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Home My WebLink AboutBuilding Permit # 5/4/2016 l IJIL.DING P RMIT G6 Sao RT®`�-(LED TOWN OF NORTH ANDOVER #0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �gssacoaus�� Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION �� /�� Print PROPERTY OWNER �61 �LVA64a Print 100 Year Structure yes nob MAP' PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑A5tdition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other e 1 Well d ood lain C]Wetlands a° 10 v DESCRIPTION OF WORK TO BE PERFORMED: 1�� 11 l vt W 't 6-ul s Q-A /ti's W L I`"lA �,� A&) LZ/e a G(1�2�Lp, Identification- Please Type or Print Clearly OWNER: Name: S-"QEA ()4�,VMl Phone: 97e Ok d-35-1 Address: G 6 q J �t fro IV, �OU-r�, � 0�� k,— J � Contractor Name: Phone': Email: Address: Supervisor's Construction LicenseDate- ['Home Home Improvement License. Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. 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.: 1�0 Receipt No.: � NOTE: Persons contracts g with unregistered contractors do not have access to the guaranty fund t '"'�';"",,-' �` t4-c s' „'. ,.f/ f t J r 3 .:+1,��rL'ifr,✓ f eI f -ri� ,,:G„ r„ ' town otIAORTH v er F f 11. lidu 0 ��-_ `k 0 Fwa ® t. _ 761 / ?+ h Ver `c1SS• OW42 O LANE / / COCHICHEWICK ®S RATE® PkIlf? �y U BOARD OF HEALTH Food/Kitchen PE �RMIT L �D_ ♦ Septic System THIS CERTIFIES THAT V BUILDING INSPECTOR ............... ....... . . . .. . .. ... !!! ............................. iitA .. . Foundation has permission to erect .......................... buildings on . .. .. . ... . o...wmei ............... Rough fkamq to be occupied as .. ... ............... ..,........ ...4"1..... ... ..... ...�. . 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 PERMIT EXPIRES 6 MONTHS ELECTRICAL INSPECTOR UNLESS T N Rough Service ... ... ....... - . '.. ...... .... ........ Fina BUILDING PE TOR GAS INSPECTOR ccupancy Permit Required t® 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 x _ BUILDING DEPARTMENT 4- _ ^4 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: _/3 JOB LOCATION: D(_t2( Sl�s_2-- �N~umber �►Street Address Map/Lot HOMEOWNER Jj {(�LZ 17ikV4(61( Y 7 Name Home Phone Work Phone PRESENT MAILING ADDRESS Vhu Ur2 G L kA, 6,k( Ye JAL cif A&A X 4 t6�c Nq � City Town tate 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 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 IIO.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 and that,,he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE 1 APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 COQ.°SERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 V The Commonwealth of Massachusefts Department qf Ind-ustriadAceldents I Congress Street,Safte 100 Boston,MA 02114-2017 . ..... wwwanass.govldla Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE, riffit,D WITH TBE PE WvHTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organizationffndividLial): eiA(�C--L 6;If-Ly Ar, Address: City/state/Zip: 4v—tdone#: zt Are you an employer?Check&e appii-oprMto box: Type .0 f project(Tqqm LE]I am.a employer with employees(full and/or part-time).* 7. []N obstruction 2.[J 1 am a solo proprietor or partnership and have no employcesworkirrg forme,in 8. rz!=ffig ply capacity.[No workers'comp,insurance required.] 9. rl Demolition 15dolam a homeowner doing all work myself.[No workers'compAnsurance required.]t 4.[ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1.0 r]Building addition ensure that all contractors either have workers'compensation insurance or are solo 11.F1 Electrical repairs or additions prop'netors with no employees. 12,F]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. Thesb sub-contractors fiav�a`cm`piqy'�e's and workers'comp.iDsurance.1 1�.[]Roof repairs • I I . . 14.Fj*Other 6.[:]We are a corporation'and its officers have exercised their right of exemption per MGL G. 152,§1(4),and we hayo nlaemp18yem[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who subn1if tis Adavit indicating they are doing all work and then hire outside contractors must s4bralt a now affidavit indicating such. tContractors;that check this box must-affached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, If the sub-contractors have cmployees,,'`tlicy,must provide their workers'comp,policy number.' .1 am an employer that ispidVid6ig worhrers compensation insurance for'my empkyees.'Below zs the policy an d)ob site inforination. Insurance Company Name: Policy#or Self-ins,Lie.It: Expiration Date: `slob Site Address: pmt city/stato/zip--LA Attach a copy of the workers'cbmpejisation policy declaration page(showing the policy number and expiration(late). 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 flue 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 :j the pains ndpen a I les ofp eiju iy Haat the hifio rin allon pr'ovid'ed ah o v e Ly trove and correct - e e- 601-4c Date: Signature: Phone 6 8,(,_ Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License 0 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 9: