HomeMy WebLinkAboutBuilding Permit # 1/21/2016.............
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BUILDING PERMIT ® 16
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit N®#: Date Received
OArEo 11"
Date Issued: IMPORTANT:Applicant must complete all items on this page
LOCATION ems IAL.,t
r nt
PROPERTY OWNE C 4 %Y-N
Print 100 Year Structure yes (n o
MAP 54PARCEL: ZONING DISTRICT: Historic District yes n)o
0
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building [I One family
11 Addition [I Two or more family [I Industrial
$AIteration No. of units: El Commercial
El Repair, replacement [I Assessory Bldg El Others:
El Demolition [I Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Nam r Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
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: $ 0 FEE: $
t No.:
Receipt.Check No.: I
NOTE: Persons c'ont+ting with unregistered contractors do not have access to the guaranty fund
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RATED p'P
U BOARD OF HEALTH
Food/Kitchen
Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
..................... Foundation
has permission to erect .............. .......... buildings on ..... ...... .. Q��.. .
oil
Rough
to be occupied as .(�� ..l ..................... Chimney
....... .... ......... .......... ..... .. . . .................
provided that the person accepting this permit shall 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 EXPIRES IN 6 PJNTrm j ELECTRICAL INSPECTOR
LESS CONSTRUCTI A Rough
Service
.................. .............. ................................. 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 Approvedt�- Building Inspector. Burner
Street No.
Smoke Det.
i
i
7
noRTa q TOWN OF NORTH ANDOVER
3�ot�1�eo 0 OFFICE OF
'00
- UILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
y?APpATeo APP�5 North Andover,Massachusetts 01845 '...
�SSMCHUSER
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: I - c201
JOB LOCATION:
Number S •eet Address Map/Lot
HOMEOWNER / '7
ame Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided
that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to
be,a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR
Section 110.R5.1.2)
The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable
codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNAT ,..
APPROVAL OF BUILDING OFF IAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
A8 Commonwealth ofMMal'C i asetts
�. Department offnilustriaZAceidents
N f X Congress Street,Suite 100
M
.Boston,MA 02114-2017
www.mass.gov/dia
•
Workers:,Compen �S � B�dxn� t tmxczanslEXum6ers.
�OBIIEA� T��ER4T�GAT�HORY
Please Print Le ihl
Applicant Tnform ation t
Name(Business/Organization/tndzvidual). t
Address:
City/State/zip: `
Axe you an employex?Checictlie appxopxlafe bax:
Type of project(required):
emp toY ees firU and/or part thne).�' 7. E]Neal constriction
1,[]I am a employerwith • •.. .
2,QI araa sole proprietor or partnership and have no employees working for mein 8. gRemodelirig
any capacity.poworkers'comp.insurance required.] g. EllDemolition
3.E]I am a homeowner doing all work myself[No wozkers'comp.insurance required.]t 10 F]Building addition
4V. am a homeowner and will be hiring contractors to conduct all work on myproperw. Twill 11.0Electxicalrepairsoradditions
ensure that all contractors either have workers'compensation insurance or are sole 12•[j Plumbing repairsoradditions
proprietors with no employees.
S. I am a general contractor and I have hired the sub-cofitractors listed on the attached sheet. 13,E]Roof repairs
'These sub-contractors have employees and have wozkers'comp.insurance.t 14.El Other
6.❑We are a corporation and its o ffieers have exercised their right of exemption per MGL c. -
152,§1(4),and we have no,e,M10y-es.[No workers'comp.insurance required.]
Any applicant that checks box must also fill outihe section below showing their workers'compensation policy information.
all work and then hire outside contractors must s4binit a
Homeowners who submit kWG Adavit indicating they are doin sheet showing th name°the sub-contractors and state whether or now nowt,t se entities have such..
tcontractors that checkthis box mustattached an additional
Eors have employees,10i must provide their workers'comp.policy number.
employees. If the sub-c6fi6
Yam an employer that ispjdvidirzgworkers'compensation insur'ancefol'My employees.'Beloty is thepolicy ar2d fob site
information.
Insurance CompanyName:
Expiration Date:
Policy#or Self-ins,Lie.#:
City/State/Zip:
fob Site Address: e showing the policynumber and expiration elate).
Attach.a copy of the Workers' compensation policy declaration pig ( JP
punishable by a fine up to$1,500-00
Failure to secure coverage as required underMOL
enalties in the foam of STOP violation
tRK ORDER and a fine of up to$250.00 a
and/or one-year imprisonment,as�r lx
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifxeation.
i^do hereby certify under thepalm andpenalties of perjury that the informationprovided above is true and correct
Date:
Si ature:
Phone##:
Official use only. Do not-w rite in this area,to be completed by city or'town official
City or Town:
• permit/License# '
Issuing Authority(circle one):
1.Board of Ifealth 2.Building Department 3.CitylTown Clerk A•.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#;
Contact Person: