HomeMy WebLinkAboutBuilding Permit # 7/6/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 62`" — i c
Date Issued: ! 15
Date Received
IMPORTANT: Applicant must complete all items on this page
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
Cmmercial
❑ration
epair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Others:
❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
P.efAtcg 41-5661hI- gLiela-�,eS
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cation/- Please Typ or Print Clearly
OWNER: Name: Cie e (ett-tt'�/ 1 ns
Address: O o.)c 87`
ARCHITECT/ENGINEER
Phone:
Phone: -so
Address: 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: $d
Check No.: 1 Receipt No.: CL b
NOT Persons co
ered contractors do not have access to he guar] y fund
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VIOLATION of the Zoning or Building Regulations Voids this Permit.
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iNFOlyiviA T ION PAGE
AssOeiateU Employers insurance eumparry
54 Third Avenue, Burlington, Massachusetts 01803.097O
(800) 876-2765
ITEM
EM
1. The
a insured: .Key LiMG iric.
rink
Mailing addre7a. 10 li 3pa.et! ._trive
North Andover. MA 01545
Legal Entity Type Corporation
Other workplaces not shown above:
N CtNn 40959
POLICY NO. [ WCC-500-5007581.2014Aj
PRIOR NO. I WCC-500-5007551-2013A1
FEIN: e• i"12{U
2. The policy period is from 09/15/2014 to 09/15/2015 12:01 a.m. standard time at the insureds 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.
,..7 limits of liability under Pert Two
Bodily injury
�; nt $ CCO,0i000 each accident
,.�.cy r{ej t3t f by rDisease,` _`4�v,. i,..v r��rt
Bodily iniuryP by $ 1,000,t 0 pol:c limit
Porfiiv inI'rry by Disease $ 1 _t00n;rif?0 ench nr`?ptoyna
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
C. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. he premium for it`ii5 p-olicy ' wilt be i eberi� ne by our Manuals ei Rules, Classifications, Ha -es and Rating Plans.
All information required below le suNect to Fcrliic=aatien and c_bon a by audit.
Classifications
IN T RA 265690
INTFR
Minimum Premium $575
GOV GOV
STATE CLASS
i`viA 6645 R.AA Asceserr mt (:hr.!.
$3,778.00 x 3 4000% $12R
This policy, including all endorsements, is hereby counlersigned by L-` 07/31 20 14
Cote
No.
Premium Basis Rates
Fatima
Total Annual
Remuneration
Per $100
Of Annual.
Remuneration Premium
RFI APR r OoE SGI-fEM1_E
Service Office:
54 Third Avenue
Burlington mA tf 1 rays
WO O 00 00 01 A (7- , i )
Includes copyrighted material of the National Council on Compensation Insurance,
lace G:,.., its
Total Estimated Annual Preraiutii $4,217
Deposit lure $1,086
Au -Moll ui S>tjneturo veto
M P Roberts Insurance Annncv
1080 Osgood Street
North Andover, MA 01645