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Home My WebLink AboutBuilding Permit # 4/11/2016 rim V%O 'Ti own ofp o E � 2 'a ,z� ® Andover 4 ,-� 11 2116 11 ver, Mass, O Ap LAKE 1 COC HICME WICK 4A 1E D S l! BOARD OF HEALTH Food/Kitchen Em I �T� L D Septic System THIS CERTIFIES THAT „ ,,,,, .......... ... .......... BUILDING INSPECTOR .....M ... ...... .. ................. ...... . Foundation has permission to erect.......................... buildings on ........ ........................................ ... ... ....... ® Rough to be occupied as .... .. .. .. /.r.. ... . .�. ........... ...... .. ... . ... .................... Chimney provided that the person accepting this 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final I I 6 MONTHS ELECTRICAL INSPECTOR n UNLESS T RTS Rough Service ...................... ... .. .. ......................... Final UILDIN GAS INSPECTOR Occupancy Permit Required to ccupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or 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 2-36 North Andover,Massachusetts 01.845 Telephone(978)688-9545 Gerald A. Brown Fax (978)688-9542 Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: r, 4 Number Street Address Map/Lot 0 811 HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Lip 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 understands the Town of North Andover Building Department minimum inspection procedures and requirements and th4the/she will comply with said procedures and requirements. ZA HOMEOWNERS SIGNATURE '4Z AL APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption The Commonwealth of Massachusetts F Department oflndustrialAccidents 1 Congress Street,Suite 100 Nm 't Boston,MA.02114-2017 www.mass.gov/dia Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITJ4 THE PERMITTING AUTHORITY. Applicant Informationi^ Please Print Legib Name (Business/Organization/Zndividual):� ✓`f�GrZ> Address: City/State/Zip:�V�iI Phone e l� Are you an employer?Check the appropriate box: 'Type of project(required): l.❑lam aemployerwith employees(full and/orpart-time).* 7, Q New construction 2.[J I am a sole proprietor or partnership and have no employees working for me in $. VLRemodelirig any capacity.[No workers'comp.insurance required.] • 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.)QI 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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[J Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.E]We are a corporation and its,officers have exercised their right of exemption per MGL c. 14.Q 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 submit 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 fiavo employees,`they must provide their workeis'comp.policy number. ]'am an employer that is providing workers'compensation insurancefor my employees.'Below is the policy and job site information. &41k Insurance Company Name: &y Policy#or Self-ins,Lie. Expiration Date: 1110V, OX c Job Site Address:_J& �'J �° City/State/Zip: � 1S� 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 e. 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 DTA,for insurance coverage verification. I do hereby certify under t iepains and penalties of perjury that the information provided above is true and correct. Signature: /f u '6 l ;> Date: 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: