HomeMy WebLinkAboutBuilding Permit # 7/7/2015 NORTy
BUILDING PERMIT oF�i�E° ,6'9ti
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 2 4/'/ea Date Received
RA°R�reo`�Pay�(5
3A
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
1-1 Residential Non- Residential
EKNew Building ne 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:
Aew'f 7P'7-1t;-
Identification
a'7-iceIdentification _Please Type or Print Clearly
OWNER: Name: key �(�`�& , ac - Phone:
Address: lo -c -zv, )0,9 ova hi ml8�,
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ /o?,O®D FEE: $
Check No.: �` Receipt No.: �
NOTE: Pers us contraft n witl .i z egistered contractor de not have ac to th fftarantyfiund
a of traSgn conSictor „ 1
OWn Of tORTI,
ftdover
-�4 -1115k
No. — 20 �
_
h
h ver, Mass,
COCKICNCWICK
A�RRTED
s U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ..C.Y.... 1..:�'1 F...�N� -
. Foundation
has permission to erect .......................... buildings on . ���.?Er.'........................................
..
Rough
to be occupied as ......... �. �.� ........ .. {.r`.' !..................................................................... Chimney
provided that the person accepting this permit shall in every respect conform 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
PERMIT EI ES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTION STARTS Rough
Service
......... . .. .p::� ..................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
d 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgmization/Individual): el -lylC
Address: /a l x ICU "o 1112Z t
City/State/Zip: & 4ycDdB4 r 404 Phone#:_9 A0 5
Are you an employer?Check the appropriate box: Type ofproject(required):
1.Fj I am a employer with employees(frill and/or part-time).* 7. bTNew construction
2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. F�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 0 Building addition
<1 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
pr rietors with no employees. 12. Plumbing repairs or additions
5. I 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.t
6.Q 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.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors 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 tliat is providing workers'compensation insurance for•my employees. Below is the policy and job site
information.
Insurance Company Name:> .X.0<-
Policy#or Self-ins.Lic.#: UA!�r_".500 7b81 -..76 ly Expiration Date:
Job Site Address: 'y0 n�A�y/�e�Dt�+02 �� City/State/Zip: () ?'4r01O110ee J#IA
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 WORD 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 under thepa�ins and enalties of erjuiy that the informationprovided above is true and correct.
Si nat ' Date: ? �s
Phone#: 08• G
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#:
+Y
Massachusetts - Department of Public Safety
Board of Building regulations and Standards
License: CS-075302
"T I
BENJAMIN C OS
69 Old Village LaYfe
North Andover M-A 0 1
r,
l 1
IS J114�1�
Expiration
121041201E
Commissioner
VV F R 8 0 9 M P E N P.!-'tT 19-N A N!D F N!P L Y E R 8 U A B IL ITT It 4 A 01 lry
INFORMATION PAOF
A-s--:n-ir9MPq! Frripoour-rs Ins"Foriep- Com- p- nv
94 Tbiraa Aver-- R
UU7—i vv
NO.
ITEM
I The Insured: Key Lime Inc
DUA:
Mailing address: ioHepaticaDrive FEIN., 1218
Nh---A � , A P
i
Af-,tj UVGVW1- 11345
Logui Entiiy Type; ("Or-poratiol)
2- The noliry poriod 19 from 0411X2014to 09115/7015 12DI e.rr,sttandqrd ting al,thn F -- 41��-Up—
A. Wo�- Compens-nVon in. One of!hze PONCY.a, r....._tu'tho Ldalw-rip 111V
states listed flare: MA
B. Emnlovers'Liability Insurance-Part TWO Of then !ICV P_onlje�R tl,)jk'CA fn na&-4 4ern In t�-
_ ,,- , , nt��' A
The limits of liability under Part Two are: Bodily Injury by AWdant $ non.rino each RcHrinnt
Bodily Injury by Disease $ pr)licv limit
Bodily injury by Disease $ — 11,000=0 each employee
C. Ofher Stant-dL by Enuursement WG 220 03 06 8
D- Thiq Polis, includes there Enc Inflp
4. The PrerniUM for this policy will be determined by our mnnuals 01 Rulon.
nil lnJU-rmallon required below is subject to vedflioation and change by audit.
mates
Estirnawd Per$100
U1I Annual
INTRA 285896
I N-I chs SECLASS CODE SGHEDU!-,�
Minimum Premium $575
U., k IUM I
X4,21 CLASS, -P i'vou
MA 5645 MA Assessment Cho.
$3,778.00 x 3.4000% 019-0
This an4cv,innh Orin all QnrInrcn-- I,
07131/2014
54 Third Avenue M F Roberts Insurance Aqoncy
Burlington IMIA018o3 'it-IOU Usgood Sireet
.11�qlh --
MA U-464-0-
WC 00 00 01 A(7-11)
It eWf1pa
used Min its parmlealorp.
