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Home My WebLink AboutBuilding Permit # 1/21/2016 - l BUILDING PE LED IT o� �aLE � .'( D /b N . TOWN OF ®�NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION _ p, IL Date Received DRA F Permit NO#: r / 89,9 DR/17ED PPp,�'(y SSgCHl15E Date Issued: � L/ IMPORTANT: Applicant must complete all items on this page � p LOCATION P rint PROPERTY OWNER V_A � 1 Ie��'�'y(� Print 100 Year Structure yes (rfo) MAP _PARCEL: ZONING DISTRICT: Historic 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 '4 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District q 1Nater/Sewer` : � l s DESCRIPTION OF WORK TO BE PERFORMED: Sdentif cation- Please Type or Print Clearly OWNER: Name: Phone: Address: �'- e'rt Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: a 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: $ > FEE: $ Check No.: Cil Receipt No.: NOTE: Persons contracting with,., g st red contractors do not have access to the guaranty fund NORTL{ MIA w. , n- A0% "e �' _ . :.' uuv 0 No. ZO LANE ONW-Ah ver, ass, • COCHIG NEWICK �•4 A°RAreo Jkf S 11 BOARD OF HEALTH P R IT T Food/Kitchen Septic System LD THIS CERTIFIES THAT ........................................................................ BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on ... ...... .. .............�.. ......... ........ Rough ��. ...... Chimney to be occupied as ..........omv.�.Awo ..................... :' !1►....��r .: ......�...... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on filein 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRCTIO T S Rough Service ................ ... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. of µoRTH q TOWN OF NORTH ANDOVER 3� bt;1- ' ^•'6 °� OFFICE OF BUILDING DEPART'MEN'T' JK * - 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01845 �SSAGHUS�� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER —� ��P�l 97;5 — 66 5-66�, Y l 979 -- -M'-9'0 Name Home Phone Work Phone PRESENT MAILING ADDRESS Z5�- ki. A-J CI,v e�' VV C»�y City Town State Zip code— The o eThe 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,provided 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 I IO.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 unde tands t own of North Andover Building Department minimum inspection procedures and requirement Rd at he/s e,will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 the Commonwealth of Massgxehusetts Department of industrid Aceldents X Congress Street,Suite 100 '' Boston,MA 02214 2017 . www mass.gov/dia 5V{ Workers,Compensation Insurance Affidavit:BuiXders/Contractors/Eleciriciansll'Xumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information PleasePx'int Les=tbiy 1, � I�w� NaME) (Business/Organization/lndividual): �� ] City/State/Zip: �� iclw e �l c)J-zq5 Phone#: Are you an employer?Chee'l<tlie apl r'oprlafe box: Type of project(x uired): I am a employer with • employees(full and/or part tune).` 7. Q New Construction 2. I ama sole proprietor or partnership and have no employees working forme in 8. Remodelhig any capacity.[No workers'comp.insurance required.] 9. Demolition 3..M I am a homeov✓ner doing all Wolk myself[No workers'comp.insurance required,]t 10 Q 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 IQ]Electrical repairs or additions proprietors with no employees: 12:Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance., 6.n We are a corporation and ifs of gers have exercised their light of exemption per MGI,C. 14.[]Other 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] t:. . . *Any applicant that checks box41 must also M out the section below showing their workers'compensation policy information. Homeowners who subriiitthis afftdavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. tContractors 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-conlrad&s have employees,'they rimst provide their workers'comp.policy number. X am an employer that is pi ovzdiiig Vork'ers'compensation insurance for my employees'Below is t/ie policy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: ExpirationDate: lob Site Address: City/State/Zip: 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. gdo hereby certify u 'argr''thepai sand nalties of perjury t/aat the information provided above isTanac orrectDate: � % �� Si nature: _ Phone# 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 M