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Home My WebLink AboutBuilding Permit # 3/15/2016 t%ORTN BUILDING PERMIT TOWN OF NORTH ANDOVER 0�^ APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received � qDo."r,D aro Date Issued: IMPORTANT: Applicant must complete all items on this page f rr , I rr r r /i1✓r ri r f / l / / r. / r r✓rrr „ur, K„� ra f / i /�.,./ � � /J, /�, i,✓ /r. rr///i///„////, sir � / �/ CI ,,/„ r//�ZON �M r �� r ✓� I / ,/ � , (��i�! /l//,//�� ,�// ri% /rr..:.„r r/r��/j/,/,��//J//�i//,///r/��/////,%;��,%,✓�//rrr,,,n,�.: / //o,ric..,.ri,o„/i,, ,..rr TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Aone family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r ✓ „el r r ! r , r✓ rJr rrr i / / / /, / /r. � / / DESCRIPTION OF WORK TO DE PERFORMED: Identifiication- Please'Type or Print Clearly � OWNER: Name: PSI't� I & ” IV Phone: C/ Address: 13 r✓ r r,. ,✓ r r, . /i / rn r / / � ✓ �/ 1, r / /, /��///��r/ rd r rr / e f�i/e,�dylr�aJD�liiO�efi,nrrll G a�ir%/ri//�adi r�,�irrlr��r/2lnr/mono✓riO/�oDirriD/ii�i�ieidi, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINC PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ - 0FEE: $ Check No.: Receipt No.:� d NOTE: Persons contractin with unr istered contractors do not have access to the guaranty„fund ;Signature ofi Agent 10wner signature of dohtrac or, AM µORTh own o Andover 801. 261 LAKEh ver, Mas 4 cocHIc„ewrcw 1 �9S Rg7ED UBOARD OF HEALTH PERMIT T L D� Food/Kitchen Septic System THIS CERTIFIES THAT ......... � �::�. �Q BUILDING INSPECTOR ... .... „ ...........................I...... has permission to erect .. buildings on `� �� Foundation ........................ ............... ............................................................. Rough to be occupied as ..........�ra �. ...... ................................................................................. Chimney provided that the person acceptihis 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 Regulatians Voids this Permit. Rough/ Final PERMITIRS IN 6 MONTHS ELECTRICAL INSPECTOR LESSCTI TART Rough Service •• .. ....... ...... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy BuildinZ Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final ® Lathing or Dry Wall 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 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: A � � a JOB LOCATION: 5 ------— Number Street Address Map/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS— (� �T � V I /l/oCTI-1 A 1VOOVEw M 0 1�L( 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, provide 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 sliall not be considered a homeowner. (780 CMR Section I I O.R5.1.2) 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 lie/she understands the Town of North Andover Building Department minimum inspection procedures and requireirients,,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 APPEALS 688-9541 CONSERVATION 689-9530 HEALPI 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of IndustrialAccidents " = 1 Congress Street,Suite 100 t Boston,AM 02114-2017 www,mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letribly Name (Business/Organization/Individuaal): ii (4 I V'r„ .Address: City/State/Zii): rLO Al 00 /• Phone#: 61 6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with—,,_employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partriership and have no employees working for me in 8• Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I 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 of additions proprietors with no employees. 12.E]Plumbing repairs or additions 5. I am a general contractor anI have rethe sub-contractors listedon e attachedsee. ❑ d hhired b ttthht 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance) 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 4l must also fill out the section below showing their workers'compensation policy information, t Homeowners who submif 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 am an employer that is prlaviding ivorkers'compensation insurancefor my employees.'Belo1v is the policy and jab site information. Insurance Company Name: Policy#or Self-ins,Lie.It: 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 WORD.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. f do hereby certify ` der the pains and penalties ofper jury that the information provided above is true and correct. Signature' Dater Phone# �a� " . _. ra l _ O 0 Official use only. Do not ivrite 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 Clerk. 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#: