HomeMy WebLinkAboutBuilding Permit # 8/8/2016 BUILDING PERMITQ� NORr
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TOWN OF NORTH ANDOVER 6
APPLICATION FOR PLAN EXAMINATION _
Permit No#: Date Received VSs^TEV try
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION k27r
Print
PROPERTY OWNER f
T
Print 100 Year Structure yes no
MAP PARCEL: d ZONING DISTRICT: Historic District yes no
Machine Shop Village yes o "
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
❑ Se tic ❑1111e11 ❑ Floodplain ❑We#lands t"`h L}istnct
❑Water �"
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- PIease Type or Print Clearly
OWNER: Name:�`r gve- . . ,T&-m 61— Phone:
Address. (/70
Contractor Name: Gilr moi. ,T Ae Phone: ? _727F7 2-
Email: Gcd '- «
Address:
Supervisor's Construction License: Exp. Date: ACI—f5--
Home Improvement License: 7 �- Exp. Date-
ARCH ITECT/ENIGI NEER
ate:ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST-BASED ON$925.00 PER S.F.
Total Project Cost: FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do Not have access e guaranty fund
ER
t%ORTH
Town of
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT J.Amo....�5�,�. -. BUILDING INSPECTOR
.,..... .......................................... ..
Foundation
has permission to erect .... buildings on � . .,.,.. �.�!
� ,t Rough
to be occupied as ...,.,..^ ................ .......................................................s L!� Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Z4VI) 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 I 6 MONTHS ELECTRICAL INSPECTOR
LESS CONST ION Rough
Service
.. ...... . .. .. Final
BUILDING IN CTOR
GAS INSPECTOR
Occupancy Permit Required to Occul2v By 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.
Y>ght� AM— 00"
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The Commonwealth of Massgehusetts
z. F Department of. 11dustrialAceldents
X Congress street,Suite 100
Boston,NIA 02.14 2 0.77
:•.yV+yro� www.mass.govldia
W,3r rens,Compeirsation ins-arance Affidavit:Builders/C0ntract03rsLEJe4*1ansfi'Xumhers.
TO BE FILLED MgTH THE I'ERMI`ITlNG A UT-RORITy'
A licantlnformtatinn . FleasePrint Ledb
Name(Bi,Tsmoss/oxgamzationthdividual): - f
Address:
City/State/Zip: hone#: r r 3 Z"
Are you an employer?CktecictIie appropriate box: Type of project(Ygquiri�d):
1. I am a employerwith l employees(full and/or part-time)-* 7. Q New Cntistxuciaon
.2..L]I am a sole proprietor or partnership and Have no employees working forma in $. Remodel3sig
any capacity.LN,workers'comp.insurance required.] 9, ❑Demolition
1❑I am a homeowner doing all work myself.[go workers'comp.-iaxsurance required]t I0 E]Biding addition
4,L]I am a homeowner and will be hiring contractors to cooduot all work on my property. I will
Electrical repairs or additions
ensure that ail contractors eitherhave workers'compensation insurance or are sole
prapzietors withno employees. 12:[ Plumbing repairs or additions
5.F1 I am a general contractor and I have lured the sub-connectors listed on the attached sheet, .�Roof repairs
These sub-contractor'Aave employees and have workers'comp.uisurance f I9. Other f 11E'��✓f��
b.Q We are a corparativn and its'Officers have exercised their right of exemption per MGL c. �
152,§1(4),andwe have na e�nployees.[No workers'comp.insurance required.]
`Any applicant thatcheeps box*1 must also fdl out the section below showing theirworkers'compensation policy infonnatiori.
i$omeowners�bho subedit"affidavit indicating they arc-doing all work and then hire outside contractors must s4bmit anew affidavit indicating such.
TContractors that check flys box mnst•aitac�red as additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-cari�ac4ars Tuve employees,}]ley mast provide their workers'comp.policy number.
X alar an erriplayertTiatisp ovid'ing7roorkers'cOmPensadon insuranceforMy employees'Below is thapolicy ancijab site
inforLmatian.
Insurance Company Name: !�-
2 � �-�r'o mpirationDate: `C T
Policy#or Self ins.LIC.#l:� �/��—._a l.,lv
Jab Site Address: 1 G�CE'.'r 'ty/State/zip: UVB
Attach a copy of tl�e o hers'coxnpep§ation policy declaration page(Shawingthe policy number and egpi�ratiobt date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$I,500.00
d and/or one-year irrxprisonment,as well as cil penalties in the_Eazm of a SWOP WORK ORDER and a ane oup to$24.(30 a
a day against the violator.A copy ofthis statement may be forwarded to the Office ofluvestigations of the DSA for insurance
l
coverage verification..
X do hereby certtf`y aBder it,epain.s'andpenaltles ofperjury it,at the information provided above is ixtie and correct
sign
atw c:
` Data:
Phone#: 3
official useonly. Do not-tvrite in this area,to be completed by city or town official,
City or Town: PermitlLlcense#
Issuing Auth.or%r(circle one):
1.Board of Health 2.Building Departanezlt 3.City/Town Clerk 4.Electrical Inspector- a.Plumbing Inspector
G.Other
i'
Phone
Cootact Persolx: #:
�y Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
t ono-ruction
License: CS-050281
by 1 1.ti �
W rLLLIAM 3 ZANN'O '•�.
806 SALEM RD _ �
DRACUT MA 01$26 .
n
1,1iA Expiration .
Commis�sionne`r' 10/1512016
Office of Consumer Affairs&Business Regulation
IMPROVEMENT CONTRACTOR
registration: 180372 Type:
l=zpiratlon: 1 111 01201 6 Corporation
WILLIAM J.ZANNONI.INC.
f,
WILLIAM ZANNONI
806 SALEM RD
DRACUT,MA 01826
Undersecretary
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