Loading...
HomeMy WebLinkAboutBuilding Permit # 3/4/2016 %AORTH BUILDING PERMIT "CD TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION PerNo m! Date Received Arr. LIS tSLAC Date Issued: 1� PORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER > 3. L Print 100 Year Structure yes 0 MAP 070 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSEDUSE Residential Non- Residential [I New Building F-i One family 11 Industrial [I Addition L1 Two or more family 1-i Alteration No. of units: 11 Commercial 0 Repair, replacement 11 Assessory Bldg [I Others: 0 Demolition El Other EE J;,4 S, . ❑...... F shed istrit ,,/" a in,,, D e 5 b El Ig5i R01111 11 DESCRIPTION OF WORK TO BE PERFORMED, e�o Identification- Please Type or Print Clearly OWNER: Name: t,c((4 VI (C', Phone: "I 7b­ 2­2Z­5 A Address: M A 09L-6 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:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CO SED ON$125.0,0 PER S.F. Total Project Cost: $ 1 ,-) FEE: $7W Check No.: le�"l� Receipt No." le) NOTE: Persons contracting with unregistered eon tractors do not have access to the kuaran tyfiind _natur A" -111111L N®RTJt Cj d-� Al ty V 2 _ 0 2,-bj� ® ' �Q ,ANE h Ve;r'9 LASS' APLA&F-1 _ COCHIC NE WICK x,95 RATED" �P� ERMIT L �D U BOARD OF HEALTH Food/Kitchen Septic System .� .� BUILDING INSPECTOR THIS CERTIFIES THAT ...... ..... ® ... ....................... ...... Foundation has permission to erect . buildings on . �+�/� .:d� ......................... .....�� A Rough IA• provided that the person accepting this pe every res • to be occupied as,5 � ........... . .. . ........ • .... ..... .. �•• .. .... Chimney permit shall in eve respect con m to the"(. rms of the application Final p 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR see UNLESS CONSTRUCTI TS Rough Service ..... ... ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy ButldtnQ Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01.845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please DATE: 3/woca, JOS LOCATION:---(OV;OsSM Number Street Address Map/Lot ,2 HOMEOWNER N,ch0u79-,2 3 5.2 NA - �9­1? Name Home Phone Work Phone PRESENT MAILING ADDRESS G 6Si;1� S . [A)roi Ando -u- /0 A 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,pmAM 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 110.85.1.2) 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 Homeowners Exemption BOARD OF APPEAUS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth ofHassachusetts Department of ludustrial Accidents k 1 Congress Street,Suite 100 4 2017 •� y 4 Boston,MA.0211 y �r www.mass.govldia e,M ' sof Wokkers'Compensation Insurance Affidavit:Builders/Contractors/)lectricians/Piumbers. TO BE FILED WITHTMRERMTTINGAUTHORITY, Please Print Le loI A .•licaut Information Name (Business/Orgabhat onitndividual): � I° `cit,reel u,1O Address: bb VLjss(..11 S �� City/State/Zip: Nos 1 ��n ©v c MA N b-lc, Phone 1h �>78 "�Z� e 7 x} .•: Type of project()Ve-quired): Ch Are you an employer? ecic the appropriate box: 1.[]I am aemployerwith employees(full andtorpar&time).Y 7, �] w construction proprietor or Partnership and have no employees Working for me in S. Remo deliiig • 2.E]l am a sole propn any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.�lam a homeowner doing all workmysel£[No workers'comp.insurance required.]t 10 E]Building addition 4•�T am a homeowner and will be hiring contractors to conduct all work on my property. l will 110 Electrical rppa*s or additions, ensure that all contractors either have workers'compensation insurance or are sole bin re alis or additions proprietors with no employees. I �•� .E'),um• g p 5,❑1 am a general contractor and Ihave hiredthe sub-confractors listed onthe attached sheet. 13. Roof repaixs These sub-contractors have employees and have workers'comp.insurance.t 14.'n Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and WO have no empldyees:[No workers'comp.insurance required.] n policy Any applicant that check Ibbs#I Vl ser hnfin egthey section below -work andthen hire outside contractorsm must submit aan w affidavit indicating such i Homeowners who submr Contractors that checkthis iidx must attached an additional sheet showing the name of the sub-contractors and state whether of pot(hose entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. loyees. Below is the policy and)oh site X am an employer'that is providing workers'compensation insurancefor my emp information. Insurance Company Name: Expiration Date: Policy##or Self-ins.Lic.#: City/State/Zip: Job Site Address: ompensation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers' c Failure to secure coverage as required a d iviM 25A is enalties in the form of criminal violation rWOzRK•ORDER and a finef up to $2500.00 a and/or one-year imprisonment,as p ay be forwaxded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement m coverage verification. X do/ler eby c tify under tliepains andpenalties ofperjury that the information provided above is true and correct .74 Si ature• Date Phone#• Q78 ZZ�'� -V Official use only. Do not write in this area,to be completed by city or•torten official. Permit/License# City or Town: Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: