HomeMy WebLinkAboutBuilding Permit # 3/22/2016 txORT�
BUILDING PERMIT °��tLeo , +a
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION � z �
Permit No#: Date Received A°RgT�o oePy�`�
�SS•aC HUS
Date Issued:
I ORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
L1A�dition L1 Two or more fami Li Industrial
UAlteration No. of units: ❑ Commercial
Cepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE--PERFORMED:
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Identification- Please e' Ty p or Print Clearly
OWNER: Name: t4 ✓ Phone:
Address
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ �,+ 000 J FEE: $
Check No.: Receipt No.: I
NOTE: Persons contracting with unregistered contractors do not nave access to the guaranty fund
r _hof ntractor ���
5i nature of A ent/Qwner ;� ��� 9. _��
-Town oftk®RT H
PAndover
"II'
No. ® -s
Z _ h ver, Mass, 061'1)
C IAHE
1.
coc"Ic N@WICK
P•P ��,c5
U
BOARD OF HEALTH
Food/Kitchen
P' EmMIT T LD Septic System
THIS CERTIFIES THATA......... BUILDING INSPECTOR
. .. .. . .. .. .......... .... . :..... .. ... ........
Foundation
. . .........................
... .......®
...has permission to erect .......................... buildin s on . .. ... ... . ......
...
Rough
to be occupied as ........... .... .....................:....:....... ............. ............ . . ... ..III Chimney
...
provided that the person accepting this permit shall In every respect conform to he terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspect, ,Alter tion and
Construction of Buildings in the Town of North Andover. 61 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
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing r Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe 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
JOB LOCATION: s 6 C/0 sz-TA)la 57, 0 P 1z' 1+1, A
Number Street Address Map/Lot
HOMEOWNER PAP4//q� 9(4_j1AKj/
N4111C 19me hone Work Phone
PRESENT MAILING ADDRESS 1
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 shall not be considered a homeowner. (780 CMR
Section 110.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
ininfinum inspection procedures and requirements and that be/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE,
APPROVAL OF BUILDING OFFICgkt�
Revised 8.2015
Form Homeowners Exemption
BOARD OB:' PPE AIS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 111ANNI1+CG688-9535
The Commonwealth of Massq chusetts
.Department of IndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print a ibI
Name (Business/Organization/lndividual): ,V
Address:
City/State/Zip: �/ G'"�/1/��'!�-� 1W Phone#:
Are you an employer?Check the appropriate box: Type of project()required):
1.❑I am a employer with employees(full and/or part-time).* 'I, ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling
agy capacity.[No workers'comp.insurance required.]
r�,/ 9. El Demolition
3. 1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
, �
4. am a homeowner and will be hiring contractors to conduct all work on my property. I will Building addition
10
` ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13. Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.t
6.F1We area 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#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit 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 employes'that is providing worlref s'compensation insurance fog'my employees.•Below is the policy 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.
Ido hereby certify under thepains andpenaltie ofp 'u�y that thein ma n provided above is true a id correct.
Signature: 6�c Date: ?J J
Phone#
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.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#: