HomeMy WebLinkAboutBuilding Permit # 2/26/2016 � Nobzte� q
BUILDINGPERMIT
TOWN OF NORTH ANDOVER
P 4
APPLICATION FOR PLAN EXAMINATION
Permit NO: _ ' � Date Received
SACHt1`����5
Date Issued:
I ORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Z Non- Residential
❑ New Building ❑ One family _
❑ Addition COY fwo or more family p Industrial
❑ Alteration No. of units: ❑ Commercial
C-rRepair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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Identification Please Type or Print Clearly)
OWNER: Name: N%<1,®143 �oc deu Phone:
Address: SU ekip e L N M o38 ? Z
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ARCHITECT/ENGINEER N \ 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: $ 26, ODd FEE: $ -3 00
Check No.: � 6Y Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
r
Si nature of contractor
ignature:of Agent/Owner ; g
t%oRv#1
Town ofE ,
a
Andover
q1t- 2AJ� 4L �i
h Ver, ass,
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COCHIGHF WICK
BOARD OF HEALTH
Food/Kitchen
MIT T %W LD Septic System
� rr BUILDING INSPECTOR
THIS CERTIFIES THAT ........ .Y.i ..... Q�°. '. t.. ?:r�rG1.............................................................
has permission to erect buildings on nq wf. . .......................................... Foundation
.......................... ........ ....
Rough
to be occupied as .........✓...�.Y/tid�....S L>, ��G. .......::...:....�.�.:y:�c?.`�c.�, !; lt. `j.......................... 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS TI N STARTS Rough
Service
....... ....... ...... ...................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
NoLathing or Dry Wall To Be ®one FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
4 OORT#4 TOWN OF NORTH ANDOVER
0, OFFICE OF
0
'A BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover,Massachusetts 01845
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:
JOB LOCATION: Cot Russell
Number Street Address Map/Lot
HOMEOWNER ?,.rkoiuN 1A. m-19-U-3,5 29 7
Name Home Phoiic Work Phone
PRESENT MAILING ADDRESS- eer-(A
Aftswil /V\N 01% 0
City T State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
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 structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the 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 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
'V`�•r www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): N tc A1;%5 &r,,,Valan�2
Address:
City/State/Zip: S�v►a u f-h 63782 Phone#: �a8'ZZ3�5247
Are you an employer?Clieck the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in $, [ "Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 Building addition
41/1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.rJ Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information
t Homeowners wlto submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing worlrers'conipetnsation litsurmtce for•my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job 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 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.
I do hereby certify ander thepains and penalties of perjury that the information provided above is true and correct.
Signature: 1�1 k Date: 2 2 5/Z01 b
Phone#: 978.2 23'vrz9
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 Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: