HomeMy WebLinkAboutBuilding Permit # 11/18/2016 0 ,
BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit NO: '.
Date Received
N
NAT.. .01
Date Issued- US
IMPORTANT: Applicant must complete all items on this page
..........
TYPE QF
IMPROVEMENT PROPOSED USE
Residential Non- Residential
1-1 New Building Cl One family
El Addition 11 Two or more family Industrial
El Alteration No. of units: [--I Commercial
D(Repair, replacement 0 Assessory Bldg 11 Others:
11 Demolition EJ Other
D, P a), ["I 6ti h Di tact„%
"Alk
Identification Please Type or Print Clearly)
OWNER: Name: N Phone:
Address:
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m
0/1 MORE' "m, W//
/z
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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: Persons contracting with unregistered contractors do not have access to the guaranty fund
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own of
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LAMR h ver, Mass, �� its Zvi&
COCKICKRWICK
FigS0 ATED 1.7¢�i,��
U BOARD OF HEALTH
Food/Kitchen
PERMIT - Tu " LD Septic System
THIS CERTIFIES THAT ......5ToN.... ... BUILDING INSPECTOR
has permission to erect .......................... buildings on ....... Foundation
r r � Rough
to be occupied as . 1�F ,/M .. . . jj �.. jWW Chimney
provided that the person accepting this permit shall in every respect conform ro thterms of the application 4AP61 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 CONS ® Rough
Service
. . .. .... . Final
BUILDING lNS ECTO
GAS INSPECTOR
Occupancy Permit Required to OccuiZE 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.
art t%ORT#1 TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
Arso North Andover, Massachusetts 01845
CHU
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Please print
DATE:
JOB LOCATION:
Number Street Address Map/Lot
O ��
HOMEOWNERb' Y\
Name Home Phone Work Phone
PRESENT MAILING ADDRESS— ) '2—
4(_
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
PQrson(s)who owns a parcel of land on which fie/she resides or intends to reside,on which there is,or is intended to
be, a oric-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 110.85.1.2)
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 fie/she will comply with said procedures and
requirements.
HOMEOWNERSSIGNATURE
RE
APPROVAL OF BUILD11<6 OFFICIAL
01
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVA11ON 688-9530 HEALTH 688-9540 PLANNING 688-9535
I'he commonwealth ofMassachusetts
z Department oflndustrial.Aceidents
h'. 1 congress,S`reet,AS`uite 100
Boston,M9i.0.2114-2017
rvww.mass.go-vldia
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' Wavkers' Com�pensat-iox�X�rsu�ra�a.ceA:�fidaYit:33u�ders/Contxaetoxsl�IectricianslJ'Xnmbe�rs.
TO BD MUD WITH TEE BERwi�`z M AT7THDIUJ S'. Please Print Le '�l
A ' licant W,o-r-Mation
Name(Busine1esslOrgariizationlindividuaJ):
o� �S` Pholae,4:
City/state/Zip:
�ieL
mplopexY Cheep the appropriate box:
Type ofproject quired):and/orpart-time).* 7. pI�e`{d6nsd-don
l,[ Iamaemployerwith p y { $. �Rexuodel'eiig
2.�I aan a sole proprietor or parttaership grid/ante no employees working forme ixi -
any capacity.�Noworkers'comp.insurance required./ 9. ❑Demolition
3,D I am ahomeovnner doing aU workmy'"K-[No workers'comp.insuzancerequiredj t 10❑BuUding addition.
¢.moi'I am ahomeowner and wM be/airing contractors to conduct an work onmy property. Iwill 11.F]EleetTzcal�epa3Ss or pddltlo}�s
assure that all contrartbis either have workers'compensation.insurance or are sole Te ajrs or addatioa s
proprietors withno empioyees. ��0 Pry g �
5.�I am a genezal contractor and I hays lairedtlae sub contractors listed authe afixched sheet.
11[�Roof repairs
These sub-contractors Uav employees andhaw workers'comp.insurane�t lA.Q Other
�•❑ eareacorporadaianclits.ofi csrshave exezcisedtheir light of'exemption perMOL o.
i52,§I(4},and We]nave no employees. No wozkers'comp.insurance roquited]
licy inbrmatio1r.
*Airy applicant#hat ohs oks bbx€1 day inscli atuag they are mgl�work amthen hue outside ccontracto s mow showing their work-S'COMPeosavon oult submitnew affidavit indicating such
T Iiomeawners who submitthis aids.
tCnntzactors the#checkfiFiis lion r cruse attaclied'an additional sbeetshowmg the name ofthe sub-contractors and state whether of nae those entities ays
employees. Ifthe sub-contractors have employees,they must protide their workers'comp.policy number.
I am an employer that is providingiporkers'compensation insurancefor my employees. BeioFv is tliepalicy arzdjob site
information.
InBurance CornpanyNaxne:
Expiration Date'
Policy 0 Or Self-ins.Lic. �f[� IPA � 18''i 1
`� City/Stag/Zip: --
Job Site Address: �• sho-wing the policy uuMber and eXpiratio-.date).
Attach a copy oftb.e�voxirers' com�pensa�tompolaey declaxation.Page
is a Criminal
Failuxe to by a ffib up to$1,500,00
secrete coverage as required undez�M penalties ins§he form of a STOP-violation
ORDER and a�of p to $250.00 a
and/or one-year inaprisonment,as-Well as x P
day against the violator.A.copy ofthis statement may'be forwarded to the O�ca of).vestigdtions of the DIA fbr I suranor;
coverage verification.
xdo liere/iy certify der the at ar�dper�alties ofpetjury t7aat tT2e information provided aha e is trrxe and car�ect
. Date: �2o t �,
Si ature:
Phone :
offcial use only. Do no,-write ire this area,to be completed by city or town official
permit/License#
City or Townz
xssui ag.Authority(circle one): � ectoz
L13LfpTealtb �.BrxildingDepartment 3.CittylTo-vm Clerk 4.IllectricalInspector 5.PlmmbzngTwp
Phoneerson.'