HomeMy WebLinkAboutBuilding Permit # 6/8/2016 01 OORTH 'q
BUILDING PERMIT '�c 6 16
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION jx
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Permit No#.- 7 Date Received TEV
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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