The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 5/18/2016 SORTH BUILDING PER IT ,g�ho TOWN OF NORTHA DOVER APPLICATION FOR PLAN EXAMINATION - ® � Permit N®#: �/) 'a Date Received TEo Date Issued: �� A IMPORTANT: Applicant must complete all items on this page LOCATIONny ��- t Print PROPERTY OWNER ` Print 100 Year Structure Yes rn`o_ MAP C_, PARCEL:ZONING DISTRICT: Historic District yes Machine Shop Village yes Mo I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 6Zne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other y . ,r ,».+. s„: ^ t,s"'tom / ?�� 7 f :,"✓✓'.h-,'�a�',:6..�rr/;�vt ,:::/iGGY+Y ySYG �'Gr��f_F, ��M.,cF r.a?x +mr"a b�.�f.'lr..�`z"��Y✓d xsM hr,Yr'��llir✓ , 19ntls � '?�� ❑ ,� e�shed�Ds r�'ct �� ,�� DESCRIPTION OF WORK TO BE PERFORMED: { Identification Please TTpe or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: 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: $ C Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �”' ..,<d r ,rx. ;% i' 1 „r ✓' \1 , Y NORTH ,q Town ofE � a _ ...'.q. �( ndover No. ® Y M AKE �O Lh Ver, ass, R -2&3ft-11 IL -%r COCKICHEMCK 1' RATED P4 U BOARD OF HEALTH Food/Kitchen PER T T Septic System THIS CERTIFIES THAT .... .. . .. ..... . .... d. a��.................................................. BUILDING INSPECTOR ............. ........ has permission to erect ... buildings on .. Foundation ................... ....... .. .. . .. . r..... ... ... c .... ` 11 Rough to be occupied as . 7.4....... . ................................... �.}.....� ............... ... .. 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 VIOLATIOP `the Zoning or Building Regulations Voids this Permit. Rough Final EXPIRESPERMIT ONTS ELECTRICAL INSPECTOR UNLESS STARTS Rough �j Service ................. ........... . •., ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT ww 4F 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 pleasq_prhmt DATE: JOB LOCATION: 13A Number Street Address Map/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS t_� AW(kwq U__ U-4 61 c q 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]arid on which be/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 and that lie/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL, Revised 8.2015 Form Homeowners Exemption BOARD OF APP All 688-9541 CONSERVATION 688-9530 HEAL1111688-9540 PIANNING 688-9535 The Commonwealth of Massachusetts F Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lee.tricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information \ Please Print LegibIy Name (Business/Organization/Individual): Address: l_ 1 114'et-_ City/State/Zip: ji):AAfkoy-fp-,,_ t,��.� Phone#: 770" W7C) oDD'7 Are you an employer?Check the appropriate box: Type of project()Vequired): L❑I 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. El Demolition 3 XI am a homeowner doing all work myself.[No workers'comp.-insurance required.]t 100.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.C1 Electrical repairs or additions proprietors with no employees. 5. • 12,[]Plumbing repairs or additions I am a general contractor and have rethe sub-contractors listedon the attached sheet. ❑ I hhidb tt • These sub-contractors have employees and have workers'comp.insurance.$ 13. Roof repairs 6.F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 sfibmif#his affidavit indicating they are doing all work and then hire outside contractors must s0mit a new affidavit indicating such. #Contractors that check this box must•attaehed an additional sheet showing the name of the sub-contractors and state whether or not those entities have , employees. If the sub-c6ritracf6rs fiays employees,they must provide their workers'comp.policy number. I am an employer that is pfovidhig workers'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 foam 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. Y do hereby certify under thepains and penalties ofpeijuiy that the information provided above is true and correct. Signature 'l1� L i 1-= � Date: Phone# �71�" C g C lo 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#: