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Home My WebLink AboutBuilding Permit # 5/17/2016 7 BUILDING PERMIT o& �aoRrm� Rte@U.'61�O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ n � o M10 Permit No#: Date Received gSSACNUS�� Date Issued: i IMPORTANT: Applicant must complete all items on this page LOCATION S KAI<� Print PROPERTY OWNERB+Ti2'i6L Abi d°`► E 0 i Print 100 Year Structure yes no MAP 9 PARCEL: 107 ZONING DISTRICT: R3 Historic District yes no'' Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building x One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial X Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other "e, ol'-' a .d T.I s ®istr r ... s DESCRIPTION OF WORK TO BE PERFORMED: CZE . � �� or- W/A/b06.J Identification- Please Type or Print Clearly OWNER: Name: FiVTfZi0i< A. -D1F—Iy f2,6KoAJ i Phone: q)6--6 O — '/3i Address: !b /4 A DQ I V foot?4- 4A 0le,4S- Contractor Name: Phone: Email: Address: NA A '-- Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT;$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 36�+ Check No.: ` Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund a, .�i Vk r rr NO 4 _ .,. ,. ..sem,,,. ., %AOR TH Town of ndover 0 to ® ® 4L ?, h Vel'' SS' O LAKII COCKICKIWICK �qS RATED "'Pa,`�5 U BOARD OF HEALTH Food/Kitchen IL P E T LD Septic System BUILDING INSPECTOR THISCERTIFIES THAT ............. .. ... ........ ...... ............ ..... ........... .... .............. has permission to erect.......... ............... buildings on .. ..... .. .. ••••• . . . ........................ Foundation Rough .... ............. .... ...x!:!.4.1 ..... ...................... to be occupied as Chimney provided that the person acc 'pting this permit shall in a espect 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 EXPIRES ELECTRICAL INSPECTOR PERMIN' 6 MONTHS Rough UNLESS ................ . .��.l�........ ................I................. Service 2 �"•''� Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in s Conspicuous Place on the Premises — Do Not Remove Final No Lathingr all TBe One FIRE DEPARTMENT Until S ecte and Approvedthe Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1.600 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 PE11MIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER PA:RZ1611- '4 - 0'fN7-aENVAj7_ C/78- �8(/SB5�5 Name Home Phone Work Phone PRESENT MAILING ADDRESS— /4, 3 k t+rZ 0- boZi Vr-- 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 one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one borne in a two-year period shall not be considered a homeowner. (780 CMR Section I I O.R5.1.2) The undersigned"homeowner"aSSUITICs responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"horneowner"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 APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 6889540 PIANNIM3 688-9535 The Commonwealth of Massachusetts Department oflndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 .� . : www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information s Please Print Legibly Name(Business/Organizationffndividual): P&i a 1 Ute-• A , Addl'ess: G K A(ZA 0 R I E Nth nIS S City/State/Zip: 00(2T-1 A JDOV E< P one#: 7�j ��' 9 Are you an employer?Check the appropriate box: Type of project(Tequired): 1.❑I am a employer with employees(full and/or part-time).* 7. [:]New construction 2.Q lam 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.R1 I am a homeowner doing all work myself.[No workers'comp.Insurance required.]t 10 Building addition 4.❑I 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.F]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.# r 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other W 1✓1 (O OIG 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. i Homeowners who submit Ws affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 pfoviding 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. I do hereby certify under thepains andpenalties ofperjuiy that the informationprovided above is true and correct. Sigiiature• acnc Date Phone# x'17 g--69 7— 2,9 79 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#: