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Home My WebLink AboutBuilding Permit # 9/2/2015 NORTH BUILDING PERMIT "6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION O PermitNo#: Date Received C Us Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION d Os ( t W14-Y1= ems. bi? bQ A--40tle--t Print PROPERTY OWNER-K-e- y �0- Print 100 Year Structure yes no MAP PARCEL: 0 4o ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Pr6 e family [I Addition [I Two or more family El Industrial El Alteration No. of units: El Commercial El Repair, replacement El Assessory Bldg El Others: El Demolition El Other D She ,1"y 11 V 3*ee r f r ,i'/ .,,.,�a�,.(li h4 DESCRI,PTION OF WORK TO BE PERFORMED, 41 L Fee & a,"* Identification- Please Type or Print Clearly OWNER: Name:eek/ Phone: Address: JO Jo -C4 be. ko Contractor Name: lZaVL-,ne -3 c. Phone: !!r'7V-& -3Ao-S 00-4707- Email: Ke!A"-ne &JI'a 'Ps da Ce"09I- - Kum Address: Supervisor's Construction License: e.5 -1975'30,A- —Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDINGPERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ /r7r, Check No.: 71�, Receipt No.: 10-1N ly�?I^" .1; NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature `,� �� COMMENTS � C� �/� f 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 Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP,9RTMLENT Temp Durnpsteron;site ;yes no Located at`.124Main Street z Fii^e Departni,nt��gature/date uu COMMENTS jA®RT#j own of And clover ® q0 ® 214 261 _ AIL C1 LcVeY'' SSS' O COC NIC"t N@WOCK V A. A�ti'AT&D 5 MPE r% U BOARD OF HEALTH Wnn T T LD Food/Kitchen Septic System ivi THIS CERTIFIES THAT ....... ...'��..°. ��.. _ ..�:: ............................................ BUILDING INSPECTOR .... ...................... has permission to erect buildings on . ...............'e� . .. Foundation p .......................... .... ..... ..... . ...................... Rough to be occupied as ............... . ..v..t� l.. .. i:. :.....0 . ................................................ chimney provided that the person accepting this permit shall in every respect conf6rm 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 EXPIRES IN T ELECTRICAL INSPECTOR UNLESS I T TS Rough Servi .cr. --•............................ Final ce BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinjz 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 fV,Jt wlvw.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant Information Please Print LelZibly Name (Business/Organization/Individual): Key ► Vie I fV C. Address: 10 e&, ' C_A be, City/State/Zip: OL9. n d o(/ePhone#: 77cd.? to Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with Z employees(full 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. ❑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.E]Plumbing repairs or additions 5.[;3"1 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.❑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 worlrers'compensation insurance foi-nay employees. Below is the policy mid job site information. Insurance Company Name:AS'SoG;4 b 1_7&P(,wmes ..G h S.. . Policy#or Self-ins.Lie.#: LU GG —S'190—SVO 74R' "010/5f Expiration Date: I FhS /lP Job Site Address: d) �1 y 6i#gi,4A�¢�e�► �(l.� City/State/Zip:pD g oyere, D/gys 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 under thepains mad penalties of peijuty that the information provided above is true and correct. Signature: Date: oZ !S Phone#: U 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PACE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 ( 00) 976-2765 NCCI NO 40959 POLICY NO. FW W�OO 7PRIDR NO. 755881-ZZ015A ITEM 1. The InSurod: Key Lime Inc DBA: Mailing address: 10 Hepatica drive FEIN:**-***1218 North Andover, MA 01845 Legal Entity"Type: Corporation Other workplaces not shown above: 2. The policy period Is from 09/15/2015 to 09/15/2016 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 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 B 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$104 Estimated No. Total Annual Annual Of Remuneration Remuneration Premium INTRA 265B96 INTER SEE CLASS CODE SCHEDU E Minimum Premium $575 Total Estimated Annual Premium $575 GOV GOV Deposit Premium $579 [STATE CLASS MA 5645 State Assessments/Surcharges $48.00 x 5.7500% $3 This policy, Including all endorsements,is hereby countersigned by _ 07/30/2015_ Authartxed Stl}n$tuse Date '— Service Office: M P Roberts Insurance Agency Third Avenue Bu 1060 Osgood Street Burlington MA 01803 North Andover,MA 01845 WC 00 00 01 A(7.11) Inctudea copyrighted material of the National Council on compensation inaurance, uoad with Ito permission. Massachusetts -Department of Public Safety Board of Building Rcgularions and Standards License: CS-075302 BENJAMIN C OSGbo ff 69 Old Village Laife North Andover AIW- 0185 J1141 Expiration Commissioner 12/04/2010 Massachusetts -Department of Public Safety Board of Building Rcgulations and Standards S Cl)I1J lI L1 Cil fi it upci{iti0F License: CS-075302 BENJAMIN C OSOOOD ' 69 Old Village Uife North Andover NFA OiQ�� ' Expiration Commissioner 1 210 412 0 1 6