HomeMy WebLinkAboutBuilding Permit # 9/28/2016 t%ORTH
BUILDING PERMIT °,
? y ,'. ". a O
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION n
*
y .w
PQICIII IVO#' ( I Date Received �Q�RAlm APa` t`�
�S�AC HH`-'��
Date Issued:
IMPORTANT Applicant must complete all items on this page
..:: �,. ,f., ..r/ . ✓ h „r / ;,.;, F �;. .r ���Ac,,.- ✓•, `���'rr:,����,�.�'-� .:'„ .s.. .v/r,.Jr^,r�'Y.�s4,, c°'.
%yam T�/r �� '� F.w:`n .,' , T . c/ ,r',. .✓'r,^ � J`."' C �'s„ ^4'� `` °,r 'rr. ���✓��r a' -r:,a,:
„N ,. r ,c ..- z ✓
LC3CATrIOI � 2
� � s,✓ r � w ✓. �c " �flli� �*i�`` *�iL" �� �, ,r'��` .r� '"L°�'� c rs'� ��. 'N- f �x
y
r � E1FL]Gtlf r /
� � I' ti'
4MAP � P ,RCEL fy ZONING D15TRICHrsor
IVicla�rze Shop 1(�Ilage yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑ Iteration No. of units: ❑ Commercial
Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ ❑Well O Floodplain ❑1Netlands ❑ 1Natershetl D�str�cl
Septjc
❑1�1ta�erl5�wer , � r �l � ..�.. , ,
DESCRlPT10N F WORK T
e IO BE PERF
• �'�,�,` ct�+! � �� 2®C� arm � '� "t["
e 9 c ! Gl
Identification- Please Type or Print Clearly
Phone: 9
OWNER: Name: bo Ar r� G�/�e , c'
dez
r
Address
f ✓
�Dn�raCi101`NaJ11P
Phone ,,
✓
Superu�sor�.sf Cans#ruction License w Exp 7 Jia#e"' `� �{
G
Home lfmrouemenfi License. `...
ARCH ITECTIENGINEER 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: $ goo �' FEE: $ / C)
,T
Check No.: 19-7 Receipt No.: '1
NOTE: Persons contracting with unregistere ontractors do not have access to the guaranty fund
Signature:ofi Agent/Owner
Signature of contractor;_
NORTfy q
Town o _ .If. b ndover
0e
No. ?P _ 1
i„KE h ver, Mass,
4
COCKICNIW.CK 1'
RATED
U BOARD OF HEALTH
Food/Kitchen
PERMIT . T D Septic System
THIS CERTIFIES THAT ........ .�. .... . ........AN. -tte Y I _W, BUILDING INSPECTOR
has permission to erect.......................... buildings on ........... Foundation
..... ... . . .. .
O � � � Rough
t0 be occupied a5 .................... ....,... ...................,........ ... ..,......,..........,. ...,.....,............. 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCT" §T Rough
,...... .. ..� .. .............. Service
...............................
BUILDING INSPECTOR Final
GAS INSPECTOR
ccupah y Permit Required t® 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.
OORTH TOWN OF NORTH ANDOVER
OFFICE OF
13UILDING DEPARTMENT
s
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01815
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Etkaseurmt
DATE:
jv—
JOB LOCATION: 1Z C14 ,,o/V j
Number Street Address Map/Lot
HOMEOWNER Act qA'a A,) Aeve& e- l/.,'1/
Wame 14oinehone Work Phone
PRESENT`MAILING ADDRESS— Uk/`0/v -P
1�f
CityTown 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
-41-S-SuRCLY-1—So r
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 I I OX5.1.2)
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 fie/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that fie/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemptim
BOARD OFAPITALS 688-9541 C.ONSF'RVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
.Department o f fndastriall9ccidents
Co axg�'ess,S`t eet,,S'tiite 100
e ;` Boston, MA 02114-2017
=~ www.m ass.go-v1dia
Workers, Compensation Usurance Affidavit:Builders/00 A�J7CH0��tricianslPluxnbexs.
z O BE PII EI3 W1xH THE PERM71 l Blease Print Le •M
Alucent Tn£orznati onsN
' cx�EL N
Name (.Business[Oigaavzatiovllndividuat):
Address: Gear r`d)N
Cit=y/State/Zip:
Type of�project()required);
Are you an erEzzployez'?Check the appz•aprlate box:
7, Q N6W'donstruction
1.�I am a employer with employees(full andtor past-Li Kr.*
2.�I an a sole proprietor or parfnership andhave no employees r�aorkingorzne in 8. Remo dai3tig
any capacity.tNowarkess'comp.iusuranoe required. 9. n Demolition
3•pl am ahoineowner doing allworkmyself4.PTO workers'comp.inauraucerequired.]t 10❑Building addition
to conduct all work onmY Prop 11•[ll Elecixical rppai?s oradditiops
4.E]I am ahomeovuner and v M be hiring contractors e X W'
ensure that all contractois either have vvorkete compensation insurance or ate sole Pliant g repairs or additions
proprictars with no employees. attached sheet. LJ
5.�I am a general contractor and J:]cavo hired the sub-contactors listed ou the
13.[ R'o6f rep airs
`These sub-contractors have employees andhave workers'camp.insurance-* MCI Other
6,❑We are a oorporatioxi and its.officers have exercised their right of'exemption per MGI c-
152,§1(4),andvve have no employees.[No workers'comp.insurance required]
*Any appiicantthat aheoirs box#1.da st ixtsdicatmg they are doing all work dthenhire outside cm ntrac a s must suhmz' new affidavit indicating such
I)-lomeowners who submit•tbis affi -vc,of the
Coniracfors that clzeckthis ra tta tois have, yeeadditiong sheet sho-wing the s,d Y t pr Vide their w rk rs'camp sub-contractors
number. d state whether or lZotflzose entitles have
employam. Ifthe sub-contrac
I am an employer tliat is providing lvorlsers'compensation insurance for•My e1nployees. Below is the policy and j obi site
information.
Insurance Company Naxn.e:
Expiration Date:
Policy#or Self-ins.Lic.#:.
CitylState/Zip:
rob Site Address: the olio number and expiration date).
Attach a copy of the woxkers' caxnpensation policy dsclaratiosn a crgimival vso anon punishable by a €xia up to$1,500.00
Failure to secure coverage as required under MGL a. 152,§25A
and/or one-year imprisonment,as well as civ[ t maybe forwarded to the 0�e of a STOP O�ORDEtioenalties in the forin
ns of tb e DIA for 1rrsZurauc0 a
day against the vralator.A copy of this statern n
coverage verification.
p Ido Icer eliy certify u er thepains andp ties of per jury that flee information provided hov true d correct
tl
signature:
Phone#:
Official use only. Da rxot-write in tliis area,to he completed by city or town official
Permit/License#
City or Town:
p xssuiugAutitority(circle one): '
I..Board of Health 2•Building Department 3.City/Town.Clerk 4.Electrical Iraspeetox 5•Plumbing Inspector
6.Other
Phone#:
r Contactrerson.