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Home My WebLink AboutFOUNDATON ONLY_ 1 BUILDING PERMIT o� %aotarry -Ct TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION A Permit No#: / Date Received �RA�RgrEo PPa"ay '4SSaCHUS�R Date Issued: Lz ®' IM//��P��ORTANT:Applicant must complete all items on this page LOCATION 7/ ��!l� F�O�(a� l �0 j` 17Z Print PROPERTY OWNER 1:4C . Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:VHistoric District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r-;,, h 13 yw�a r `,� " ^€ „` .! .,,rt,=n`r ❑Se tic 1Nell F ❑ Floodplain Wetlar�tlsr f rwf rte,❑ Watershed,Distnct ,�"'f ✓``;�r,'�'rr'�,;sL,a�l/��,�rs T "�"'rr-:"`r''rl"�er r�� 1.. r�ym t 3"`�l`., ✓'...�"�` �r �� } �r?� >� ,. �� .f`�. f � d k✓..rx � ^^�f ,/ ,� � u�,rv'+ H"`" a Fri �y ".r':. DESCRIPTION OF WORK TO BE PERFORMED: Daot0 c`4m CPJAV Identification- Please Type or Print Clearly. OWNER: Name: Keyl-1-ste 1:4c,. Phone: Address: IO J' r-eA l 16 4 'beiyil Contractor Name: -9ev. C.SG-0,p b Phone: 5` ®cT -3JL 8-` to 80 Email: W e V L,', w-; i.AeQ o2oolr-*s� . ro e. Address: 617 4V44 wl a n ®tee C < 46 Supervisor's Construction License: G' S - 4v75,3®a, Exp. Date: lazyll& Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 4 L141y ( bARR®LL Phone: ?7B _ 119;- d ®!3 Address:) ® . fox 1Jnd®Ue4e. lM4 67/810 Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /&� FEE: $ Check No.: Receipt No.: �C, NOTE: Persons contracti ith ugTegistered contractors do not have access to the guara nty fund Plans Submitted 11 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales El Food Packaging/Sales 11 Private(septic tank,etc. ❑ permanent Dumpster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE,ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING DEVELOPMENT Reviewed On Signature LA COMMENTS CONSERVATION Reviewed on, A /I JI(- Signature COMMENTS P-4 \'I �\oo2s > c)")vz tx 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 ConneGfion/sic .1nature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street E A 0, T pQuTpster.on,sit&— yes, no X LocaFIFFt-e 'a '24 Mam Street ir F e , "D pa n Idate' COMMENTS F tk®RT H —Al,Town OfE over � o h ver, Mass COCHIC"t WICK AORATED S �JD BOARD OF HEALTH Food/Kitchen ijER �MIT T L Septic System THISCERTIFIES THAT .............1 er_ ..��' r :................................................................. BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on ..71. G /�? �:`:...... ./7............. Rough tobe occupied as ................�� ..' ..a�'y. '............................................................... 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT E IR IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION ST TS Rough Service ............... ......... .. . ILDINgals.....................G INSPECTOR.. Final �p y GAS INSPECTOR Occupancy Permit Required to Occupy BuilLiine 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. (DOMIPENSATION AND EMPLUYER-0 LIABILITY INSURANCE POLICY INFORMATION PAGE Assoclateu-1 FErnployers insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. I WCC-500-5007581-2015a I PRIOR NO. I WCC-500-5007581-2014A! ITEM 1. Bey Lime inc K Thelipsured: r\ DBA! Mailing address: 10Hepatica Drive FEIN:`'-**`1218 North Andover, MA 01845 Legal Entity Type, Corporation Other workplaces not shown above: 2. The policy period is from 09/1512015 to 09/1512016 12K01 a.m. address. U 3. A. Workers Compensation Insurance:Part One of the polity applies to the Workers Compensation Law of the states listed here: MA B. Emplovers'Llability Insurance- Part Two of the VV policy applies to work In ouchouchstate listed ii, item 3.A. r, y The limits of liability under Part Two are. Bodily Injury by Accident $ 1,000,000 each accident Bodily Inlury by Disease $ 1,000,000- policy limit Bodily Iniur'y by Disease $ —1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 8 D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium lorthle policy will be daternnined 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$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 285896 INTEM SEE CLASS CODE SCHE-Dur Minimum Premium $575 Total Estimated Annual Premium $575 GOVGOV Deposit Premium $578 STATE]CLASS MA 1 5645 State Assessments/Surcharges $48.00 x 5.7500% $3 This policy,Including all endorsements, is hereby countersigned by 07/30/2015 Authodzed Signature Data Service Office: M P Roberts Insurance Agency 54 Third Av-.nus 1060 Osgood Street Burlington MA 01803 North Andover, MA 01845 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. Massachusetts -Department of Public Safety Board of Building Regulations and Standards c.uie9u u�.uuii auj�ci tsvi License: C5-075302 BENJAMIN C OSG-bOp3,, 69 O1d Village La4e North Andover 1 A Oh'45 Expiration Commissioner 12/04/2016