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Home My WebLink AboutBuilding Permit # 6/15/2016 .............. RJUILUINU VLKMI I 'TOWN OF NORTH ANDOVER 0 ,.,APPLICATION FOR PLAN EXAMINATION Permit 140:j-�-O--001,6 Date'keceived----,--. 0"ATep A" Date Issued:.�.J '7SACHU IMP'OIt'I'r1I � : A licault must com late all items on this a e LOCATION 3 t ikzl 1'e PROPERTY OWNER Print BONING MAP NO. PARCEL: DISTRICT: Historic District yes n6,) Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Li New Building W—Onefamily Li Addition FJ Two or more family Ll Industrial )dAlteration No. of units: 11 Commercial 11 Repair, replacement 11 Assessory Bldg F-1 Others: El Demolition 0 Other 11 Septic 11 Well 11 Floodplain F-1 Wetlands 11 Watershed District 11 Water/Sewer Identification Please Type or Print Clearly) Phone: OWNER: Name: LEW2$�of -q'�s Address: r 1 f U119 /? La:L CONTRACTOR Name: Phone-, Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address:— Rea. 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: $ FEE: Check No.: Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaran(yfund Signature of Agent/Owner ---u- Signature of contractor t4®RTH ' r . Town of 1, Andover ® ® ® 201� 4 ' _ n® LAKE \ ver' ass, _0 If SCOCMICHC WICK GATED Pg A U BOARD OF HEALTH ME I— LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ...... .... ... ..... .......... . .. .... .... . ... ...................................... 4M de .. . has permission to erect.......................... buildings on ........... ...... Foundation .. .. ' .... .. Rough to be occupied as ... Jr. .......... ..... .. ............................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provision&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 EXPIRESl ELECTRICAL INSPECTOR UNLESS CONST 0 S Rough - Service .. . . . . .aLDING . . Final .. SP OR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Display in aons iLathing cuous lace o the remises — Do Not Remove Final No Lat ' r Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Town of North Andover Building Department ent 400 Osgood Street SAC'"� North Andover MA 01845 Tel: 970-608-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE I 5 1 t �, JOB LOCATION Number Street Address Section of Town "HOMEOWNER_ e e � e �.. �� c Number Home Phone Work Phone PRESENT MAILING ADDRESS 3 ' 'gy m.... °"�• City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: 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 to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIA oe Note:Three family dwelling 35,000 cubic feet, or larger,will be required to comply with State Building Code Section 127.0 Construction Control. The Commonwealth ofMassc ehusetts F Department o, In dlustria-l.Accidents _ aid 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LgnblY g ) SON— R ASS r Name usiness/Or anization/Iridividual : C'�t�S, .Address: 3 ` e rk—e-l City/State/Zip: ,M, OULd Phone#: Are you an employer?Checkflie appiopriafe box: Type of project()Vequired): 1.❑I am a employer with employees(full and/or part-time).* '/• ❑New construction 2. 1 am a sole proprietor or partnership and have no employees Working for me in 8. [�Remo delirig any capacity.[No workers'comp,insurance required] 3. 1 am a homeowner doing all work myself.[No workers'comp.-insurance required.]t 9• Demolition 0 4.[]1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 []Building addition ensure that all contractors either have workers'compensation insurance or are sole ll..E]Electrical repairs or additions proprietors with no employees. 12•❑Plumbing repairs or additions 5. 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. ❑ r 13.❑Roof repairs These siib-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its ofcers have exercised their tight of exemption per MGL c. 14••❑Other 152,§1(4),and we have na employees .[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also till out the section below showing their workers'compensationpolicy information. Homeowners who siilimiEthis affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating mc h. that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities fiave employees. Ifthe sub-coriiractors fiave employeeslieymust provide their workers'comp.policy numbEr. f arra an employer that ispr ovidiiig ivorkrs9 compensation insurance for my employees' Below is the policy anclyob site information. Insurance Company Name: Policy#or S elf-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 S'T'OP WORK ORDER and a fuze 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 her ehy certify under t/epains andpenaldes ofpeijuiy that the information provided above is true and correct. sign 0: Date Phone# Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Boar.of Health 2.Building Department- 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: + � R {' I s , � _ .iy ,! _.,�-.-•-tea._ I +4j ` t r � '+ � � 4 \c�,• r i I , [ ' k i t r oust Olt LA 317 Ell A VA + I r " •-�� '• =1 — ,fes--� ulrG �,( + I i �l{!