HomeMy WebLinkAboutBuilding Permit # 8/8/2016 11
BUILDING PERMIT t&ORT
TOWN OF NORTH ANDOVER to
APPLICATION FOR PLAN EXAMINATION
Permit No#: /,X Date Received
US
41
Date Issued:,,
�f ? (�
E_ IMPORTAN�T. Applicant inuA_c complete all items on this page
LOCATION
Print
PROPERTY OWNED j�,`,, Lk, ,J
Print 1 0 Year Structure yes "U"
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes 5M
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
11 Addition U Two or more farnily 0 Industrial
Alteration No. of units: 0 commercial
.Repair, replacement - E Assessory Bldg E Others:
F.1 Demolition 11 Other
g,
ORK TBE PERF,
�
M
,� Iden fixation- Tyke
OWNER. Name.
z_,phone:
Address:
...............
Contractor Name.-_a�� Phone:
Email:
Address: Z,_ )\1
Supervisor's Construction Licens Exp, Date:
Home Im rovement License: Exp.
ARCH ITECT/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.
�12 0
Total Project Cost: $ 4FEE: $
C
Date: '5
-7e.?
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not:access to uarant
have yfund
................ ...........
-----------
OQRTH q
own of 2 ._�t. 6 ndover
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No. 1 -�
h ver, Mass,40 AAF
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�a BOARD OF HEALTH
Food/Kitchen
Septic System
PE IT T LD
THIS CERTIFIES THAT .�. ... ...
....................................... BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ... ... �. �.
Rough
to be occupied as ..... /� /tco!form
.40 ............... Chimney
provided that the person accepting this permit shall in every resp to the ferm 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 C® STRU TI® T Rough
Service
. `.....` .., .'. Final
BUILD'I'NG PECT R
GAS INSPECTOR
Occupancy Permit Required to Occupy BuRough
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.
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The Commonwealth ofmassa'chusetts
:.z s Department of IadastriaZAccideiats
Z Congress street,,Waste 100
yt N-J m Boston,MA 021:14.20.17
- ' yvww.mass.govldia
oxlters'Caxnpensation£xrsuranceAffidavit:l3uuders/Conti^arta s +lectxacians/E'Xxxxnbers.
TO 131,InFm vJ Tff Tff E, REI2l&TTIi`7G A.` "'HORT.TY
licantinformation
;Please print Le
A 'bl
Name, (Business/OxgauizatianC.Cn.dzvzdual)
-A.d:drem: �._...- .O -.-- -.
C%ty/stake/Lip:__ `�'�c �,,�c ►h��l' .__._s' 1 ' on #:�.g'C7 ..'9Z 2 6 _. _
Type o£project ect e tired
Aroyou an employer?Cheelrtlio appropriate Brox: Typ J (3.
1.L]Is.ma emplcyerwith !employees(fall and/or part-time).* 7.- E]New coxist uetiou.
2.�I am'a sole proprietor;or partnership andhave no employees working for mein $. ry Rerx[xxoclel ig
any capacity.[No workars'comp.insurance required.] �. Demolition
3_E]I am a homeowner doing all workrayself[No workers'comp..iusurauce required.]t 10 E]Builcyng addition
4.&fI am a hameowner and will be hiring contractors to conduct all work on my property. I will
sale k
i ]eot7xcal repairs Ux,addzttons
ensure that all contractors either have workers'compensation insurance or are
proprietors withno cmloyees. 12: Plumbing repairs or additions
5, I arra a general contractor and I hate hired tbo sub-contractors listed on the attached sheet. 13. )?,o o' iepairs
employees and have workcrs'comp.insurance.
Tiaese sub-contractors Hada 14 Other
6.C[We area corporation pud its ofrjcers have exercisedtheirright of exemption perMCTL c.
152,§1(4),andwolrava na errrployees.[No workers'camp.insurance required.]
tom;. f �
Arxy applicant tbsit ohecics box#1 must also`fall out the section below showing their workers'compensation policy information
1'Homeowners who submit tlo affidavit indicating they are doing all work and then hire outside contractors must s4bmit anew affidavit indicating such.
tContractors that check this box must'q.tfacJred an additional sheet showing the name of the sub-contractors and state whether arnot those entities have
employees. if sub-c6iiifractors have employees,[lieq must provido their workeFs'comp.policy number."
Iain an emptoy erthat is p/^ovzdirxgworlierscompensation ins wran ceformy emplbyees.'Bela iv is thepolicy anidjob site
information.
Insurance Company Name: _
Policy#or Self-ins.'L"ic.#l:__ Expiration Date:__ - ;
" tfiw.r Czty/State%�ip:,�_
lob Site Address: -
Attaclx acopy oifthe Work compelrsa_o policy declaration page(showingthe policymunber and expiration date).
Failure to secure coverage as required under MGI.c, 152, §25A is a criminal violation punishable by a fm up to$1,500.00
anal/or one-year'imprisonment,as well as civil penalties in the form,of a STOP'WORD ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be Jbrwarded to the Office of investigations of the DIA for insurance
coverage'verifioatioxx.
X rlo hereby cerci u er tlaepains andpen rues ofperjury that the information provided above is true and correct
i mature:
Date:
Official use only. _0o not-write in this area,to be completer)by city or town official
City or Town: I'erxnuit/x icense#� _
1'8suing Authority(circle one): i
1..Board of Ifealth 2.BuildingDepartment I City/Town Clerk d.EXectrical inspector 5.Plumbing inspector
Cr.Other
I'Ixono
---
Contact£`erson:__ :.�_
UL "
0' s'
I
Board Of k I il�nI Of PublicSUild'irIg Regulation, dlety (W,
and StandardsI'L-', Office bf ConsumerAffairs&Business Regulation
License: CS-'109119 . HOME IMPROVEMENT CONTRACTOR
Construction Supervi.$orRegistration: '185227 Type:
Expiration,�-5421-2018 LLC
PATRICK RUSSELL
80 SAILE WAY SAINT CHRISTOPHER PR0PERTII,8`,LLC
NORTH ANDOVER MA
31845
PATRICK RUSSELL
231 BROADWAY
METHUEN,MA 01844
Undersecretary
Cornmjssjoj)�,
001UZ/2019