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Home My WebLink AboutBuilding Permit # 9/22/2016 i I poRTH Q tYy,Ro 76 BUILDING PERMIT .. ... °L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * e„ Permit NO: �y�-,��/ � Date Received 9 • �� * �. a�,F:� . ,. � AO *V C Date Issued: ��SSRHU— EMPORTANT:A2plicant must com lete all items on this page 3 , LOCATION cam.` f ., lPinr PROPERTY OWNER: �✓ i{ cam- =; ru P.int MAP NO. PARCEL ZONING DISTRICT Hlstarc District yes no Machine Shpp Village ares no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial VfRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑,Septic ❑Well ❑ Mi.dplaii} ❑;ilVetlands ❑ .V#latetshed�istnat EJWaterlSewer ,S � C 4W— A, c�� rem ' cL.t °F ��v t�� (� 1� ��feteu�.�uF re J. L Tdentificatio Please Type or Print Clearly) f /`1 OWNER: Name: ft/"i � �,.� (�-�. c• Phone: 1^0 zC-7 Address: C0NTRACTOR Name Phone: � Address Supen/isor's Construction License Exp pate Home Improvement License Exp mate: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEESCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED, aoCCOSSTBASED ON$925.00 PER S.F. a� Tota! Project Cost: $ �CO. 00d FEE: $ `"!9', Check No.: t#� � Receipt No.: NOTE: Persons contracting with unr iste ed contractors do not have access to the guaranty fund Signature`'of AgentlOwrler ' Signature of contractor %40RTF� own of s bAndover ® - 0 ........... `, LAMS h ver, Mass, a.� � � • 0 Coc"K'Z... V.1' Q A0 ATED 9S U BOARD OF HEALTH Food/Kitchen PERMIT , T LD Septic System THIS CERTIFIES THAT ................:....tN.. �.f M ........G. .L�r M/V. ............................... BUILDING INSPECTOR 1 s �F + S ... Foundation has permission to erect .......................... buildings o .... / . ........... ............... �/ r. N ! Rough t0be OCCUpled a5 ...!��.�......................9�t ............................+�.�....,.......,.....................,......,......... 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 XI ES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS 10 Rougl, Service .,......... Final ffullv INJECTOR GAS INSPECTOR OccupancV Permit Required to Occupy Building 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. ., Elie Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Sheet,Suite 100 2017 Boston,.2VIA 02114 N ; oar www.mass.gov/dia Wgrkerso Compensation Tusuran.c6 Affidavit:Buildex�ICont�ractoxsli♦�ectriciansl�iuxn exs. TD SE i+3L E33 Wi[TH THE PEHM[T 1'xN�ATJTI�[�HT�Y. Please Print Le •bl A licant Tnformation N T70(Business/O�rganizationftdividual): c.� Ad(ftess: Phone#: 1471 ZC1 City/state/Zip: u :, �.... -. Are you an empXoyer?C&e*tiie aper aprlate box: Type of project(required); 7• Q N&i'constr6tion rparttime).loyes Rill and/0 l.❑Iamaemployerer 20 I a�n asale proprietor or partnership and have no employees Working for mein 8. El Remodeling any capacity.[Nnwarkers'comp.insurance required.] 9, ❑Demolition 3, I a<n a homeowner doing a14 work myself.[No workers' romp-insurance required.]t 1 ❑BjjdlTtg addition 4 i am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical Tepa7Ss or additions ensure that all contractors either have workers'compensation insurance or are sole T'�umb repairs or additions proprietors with no employees. contractor and Ihave hvredtho sub-contraetors listed on the attached sheet. 5 E]I am a general 13%E]Roof repairs These sub-coniractozs have employees and have workers'comp.insurance" 14.0 Oti er 6.Q We are acozporatiort and its,officers have exercised their right of exemption per MGL c. 3 152,§1{4),and eve have no employees.[No workers'comp.insurance required.] Any applicant that checks box#1 must also fill out the sectionbelow showing their workers'compervsationpnlicy info7mation: icating davit t all m Homeowners who MIrs mu affrdavlt indicating bbY are doingshowing theamrork and e e of tl en hire nsub conkractotside os and state vst mhethert a eoz gOthoseent ties have such. tcontractors that cheek this b6i must attached an additionalnumber. • .. a employees. Ifthe sub-co_ €Tactors have employees,they must provide their workers'comp.p olio y orker's,compensation insurance fol•my ernplbyees. ,below is thepolicy and)oh site lam an employer'tlrat is providing-w information. Xnsurauee Company Name: ExpirationDOO' Policy 0 or Self--ins.Lic.#: City/State/Zip: Job Site Address: the olie number and expiration date). Attach a copy of the wo>rl�ers' compensation policy declaration page(showing p Y j Failure to secure 0-00 coverage as requited undercivil enaltieszxnite form of a S 101'xD ORDER and a ane of up to $2U16 UP to 00.00 a and/or one imprisonment,as well as p day against the violator.A copy of this statement may be forwarded to tlio Office of Tnvestigations of the DJA for insurance coverage verification_ I da lzer eby certi unri th pains pe ties of penury that t12e information provided above is 1I arid,correct Date: Si ature: 2-0 Phone#: Official use only. 73o izotwr•ite in this area,to he completed by city or town of�ciai Permit/License# City or Town. issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTOwn Clerlr 4.Electrical Inspector a.Plumbing Tnspector 6.Other Phone#: Contact Person. t%ORTH TOWN OF NOIU'H ANDOVER 0.4 *. ,.. ,0 OFFICE OF 0 0 BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01845 CHUS Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE;EXEMPTION BUIDING PERMIT APPLICATION 1"jeLise�nt DATE: z JOB LOCATION: Number Street Address Map/Lot HOMEOWNER-A�'/ 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 that the owner acts-As supervisor. DEFINITION OF 140MEOWNER Person(s)who owns a parcel of land on which lie/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 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 Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE 4 APPROVAL OF BUILDING OFFICIAL____ Revised 8.2015 Form I-lomeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEAL'I'll 688-9540 PLANNING 688-9535 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application Li Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses El Copy Of Contract Q Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a ❑ Mass check Energy Compliance Report (if Applicable) El Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li Building Permit Application U Certified Proposed Plot Plan '? w Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Pian And Hydraulic Calculations (If Applicable) ❑ Copy of Contract v Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:INSPECTIONAL SERVICES DEPARTMENT-BPFORM07 Revised 2.2007 i Dimension V Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL. Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1004100Q fine NOTES and DATA — (For department use) ❑ Notified for pickup - Date E Doc.Building Permit Revised 2012