HomeMy WebLinkAboutBuilding Permit # 8/31/2016 BUILDING PERMIT Notary„ ED
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
"17 Ac"U
Date Issued:
IMPOWFANT: Applicant must complete 411 items on this page
�g
LOCATION /14 e4ke e-,
Print
PROPERTY OWNER R&
Print 100 Year structure yes no
MAP PARCEL- ZONING DISTRICT: —Historic District ye no
, 0
Machine Shop Village yes'yes
n
TYPE OF IMPROVEMENT PROPOSED USE
,Residential Non- Residential
0 New Building ”7,T,,0_ne family
F1,A AI 0 Industrial
Addition E Two or more family
No, of units: L Commercial
[I Repair, replacement D Assessory Bldg Li Others:
[I Demolition [I Other
.. ...... D Flood lain ,11 Wetlands
N
10
g/P
J;
N
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly Phone: -7 81 '7�>
OWNER: Name: -Scivoa:
Address: 20 e�,�,I-
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp, Date:
Horne Improvement License: Exp. Date:
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.
.
Total Project Cost- $ /?z 6 o FEE. $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th eguaranty fund
—4 A _qinnnfitrp r)f r.r)ntrnr.fnr
t%ORT#i '9
Town of 2 � _� B ndover
V "'a M
I
No. a 41
� aAIL
y� C h ver, Mass
"C Q I.AKIE > , %P I (I
COC MIC ME WK:K yh•
lu 400
U
BOARD OF HEALTH
Food/Kitchen
P---ERM T D Septic System
THIS CERTIFIES THAT .............................. BUILDING INSPECTOR
a Foundation
p ....... buildings on
has permission to erect .. �r. ..,,,.. •
Rough
to be occupied as� ftr<.'. fdx ► , irc�• � Chimney
provided that the person accepting this permi shall in every r spect conform the terms ofli ab tion Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the In action, teration and
Construction of Buildings in the Town of North Andover. f� /�f PLUMBING INSPECTOR
VIOLATION of the Zoning or Building.Regulations Voids-this Permit.
Rough
Final
PERMIT EPII+RE I 6 ®NTS ELECTRICAL INSPECTOR
ps
LESS TION S A , Rough
Service
BUILDI INFinal
SPECTOR
GAS INSPECTOR
ccupancy Permit Required t® ®ccupV Buildin 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.
3
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TOWN OF NORTH A DOVER
m� Rim e'er
OFFICE OF
�-
BUILDING DEPARTMENT
- 1.600 Osgood Street,Building 20, Sttite 203 5
North Andover Massachusetts 01845
Gerald A. Brown Telephone(978) 688-9545
Inspector of Buildings• Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUDING PERMIT APPLICATION
Please uriz3t
DATE: �I 2" L
JOB LOCATI.ON: 2 U 1�1 -1. ,-C
`Number Street Address Map/Lot
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
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
u that the owner acts as supervisor.
V
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 stt�etures accessory to such use and/or farm structures.A
person who constructs more than one home hi a two-year period shall not be considered a homeowner. (780 CMA
Section i I O.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 Deparhnent
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
u
si
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 638-9541 CONSERVATION 685-9530 HEALTH 688-9540 PLANNING 699-9535
The Commonwealth o,fHass chusetts
D,,,
agMentoprndastfialAecldents
M _ 1 Corzgresv street, SuUe 100
t Foston,HA 02114-2017
ro� 1WWW.r usy.gov1d1a
4 szs'Cobope sal o sr xa�ceA fic avit:Eufders/CantxactorslE eetric asf'r�mbexs.
TO BE Fff X1)W ITS TSG:PERAUff'N(x AV-C)10'aTy
A iZcant ation
please pr�ot x.,e ' T
Naha(Business/oxganizationfluLdi-dduol): G �--
.�id:C�x'eSs: 2� t��h.� � ✓�' .
Citylstato/zip:
Cil V( 'home#: -7f I - 7GYa r
Areycu an employer? c esk- e ap�xo rr-aie hex: Type of project(x,gclmxed):
.r
1.p I am a employer ith employeos(full andlarparC ti�ve).* 7. NOW coAgiraotion
2.0 I am a sole propriefoz orpartu=, ip and have no employees Vorlring for mein 8. Remorlel3 g
any capaoity.[No markers'aamp.insurance regakcd] g Demolition.
3❑Iamahazueo �zdoangallworl�mysel [Novfczkers'camp.iusursttcersgp;tcd]t loE]$uRc. ingeddWon
4. am.ahomeovmerand Vill b5hidng contractor"fo couduatan Volk on my property. I-WEI I1.�E1ec#€ical repays o�.�ddXtIol�s
ensure that all corr:ra dors either have Svorkers'compensation insurance or are sale
proprietors ihrzaevipiayees. 12. Plumbingxepairs or additions
S.�Iamagenaralco�haafnrandliaYebiredthesub uonizactorslistodeuttreatEachcdslreet. 13: Rooffepairs
These sub-oouizactorsiia�ee�ployees andhavevrnrkers'comp.insurance. 1$.El Othez
$,❑We areaCazpnratinrtand�fsa ershave exorcisedthokrightatexemptionperPllGLc, r
152,§1(4},andweTravena., npinyees.[i`?oworkers'cuznp.insuzancerequi;ed.I
` nY aPPhcaa t that eheclaboxl must elsei outthe section belowsboQvingthe3rvrorkers'cnmpensaiinn
poli-yiu 0zmatinr3
fiSomenwners�rfiosislimif Sais davitindicatingtheyeradoingalWorkandthenhireoutsidecontractorsmustsubmitaneviaf davrlindicaiingsuch
entitiesbave
xCwfractnrs jhatclrecletb�s box musi-a�tached an additional sheetshovring thename of the sub con�ractozs and state tether ez untihasa
employees. If the soh-cuzirarozs Have employees, t%ey muse providetTiarr vYa3efs'aa-p.policy number.
Z ire r r2 employer f1 at zs� o�iarng or er�'car�xpe adon insarance for MY errrployee�:'Below is i`lie�olicy gradjob site
infamadoll.
fngLuan.ce Company 21RM
Poky#or Self gas.lric.r: Expire onDate:
Job Site Address: CatylState/Zip:
Attach a copy a thev ax3 era' coxnper atianpolAcydeeZarationpage(shoe ingthepolicyx� bexand exp
brati(m date).
Eait e to ascots coverage as re
gl&8cl nnderMOL c. 152, §25A is a oziminal violatzoA punishable by a fine up to$1,500.00
enalties in fozm o£a STOP WOMT ORDER and a fine of up to$250.00 a
and/or one.yeaz impxisnn�azent,as well as civil p
day against the vlola-i ox.!�copy o£tb7s statement may forwarded to`iba Office ofvestigatOns of the DLAfar insrxxarce
coverage verlftcation..
I
X do Hereby cerxify u cher tliepains audperaalffes of pe�jzrry tlaici the rnlarnerctionptavider��7iove is true��correct
Date: Jv/Co
9 Si attire:
Phone#: - 7oG r it l
Official rise only. Da not-t T96 in this area,to be completed by city or Coign official`.
Uty or Town• Perxoitll.fcexzse#
Iss gAuthoxity(ezrcle one):
Ci�/Town.Clerk' �'.Electrical Ins)?eetor 5.1'zurubinglnspectox'
.Bnard ai�ealtz�.B�xzlclzngDepartmeiat 3.
6.Other
Coxutact Person- ]?hone#:
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