HomeMy WebLinkAboutBuilding Permit # 2/19/2016 BUILDING PERMIT �aosarH
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TOWN OF NORTH ANDOVER �
APPLICATION FOR PLAN EXAMINATION
Permit No#:� � m Date Received � �RA7ED PPp` c5
�SSACHU$
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION?k �N�1, f �Ad ��
Print
PROPERTY OWNERS e - 5
Print 100 Year Structure yes no
MAP �' PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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
��❑ Septic� ❑,1Nell ❑ Floodplain ❑Wetlands ,�❑ Watershed Distract
❑:Wates/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please'Type or Print Clearly
OWNER: Name: Z\rZc V C0154Phone: 1'A- YP -2
Address: °W
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:$1200 PER$9000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F,
.0
Total Project Cost: $ CIVD FEE: $ ®
t No.:
Check No.: 0 Receipt
NOTE: Persons contracting with nregzstered contractors do not have access to the guaranty fund
-Town of
ndover
ioah
ver, Mas
O 0 LAKE
'S1A COCNICNEWICI( 00V
RATED
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BOARD OF HEALTH
Food/Kitchen
PtM Septic System
THIS CERTIFIES THAT
................. ...IT
.. ............C&s.a.LAw ................................. BUILDING INSPECTOR
has permission to erect....Adhk.. .......... buildings on Foundation
I A 10 JIM
to be occupied as .......... . .. ... .... Rough
II ®® u h
.........�1..... .. ....... ....MSA .. Chimney
.. .... ..... .................
provided that the person accepting this permit shall in every respect conform to the terms ol the application
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
FinzrF—
MONTHSPERMIT EXPIRES IN 6
ELECTRICAL INSPECTOR
® UNLESS CONSTRUCTIOT
Rough
Service
.. ......
BUILDING.INSPECT®R. Final
GAS INSPECTOR
Occupancy Permit Reouired t® Occupy Buildin
Rough
Display in a Conspicuous Place on the Premises - Do Not Remove Final
No Lathing r Dry Wall To Be One FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of'massachusetts
. .Department of. fillUSIVi Z.Atccidet2ts
M _ 1 Congress Street,Suite 100
"R Roston,MA 02114-2017
a www mass gov1dza
'� �•,-sus°`•
To Compensation7ousnya ce�THE� �xTJ3`T��UTk�OR7�SZ ��zczazcslPXumbexs.
Rff
Please Print Le ibl
A licant Information
Nalzlo(Business/Oxganizataon/.Tndividnal): YMA�v
-A.ddxess: (ln S d
City/Statf lZ:ip: t.�r ,
rayou all employer?Checkt&appropriate box: Type Of project(7 ec nixed):
.A
em to ees full andior part timc).* ]. [�New. construction
1.[]I am a employerwith . •.. - P y
2. lamasoleproprietorOrparfnershipandhavenoemployeeswrorkirigformein 8. �Remodelirig
Q
any capacity.[l9oworkers'comp.insurance required.] 9. ❑Demolition
3.0 lam ahomeowncr doing allwozkmyselt[No workers'comp.iusurancezequired.]t iO El RuilcYng addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. Twill 11 F]Eleetrical xapairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
TTT,-.. —-—12:[f=3'1umbg repaizs oaddxtlons T T—_
propzrefors with no employe
S.E]I am a general contractor and l have hired tho sub-coirtractors listed onthe attached sheet. 13,C]Roof repairs
These sub-contraotozs hale employees and haveworkers'comp.insurance-1 14.E]Other
6.[[We area corporation and ifs of-leers have exeroisedtheir right of'exemption PGrMGf,c.
152,§1(4),andwehave no.emplayees.[No workers'comp.insurance required.] r
xAny applicantthat checks bok#1 must also fill outthe section belowshowingtheirworkers'compensationpolicyinfozmafion
i Homeowners who suBmitthis aft"idavit indicda R gdditional shegshowing th,nthatneOe outside the sub-confractocontractors
s and state whether affidavit
thoseentitie{s have such.. '
?Contractorsffiatchecktbisboxmusk•attach
employees. Ifthe sub-contractors have employees,they rimst provide their workers'comp.policy number. - _._,
�'am an erriployer t1aat isp�oviclir�g�Vorrcexs'compensation insur'ar�ce for my employees.'Below is tree policy a�td,�ori site
information.
Insurance CompabyName:
Policy#or S elf-ins,tic. ExpirationDate:Citq/State/Zip:
,
"
fob Site Addxess:
Attach.a copy O the-WOxkbrs'c'omapepsation policy declaration page(showing the policyn-am oer and expiration date).
Failure to secure coverage as required under MGL G. 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 thwa�d d to the Office f a STOP WORK 7nvOgations of thoDIA for iasuxancO
0 a
day against tlao violator.A copy of this statement may b f
coverage vermoatiou.
X cla ex'ey certify a e�tr�epains �dpena�ffle,5110�131 trial trte inforryz�ction pr opided aboue is true and correct.
Date: � �
Sinature-
Phone#: ��,✓
offtczal use on y. Do not-wr'ite in th's a"ea,to he completed by city or town off-tcia4'
City or Town• Permit[L iceuse#�
Issuing Authority(circle one):
1.]Board.of Malth 2.Building Department 3.City/'Town Clerk 4.)Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person.
%40RTII TOWN OF NORTH ANDOVER
0 OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
oi
cwrus
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:- 'X'-Yk- LV�
JOB LOCATION: 'It &Utkt>�T
Number Street Address Map/Lot
IJOMEOWNERKc +,( J� 6'� -Q -�Yf I-1�14
4
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 50 $"
cavotcLn or
mpk otyLq
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,provided
that the owner acts as supervisor.
DEFINITION OF 140MEOWNER
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 110.85.1.2)
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 Homeowner's Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535