HomeMy WebLinkAboutBuilding Permit # 10/31/2016 tkO R T11
BUILDING PERMIT a4 ,6 '�0
TOWN OF NORTH ANDOVER � ' ''�'•
APPLICATION FOR PLAN EXAMINATION -
Pd ��� �/
DateReceived " Zt �a�C
permit No#:
Date Issued:_--
- impoluA,I' T: Applicant must complete all items on this page
LOCATION'
PROPERTY OWNER '
,r
�oD°Ye6rsf�ucture ' +es /, no
Print
MAP PARCEL: ZONING DISTRICT:�.: Nistoric District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE _ _ --
--
Residential Non- Residential
C:] New Building ❑ One family
C]Addition ❑ Two or more family [J Industrial
[I Alteration NO. of units: � ❑ Commercial _
C] Repair, replacement.. �E)Assessory Bldg ❑ Others:
Cl Demolition ❑ Other
F] Septic []Well El Floodplain [I Wetlands ❑ Watershed District
❑Water/Sewer -
K TO PERF
_ "
DESCRIPTION C)F '�I`�7R � ME®
�rlentr�'c�ti h'Icasc":t`ype oart�'a�trxt Clearly
OWNER: Flame: t r Phone:
Address: ----
Contractor Name, Phone:
Email:
Address:
,Supervisor's Construction License: Exp Date:
Home ImpravementLicense Ecp, Bate
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: $ FEE: $
Check No.: Receipt No.:
NOTE: pervons contracting riga unr° red contractors do not have access to the guaraanty f rind
,Signature of Agent/(Owner Signature of contractor
............... " ................................................... ............................. ............... .
T
t4ORT#1
own of E Andover
No. - _ - h -
C' LAKE h ver, Mass,
cocci "ZWICK
c)4A'rEg)
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ..........>. fl.b. ...... .......................I......... BUILDING INSPECTOR
has permission to erect .......................... buildings on ..s.....0"... .#1...... r....... Foundation
Rough
......................... ............ Chimney
to be occupied as ......... ....C.90.
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 PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI A Rough
CTI
Service
W40
............. .......I",............ .. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildin 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 of Massachusetts
Department of IndusirialAecidents
r X Cong-ress Street, SO .700
' Foston,MA-02,114-2,017
tl
www.mass.gav/dia
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friXders)C +Zectzciaxsl lxnbexs.r
VTarzers' Compensation(nsuxanee A� davit
'�OI3E:C+SLEDWZ�'�7':H1a�'EEMT".[":i''I:l`IC,A73'J'HC?I2:LTS.''. -Please VEIL
'`licant fnfarmation
Name e(Business/Orgaaiization/individual): )
Address: ma Aono
City/Stafie/ip: -y
. — Typo oi<project(J,-eclulred):
Areyou an employer?CLe.eltttic appropriate box:
frall and/or part tune):a 7. E]1`�CVv'coristxuCo]]
1.E]I am a employer with em to ees p y (
2Q1 aan a solo proprietor or partnership and_have no employees Working for mo m 8, 1 De o Demolition g
any capacity.[No workers'comp,insurance regained.) 9. Demoliliorl
3.� a homeowner doing all work myseif [N"o workers'comp.in suranco zecluired.]t 10 E 6$ ilding addition
4.�"I am a homeowner and will be Wring contractors to conduct all work on my property. Twill 11 1` l ice ical le {i1?s or additions
t_I
ensure that all contractors either have workers'compensation insauanco or aro sale urn�in re airs or additions
proprietors with no dmpl vre's. lbw r°`" . g p
5. I am a general contractor and Thave hired tlaesub-couttactars listed on the attached sheet,
13'. aofre�aits
`1'beso sub-contractors have Lan'Ployees and have workers'comp.insurance.$ 14, Other _
6.E]We,are a corporation and its.ofl ic:e�rs bave exercised their right of exomptian per MCAT,c.
152,§1(4),and we bavo na eanpldydm[No workers'camp.insurance required,
nf
-- --'""
kAsay apphco trac
canttbat cheoks f ox 1 must also fall out the section below showing their workers'compensation policy tors must bn-dmatioaa.
t Homeowners who subtha this box rhuat attacked indicating
sbonet owing the all work andname a the en bitu ub outside
a tors and state whether ox no Thos indicating
have�
tContractors that cbeok ..j --
employees, Tt tlao sub-contractors have employees,they must provide their workers'comp.policy number.
�X am yen tliczt is pzovidil gWov ceps,eomperisation r•irtsul,(incefomy emPZoyees. Below is the policy and)ob site
information.
fusuranco ----
_ FmpirationD00: - –
:Policy#or Self ins.Lie.
Job Site ,�
.Address: --
Attach a copy'of�4he�varl�ors' caxnpextsationpobicy declaration page(sla.avvingiliopolicy number and expiration date).
a fift up to
11,500-00
Failure to socilrO coverage as required Linder ll/XC�=Laltic. 152, §hof rm a�a sh P25A irWORK(RDFS and olation ya fin o 111 to $250.00 a
and/or one-year imprisonment,as Vvell as crvil pelt
day against Mlle violator.A copy Of statement may be forwarded.to the Of�co of investigations of the DfA fax irts�7xance
coverage verification. _
X do liere7ry certifyrtify render'tlzep rsand=enaldeS pof perjury that the information provided above i.s true
/and correct
Date: cap/
Sigga
:Phone
Of use only. T o not Ivrite in this area,to he completed by city or�town official.
City or Town:
Permit/C�icense#issuing authority(circle one):
:l.Board a Health 2.f3uildin.g f)epartment 3.City/Town Clerk Al.Electricalfuspector 5.Plumbing Inspector
6.Other
Phone
Contact
.00
821
. . �. tC F1 (#53 31dt C t
bA@P P G11. ZlAN
428 PLEASANT St.
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