HomeMy WebLinkAboutBuilding Permit # 9/27/2016 BUILDING PERMIT a�
T OWN OF NORTH ANDOVER
t PPI_ICATION FOR PLAN EXAMINATION
Pease€t NO: -'= _ t Date Received
Date lssuea: 112 I
0PROPE .. - a
.TY .# "
.MAP Noll
s1O yes fm
TYPE OF IMPROVE-MENT PROPOSED USE
e-'denbal fon-Residential
New Building jbne family
-Addition T)uo or more Farm€p ; Industrial
FIteration No.of units: Com ercia'
Repair,replacement I Assessory Bldg Others:
Demolition Other
Y ialer 1
Identification Please Type cF Print Clearly)
O
t
'RJER: Name: 1 2 a= Phone 'i .tel 6k 'vl
Address:
t 0 . T-ONam_
F
s Exp,'
Impro
vernennt xn� Date,�
RCHITECT/EGINEER
Phone:
Address: Reg-No,
FEE SCHFDULE:BULDING PERMIT.'S12.00,FESS$-000.004F THE TOTAL ESTIMATED COST SASED0B°S1ZY. PERS.F.
Total Project Cost: Q ? FEE.S
Check No ` Receipt No.:
NOTE: Persons contre ting r reg stew ed c nt dears do nota e access n the guar not fund
;F ft t `
Plans Submitted❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ +Ta ining/hgassageBody=Art ❑ Sw��tngPools ❑ I
Well ❑ Tobacco Sales J� Fo.d
Packaging/Sales FjPrivate(sept c tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
�l PLANNI lu r
NG&DEVELOPMENT Reviewed On L ���I Signature_
I
COMMENTS � ��ti/}/It/ly 7 /llfY1" ( CtLr� ec�l ��f S� i�t�sJ
NSERVATION Reviewed on. f� Si nature � "
COMMENTS
u
/HEATH Reviewed on Z �, Si nature
ENTS_ °� 5 }, 1 l
Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water&Sewer Connection/Si nature&Date Driveway Permif
DPW Town Engineer:Signature:
Located 384 Osgood Street
LI--
MENT Temp NTS,
Town of � "°RT" Andover
° 0
No. 3 -ao�1
h " * ver, Masshpdrvn6 a1
�s u
BOARD OF HEALTH
P-ERM TILD
Food/Kitchen
Septic System
THIS CERTIFIES THAT.................... .A Q` BUILDING INSPECTOR
..
Y7 ....�re xt. �r/..A' ................ Foundation
has permission to erect,... .... buildings on.. ..,, .......... .... ........
............. `_ ,' (�
go C Rough
to be occupied as.................. ..ri1`a'S'.........� !�!'!,,,,, O„ 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 16 MONTHS ELECTRICAL INSPECTOR.
UNLESS CONSPO Rough
Service
.. ... :... .......... ...... ...
Final
BUILDING 1 ECT R
GAS INSPECTOR
Occupancy 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.
,vie Commonwealth oflVMassachusetts
Department oondustrial Aceidents
_ X Congress,Street,Suite 100
Roston,11A 02114-2017
www.massgovldia
Workers'CompensationpM;mnoTTTNGA'O.THOIiiTy, cians/Plutnbers.
Please hint Le'bi
A 'licant Information
Natlle(Business/drgat&atioulln'vidua9): `
Address:
City/State/Zip: .
`pyp ptoject(;egmred)
Are You an employer?Cheek the appropriate box: _ -
t(�I
or,aeaud jr rwith employees(full andlor pert-time}.°
7, ew`constr ict€on
2.❑Ta�nasoIa propriatoror parhtetsbiP andhaveno emgiayeas Working formein S. �Remodeliii$
c aci (No workers'camg.insurance required-] 9 emolition
aF �'-
g am ahomeownzr doing alI workmyse]£(Naworkers'cenrp.insorancarequired.]t I Building addition
4.❑Tam ahomeownar andwitlbebiring ses etra to c,,dact ail workonmY property.Iwilt 11,0 Eleet•ric.I rpp�ails or additions
ansmetirat aII eontmctors either have Workers'compensation insuance or are solo 12-,E]Plumbing repairs or additions
proprietors with no employees.
5-❑T a ma general contractor and Ihgve hiredtresub-canftaators Pi i o=.rthe offs-hodsheet.
13.[�Roof repairs
These sub-contractors have employees mdheye w-kere camp.insu[ancet 14JO Other
60aootiand itsoffoorshave exrdedtheirfght
W2erimy .[Noecomp.incof ex-ampctiqo-n'.pdor]
, (4) ndwz have no M(iL c.
[ tm tchzcks box#t ust also fill ardthe szctianbelaw showing theirwarkers'aompensatioapollcy infonnarion:
h.
`Ar[Y Pik can P entities.haVe
tContiaafarsthat checkthisOx.must a}ttaclied'en additional sheat shawingth name o£ethe sub contraaN[os and shatzwhether or�otfhosp'ndicating suc
omplayees.I{tha rub-Contractors have zmployeas,fhey mmtpmvidothair workers'comp.policy number. - - -
X am an employer that isgroviding rkers'compensation insurancefor}ny employees. Palo}v is the oticy andj•ob site
information.
Insurance CompanYName:
Expiration➢a#e:
Policy#or Self-'ins.Lic.#:
, .�' City/State/Zip: .
Sob Site Address:
Attach a copy of the workers'compensation Pettey declaration page{showingthe policy number and expiration date)-
Attach
Failure to secure coverage as required uaderMGL e.152,§25A is a criminal violation punishable by a foie up to$1,500.00
and/or one-year'impxlsonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$350.00 a
e forwarded to the Office of Investigations ofthe DIA for insurance
day against the violator.A copy oftl s statement may
coverage verificatio .
Ido7zez•ebycert deetlzepainsandpenaltiesofgezjuryt&attbeinformaBonprovidedae d'n �dorreca:
Date:
Si ature:
Phone#:
Official use on o not write in tlzis area,to be completed by city or town official.
Permit/License#
City or Town:
Issuing Authority(circle one):
1.Board of Health?.Building Department 3.CitylTowir Clerk 4.Electrical Inspector 5.plumbing Inspector
6.other
Phone#'
Contact Rerson:
TOWN DP NORTH ANDOVER
aFP eo>.�a OFFICE OF
m
BUILDING DEPARTMENT -
1600 Osgood Street,Building 20,Suite 2035
North Andover,Massachusetts 01845
Telephone(978)688-9`545
Gerald A.Brown Fax (978)688-95
Inspector of Buildings, 42
HOMEOA NER LICENSE EXEMPTION
BI;IDDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: b 11 ",f\
NNuu�mbber�_(�—;StreetAddress
�Map/Lot —7 r
Name tt Home Phone (� Nark 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 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 hvo-year period shall not be considered a homeowner.(780 CMR
Section I IO.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"c4thathderstands the Town of North Andover Building Department
minimum inspection procedures that he/s vill comply with said procedures and
requirements.
HO;MEOT§TIERS SIGNATURE
APPROVAL OF BUILDING O
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANI3 r1 IG 683-9535
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