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Home My WebLink AboutBuilding Permit # 5/19/2016 l BUILDINGP MIT �� , � ,O.¢ TOWN OF NORTH AD VE ; .. . . ; APPLICATION FOR PLAN EXAMINATION Permit No#: A) 7 -_ Date ReceivedEa S � "8 R� Date Issued: — to IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Sa 1 C )yk,APe e5 Le, Print 100 Year Structure yes no MAP �� PARCEL ' . ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ; „One family 11 Addition [I Two or more family 11 Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other KRAL111WN DESCRIPTION OF WORK TO DE PERFORMED: r � 71 Identification- Please'Typor I'ri t Clearly OWNER: Name: ”" , r � Phone: Address: ` 4 Contractor Name: 1' �,,' , .. Phone: 51, -, 5 " _ 1e`i°" Email. Address: Supervisor's Construction License: QS -- IC) \` ee Exp. Date: Home_Improvement License: s 5 Exp. Date: 3 ° 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. Teal Project Cost: $ �� 1 ,� c r ��:� FEE: $ > Receipt No.: c){ Check No.: P NOTE: Persons contracting ith unregi red contractors do not have access to he guaranty rind Y e ,;-iir r,,i r „rd//fii�//il /%,��mji///I// ��,;r/,,, �,,. p/ �. rs.✓ �/ ,� „ /i ////////r/�/ ":.;, " �, ,r, �„ .,��/��,,,;�� 0i., 1,,.' „ ; V ,, �r �. a:. r �q ��/l%/iep „/,/J/r,�,//(l/////%///��r r� ..�n n,you .✓.,,,,.., .._ ttORTH Town of ndover ® - ��K� h ver, Mass, ,O��i� coc"Ic"t-ICK RATED 0"%* U BOARD OF HEALTH Food/Kitchen Ph �RIVI 'I �T� I Septic System �p / ��6��1s / BUILDING INSPECTOR THIS CERTIFIES THAT .......................................�1 .........., ................1. ............................................ �'7. CJe.7l ;y7..j ..��............................. Foundation has permission to erect �.`............�..�..pbuildings onf7 777 ....�................... - Rough to be Occupied as !,� l v . - sr ^r .......r"! ........... ................. .........................�. .... ............................................ `l.� Chimney provided that the person accepting this permit sfaail in every respect conform to the terWS 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 I 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ...................... Service .......... ... G;�'y�� ........... 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 Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth ofMassachusetts Department of IndlustrialAccidents X Congress Street,Suite 100 Boston,MA.02114-2017 yV4y�t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Li lectricians/Plumbers. TO BE MED WITH THE PERM[TT1NG AUTHORITY. • Applicant Information ` l (� Please Print Legibly Name (Business/Organization/tridividual): �` �yV • k hr,S�tr r C fc� ai f, J R &�CiLL Address: 03 k 5ru City/State/Zip: Phone#: 5ccgg 1,92 -2_ b Are you an employer?Checktiie appzopriatebox: Type of project )Vequired): 1.❑1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.W 1 am a sole proprietor or partnership and have no employees working for me in 8. k Remodeling any capacity.[No workers'comp.insurance required.] • 9. F1 Demolition 3.❑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. 1 will 10 F1 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑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.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.F1We are a corporation and ifs officers have exercised their right of'exemption per MGL c. 19•❑Other 152,§1(4),and we have na,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 this affidavit indicating they are doing all work and then hire outside contractors must sihmit 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. Ifthe sub-corilractors fiave employe s they rr-mst provide their workers'comp,policy number. X ciin an employer that is pi•ovid619 rvorlcers'compensation insurancefor my employees.'.Beloit/is the policy and job site information. Insurance Company Name: — Pol"icy#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 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 X do ltet eby eertif u er•thee pAAa1ns and n s ofpeijuiy that the information provided above is true and correct. Signature: Date S 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): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor atrdc,tor Registration Registration: 185227 Type: LLC Expiration: 5/12/2018 Tr# 288600 SAINT CHRISTOPHER PROPERTIES L PATRICK RUSSELL 231 BROADWAY METHUEN, MA 01844 Update Address and return card.Mark reason for change. SCA 1 C. 20M-05/11 E] Address F-] Renewal � Employment Fj'Lost Card Office of Consumer Affairs&Business Regulation License or registration valid for individual use only IMPROVEMENT CONTRACTOR before the expiration date. If found return to: '185227 Type: Office of Consumer Affairs and Business Regulation _ � Registration:511-21201-8 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 SAINT CHRISTOPHER PROPERTIES, LLC PATRICK RUSSELL 231 BROADWAY METHUEN, MA 01844 Undersecretary Not valid without signature Mi ass acriuSe S Depai-Liiient of Pub iic Safety Board of Building Regulations and Standards License: CS-109119 Construction Supervisor PATRICK RUSSELL 80 SAILE WAY NORTH ANDOVER MA 01845 � n r. Expiratic ('nrvmiccinnar n..,.��7nao