Loading...
HomeMy WebLinkAboutBuilding Permit # 6/8/2016 01 OORTH 'q BUILDING PERMIT '�c 6 16 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION jx VL Permit No#.- 7 Date Received TEV C Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATIONS> - ZAJ 'd%&UeSex 5--� Print PROPERTY OWNER 1-t,eno-Iku Sly-ont",'(k Print 100 Year Structure 6 MAP PARCEL: ZONING DISTRICT:— Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building Li One family [I Addition ;4 Two or more family Li Industrial 0 Alteration No. of units: '2- El Commercial $Repair, replacement ri Assessory Bldg ri Others: Li Demolition Ll Other El Septic; 'D Well 0 Floodolain 0 Wetlands 0 ,Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: C'n(I Oict skinq�esnnc'\ 4"ey"A veJ�� J Identification- Please Type or Print Clearly OWNER: Name: Phone: 9*11 ­Iz�is­2225 Address: S� Contractor Name: Phone: Email: Address: "9 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: $ '45DO. 00 F E E: Check No.: Receipt No.: OTE: Persons contracting with unregistered contractors do not have,�access to the guarantyfund ------------- ------ - ignature FORTH Town of Andover No. � C.oh ver, Mass, 046 40 it COC NIC MI w�tN 1' 0��reo P`4a�,��(5 U LDBOARD OF HEALTH Fm MIT T Food/Kitchen Septic System THIS CERTIFIES THAT f 0411P. .ia ..owwo ................................... BUILDING INSPECTOR . Foundation has permission to erect .......................... buildings on . r�...�.�. .. ........., ...oi � c ................................................................................. Rough to be occupied as*��� ....AAA. � � Chimney provided that the person accept g 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST ION Rough Service . ........ . . . .. ......... .... . Final BUILDIN INSPE TOR.. GAS INSPECTOR Occupancy Permit Required to 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 Approved by the Building Inspector. Burner Street No. Smoke Det. 7`he Commonwealth of Massachusetts A F Department ofIndlustrial.Aceidents �z� d X Congress Street,Suite 100 Boston,MA 02114-2017 www.rnass.gov/dia Wovkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE(FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organization/Iridividual): 7yj,( .A Address: 'LG5 tAtcW s<x 5+ City/State/Zip: MU:x-t VN tAn00 W i\i Phone Ts `-M-S Areyou an employer?Checktlie appioprlate box: Type of project()required): l f]I am a employer with t employees(full and/or part time).' 'l. Q New construction 2.Q I am a sole proprietor or partnership and have no employees worldng forme in 8. Remo deliYig any capacity.[No workers'comp.insurance required.] Demolition 3.W I am a homeowner doing all work myself.[No workers'comp,-insurance required.]t 9. ❑ 10 F1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. l will ensure that all contractors either have workers'compensation insurance or are sole 11.[(Electrical repairs or additions proprietors with no employees. 12.F]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.instuance.1 6.F]We are a corporation and its officers have exercised their right of exemption per MGL G. 14.[]'Other 152,§1(4),and we have nq employees.Wo workerscomp.insurance required.] *tiny applicant that checks b6x4l must also fill out the section below showing their workers'compensationpolicy information. t Homeowners who submit#his affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must•atfached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If tho sub-c6fi ncctors cavo employees,they const provide their workers'cam11 poflcy number. X air an employer that is pi•dviding ivorliers'compensation insurance for my employees.'Below is the policy andjob site information. Insurance Company Name: Policy##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. I do hereby certify un er Me Pains andpenaldes ofpei juiy Haat the information provided above is true and correct. signature: Date: Phone#• C11i­ s'1S-'?_V75 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#: TOWN OF NORTH ANDOVER OFFICE OF 2 BUILDING- DEPARTMENT m 1600 Osgood Sheet,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 DATE: L 1 s I I I1 JOB LOCATION: 2_65-2U1 (,-1 +CIA Icscx. SV Number Sheet Address Map/Lot HOMEOWNER lon, 6 ti +Ca nc,th "I1 S-2:2-+5 Name Home Phone Work Phone PRESENT MAILING ADDRESS 2.e5 H i dd l c Sex S4 Mocl-h AF,A�we_c Hii 01 S 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 minnnum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE , �s APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLAN TING 688-9535