HomeMy WebLinkAboutBuilding Permit # 3/17/2016 ......................
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BUILDING PERMIT D
TOWN OF NORTH ANDOVER 0
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APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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110
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building [I One family
Ll Addition El Two or more family Ll Industrial
[I Alteration No. of units: F-1 Commercial
Repair, replacement [I Assessory Bldg [I Others:
[I Demolition [I Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:-
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ARCH ITECT/ENGI NEER-," 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: $ FEE:
Check No.: , �L,� Receipt No.:
NOTE: Persons contra4�tig with unregistered contractors do not have access to the guarantyfund
ig a u 10 A06nt/Ownibr� �� Signatuire o,-contra'ctor
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Town of0Andover
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L) BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
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THIS CERTIFIES THAT BUILDING INSPECTOR
has permission to erect ...... Foundation
.................... buildin son .. ... ... .. ,�. .. ... ... .... . .......
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tobe occupied as .. ... .. ... ....................... ....... . .. ��► .. .!.. ..�.... ... ..... .... ................ Chimney
provided that the person accepting this permit shall in every respec7conform to the t rms 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 CONSTRUCTI TARTS, Rough
Service
......... .... ... .. .................. Final
UILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BuzldZn Rough
Display in S is S Place a Premise's — Do Not Remove Final
No Lath' r Dry WaIlToe Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector, Burner
Street No.
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TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
V 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 prin
DATE:
JOB LOCATION: 43 AuE
Number Street Address Map/Lot
HOMEOWNER b 4 LID L." 22 ? 7 1 "1 9 -7 0-1
Name Home Phone Worl(Phone
PRESENT MAILING ADDRESS- 4 -1 A L/E
AIM AA16Q(,,�FO, 11 8
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,proyiM
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 I I0.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 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 APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth ofMassachusetts
.Department of IndustrialAceidents
" r d 1 Congress Street,Suite 100
�<• Boston,MA 021142017
yJ,y�t www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information Please Print Lei=ibly
Name (Business/Organization/Individual): 4-V 46 • %/4.0,5
Address: 8e.1 G--,V 7-e_&&V A A L/JE
City/State/Zip: 610. 41Vdac• f,�J_ Phone#: / `7 q7 moi'
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 partnership and have no employees working for me in $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.X I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑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 or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.;
6.F1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F]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 who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors 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 providing workers'compensation insurance for my employees.'Below is thepolicy 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 under the pains annddpyenalties ofperjnry that the information provided above is true and correct.
Signature: Date: "' ..7
�
Phone#• 9128 -- 7 -71 -2 co
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 Clerk 4.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: