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Home My WebLink AboutBuilding Permit # 4/5/2016 .„.,,.....u,.,. ORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received TOD Date Issued: & ACHU IMPORTA 4T: Applicant must complete all items on this El"Me LOCATION 'jc'� vv\Ve Print a PROPERTY OWNER we Print ZONING NING DISTRICT: Historic District yes 0 MAP NO: Machine Shop Village yeses TYPE OF IMPROVEMENT PROPOSED USE Residential , Non- Residential FJ New Building One family 0 Addition 11 Two or more family El Industrial )(Alteration No. of units: 11 Commercial El Repair, replacement 0 Assessory Bldg El Others: 11 Demolition El Other El Septic 0 Well El Floodplain 11 Wetlands El Watershed District El Water/Sewer 04 jet, VVN La Identification Please Typeor Print Clearly) N )a v(J Phone: OWNER: Name: C4 Address: 0 CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER" Phone: Address: Req. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 41, �'— C Total Project Cost: $ b FEE: $ Check No.: Receipt No.: e.� Q L11 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 11 Signature of Agent/Owner 11�4oce” llw_o Signature of contractor _G7 ttORTHfown 01 9 \Andover ® ® -� _ C%0 h , ver, Mass,4'q_.* LAKE t� coc"Ic KtwicK 4' A�RgTED S U BOARD OF HEALTH PE T T E a Food/Kitchen LIEF Septic System THIS CERTIFIES THAT ' BUILDING INSPECTOR has permission to erect .... Foundation p .......................... buildings on . ......... .... ..fir.:.!:::................................ Rough to be occupied as U h ..... .. ... .... ....I................O5` ......................................... Chimney this permit shall in ever provided that the person accepting y 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 EXPIRES ONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO!.N S A TS Rough � ? Service .... . .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department oflndustrialAccidents m d 1 Congress Street,Suite 100 Boston,AM 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Lel4ibl Name (Business/Organization/Individual): �� tM k( Address: 3 _ � C) Ga s"V, rd- City/State/Zip:-- A�'1 r V I"�� Lt-Phone#: �r 1 `t LJ 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. rl 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.] 3.[JI am a homeowner doing all work myself.[No workers'comp.-insurance required.]t 9 R.Demolition 0 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 11.Q 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.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑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. Homeowners who subrriif 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 have employees,they must provide their workers'comp.policy number. I am an employer that is providing workerscompensation insurance for•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. X do hereby certify uilder the pains nod po-enaltles ofpef jury that the information provided above is true and correct. Sign re: ✓uC wl/ Date: —s- Phone Phone#: ' -7,� d"Q 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.Plumbing Inspector 6.Other Contact Person: Phone#: 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 prin DATE: JOB LOCATION: ci V VI'l Number Street Address Map/.Lot HOMEOWNER f r" 0a V( 6 q- ca - -),o C)L Name Home Phone Work Phone PRESENT MAILING ADDRESS kfi/,N AY\13 v(,,� NA City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellhigs 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 whicli 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 I O.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 nd that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APP AIS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535