HomeMy WebLinkAboutBuilding Permit # 10/4/2016 F
BUILDING PERMIT µo�TK
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TOWN OF NORTH ANDOVER o? y� o
APPLICATION FOR PLAN EXAM[NATION
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Permit No#: - 1 !// Date Received
I �Ss�acwus�t
Date Issued: /e
IMPORTANT: Applicant must complete all items on this page
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I`illAl' P�,RCEL ZONING DISTRICT F �stanc4Drstract
f ...:_Machine S17�p U�llageNG yes,�✓.� n0
TYPE OF IMPROVEMENT PROPOSED USE
Reside tial Non- Residential
❑ New Building (�Cine family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well D Floodplain ❑11Vetlartds ❑ `l�lafiersher D�stnct
W Sewer f
DESCRIPTION OF WORK TO BE PERFORMED:
L
_ of
Identification- Please Type or Print Clearly
OWNER: Name: �. M � Phone:
Address: i '
Contractor Name
Phone � '
I�ddress '
f � x Dale �" ��:✓�� �� � ���� . �4
Si�peTVtSOr'S CDnStrLIGtIDn LlGense E p 4.
HDr�ne�Impro��ri��e�it�L�Gense � � /-�_...:� . ... �. . �/_:; �"..Exo date� � � ``'.� ,..."r>?a�✓ �.��
ARCHITECT/ENGINEER 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: $ Ll CPFEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
5zgnature..of A'J VOwner °.s�.I S gnafure of contractor'
.......... .......
OORT# q
Town of _ 6 ndover
No.
�o.4"__ h ver, Mass, to
cocmcri[ K 1. .
S U
BOARD OF HEALTH
Food/Kitchen
PERMI. T T. D Septic System
THIS CERTIFIES THAT ES A.LCYL� BUILDING INSPECTOR
........... ...........I ..... .......... ........................................
... ."
has permission to erect ....................:..... buildings on ....�.�.Q.......Q�.D....... „r�!th!!,,....�, Foundation
w Rough
QQt
tobe occupied as .......... ...... ....................�"$........................................................ 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 C® STRUCTI TA Rough
GService
....... ................ . ............................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy By 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.
The Commonwealth ofHassachuselts
_ Department of Industrial Aceidents
x Street,Sr fm 100
Cngress Sto1"
X ' - - Boston,MI 02114-2017
�•vww.mass.g ��o die
w
' Workers'Cosxtpensation�nsnxantce A£�davit:y�uildexslCantz•actoxs/�Xectriciansl�.'Zwmbers.
TO BE WEED WITS[T1'E PFRMjT"TjNC Art TjIOPT Y. Vease print Le 'bi
A ' licant
Information
tionlrndividual):
Name (Business10 gahiza.
Address: -
Phone 4: y;s. U
City/state/Zip:
..,; Type of�prajeet(�'ecluircd)• .
Are you an enxpXnyc�?Cheek Y Sa appropriate box'
NeVI constrirc'd
1.� loycr with employees 0111 and/or part time).* 1
On
5 g
2.� a sole proprietor or partnership and have no employees/working for me br j F $. Rernodeli#i
Ja capacity (hTnWorkers'comp.insurance required,] 9, ❑Demolition
o vrorkers'comp.insurance required.]+ 10 $uilcling addition
3. -'J am.a homeowner doing all work myself 1N roe x yvi]I
4.El X era a homeowner and will
be hiring contractors to conduct all work on my p p rty l ❑Electrical r8P=a ox'additions
ensure tlia't all contractors eitherhave workers'conapensatton insurance or are solo 12�[j Pbing repairs or additions
proprietors with no employees.
5.1-1 X am a general contractor and have hiredthe sub contractors listed ontbe attached sheet.
l 3. ]Roo xep
These sub-contractors have ainplaYess and have worker-'
comp.insurance., 14[ 'ther
b.QWe are a nnxporatian and its nf£icars have exercised their right oi'exernpticn per MCrI c.
15e §1(4),aVand ive Piave no emplofyees.[No workers'comp,insurance required.
npolio
pnsaf
*pmy applicant that eheeks box 41 must alsai�ll out�y are dainglallwork and thenhire outside aantractoworke �s must subAu't�a-now affidavit irldicatixlg such
I I3omeowners wha submit this affidavit m g
tCont[aoYors that check q is Uoi must attachocl kn additionRsh provide theirtllonworkers,0comp.heub-co number.and staYewlrether a�zrotthose entities have
employees. Ifthe sub canf[actors have etnployccs,they iz
an e�rc to er that isproWdingwotffers'eompensation insurancefor my employees Below is theporky andjo7�site
I am P y
information.
Insurance CoxnpanyNaano:
Expiration We'
-
Policy#or Self-its.Lic.41
City/State/Zip: ..
Job Site Address: the otic number and expivatzou date).
Attach a copy o f the vvolrkers' compexrsation poliey dodaration Page(slxo rvixtg policy
9 e coverage as rerluired under MGI,a.152,§25A is a criminal violation punishable by a fine up to$I,5ba.00
Failure to seaur
awes in tho f0mi
and/or one year inupxisonusent,as-well as civil p t may be forwarded to the 0 WORKv0 of of t o DIA Pax insurance a
day against the violator.A cagy of this statemen y
caverage verification.
ado Iiereliy certify under 17 pains andpenalties ofperjury at the information provided above s true and correct.
Date:
Si afore:
Phone#:
write in this area,to he completed by city or town d-fleial.
pfficicil use only. Do not
PexmxttLYcense#
City or Town-
TssufngA uthoxity(circle one): i
x
.Board of Health
Z.BtrildiagDepartment 3.City1Towrt C1erlr_ 4.Electricallinspector s.Plumbing Inspector
i' 6.Other
i.
Phone#f:
Contact Person.
NORTH TOWN OF NORTH ANDOVER
0 Ol"FICE OF
Z.
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
CH
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: Z)
Number Street Address Map/Lot
3- C7- )
HOMEOWNER
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
6
dity 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 sqPKI:mor.
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 firm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section 110.8.5.1.2)
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
rninimurn inspection procedures and requirements and that he/she will comply with said procedures and
requirements,
HOMEOWNERS SIGNATURE,
APPROVAL OF BUILDIN&OF"FICIAL
Revised 8.2015
F'orni Homeowners Exemption
BOARD OF"APP EALS 688-9541 CONSERVATION 688-9530 1I ALTI1688-9540 PLANNING 688-9535