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Home My WebLink AboutBuilding Permit # 2/17/2016 BUILDING PERMIT .1r=� ,6�ba TOWN OF NORTH ANDOVER �,� h�:;r• APPLICATION FOR PLAN EXAMINATION Permit No#: ✓' Date Received ��•acwus``�� Date Issued: POEtTAN'I': Applicant must complete all items on this page —� LOCATION e d `"L( R"WCV- Print PROPERTY OWNERC C Print 100 Year Structure yesQn MAP PARCEL: ZONING DISTRICT: Historic District yesMachine Shop Village yes 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 :<oo❑ °slain %❑Wetlands %/ ❑„Watershed Dastnct�Se tic. ,❑Well > ,,, ,, ,�, ❑ FI p ❑Water/Se��r %,,,.,, /%, .c.:�;,. %� �/ ///✓r„ �,.�. / , ��/ fe J ' , ,.a ;,,: DESCRIPTION OF WORK TO BE PERFORMED: Identification- :Tease Type or Print Clearly OWNER: Name: Phone: : ' , .. a p 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:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ _ FEE: $�`� . `. Check No.: Receipt NOTE: Persons contracting w°th unregistered contractors do not have access to the g?arartyfund �gnatuc of Ag�nf/S n-ature of contractor 4, NOR Th Andl L UVV11 ut over ® ® _ zbo : LAKE h ver, ass, COCHICH9WICK V� U BOARD OF HEALTH Food/Kitchen rFER IT T LD Septic System THIS CERTIFIES THAT ....... *V �g,. ►V`. r BUILDING INSPECTOR .(a. 4�. rt.�.�. ..... . Foundation has permission to erect .......................... buildings on ..(0.(a ........... .......... :`!/ 00 Rough to be occupied as ........... .. .. ..V....I .. r....... RuNwo .............. 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 PERMIT R IN 6 MONTH ELECTRICAL INSPECTOR ® LESS STR CT A Rough Service .............. ............ ........................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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 Approved by the Building Inspector. Burner Street No. Smoke Det. IAORTH TOWN OF NORTH ANDOVER 0 OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01845 ACHUS 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 Z &A ("S1,11 wu Name Home Phone Work Phone PRESENT MAILING ADDRESS Aj_� Anby&Y City To" 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 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 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 -he Commonwealth ofHassoehusetts Department of-in ustrial.Aeddents X Congress Street,Sete 100 Boston,.l YA 02114-2,017 www.mass.gov1dia Wovkers'CompensationInsurao,ce Affidavit,JBuilders/Contractors/El�etr�zciaos/J2XumToex's. TO:BE I+MED''s7VXTH THE RE,RMTTINGi A-UTHOPJTX. Applicant Information please, Ie�ihly Nazi c(Iiixsiness/Oxganization/Xndtvidnal}< — .A ddress: city/stafe/zip:_N Phono#; ✓ ,6"" Areyon an employer?ChecIrtlieapliroprlatebox; Type of project(�equixed): 1.Q I am a employer with employees(full and/or part time)�_ "7'. Q New construotion 2, I am a sole proprietor or partnership and have no employees Working forme in $. ReYnodeliYag Q any capacity.[No workers'comp.insurance required.] 9, Q Demolition 3.Q I am a homeowner doing all work myself:[No workers'comp.insurance required.]t JOE]Building addition I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.Q Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole ; proprietors witlino employees - 12[ -llumtbing xepaits-oz'addYttozisr._ 5Q I am a general contractor and I have hired tha sub-contractors listed on the attached sheet. 13. Roof iep airs These sub-contractor's hada eiriployees and have workers'comp.insurance,1 14. Other 5Q We are a corporation anal ifs offirrers have exercised their right of exemption perMGL c. 152,§1(4),and-We have nq employees,[K6 workers'comp.insurance required,] y *Any applicant that checks box#1 st also fill out the section below showing their workers'compensation policy iuformation mu 't Roxneowners who sirtiriiit flus affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. xContraotoxs that check this box musf-attachcd an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-conlraclors fiave employees,ltiey must provide theirworkers'comp.policy number. fam an employer Mat zspiovidlizg-Worffers'compensation insur'anceformy employees.'Below is t/Zepalicy ar2dlob site information. Ins>arance CompaayNamo, Policy#or SeIC ins,Lie. Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers'cbmpepsation policy declaration page(showing the policy number and exp ix'ation date). Failure to secure coverage as required under MGL o. 1.52,§25A is a ctimiMif violation punishable by a fine up to$1,500.00 and/ox one-year imprisonment,as well as civil penalties in the farm of a STOP WORD 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 fnvestigations ofthe DTA for insurance coverage verification. I da herebiy certify under tbae pains andpenalties of perjury t11 at tbae inforrmction provided above is true all correct. 1 Si nature: Date: Phone 0: Offtcial use only. Do not write in this area,to be completedby city or'town officiar, City or Town: Permit/License Issuing Authority(circle orae): i 1.Board.of Lfealth. 2.Building Department 3,City'/'I'oWu CleYlK 4.Elect-yical Inspector 5.Plumbing Inspector 6<tither Contact Person- Phone#f: