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HomeMy WebLinkAboutBuilding Permit # 9/28/2016 � poRYy a BUILDING PERMIT o (-%AD �o TOWN OF NORTH ANDOVER tidy ' *6 APPLICATION FOR PLAN EXAMINATION * �~ Date Received Permit No#• 4SSac►+u��c Date Issued: �IPORTANT: Applicant must complete all items on this page f ry�'`,/ansa ?..r s c., � w ,� / i .s✓...>:...� r,�, ;^����� .,"���e,.r ,�.G/..�!r,F -, � ` ! r ,:. - 'c .'' 1 ,�- f. _' < � n! � P r� .� .lam :✓ t .�/ , �.;, r�{��PEPSTY�WI'��� �w _ � ^� ✓.,� �'u^- a`=�cr '�� r `i�` i r 3 � MAP P.AROEL ZONING DISTRICT `Hi��or��©isfriet��� f� � �Y r�o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family F1 Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q Septic ❑1Ne11 ❑ Floodplain ds at rsd ID ct 111fetlan ❑ VIJ e lied asin ❑,VllaterlSewer.. . . ... � , y SCRI . DE PTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: ' Phone., Address: GOTltrAbtOr Name PhOnf; Ernaal .: r .Addr2S5 :"✓. c rc r Sop�nt�s�r's�Constru�ct�on License 4 i I' o17)e`YtT1p . ... 71ent License .. F.. ;Exp Date�� 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: $_3 FEE: $ � Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 9 Jana I nature of Age Owner ture a contractor'. ttORTI Town :� ndover o No. SM,,;6q yyah ver, Mass LAKE .` 3 COC 41C NE WI[N ..r ADj4A.r D S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect�. .. . . . .. buildings on4A.141. .I4T.........6.�i'....... Foundation . Rough tobe occupied as ........ 4 ....... ... ..G. .,.,.............,.......,.............,............................, Chimney provided that the person acce tin 'this permit shall in eve respect conform to the terms of the application p p g p every p Pp f=inal 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 EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS CONST CTION Rough Service .. .... ..,. Final ILDING IN EC R GAS INSPECTOR Occupancy Permit Required to Occupy Puiddin,; 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. t%ORT#q TOWN OF NORTH ANDOVER 1"1. e" ° OFFICE OF 0 BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 AY North Andover, Massachusetts 01.845 � SACMUS Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION:- 7,,;( %i r'l ------ Number Street Address Map/Lot HOMEOWNER Name Home PlAlev;(Kp ione Work Phone e- PRESENT MAILING ADDRESS A-10 A) I�el-d p C --------- City'l,own 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 assup iso . j- _ --- 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 110.85.1.2) 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. 14OMEOWNERS SIGNATURE_... APPROVAL OF BUILDING OFF1 Revised 8.2015 Form Homeowners Exemption BOARD 017APPEALS 688-954t CONSERVATiON 688-9530 HEALT1.1 688-9540 PLANNING 688-9535 The Commonwealth of.Massachusetts _ Departinefxt of ludustrialA.celdents Congress Street, Smite 100 ' - d .114-2017 Boston,Boston,�- 02 www.m ass govfdla 5y* ' �L7arkexs'comp ens.atiou.xusurauceA£�idavit:$uiilclerr/Cont�actoxslEleciar;iciansf�'X�m. err. TO BE 1�1�A WITH THE]PERM�'TT NG AUTIdQ�TX• Dlease Print Legibly ApixcantInformationt r Name[Business/0>gariizatian/Iudividnal): Address:iA one citylstate/zip: J' L'. � � Ph ..,:.xs r: Type of project(Tecluired)' • Are you an employer?Check the appx'opriafe box: 1,❑T am a employer with emgloyees(full andlor part Bute). 7, ❑N� i'donstriictiort es Working for rae in $. Remodeling 2,L x ant a sole proprietor orpartnusbip and have no ernplaye any capacity.[0,W,d ers comp.in urance required.l q. Demolition 3�)am a homeowner doing all wozkrayself.[Ne workers'comp.istsurancerequired.]t 10❑Building addition k.�I am ahom.eowner and will be hiring cantracctors to conduct all work an my property- Twill 11.❑Electrical xepatxs or additions ensmo that all contractors either have workers'compensation insurance or ate sale 12 OPIUM repairs or additions proprietors with no employees. 5•❑T am a general contractor and IpAve hiredthe sub contractors 3isted on the attached sheet. 13•.MRaofrel airs These sub-contractors have epaployaes andhave Workers'Acarid.insrtrance t 14 Other 6.❑We are a corporation and its.officers have exereisedtheir Tight of bxemption per MOL c. 152,§1(4),andvve Have no employees.[No workers"comp.ins--co required.] poRcy *Any applicant that eheoks bbic�#i day t indicating t1a Y are doing sll wr k andthen hire oufside cwing thpirwork4-,Ts' monfrac opsmust subxni�ew.affidavit indicating such i Homeowners who sultmit this afii . Contractors that checkthis box must attached.an additional sheat showing the name of the sob-contractors and stat�vrhether or pot fltosa,,entittes ave employees. that hecksub- 6n#aotois have employees,they mast provide their workers'comp.policy number. Toyer III at is providing-workers'compensation insaayancefor•my employees. Below is tylepolicy and job site am an ernP I information. Insurance Company Name: • ExpixatiduDate: Policy#or Self ins.Lzc.#:. City/state/Zip: lob Site Address: thePolicynntnatber and exlairatzorx date). Attach a Addy of the workers' compensation policy declaratlion page(showing Failure to secure ce by afirlb up tO$1,5 00-00 overage as required.under MGI.,e. 152,§25A is a criminalzWORK 4RDERolation la�d as���P to $250.00 a p Penalties in the form of a STOP and/or one yeah ianpxisomnent,as well as civil p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covaxage verification. do yzere by cern r2aiel'thePax andpenalties of perjury t7iat the inforrxaation provided above is true and cor'r'ect. Date: Z� Si ature: S'hone Official use only. Do notwritein tlzis areaa,to he completed�y city or town offi Gaal. • PermitlLicex�se# City or Town.: Issuing Authority(eirele one): s p g ectar 9 1.Board of Efealth 2.Building Departmentt 3.City/Town Clem 4.Electrical ins ector 5.Plumbing Imp I 6.other phone#: E Contactrerso ., 1