HomeMy WebLinkAboutBuilding Permit # 2/26/2016 ------------------------------------------- --------------------------------- ------------------------___
BUILDING PERMIT 01%dORTH
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
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Permit No#: Date Received
SSS
Datelssuq ---------------------------------------------------- --—----------------------�._,reo ACHU
....................__ - I
MPORTANT:Applicant nnIq_coTpdete_all items on thisp ....................... I
LOCATION CA) SI
Print
PROPERTY OWNER OPJNC
Print 100 Year Structure yes no
MAP 104,CPARCEL -2,2 ZONING DISTRICT: HistoricDistrict yes no
Machine Shop Village yes no
PE OF IMPROVEMENT PROPOSED USE ------- -------
---------------------------..--
Residential Non-Residential
11 New Building 0 One family
El Addition 0 Two or more family 0 Industrial
El Alteration No.of units: [I Commercial
0 Repair,replacement D Assessory Bldg 1.1 Others:
D Demolition 11 Other
-----❑---------- —----------------------------
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k,
0 ftit 0
DESCRIPTION OF WORK TO BE PERFORMED:
I�rU A1162 % n -8 hf_x1,S7_11 V__C----- -_35--
...... mwse—-——------------------------------------------------------------------------------
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name-_rZj$ ,i-<�, Phone:
Email: Muw L-,-
Address:
Supervisor's Construction License: C_ 0")g /RR Exp. Date: 0 n /;7
Home Improvenn'ent License: le l 3Q ..................................................Exp. Date: 017
ARCHITECT/ENGINEER Phone:
Address: —Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost:$ 0 61 U FEE:$�
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contra,Z� d not have access to the gnaranty fund
Town of Andover
No.
0 h ver, Mass,
0' C
ArEO I
U r% BOARD OF HEALTH
Food/Kitchen
PERMIT T ILL) Septic System
THIS CERTIFIES THAT.......If 9/4.......................... BUILDING INSPECTOR
has permission to erect..........................buildings on ..........._.................... Foundation
Rough
to be occupied as.... Chimney
provided that the person accepting this permit shall in every respe6t 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 CONSTRUCTION STARTS Rough
Service
Final
131.11114G INSPECTOR
" .
..
GAS INSPECTOR
Occupancy Permit Required to Occupy BuAldingr 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.
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1'he Commonwealth of Afassadiusetts
Department o,flaadt£striglAccidents
_ 1 Congress Street,Suite 100
Boston,1'11A®2X14 2017
www.mass.govldla
¢Workers'Compensation Insurance Affidavit:Builders/ContractorstE�ctricsans!Plumbers.
To BIl Fag))VXTHTHK PERMUTING AUTHOR1Ty.
Ahcantlnformation please Print IeeiblV
u
Name(Busn,s,/Organ zationillahvidual): ('(�4�✓�J ��tUf`/' 1�T —
Address:
City/State/Zip: 9 Mo' U Phone
Arey an employer?Check&a appraprlatebox: Type of project(r'iuixed):
S.�Iamaemployrr�vithemgloyees(fiill andlozparf-fhne). 7. El Now construction
2.❑Iamasoleproprietor orpartnarsMp and have no employees working fermoin s. ❑Romoddiag
any..parity.(No vmrkers'comp.insumn-required.] 9• ❑Demolition
3.Q lam ahamrovmerdoingallworkmysel£[Nowarkem'comp.ft-aeancezequired.]t 10 E]Building addition
4.Q I am ahomeowner andwill be hiring co¢tractors fo conduetalf workonmy property.Iwill
0 P
11. Electrical repairs or additions
ensurefhat all contractors eifherhave workazs'compensation insurance or ace sole
proPizrtorswrthnoampfiyccs�--��--- -- -. —7-2.�]Izlzmtbmgrepaus-onaddtttons��.--
5.❑I am a general contmotorand I hayehiredthe aub-nnktractov Ustedanthe attached sheet. 13.0 Roofiepairs
These snb-confractor'sfiade ainployers andhaveworkers'comp.instiranee.# 14.Q Other
6.[]We area co:porationandiis offi+(emhave exereisediheirxight o£bxemptionperMGL c,
152,§S(4},andwe have nq,e�plciyees.[No workers'eomp.insuranca rrquired.]
Any applieantthat checks box#1 mustalso fiD.o.u.the seetionb-low showingthekwoikus'eompensationpolicyinfoimation.
t homeowners wfio su6riufthisaf5davitindicating they aro doing all workandthenhire nufside contractorsmustsubmit anew affidavid dieding suet.
?'Canharfors thai chaekthis boxmus�'sttachrd an additional shartsbowingthe name o£the sub-contractors andsfate whether ornotthosa entities have
employees Iffhe sub-conhae(orsfiaYe employees,llieymust provide thrix wakers'comp.policy nnmbar.
Zamanerrip7oyerthatisprovidittgworZrsrs'compensafioninsurancefortnyemployees.$e7owisthepolzcyandJobsate
information.
Insurance Company Name:
Policy#orSelf--ins,Lie.4: lU T i' -3) 5 7J � jExpirationDate:
rob Site Address:
11'1% city/State/zip:n?n d�,,slti9� tJt64_S'�
Attach a copy oftheworkers'compepsationpolicy declaration page(showing"he Policy number andexpiration ate),
F'a'ilure 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 dull penalties in the farm of a STOP WORD ORDER and a fine of np to$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Oftieo of Investigations ofthe DIA for insurance
coverage verification.
fdoherebyce I Urs er hepainsandpenaltieao,¢'peijzstyilaattheinforntution provided above isirueandeoarecr'.
1
Si nature: Date: '
Phone#:
Official use only.Do not write in this area,to be completed by city or town ojfleial.
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of flealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
ContaetPerson: Phone#:
Office of Consumer Af&—&Business Regulation
""—,TOME IMPROVEMENT CONTRACTOR
1 4Registration: 113130 Type:
. �Expiration: 511812017 Private Corporation
GRASSO CONSTRUCTION CO.,INC.
JOHN GRASSO
865 TURNPIKE ST
N,ANDOVER,MA 01845 Undersecretary
Massachusetts Departmertt of Public Safety
- Board of BLilding Regulations and Standards
License:CS-022988
Construction Supervisor
JOHN GRASSO
i 865 TURNPIKE STRW
' NORTH ANDOVER M1 t '
Expiration:
Commissioner 10131/2017