 4,1,1ovoe0m� Phone#:
Are you an employer?Check the appropriate box: Type of Droject(required):
L❑I am a employer with employees(frill and/or part-time).* 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5. am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is pf-oviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. 4s_-.0<. _ /!
Insurance Company Name: /?.. eloyee5, .la '/x t-o0 S vew& •
Policy#or Self-ins.Lie.#: Q.,C CC-y00-$007,5.8t " ad f l d Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify undgt-the pains andpenalties of peijriiy that the information provided above is true and correct.
Signature: �` Date:
Phone#:
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#:
vVORKERS COMPENSATION AND EMP Y PAGE LIABILITY INSURANCE POLICY
INFORMATION
Associated 9 ' �� 4n 1�ranc Company
01803-0970
54 Third Avenue, rlin tOn, Massachusetts NCCt NO 40959
(Sao) 876-2765
POLICY No. WCC-500-5007581.2014A
PRIOR NO. WCC.-500-5007681-20-1 3A
ITEM
1, The insured: Key Lime Inc
DDA: FEIN'. "_,.,1218
Mailing address: ve
North Andove,rrMA 01845-
Legal
1845Legal Entity Type: Corporation
Other workpincos not shown abtNe' time
2, The policy period is from 09/15/2014 to 0911 512015 12:01 a.m. o darWorke st the insured's mailing C mpensation La v of theress.
3. A. Workers Compensation Insurance:Part One of the policy applies
states listed here: NIA hes to worts in each state listed in item 3.A,
B. Employers'Liability insurance:Part Two of the policy app
Iry by Accident $ 1,000,400 each accident
The limits of liability under Part Two are: Bodily In,G., -
Bodily tniury by Disease $ 1,000,000 policy limit
1,{300,000 each employee
Bodily injury by Disease � _ ----
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This policy includes these Endorsements and Schedules: SEE SCHEDULE
4. Ths pray !n for this policy will be determined by our Manuals of Rules,Classifications,Bates and Rating}Tans.
All information required below is subject to verification and change by audit.
— _ _ —.._. dates
-- -- -- Premium Basis
Classifications — _ __ — t
-- Per$100 Estimated
Cade Estimatedd I OfAnnuar.
No. j Total Annual
Remunnraticri _ Remuneration Premium
INTRA 285696
INTER SEE CLASS cODE SCHEDULE
f —
Minimum Premium x575 Total Estimated Annual Premium $4,217
Deposit Premium $1,ot75
GOO COIL
yTATE CLASS MA Assessment Cing,
MA 5645 $3,778.00 x 3.4000% $126
�_-=`- J ( - �I��� �
This policy,including all endorsements,is hereby countersigned by 07/31/2014
_ —- —
Authorized Signature
Service Office: M P Roberts Insurance Agency
54 Third Avenue 1060 Osgood Street
Burlington MAGI 903 North Andover,MA 01845
WC 000041 A(7•t11
Inctudus copyrighted material of Iha N=ationsi council on Gomp-anoati®n insurance,
„cad.19h itc❑2YrttiC6fOr1.
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
%-on.s MCH V11 JI.��/Ci 11101
License: CS-075302
BENJAMIN C OS�OO `
69 Old Village I-atfe
North Andover NSA 018
4�
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Expiration
Commissioner 12104/201C