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Home My WebLink AboutBuilding Permit # 2/11/2016 BUILDING PERMIT %AORTH D D TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 0LA- Permit No#: Date Received o ATED Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION hadwr Print PROPERTY OWNER. 11�/ kvLl, �rqvl Print 100 Year Structure yes no MAP PARCEL: (7� ZONING DISTRICT: Historic District yes Machine Shop Village yes no) TYPE OF IMPROVEMENT PROPOSED USE Resioential Non- Residential [I New Building N/One family El Addition D Two or more family El Industrial El Alteration No. of units: El Commercial NAepair, replacement El Assessory Bldg El Others: El Demolition El Other Weil, a, DESCRIPTION OF WORK TO BE PERFORMED: ,D-'616GLAn jji�- a 2,A JVC T- Identification- Please Type or Print Clearly -76?- OWNER: Name: 7��)e--x id!.e, &�G C Phone: CD Address: 2C?(,p -��(vtA yd- Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCH ITECT/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. C\ , Total Project Cost: $ 6 0 FEE: $ r4� Check No.: Receipt No.: NOTE: Persons cont actin with unregistered contractors do not have access to the guaranty fund a 64 —----- g- aq WM-Qf&Ii;q Siqnatur66f-c NORTH _t own of W Ajac-Elover Am& L ® _ Zh ver, Mas S, z5? coc Klc MtwlcK 1. AO� CNV i4 RATED A4 5 , S V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR Gl'� �/rl, S Foundation has permission to erect.......................... buildings on ...............f/l. .......... .............................................. Rough to be occupied as .............. ..�. ?. ?.... � .� .�(s p� ..... . ....................................................................... 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESSCONSTRUCTION STARTS Rough Service ................. .%4 411;�..,,..�........................... 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: e. �� JOB LOCATION: Number Street ddress Map/Lot A *k HOMEOWNER -,VAI wvlwi Name 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,provide that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who Owns a parcel of land on which lie/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]ionic in a two-year period shall not be considered a homeowner.(780 CMR Section I I O.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 lie/she understands the Town of North Andover Building Department minimum inspection procedures at uirements and that he/she will comply ith said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL,.... Revised 8.2015 Form Homeowners Exemption BOAC D 01"APPEAUS 688-9541 CONSERVATION 688-95.30 HEALTH 688-9540 PI ANNENG 688-9535 �'he Commonwealth ofMassq�cuseits Department of IfidlustrIQIlAceldents z. 1 Congress Street,Suite 100 —� Soston,AYA 02114-2017 a wwlw.mass.gov/dia Workers'compensation insurance Affidavit:Bididers/Contractors/Electrciciaus/Plumbers. TO BE F"D VITH TJX+ 7'MATTITG ATIT:QORXT SZ. Applxcautluformation Please Print Legitbly NaMo(Business/Oxganizadon&divid xal): City/Sate/Zip: G� e/ i I k b0 pone#: Are-you an employer?d ekt6e appiopriatebox: Type Of project(Cec]uired}: Are-you 1,0 I am.a.employerwith employees(full and/or part time).4' 7. New'construction 2. I am a sole proprietor or partnership and have no employees Working forme in 8. R emodelirig capacity.[Noworkers'comp.insurance required,] 9. El Demolition 3, 5 am ahomeowner doing allwozkmysel [No workers'comp.insurancezequired.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill 11.[]Electrical repairs or additions ensuro that all contractors either have workers'compensation insurance or are sole -- . a_. . no propzretorswrthemploye - n--T--�--.-- - . ------�12:[l-l.'-1t.7m:�bing-x'epaixs-o�additionsT ---- 5.F]I am a general contraotor and l have hiredtho sub-contractors listed on the attached sheet. 13•0 Roof repairs These sub-contzactozs have employees and have workers'comp.insurance, 14Other 6.❑We are a corporation and ifs of 9ers have exercised their right o£exemption per MGIC G. 152,§1(4),andwe have no.."fplayeg%[No workers'comp.insurance required.] kAny applicant that checks box#i must also fill outthe section below showing theirworkers'compensation policy inforrnation. -Homeowners who checks phis affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors that o siil5 his boxmusf�attached an additional sheet showing t110 name of the sub contractors and state whether or not those entities have a ek employees. If the sub-con$racf ors kava employees, liey must pro vide their workers'comp.policy number. X ane an eMptoy er that is pi ovidirzg worrcers'compensation ir�sux'ance foN my ernproyees'Below is t/ie policy and,job site information. Insurance CompanyName: Policy#or Self-ins,Lic.#: Expiration.Date: fob Site Addxess- aO�P�( ( 5� City/State/Zip: Atfach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o. 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 inthe,forms of a STOP WORK ORDER and a fine ofup 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 lre�e�y ce ' zed/er the amts andpenalties ofper jury that the informationpr ovicled alp v is true and correct. Signature: K ( Date: Z Phone#: Official use only. Do notwrite in this area,to be completed by city Or town official _ City or Town: Perwit/License� issuing Authority(circle one): i 1.Board of Health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Coutact Person: Phone#: