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HomeMy WebLinkAboutBuilding Permit # 11/14/2016 f �dRT}1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION x a � Tp ppermitIVO#: a ©ate Received �RArED SPR (5 �SSf1GFiUs�� Date Issued: 1 IMPORTANT: Applicant must complete all items on this page LOCATIQN "� Pnnt PROPI=RTS' OWNER �f ' d 07�'earStructure yes no MAP pp,RC _ -BONING DISTRICT Ntstaric Dtstnc yes o Macilrne Shop Village yes na TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building wOne family ElAddition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg El Others: ❑ Demolition ❑ Other ❑Septic ❑VITe[l J Floodplain ❑Wetlands ❑ V1latershed I]rstnet [ IVaterlSeviier DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: �� L Contractor Name: Phone. 7� �' 7 Adtlress. � L< Supervisor's Construction License. =r?� 1 Exp. Date: � Home lmpro�ement License: Exp Date ` ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ WL? GCS D FEE: $_ -- Check No.- /0., _ Receipt No.:_:U/­­9__/ NOTF Persons contracting with unregistered contracto do not have access to the guaranty fund '' -''` ig ature of contractor Sig _trace of AgentlOwner - _ ___ _ -._._.. own of "N ndover oy No. oh J �6 h ver, Mass, +� coc.iecOt—C y01'G. ATED S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System r BUILDING INSPECTOR THIS CERTIFIES THAT ............... �1�......... .. ... ......������.......... Foundation has permission to erect .......................... buildings on .. :;� :1 Rough to be occupied as ... .. .. .. �. .�..� ... Chimney provided that the person accepting this permit shall in every respect conform to the terms o the applicationFinal 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 CONST ® Rough Service ..... Final BUILDING INSP OR GAS INSPECTOR Occu ancI Permit Required to Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. jrXORTil TOWN OF NORTH ANDOVER OE 1T4RD Abe'YO OFFICE OF 0 BUILDING DEPARTMENT rx 1600 Osgood Street,Building 20, Suite 2035 4Tffb North Andover,Massachusetts 01845 C US Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: 0 JOB LOCATION: Number Street A6dress Map/Lot HOMEOWNER Name Horne Phone Work Phone PRESENT MAILING ADDRESS f 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,provide 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 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 SIGNATURE APPROVAL OF BUILDING OFFICIAL.(��"_,A Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 F a s a s ` 2 3 E z s— $, � a • i 1, ClIx The Commonwealth of Massachusetts _ z Department of3ndustrialAccidents t X Congress Street, SOS 100 Boston,MA.02114-2017 www.mass.gov/dia M 5y • -WaVleexs' CanzpensationZnsurance Affida"S'xt:$niXderslContx', 'lumbexs. TO BE MED-MTH THg PERMITTING AUT�ORt '- lease Print Legibly A ' lzcant information Name(Business/Oigatiizationllndividual): Address: un/► City/State/Zip: :: K. ,Axe you an amployer?Clteclt the appropxia#e box: Type of project Orequitre(I:); ern to ees full and/or part time).* 7. p 1�evsT`coiastriictton l.[ I am a employer with P Y 2, at a sole proprietor or pa€inership and hate no employees Working forme iu 8. e7rlo deling any capacity.[1Toworkers,comp.insurance required.] g. ❑Demolition 3. I am a homeowmr doing all work MY 10[No workers'comp.insurance required.]` 10❑Building addition Q, ctllorkommyproperty Inill arahom ❑ '�par ,ownidw , Tditlgps ensure that all contractors eitherhave workers'compensation insurance or aro sola 12,a Pig Sep s or additions Proprietors with no eiriployees. 5.F]I am a general contractor and Ihayehiredthe sub-confractors listed on the attached sheet. 11 Roof xeli airs These sub-contractors have employees andhave workers'camp.insurance,$ 14 Other 6.QWe ora a corporation and its.officers have exercised their right of exemption per MGI,G. 152,§l(�),and vta have rro employees.(I`7o workers'camp.insurance required,] *Arry applieaatthat checks bbxI must also fill out the section below showingtheirworkers' compensation policy information,inust ' such i Homeowners who submit#his afiirlavit indicatingthey dhmgshowing the name ofthe sub contractorall-work Pud then hire outside s and state whetht ae oFow pO#hosaenti4et have Gnntractors that check 4&fioxriaust attached an addition al employees. If the snb contractors nava employees,they must proside their workers'comp.policy number. f7lat is pr'ovidingwor`bcews'Compensation irzsurancefor°my erazployees. 1:eloit�is tllepolicy and)ah site rarrz an errrpioyer' information. Insurance CompaayName: ExpirationDate: Policy#or Self-ins.Lic. City/State/zip: lob Site Address: compezisatian policy declaration page(s oVving the policy b number a up o$1,500,00 ) Attach a copy of the-WPTI�eys' Failure to secure coverage as requited under MGL e. 152,§25A is a criminal-violation putt Y and/or one ixnprisannrent,as well as civil penalties in the form of a e Obi ions of the D7A for irasuran 0 a day against the violator.A copy of this statement may be farvraxded to th coverage-verification. ado hereby certify under tlzepairzs andpenalties ofperjury that the information provided above is true and.correct. Si ature�- Phone#: official use orery. Do not write in this area,to he completed by city or tOwn offIcial Permit/License# City or ToNm: issuing A.uthoYlty(circle ane): 1.)Board of Health 2.Building Department 3.CitylTown Clerk d•.Electrical inspector 5.PlumbingNspector b.Other Phone 0: Contact Person: