HomeMy WebLinkAboutBuilding Permit # 9/27/2016 XAORTF{
BUILDING PERMIT °�<�4D �tio
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
e
Permit No#• 3 d Date Receive ? �yS-OAT,.��15
Date Issued!
IMPORTANT: Applicant mist complete all items on this page
LOCATIOhI
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P in
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PROPERTY OWNER
,� Print � KDE]`YEarStructure yes no
MAP�_PARGE� �� � :ZONING DISTRICT H�star�c Dxstr��t yes �n
Machrne Shop Vallage,,,,yes ... .;;no,
TYPE OF IMPROVEMENT PROPOSED USE
Resi ntial Non- Residential
❑ New Building One family
F1 Addition Li Two or more family 11 Industrial
❑AI ration No. of units: ❑ Commercial
epair, ,replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
5e tic Q Well ❑
co 01 ❑Wetlands ❑ Watershed District
P
t7 WaterlSewer,;- \'
DESCRI TION OF WO BE P RFRMEE
4 Identification- Please Type or ,int Clearly
OWNER: Name: Phone: /
Address:
Contractor Narn Phone
Ema !
Address
5u erutsor's Construction License Exp Date
R
Home lrnpro�ement License . Exp Date
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:SULDING PERMIT:$12.00 PER$900 f.Q0 OF TFIE TOTAL ESTIMA D COST D ON$925.00 PER S.F.
Total Project Cost: $ c rJ FEE.
Check No.: I Y Receipt No.: D� V
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature;of Ageh-UOwner S;gna ure of contractor;
FORTH '9
Town of
ndover
No. 74
no h ver, Mass, 7 ! G�
CO[M[CNL'wKK y1-
S U
BOARD OF HEALTH
Food/Kitchen
PER [[ Septic System
LD
THIS CERTIFIES THAT ........ ..kIT
�.�. ......x. BUILDING INSPECTOR
has permission to erect .......................... buildings o ... .,..I ................
�...... .S� Foundation
....... . ... .
Rough
to be occupied asXA ... 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
Fina]
PERMIT EXPIRES 16 NINTHS ELECTRICAL INSPECTOR-
UNLESS C®NSTRUCTI ART Rough
'Service
.............
............ .. .... .... .... .. .. ...... . ,..
BUILDING INSPECTOR.. Final
GAS INSPECTOR
Occupancy Permit Reguired to ®ccupv 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.
�Me Commonwealth of Massachusetts
Department of IndustrialAccidents
r 1 Congress Street,,Suite 100
a02114-201 7
Boston,MA
q�r www.rnass.govldia
* yes
' VVaVkers'Compensation Insurance.Affidavit:Builders/Contractors/y,ilectriciaxns/Pluna. ers.
TO BE-FILEDWITHTM�PERNIIfNGAUTl012ITtY. -Please Print Le 'bl
A scant informatiton. 117
NaMe(Business/Otganizafon/lndi�tidual):
Ad(hess:
/1Gtd oe'pz' �, Phalae del ,
City/state/Zip: -'pro
Type of project-Oreg fired);
An you an errrpIor7 Checict7ie appropriate box-
Ye 7. r(N�i,�'coinsti-notion
1.[]I am a employer wither
employees(full and/or part th-ae). { E
2.❑I am a sole proprietor or partn.ersbip and have no employees r�lofor me in I irig $, Reroodeliii�;
any paeity.[Nowarkers'comp.insursnee required.] g, 1)eraolition
3 homeowner doing a31 wor�nysel£[Na workers'camp,insurance required.]; 10❑Building addition
4.0 lam a homeowner and wiU be hiring contractors to conduct all work on my propezty. X will 11-F]Bye,all xep g or additigns
enuwathat all contractors either have workers'compensation insurance or are sole 12,Frepairs or additions
proprietors with no ernpl()ye6s.
s�X am a general contractor and J:gave hired the sub-canfractors listed on the atsheet, •
13. 06 repairs
These sub-conhactors have e6n ioyees andhaveworkers'comp.insurance t 14. Offer
6,0 We are a corporation and its,officers have exercised ttreiz right of exemption per MGI c.
152,Te a G,rP0J /lave no empldyees.[To workers'comp.insurance required.]
atiom
"Any applicant that checks bbir#1 iriust slso fill au�e are doing the.section tlia section all work andtben hire outside ccontrac o s must submit new aw showing their Welk' fffdavit indicating such
I Homeowners who submit•this afdavit indicating y
tcont{actors that cbeckthis a i must attached kn athey must shect showing
vide heir worthekers'00-Pe of the,Policy number.and state whether ar notthose eutittes have
employees. Hthe sub-conk
Z am an emptoyer'treat is pr'ovidingwo-r1fers'ca�npensation insurance for MY employees. L'erory is the policy andJob site
information.
Insurance Company Name,
Expiration Date-
Policy#or Sem errs.Li:C.#:.
1/t' City/StatelZip:
lob Site Address: dor and eXpiration the
Attach a copy of the vvorke�rs' compensati'.oxn politcy declaration page(s� �onp by a fine up to$1,500.00)•
Failure to SOCUre coverage as required sunder MGL e.152,§25A is a crimin punishable
penalties in the,foTra of a STOP WORK
ER and a fine of UP to $2
and/or one-year imprisonment,as
we as went may
b forwarded to the Offi a Offnveesgatlons of% DIA i'or ins Ian D a
day against the violator.A COPY Of this stat y
covexage venff.cation.
under'tlaepahns andpenalties/ erjury that the informationpro vid'edabovo isis tr eapdconect
Z do rzer eliy Certs .
Si atare: r
Phone#:
Official use orzly. .Do not wl ite in this area,to be completed by city or town official.
• Per�mitlLicense#
City or Town:
Issuing AtrthoOty(civele one)'
tor
rtment 3.City/TowA Clerk d.Electrical inspector 5.Ply„mbinglnspec
].Boaxd of�[ealtb ?-Building Bepa
b.Other
Phone 0:
Contact Person'
I
00RTfj TOWN OF NORTH ANDOVER
OFFICE OF
0 0
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
S C14US
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER 1,10ENSE EXEMPTION
BUIDING PERMIT APPLICATION
I'lease print
DATE: 7
JOB LOCATION: ,_� .. ....
Number Street Address Map/Lot
HOMEOWNER 2w, 5' AWle e, Yl- ,:i6-3 -7
Nate Home Phone Work Phone
PRESENT MAILING ADDRESS --------------
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 gcts 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 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 SIGNATU
APPROVAL OF BUILDING OFFICIAL___.,....................
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535