HomeMy WebLinkAboutBuilding Permit # 5/24/2016Permit NO:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IM ORTANT: Applicant must complete all items on this page
LOCATION 10000/be
PROPERTY OVVNER cio1/4.C4
MAP NO: PARCEL:
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ZONING DISTRICT: Historic District yes
Machine Shop Village yes
no
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o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Li New Building
I Addition
Li Alteration
i i One family
Li Two or more family
No. of units:
Li Industrial
Li Commercial
i I Repair, replacement
i i Demolition
Li Assessory Bldg
Ii Others:
Li Other
Ill Septic Li Well
ri Water/Sewer
i i Floodplain 11 Wetlands
Li Watershed District
OWNER: Name:
Address: /6)
Identification Please Type or Print Clearly)
Tql(it
(l)be,t1( or
CONTRACTOR Name:
Address:
erPIMMOM
Supervisor's Construction License:
Home Improvement License:
Phone: „i
Phone:
Exp. Date:
Exp. Date:
i\-1A ())Y,
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 C st: $ , t, cA.:3
Check No.: IL 1
—
FEE: $
Receipt No.: '-',5)-111.
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty find
gnature of Agent/Owner ignature of contractor
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VIOLATION of the Zoning or Building Regulations Voids this Permit.
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Gerald A. Brown
Inspector of Buildings
TOWN OF NORTH ANDOVE
OFFICE OF
UILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
Telephone (978) 688-9545
Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
GUIDING PERMIT APPLICATION
Please print
DATE: C ,' / / l 20 /
JOB LOCATION: / ( a)/ rr A Cep
Number
Street Addre Map/Lot
HOMEOWNER GP);c.hot rc)d-lafrie -ks-1
Name Home Phone Work Phone
PRESENT MAILING ADDRESS /6 C<)G
iNo f - , cJov-Prt %{ o 1
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 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 requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING •FFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530
HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
yartrnent oflndustr"ia1Accidents
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 TH le, PERMITTING AUTHORITY.
Applicant Information
Name (Business/Organization/individual):
Address: / (e wooel6'
..L c* 84-r0 i (er
kc=c vt1L
City/State/Zip: N or=` (' Vn J ®Uf lc t 0,1 A Phone #:
Are you an employer? Checktile appiopriate box:
1. n 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.]
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. n 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
6.11 We are a corporation and its ofcers have exercised their right of exemption per MGI. c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] .
Please Print Legibly
Type of project (recXuired):
7. [] New construction
8. i Remodeling
9. ❑ Demolition
10 [] Building addition
11. ❑ Electrical repairs or additions
12. Lf Plumbing repairs or additions
13. 0 Roof repairs
14. Other
*Any applicant that checks Box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who militia '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 mustattached an additional sheet showing the name of the sub -contractors and state whether or not those entities have .
employees. It the sub-contra?fors have emplc 'ees, they must provide their workers' comp. policy number.
X am an employer that ispi'oviding workers' compensation insurance for my employees.' Below is. the policy and job site
information.
Insurance Company Name: r19RA t
Policy # or Self -ins, Lic. #:
Signature:
Phone #:
Fs oCb0 461,0z ik4 (-a Expiration Date: / / /} /26 ' (c,
•
Job Site Address: SrFI.LIe- - (st NCL(x City/State/Zip: »O 1 hlil QlCll l;`6(/ A d l cYtr \t
Attach a copy of the workers' compensations 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.
X do hereby cehtify under the pans and penalties ofperjury that the information provided above is true and correct.
Date: 5 / zY/. /
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 #: