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Home My WebLink AboutBuilding Permit # 5/23/2016Permit No#: Date Issued: D BUILDING PERMIT TOWN OF NORTH ANDOVE APPLICATION FOR PLAN EXAMINATION:.: Date Received. IMPORTANT: Applicant must complete all itemsMI this, page LOCATION l Cp J 6 m -Fr e Print -� PROPERTY OWNER C h OV I e F C I l n Ul�ll'70 Print 100 Year Sfructure MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Village yes yes a yes no7 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family 0 Two or more family No. of units: O Industrial O Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: DESCRIPTION OF WORK TO BE PERFORMED: Q x O CCu1op _.j 4CidVCe4 ior� l Identification - Please Type otir Print Clearly C,I eUPrl 013 OWNER: Name: Address: 1(113 501em (31(1 - Contractor Name: Email: Phone: Phone: 77 a5 % �3 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 cpsr:EasarON.$125.00 PER S.F. Total Project Cost: $ Check No.: NOTE: Pe ignature of FEE: $ Receipt tli gistered contractors do not have access lathe guaranty fund — ent ner Signature of contra U 0 CD I - CD CD co co 0 CQ CD Cn CD 0 cn 0 Cif) 0 U) 0 CD 0 CD CD CD en CD 3 CD z nod p o7 pa gn • w G) cn 0 m C' 1�1M co CO 7-1 ® C3") Col co 0 VIOLATION of the Zoning or Building Regulations Voids this Permit. 0 zs 0 0 0 C') -a. Q 0 rt) as o} uo!sslwaad seq 1VH1 S31lI12130 SIHi Gerald A. Brown Inspector of Buildings TOWN OF NORTH ANDOVE OFFICE OF F®F UIL LNG DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot q/ � HOMEOWNER div � � 0 Q ~I c 3 �% ��y ` �/ ) Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town St04— ate of �S 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 110.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 requirement and at he/ e 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 Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114 2017 , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name (Business/Organi7ation/Ilidividual): C.11AffS's bik /- ) t Address: c� a City/State/Zip: �i CQ.0 r _ 0 ( c�J `iV Phone #: TCi �\1 2 ^� �j iJ• Please Print Legibly Are you an employer? Check the appropriate box: 1.11 I am a employer with t employees (full and/or part time).* 2. n I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3_n 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 ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5 ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (re(juired): 7. 0 New construction 8. i Remodeling 9. ❑ Demolition 10 [] Building addition 11. n Electrical repairs or additions 12. [] Plumbing repairs or additions 13. fl Roof repairs 14. Et Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who snbnut this affidavit indicating they are doing all work and then hire outside contractors must submit 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. If the sob -contractors have employees,'they must provide their workers' comp. policy number..' lain an employer that is providing worlkers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins, Lic. #: Expiration Date: fob 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 the pains and penalties ofpeijury that the information provided above is true and correct. Signature: Phone #: Date: 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 I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ^M1 REGISTERED FABRIC NUMBER F-140.01 c t ISSUED BY JOHNSON OUTDOORS INC. BINGHAMTON, NEW YORK 13902 Manufacturers of the Finest Tent Products Described Herein Date of Manufacture JANUARY 2007 This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: SUDBURY TAYLOR RENTAL CENTER CITY: SADBURY MA Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701`, Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Seecificatiens of MIL-C-43006G. Tvoe, color and weight of material 13 OZ vinyl WHI IL: BLOCK OUT Descriotion of item certed: ELITE PARTY CANOPY 20X30 T Flame Retardant Process Used WM Not Be Removed By Washing And is Effective For The Life Of The Fabric Snyder Manufacturing, inc. Manufacturer of Flame Retardant Vinyl Laminates TENT DEPARTMENT JOHNSON GUI ORS Large Scale