HomeMy WebLinkAboutBuilding Permit # 5/20/2016 i
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BUILDING E IT O� %aoED
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T OF THA OV ��
APPLICATION FOR PLAN EXAMINATION ® :
Permit No#: I — Date ReceivedVA,
SSgcHuse
Date Issued:
IMP RTANT: Applicant must complete all items on this page
LOCATION f }11 \Is, - A )ez' i't 1-At nyori
rint
PROPERTY OWNER , 'C'� L ��" h,r1� --
Print 100 Year Structure yes �"
MAP" PARCEL: ®��3ZONING DISTRICT: Historic District yes � l�
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Prinf Clearl
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OWNER: Name: -CA Y\. .)kv �.;k Phone: �
Address: CY C1 b
Contractor Name: Phone:
Email:
Address: 4 `
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: $ y : zl-j FEE: $
Check No.: �-6b� Receipt No.: 36`x22 i
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
FORTH
Town of 'WE 9
��.
Andover
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ver, ass,
0tAAJ,5 , 2041(V
® LANE �.
COC RICHE WICK
14 0,1?
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BOARD OF HEALTH
Food/Kitchen
PER I LD Septic System
THIS CERTIFIES THAT ....... BUILDING INSPECTOR
.. . .. . .................. .... .. ...................................... .............. ...... ..
Foundation
has permission to erect buildings on ... . ... .. ....... ..
.......................... .......... ................ ...... ....... ..... ....
Rough
to be occupied as ...... ... .. .....2.Uw..... .. .Vi
................ .... ... ............ Chimney
provided that the person accepting this permit shall in every res t conhe terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Iterati n and
Construction of Buildings in the Town of North Andover. t& fin.
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS IRough
Service
.................. F . ..:..........................................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Buildin Rough
Display in a Conspicuous Place on the Premises — Do Not Remove
Final
No Lathingr Dry WallTo Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
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3 7
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
;F 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
Please print
j 9
DATE:
JOB LOCATION:
Number Street Address Map/Lot
HOMEOWNER %' zm
Name Home Phone Work Phone
PRESENT MAILING ADDRESS , f
4L-� 4 11_/_/
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 I IO.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 Deparhnent
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. r�
HOMEOWNERS SIGNATURE --�' 1/�
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 ofMassgchusetts
W Department of Indast'rzalAcczdents
" X Congress Street,Suite 100
Boston,M4.02114 2,017
F ,
w minass.govIdza
Workers'Compensation Insurance Affidavit:Builders/ContractorsfElectricians/1'lumbers,
TO BE Fffiti D WITH THE PFPdMTTING AUTFIORITY.
Applicant Information. Please Print Legh
NaMe (Business/Organization/Gidividual);
AdclxeSS; %/tf C
6
City/State/Zip: l 1 � � #; _ 1 // C
"Cl '1 Phone#:
Are you an employer?ChecIttlie atrpxopriate box; Tyne of project(x'ecluii'ed);
1•Q I am a employer with c employees(full and/or part-time)." 'l. New constriction
2.Q 1 an a sole proprietor or partnership and have no employees worldng forme in b,, Remodeling
zany capacity.RToworkers'comp.insurance required.]
9. Demolition
3.. I am a homeowner doing all work myself.[No workers'comp.insurance required,]i
10 ❑Building addition
4.E]1 am a homeowner and will be]tiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11,❑Electi:ical 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'.F1 Roof repairs
These sub-contractors have employees and have worlcers'comp,insnrance.t
. 14.[�Other
6.Q We are a corporation and its of�cers have exercised their right of exemption per MGI,c.
152,§1(4),and yte have no employees.[No workers'comp,insurance required.]
'Arty applicant that checks box#1 must alsd fill out the section below showing their workers'compensation policy information,
i homeowners who submit#tis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TC(mtractors 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. ithe sub-contractors have employees,they must provide their workcis'comp.policy number,
f arra an employer that zs pi opzdlhg worfWs'compensation insurance for'my erizpr6yees. Below is the policy and)ob site
information.
Insurance Company Name:
Policy#or Self--ins,Lic.#: Expiration Date:_
A � a Ci /State/Zi a .t '......
lob Site Address:� nsatzo olxc declaration page(showing the aolzc pnuxnb6r and etc n' tzoi e .. r
ttaeh a copy'of the worlcers p , . p y P g.( g 1 y p )
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 tip to$250.00 a
day against the violator.A,copy of this statement may be forwarded to the Office of Investigations ofthe DIA.for insurance
coverage verification.
Ido hereby cer'ta y underthepains and enaldes ofpeiYwy that the hzforination pr'ovzded air ve is true and correct
Signature.-_., Date: D AFIM4
s
Phone#
Offzetal use only. 17o riot write an this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one): ;
1.Board of Ifealth 2.130dingDepartment 3.Cityffown Cleric 4.Iffectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4: