HomeMy WebLinkAboutBuilding Permit # 2/19/2016 RTH
BUILDING PERMIT "iLe, FD...,
O� m"'VO
TOWN OF NORTH ANDOVER `-
APPLICATION FOR PLAN EXAMINATION ® p
Date Received
Permit NOs�: grEo n �
cNus��
Date Issued::
IMPORTANT: Applicant must complete all items on this page
LOCATION '/ � � k /V
Print
PROPERTY OWNER %T-62 e l.14 �
Print 100 Year Structure yes o
MAP PARCEL.t ZONING DISTRICT:_ Historic District yes no
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED bSE
Residential Non- Residential
❑ New Building Xone family
❑Addition /❑ Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic % ❑Well ❑ Floodplain Q Wetlands � 1Natershed�rDistnct
p;.111/ate�/Sewer ✓s ,.,;, f,, ,°.`, �.. � �'�,��� �
DESCRIPTION OF WORK TO BE PERFORMED:
45o �
Identification- Please Type or Print Clearly
OWNER: Name: � �' Phone:
Address:
Contractor Name: � �) Phone:
Email: L•.
Address: _/ s f
Supervisor's Construction License: Z oG Exp. Date: /l
Home Improvement License: Exp. Date:-
ARCH ITECT/ENGI NEER
ate:ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT_$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ S FEE: $
Check No.: F Receipt No.:
NOTE: Persons contracting with un egistered c r tors do not have access to the guaranty fu zd
NORTH
AndUA'h' vCj1
2
h ver, Mas,o 1� S9
T O LAKE
-'S� [Oc MIc NEWIc1( y1'
RATED
S u
BOARD OF HEALTH
Food/Kitchen
Septic System
ER T T� L now
THIS CERTIFIES THAT BUILDING INSPECTOR
............. .. .. ............ ... ........ ................................ .. ............. ....
c - Foundation
has permission to erect.......................... buildings on ........... ..� ....... .. ....... .... ....®.......... •
Rough
9.
t0 beOCCUpI@d aS ........... ........ .. ..... ..... .. .... ........................ 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
ER EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR
® UNLESS CONSTRUCT109ST TS
Rough
DService
............... ............... .. ......................................... 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The commonwealth of lklassachaseI18
.Depcs�e£zner��ofIndustrzulAceldefits
z.
I congres',street,Suite 100
Bosjo(n,� /MSA[02.1Zy�4/�y�/017
Wovirers'Compensatiouxnsuxan,ceAffdav:it:SuuXclexs/Contrac�oxs/D+X�c xXczans/J2Xumbexs.
TO BE MED VXTR THE RMYRTTING.AUTROMX.
A,pplicantlnformation Please Print Le�ibiy
Name(sitsiness/Organization&dividual):
Address: 1Sm'CJ—
,
�
Cz IState/Zi f 'hone#: r�(
ty p:
Are-you an employer?Checkf&appropriate box: Type of project(7; mored):
1. I am a employerwith_ l employew(full.andlor Part
7. New constl Ilct1o11
f2,u I am a sole proprietor or partnership and have no employees working for me in. 8�. Remodcll g
any capacity.[Noworkers'comp.insurance required.] 9r U Demolition
1'am a homeowner doing all.work myself[No workers'comp.insurance required.]t 10 I Building addition
4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. 'Mill
11.[(Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole ;
propiie of rs with no employe ---
—-F=i-2:[�PXun:xbingrepaixs-orad ttons--�—�.--
5.r]I am a general contractor and I have hired the sub-cointractors listed on the attached sheet. 13,C]Roof repairs
Thesesi,b-contractors bade employees and have workers'comp.iusurance. 14.Q Other
6.0 We area corporation and its of ftrs have exercised their right o£exemption per MGI c,
152,§1(4),andwe have nrt employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also£'ill,outtho section below showingtheirworkers'compensationpolioy information.
i Homeowners who stbati ibis affidavit indicating they are doing all work andthea hire outside contractors must submit anew affidavit indicating such.
tcontractors that check tbis 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-conIracfors have employees,jee must provide their workers'comp.policy number.
I am an employer Mat is p/'d P101g worl�ers'compensation insurance fox my employees below zs t/ie polacy andjob site
information.
Insurance CompapyName: 1
Policy#or Self ins,Lic.#: GUS S' 1�t,�� Zyt��A ExpirationDate: /
lob Site A ddxess: 7/ S�/� e 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 flno up to$1,500.00
and/or one-year imprisonmmnt,as well as civil penalties in tho form of a STOP WORK.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. _
do ereby certify un r t, pains andpenafties of /' _ .t the inforination provided above is true and correct.
h
Date.
Signature:
Phone
i nature-
Phone# O
Official use only. Do notwrite in this area,to be completed by city or town official:•
City or Town: Perznit/Licensa#
IssuingA.uthority(circle one):
1.Board of Health. 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person.: Phone##: