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HomeMy WebLinkAboutBuilding Permit # 4/19/2016 BUILIAORTHDING PERMIT 0, TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: a Date Received —1 r I C I a C" Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER �r%x 's, Print 100 Year Structure yes ono MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes (.no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 11 New Building N One family L1 Addition Li Two or more family Li Industrial RAlteration No. of units: ❑ Commercial 11 Repair, replacement 11 Assessory Bldg 11 Others: 11 Demolition Li Other 'sh NPi DESCRIPTION OF WORK TO BE PERFORMED: C5, \J Identification- Please TY pe or Pi-int Clearly OWNER: Name: Phone: Address: 6'17 Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Rea. 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.: Receipt No.: 10 NOTE: Persons contracthig with tymegistered conti*actors do not have access to the giiarantyfuiid Si .qnature of Agent/ iNner- � NORTH 11dover][ own Ot 2 O ® ass ` X/4 / ver, , D 1, coc MIc"a WICK ADRATED S V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System &_� l� ...........................'..... BUILDING INSPECTOR THIS CERTIFIES THAT � ......................................, %y�/'kr, Ji .............................. Foundation has permission to erect .......................... buildings on ........................... .................. Rough �I�1 ���.. � Chimney to be occupied as .......................... ... .....© ........... provided that the person accepting this permit shall in every respect conform to the terms of the a Altepationlicat l and on Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR LESS C IO - TARTS Rough ............ Service ................. . .... ..`z.:...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit required to Occupy Building Rough Final Islay in a Conspicuous Place on the Premises — Do Not Remove ""u`` FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Burner Until Inspected and Approved by the Building Inspector, Street No. Smoke Det. of NORrH TOWN OF NORTH ANDOVER tt" +� OFFICE OF Z. 0 A BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 1s4..,Argo L� North Andover,Massachusetts 01845 CHUS 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 Q���� �dvJ�y " ) L\\L,`\ Name Home Phone Work Phone PRESENT MAILING ADDRESS ��� NN 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, rop vided 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 IO.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 requirem�gp 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 of Massachusetts F Department of Industrial.ACCidents " I Congress Street,Suite 100 Boston,MA 02114-2017 sV;V;t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib, Name(Business/Or`ganiz`ation/fndividuall): Address: /�C ,/ / y�`�n�l`� ✓l City/State/Zip: kdlf� AfAlu' Phone#: ��US 6ao Are you an employer?Check tfte appropriate box: Type Of project(xequil'ed): 1.Q 1 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 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp..insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 []Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions prop.rietors 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.[�Roof repairs These sub-contractors have employees and have workers'comp.insurance.I 6.F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[J 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 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors Pat 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-coritraciors fiave employees,they must provide their workers'comp.policy number. T ain an employer that is providing workers'compensation insurancefor 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 and lie pain andpenalties ofperjury that the information provided above is true and correct. Signature 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#: