HomeMy WebLinkAboutBuilding Permit # 10/17/2016 p2,aRT"
BUILDING PERMIT
TOWN OF NORTH ANDOVER a '
APPLICATION FOR PLAN EXAMINATION
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permit No#; _ "�° " Date Received a� J_d �
Ssac Hu ��
Date Issue " IMPORTANT:r -
Applicant must corgi lete all items on this page
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LOCATION -
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PROPERTY OWNER
Print „�; �5 10D'1'ear Str"ucture
MAP PARCEL: ZONING DISTRICT _Nis �ric District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
_ n-NoResidential
Residential Non-
L-1 New Building 'R'One family
F1 Addition F1 Two or more family F1 li�dustrial
11 Alteration No. of units: 11Commercial
0 Repair, replacement ElAssessory Bldg El Others:
Demolition ❑ Other
❑ Septic ❑Well ElFloodplain ❑Wetlands El Watershed District
Water/,Sewer
DESCRIPTION OF WORK TO DE PERFORMED:
CakiteleULUlf-eveirw
__._._.
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name., s Phone.
Email:
Address:
Supervisor's Construction License: Exp. Date:
I--lorne Improvement License: Exp. Date:
ARCH ITECT/ENGINEER_ .- Phone:---
Reg,
hone: _-Reg. No.
FEE SCHEDULE:BULDINC PERMIT:$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$128.00 PER S.F.
Total Project Cost: $ _ _FEE:
Check No.: _. _.. _ Receipt No.:_.
NOTE: arsons contracting with unregistered contractors cin not have access to the guaranty f rcracl
signature of ent/Own�Wr ,. , _ _. LLS_gnature of contractor
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Town of6� over
0 ti - 0
No. 4 -
C, ��K� h ver, Mass,
i9 ()RATED A4 (C)
U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .............. . ............................................................ BUILDING INSPECTOR
0
has permission to erect ....... buildings on .....� .�..+�If.AA. vh C„f,n Foundation
................... ......... ....
Rough
to be occupied as ....k.Acko ov ...,C*1prow .........�r Aice....�f�7 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 IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS C® STRUCTIO A TS'moot Rough
Service
........ ...... .. .................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina,
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Bet.
...........
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All dimensions and size designation: t Tri Design drawings are provided Designed:08.08.1
must be verified on the site to fit jab may✓ for the fatr use by the client or Printed:08.08.16
Client accepts these drawings as is r1t, his agent in completing the
can use them on its own risk. project as listed within this contract
Design:Nicole Bertol-di Final Drawing#: 1 Display settings 3116"=1'
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The Cortnmonwearth q fMassachusetts
Department of Industrzal.Accidents
1 Congregy Street,StMe 100
Raston,Mei 02114.2017
www.rnass.gov/dia
"W.V1rers,Compensation Insurance Affidavit:Bnilders/Contractor's/i Jectx%cians/Perim ex s.
roBE,-FMr,,)D WEERTMI pj,,pjm7C"T:�Q`�iG AU'CT�[a3t7[7C�. 'Please Print Le 'bi
A licant Information
Name(Busineesus/Otgarii1'atiorr/lndividual): - 1
Address:
' one
City/State/ZiP: + _�..
Are you anemplayer?Check.the aper oprlate box:
Type of project(:required):
em to ees full and/or part-time).* 7. j N& Wdinstr6 tion
1.]I am a employer wittn� _ P y
2.tJ I am a sole proprietor or partnership and have no employees Working for mein 8. ®Rerxagcleliii;
any capacity.[tloworkers'eamp.insurance required.] 9. 0 Demglitigxx
3,[j I am a bomeowner doing all work myself.[No workers'comp.insurance required.]t i D E-]Building addition
d.N'farrr ahomeowncr andwill be hiring contractors to conduct all work on my property. twill 11,.[]Electrical iepait.'S q2 additiTis
ensure that all contractors either have workers'compensation insurance or are sole �' repairs or additions
proprietors with no e'niployces. L=k � 1
5.0 1 am a general contractor and 1 have hired the sub-contractors listed onthe attached sheet.
11 Ro6frepairs
These sub-aoutractor'bave ezuployecs and have workers'comp.iarsuranco 14. Other
6.1-1 We are a corporation and its,officers have exercised their right of'exemption per MGL c.
152y§1(4),and we have no employees.[No workers'comp.insurance required.]
AAny appli� Dant that oheak,tzox,til must also fill out the section below showing their waxkers'camper�satian policy infora-now mation.
i iiorneowners who subrms I . att ched'an additional sheet showing he name o the sub-contractors an st to wrs must h�tll r or no tbose�ent taes have
la.
(Contractors that Check th 86k
employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer'treat is pr vvicling�vor Zser^s"compensation insurance fvr°my employees. F3elaw is tlxe_policy and)0h site
information.
Insurance Corxzpany
ExpirationDate: —
Policy if or Self ins.Lic.#:_
_
City/State/Lip:,_ -—
lob Site
compensation policy declaration page(showing the policy number and expiratio-n dat
Attach a copy of the woxlxexs" e).
5DO.OD
Failure to secure coverage as required
as civinder l penalties in the for"-'of STOP WOtRK ORDER andon punishable a fine o#u p too $250.00 a
and/or one_yeaX imprisonment,as yr p
day against the violator.A copy of'this statement may be forwariied to the Office of Investigations of the DCA for Insurance
cgvexage vexifrcation. _
X da Icer eery cez trfy under txe ain
ls and penalt p 1jur ya that the information provided above is true and cor'r'ect�
write in this area,to be completer)by city or town official,
Of
fzcial use only. Do rxat
Permit/License
City or Town: _ -- -- — —
Issuing Authority(circle one);
1.Board of Health 2.Building 17epartxnexxt 3.CityPi'o�wn Clerk 4.L;lectxical7xxspector 5.Plumbing Inspector
6.Other
Phone
Cor tact
t%0RTjj TOWN OF NORTH ANDOVER
"10 "s -
0"10 , '."d OFFICE OF
0
to BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
CHUS
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Plewse print
DATA?:
JOB LOCATION:
ftjd 't2k
Number Street Address Map/Lot
HOMEOWNEf�h�21 0 13 s�'
44
Narne Home Phone Work Phone
PRESENT MAILING ADDRESS 91 ALano( C161_11e - -------------
Ahyu A71do&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-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 OR5.1.2)
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 SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 11 FALTI 168 8-9540 PLANNING 688-9535