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Home My WebLink AboutBuilding Permit # 4/7/2016 01 hyo RTJ1 .1 BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION LA— Permit No#: Date Received Areo SSp1C Date Issued: PORTANT: Applicant must complete all items on this page LOCATION 4 �w int PROPERTY OWNER ' ./ 6 -01 r P_eC.__- Print 100 Year Structure yes no MAP C)q"5 PARCEL6,16 ZONING DISTRICT: Historic District yes no Machine Shop Village yes, no TYPE OF IMPROVEMENT PROPOSED L)SE Residential Non- Residential El New Building [YOne family El Addition A Two or more family El Industrial El Alteration No. of units: El Commercial El Repair, replacement El Assessory Bldg El Others: El Demolition El Other ,,-557777n-TT7r—p,7TTx'j MIN g". MY2 W- 1,W ity I I yy, "Id r t q S1 ate g,5+ �e RIPTION OF WORK TO BE PERFORMED: -e-L � denti irlcqt' n- Please Type or Print Clearly OWNER: Name Phone: Address: -5 Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home improvement License: Exp. Date: ARCH ITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$1 �op$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ '126 FEE Check No.: '1")6t) Receipt No.: �A NOTE4 : Persons contracting with u tere ontractors do I not have access to the guaranty fund -,........ §J g -n_' 9PE11LU" NORTH Town of F Andover jb6a-w2m� "z 4 c/l oh , ver, Mass, - cocMicNew�cw ATIED monk S U BOARD OF HEALTH Food/Kitchen rERM- IT T LD Septic System THIS CERTIFIES THAT . �� 6A— .... BUILDING INSPECTOR ........... ............................................................................................................ has permission to erect buildings on c�..�'G �,��, ,,,, �, �� Foundation .......................... .;:=A7Cl,,.l�.T C C'.I ..... ....................... Rough to be occupied as .......................`:::.`, nrC , r:L...!�. '��. y 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT I IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STARTS Rough Service ........... .... ......... .. ....... ................ Final UILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy 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 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: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER o 14 '1Ar o o ---------------------- Name Home Phone Work Phone PRESENT MAILING ADDRESS 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,provided 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 ane-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 110.85.1.2) 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 requirements and that lie/she w' comp] with said procedures and requirements. HOMEOWNERS SIGNATURE_��-'_/,//J, APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSFiRVATION 688-9530 11G" 1.T1 1689-9540 PLANNING 688-9535 The Commonwealth ofMassachusetts F .Department of IndustrialAceidents d F d I Congress Street,Suite 100 Boston,MA 02-114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print Le 'bl Name(Business/Organization/Individnal): �•s r r ��2•/1Ps� n / Address: J S 7 City/State/Zip: Q `�< Phone#: 79 807 d J Are you an employer?Check the appropriate box: Type of project()required): LQ l am a employer with - employees(full and/or part-time).* 'l. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. , Remodeling any capacity.[No workers'comp.insurance required.] ,/, 9. Demolition 3[/ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t i— 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 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 l have hired the sub-contractors listed on the attached sheet. ❑ 1 13.[]Roof repairs • These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance requited.] dr *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who subniif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors shat check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not,those entities have employees. Ifthe sub-coritractors have employees,'tliey must provide their workers'comp.policy number. Iain an employes'that is pi'ovidiing worltef s'compensation insurance for my employees.'Below is the policy and•job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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. I do hereby certify u tl p in a n lttes ofperjury that the infos-mation pf ovided a ov is true and correct. Sign ro: Date: Phone#• 0:> �o-2 – b T 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: