HomeMy WebLinkAboutBuilding Permit # 3/17/2016 14ORTN
BUILDING PERMIT
0
TOWN OF NORTH ANDOVER
GILAN EXAM NAIT
APPLICATION FOR P I
Date Recei
Permit NO. ved
O"Argo
Date Issued: ITS cmus
IMPORTANT- licant must co lete all items o his e
it
jm
TYPE OF IMPROVEMENT PROPOSED USE
Residential , Non-- Residential
0 New Building 11 One family
11 Addition 11 Two or more family 11 Industrial
11 Alteration No. of units: 11 Commercial
"M Repair, replacement El Assessory Bldg 11 Others:
Demolition El Other
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
IV
Address: LPc>,IrvA—�� ka� 111f, 0
ARCH ITECT/ENGI NEER Phone:--
Address: Reg. No.
FEESCHEDULE':BULDING PERMIT$12.00 PER$1000.00 OF THF TOTAL ESTIMATED COST'BASFD ON$125.00 PER S.F.
Total Project Cost:
Check No.:
2-kil _---Receipt No.:—------------
NOTE: Persons contracting!�*h -e t red contractors do not have access to the guarantyfund
Al"
60,
66 '16 "1
... .. .... 11 "a MIN=
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body All ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank etc, ❑ Permanent Durapster on Site ❑
THE FOLLOWING SECTIONS FO OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF ® U FORM
PLANNING EV LOP ENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on
S1 naturemm
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/SLqnature& Date Driveway Permit _
DPW Town Engineer: Signature:
Located 384 Qs ood Street
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U BOARD OF HEALTH
Food/Kitchen
PERMIT T L ,D Septic System
THIS.CERTIFIES THAT ..........Apd-deomo...... ....... -... .. ................................................
BUILDING INSPECTOR
Foundation
has permission to erect... ...................... buildings on . ... ... .. ... .......................................
® 4 Rough
tobe ovlded that the person accepting this permit shall .... ... ............ .:... ... ......... ...................... Chimney .
p p p g p hall in every r pect 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT-EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO ARTS Rough
Service
.............. .... .. .. .. ....................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy-Permit Required toOccupy BuzldinRough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
Lathing r Dry Wal] To BeDone FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
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INV
70
North Andover MIMAP March 17, 2016
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Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
`-I Meters Data Sources:The data for this map was produced by Merrimack
—SR
NORTH Valley Planning Commission(MVPC)using data provided by the Town of
RoadsO@ 4a o North Andover.Additional data provided by the Executive Office of
`ts rata O Environmental AffairslMassGIS.The information depicted on this map is
t"e Easements ^�' q O
�. (, for planning purposes only.It may not he adequate for legal boundary
Parcels d ...,- "' to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
t" Tl MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
1t * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
K o ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
SA US
1"=30 ft °
R}t1fd1'Pd TOWN OF NORTH ANDOVER.
OFFICE OF
BUILDING DEPARTMENT
M 1600 Osgood Street Building 20, Suite 2-36
°k�raG a North Andover,Massachusetts 01845
Is'rp1�4tU=^'HA
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: /3/201
JOB LOCATION:6 Derry st
Number Street Address Map/Lot
HOMEOWNERAndrew Graham 978-809-1190
Name Home Phone Work Phone
PRESENT MAILING ADDRESS6 Perry St
North Andover MA 01845
City Town 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 unde nds the Town of North Andover Building Department
minimum inspection procedures and requires and that /she ill comply said pro dures and
requirements. / /
HOMEOWNERS SIGNA (®
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 of.ndustr'ialAceldents
I Congress Street,Suite 100
Boston,MA 02114-2017
wwwmass.govIdia
Workers'Compensation Insurance Affidavit:Builders/Contractorrs/Ei lectricians/Plumbers.
TO BE FILED WITH THE PERMITUNG AUTHOMY,
Armlicant InformationPlEase Print L&gLbly
Name(Business/Organization/Indilvidual)--
Address: (0-- pe a S
City/State/Zip: )Norr N '-") 0Je Phone#:
Are you an employer?Cheek the appropriate box: Type of project(required):
if-I I am a employer with employe"(fall and/or part-time).* 7. El New construction
2Q I am a sole proprietor or partnership and have no employees working for me in 8. R Remodeling
any capacity,[No workers'comp,insurance required.] 9. Demolition
3.E]i am a homeowner doing all work myself,[No workers'comp.insurance required.]t
,kI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10F�Building addition
suro that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof r ir6F—
Those sub-contractors have employees and have workers'comp.insuranco.1'
_b (dL11_Vb-vP
6.[:]We are acorporation and its officers have exercised their right of'exemption per MGL 0. 14.WthertA
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 who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now 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,
1 arra an employer that Isproviding workers'compensation Insurance for my employees. Beloip is the policy reran job site
information.
Insurance Company Name:
Policy#or Self-ins,Lie. Expiration Date:
Job Site Address: City/State/Zip: III
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.
Ido 1hereby co- under penalties of �yhny that the Information provided and Correct.
��:5�ry�rla
Date:
Si re:
n
Offleial use only. Do not Ipplie in this area,to be completed by city or loml Official
City or Town: Permit/License
Issuing Authority(circle one): i
T.Board of Health 2,Building Department 3.City/Towmi Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
............
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