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Home My WebLink AboutBuilding Permit # 10/11/2016 �o RT!-j BUILDING PERMIT �faS�E�.=6+4�'� O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Permit No#.- 0 -7 c Date Received �S$ACFilJS�4 Date Issued: r cr r I r IMPORTANT Applicant must complete all items on this page PROPERTY OWNER P1!]f NUe 7�0 YearSfruGfure )75 i< f1O MAP _PARCELZONING'DI T ,, T �� Historic Distr�ct ' yes nog %� Machine Shap Utllage Y,�s no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition D Two or more family ❑ Industrial ❑Alteration No. of units: --?- ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Se tptc ❑Well ❑ Floadp[ain ❑Wetlands ❑ Watershed T]�strict ❑1NaterlSewer, K i DESCRIPTION OF WORK TO BE PERFORMED: LZ Identification- Please Type or Print Clearly OWNER: Name: n e -T C r -te' 4 Phone-. ..81V2. 7'7`7 -7 Address: � � ,a c A �k Contractor Name: Phone hmail Atltlress Superusor's Construction License Ex Date ,..: - Home Improvement License Exp :Date ARCH ITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINC PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ ,30 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 5igrature of AgentlOwner Signature of contractor, ... .. ... .. ... ..... . Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOVI PublicSewer TazanIassageBody Art ❑ Swimming pools ❑ well ❑ Tobacco Sales ❑ Food packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on.Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U' FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on [b I l 1 Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ,7 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/sl nature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Tem Located at 124,Main Street Frro De awk rtment srgnat, 4d: at ;* COMMENTS itORTH ' own of Andover No. Shl.- abll o «. h ver, Mass, / p/ cnc«ic«ew�ca 1' P S U BOARD OF HEALTH PERMIT- T LD Food/Kitchen Septic System THIS CERTIFIES THAT ................: ; N! .........C l.�4,..,,, . ..,. . .... .. BUILDING INSPECTOR has permission to erect � a Foundation .......................... buildings on ..........�. ......., ............ .... .. ...,..... .. ...,.......... Rough 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 LESS C TRCTI N STA TS Rough ..... .. .� .. .. Service BUILDING INSPE•�.�� Final GASINSPECTOR 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, t%ORTN �ti TOWN OF NORTH ANDOVER OFFICE OF 0Z. BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 SS US Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: -nd- Wrf, 61 ��l Number Street Address Map/Lot HOMEOWNER (5,37 62 If Name Home Phone Work Phone PRESENT MAILING ADDRESS iS C� ............. _ () I K 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-farnily 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 require5d that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE Aj APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 If EAIA'I 1688-9540 PLANNING 688-9535 jhe Commonwealth of Massachusetts Department of IndustrialAecidents h _ Y Y Cong-cess Street,Suite 100 02x.14-2017 Boston,.Mfj www mass.gov/dia Woilrers' CO)napensationlnsurancd Affidavit:Builders/CoxrtxactorslEleetriciansl�lumbers. TO BE FILED WfTFI TM'"RMYTTh' (3 ACJTSOR X, '•Blease Print Le •bl AP WLcantxuformatiorx Nalxie (Business/Orgaraizationllndividual): Address: �1 °f ' 42 - 11 ` - 9`-i 3 _7 Phone#: City/State/Zip: _— Type �.. . .. � f project(fecluix'ed); . Are you an employer?Check the approprlate box: em to ees full and/or part time)." 1. ❑N&W'dhast4dtiOn 1. I am a employer with p y 2Qlain a solo proprietor or partnership and have no employees Working forme in 8. Bern odelirag an opacity.[No Workers'comp.insurance required.] 9• �Demolition. [N am'homeowner doing all workmyselt o workers'comp.insurance required.]t 10❑Building addition 3• ei.❑lam ahameowner andwill be hiring contractors to conduct all work on my property. Iwill 11❑Electrlcal repairs or additions ensaretlnat all contractors either have workers'compensation insurance or are sole bin re airs or additions proprietors with no enapIoye6s. >L !p g S.[]I am a general contractor and I3nave hiredthesub-contractors listed on the attached sheet. IIE]Roofreliairs These sub-contractors have employees and have workers'comp.insurancB$ 14'• Other 6.❑We are a corporation and ids,off,06rs nave exercised their right of exemption per MGL c. 152,§1(4 ),and We have no e mutpldy4s. NO workers'comp.insurance required.] icy *Any applicant that checksV00I Dius t indicating ttrey are d mgout the section lall work and than hire ou ide ow showing their workers' oonfractons mulst submiagnew affidavit indicating such Iicmeowners who submit this tContractors that cheek this Uox.must attached an additional sheet showing the name of the sub r.and state whether oirot those entities ave employees. I that sub contractors have employees,they must provide their workers'comp.policy rrumber. lam an employer•that isprovidingwor/iers'compensation insurancefor my employees. 8elary is tFieporicy arzdrob site information. insurance Company Nae ExpirationDOm Policy#or Self-ins.Lic.#: City/State/Zip: fob Site Address: (showing the number and ercpiration date). Attach a copy Of the W"kers' comp e�nsation policy declaration Page( g p one�' Failure to sectrr D coverage as required to$1500 under .00 MGL c.152,§25A is a criminalviolationo RK Rl and ame ib of up to $250.00 a and/or one-year irnps'Isanment,as well as civil penalties in the foxrrr of a ST day against -he violator.A cagy of this statement may be forwarded to the Office of Xnvestigations of the DTA for insurance coverage -verification. I do lzere/%y certify a aepains andpenalties ofperjury that the information p.ovided above is true ar?d correct. d Phone#: Official use only. ot-rvrite i t/ais area,to be completed/iy city ar town official. permit/License# City or Town- issuing Autthoiity(circle erne): 7.Board.of Health 2.Building pepax•tmMerrt 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact•P erson: 3 o t