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Home My WebLink AboutBuilding Permit # 6/21/2016 BUILDING PER ®RT1, q" IT o g4ED / •d TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: / Date Received Date Issued: e IMPOR ANT: Applicant must complete all items on this page LOCATION L ring! PROPERTY OWNER GCAX-v� _ ` Print 100 Year Structure yes - MAP PARCEL: % ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 ❑ Septic ❑1Nell ❑ Floodplain Weflands ;� ❑ Watershed Distract 0mater/Sewer" DESCRIPTION OF WORK TO BE PERFORMED Identific tion- Pleas Type or Print Clearly OWNER: Name: N IC .n I Phone: Oil1 09 4 Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: xp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 101 C)o FEE: $� Check No.: z Receipt No.: '770 NOTE: Persons contractin itli unre 'stere'contractors Flo not haveairccess to the guaranty fund 49 m t%ORTtH Town of1,. ndover ® ® ® t h ver, ass, Otost O LAKE COCMICf.EWICK �� A�4A,rED S U BOARD OF HEALTH P �ERMIT T LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ...ZJ&04. . . ... . . .....xa.. ... ..... .. .................................................. Foundoun ation has permission to erect .......................... buildings on . . ...... .... . . ... . ... ............ . Rough tobe occupied as . . ..... . ... . . ....................................................................................... 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 provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT ELECTRICAL INSPECTOR UNLESS CONS _, T , Rough -Service .... .. .. .... Final BUILDING INSPE OR GAS INSPECTOR Occupancy Permit Required t® Occupy By Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or all o Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF BUILDING D ]BAR I T�/�I�`I[ �+ a 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 UIDING PERMIT APPLICATION Pleaseip.int DATE: 6 �(2' 2o` �1 JOB LOCATION: �_) b M WS L& Number Street Address Map/Lot HOMEOWNERJAG�t(% CJ] '1 0 _090 Name Home Phone Work Phone PRESENT MAILING ADDRESS 1 Nom AAODS U1 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 rninirmum inspection procedures and requirements and that he/ e will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVAT[ON 638-9530 HEALTH 688-9540 PLANNR\TG 688-9535 The Commonwealth ofHassochusetis Department of Industrial.Accidents A w a X Congress Street,Suite 100 Boston,MA 02114-2017 www.anass,gov1d1a Workers'Compensation.Insurance Affidavit::Builders/Contractors/Electricians/Piumbexs, TO BE FILtD WITH TM PERA iTTING AUTHORITY. Applicant Information Please Print Ledbly Name (Business/Organization/Iridividual): �Q Address: W .) M673-( (, _'1 City/State/Zip: NO/11[ A. o0L • Ctrl(A. 'hone#k: 11 <. 1 f a ._ ..._ Are you an employer?C' eek tlio appropriate box: Type Qf prOjeCt(l°e[�llired): 1.[1 I am a employer with employecs(fullandfor part time).' 'l, [l Now construction 2• I am a sole proprietor or partnership and have no employees worldn'g for me in $, 0 Rezno delitig any capacity.(No workers'comp.insurance required.] ' ' 9. El Demolition 3,[I I am a homeowner doing all work myself[No workers'comp-insurance required.]i 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [l Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. i ' 12.d Plumbing repairs or additions 5. I am,a general contractor and I have hiredtlre sub-contractors listed on the attached sheet. ❑ 13. Roof re airs These sub-contractors havo employees and have workers'comp.inseuance.t p 6.[1 We are a corporation and its of�cers have exercised their right of exemption per MGL c, 14.[j Other 152,§1(4),and we have rio employees.[No workers'comp.insurance required.] Any applicant that checks b6x#1 must also hill out the section below showing their workers'compensation policy information. 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-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have , employees. Iftho sub-c;6 ractors fiave employees;:they must provide their workers'comp,policy number.' . f ai" an employer that is pi°avidiiig ivorlrers'compensation insurance for my employees.'B'eloly is the policy and)ob site information. Itrsurance Company Name: — Policy/#or Self-ins°Lic,#: Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers'coznpepz ation p olicy declaration page:(showing the policy number and expiration(late). Failure to secure courage as required under MGL c. 152,§25A is a criminal violation punishable by a fie 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:GaG of up to$250.00 a day against the violator.A copy of this statement may be forwarded-to the Office of 7ixvestigations of the DSS.for insurance coverage verification. X do hereby cet4 y under tliTZ 'ns°ondpenalties ofpeijuiy Haat the information provided above is true and correct. Signature: C 1 A— Date: Phone#t: q j )� '� �._ Official use only. Do not write in this area,to he completed by city or toren official.. City or Town: Permit/License# IssuizzgAuthority(circle one): 1.Boar of Health 2.BuildingDepartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#t: r i t