HomeMy WebLinkAboutBuilding Permit # 10/19/2016 OORT H
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit 1110#: Date Received .rep
SSACHtJ
Date Issued: 1i
IMPORTANT: Applicant must complete all items on this pale
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PR!DPERTY OWNER /
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PARSTRICT, Historao is n „„yes na
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TYPE OF IMPROVEMENT PROPOSED USE
_ Residential Non- Residential
❑ New Building _^- - Cai One family
El Addition p.�Two or more family ❑ Industrial
Alteration No. of units. 11 Commercial
_.._.._-_
Nl�
�epair, replacement _._�.. ❑Assessory Bldg ❑ Others.
❑ Demolition ❑ Other
0 Septic ❑Well El Floodplain 11 Wetlands [I Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO DE PERFORMED:
enti ication- Please Type or Print Clearly
OWNER: Name: °�4 ., + 0 Phone: 603' �w '
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Addres � 4_ ....�.:: �`
s: Ale
Contractor Name: Phone:
Email:
Address:
Supervisor's C"onstruction License: Exp: °1)ate
Home<Improrlement License Exp: Dater ;; ; ;
ARCHITECT/ENGINEER Phone:
Address: Reg. No. .
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
"Total Project Cost- $ 1. �� FEE:
Check No.: _ Receipt No.: _
NOTE: persons contracting with unregistered contractus do not have access to the guaranty fume
,Signature of Agent/Owne ignature of contractor _
00RTH
own of aT � ndover
0
No. 424*w2osi -W
�Mh ver, Mass, 1« til'
A TE O 014Q`�,�5
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T L .D Septic System
. BUILDING INSPECTOR
THIS CERTIFIES THAT ........................................::...:........ .........................:...:...�......... ...............
. 4. Foundation
has permission to erect.......................... buildings on ........... .,...................... ,.......... ...:......so..�,........
� Rough
bt
to be 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 IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIP, S ARX
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 Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
of tkoRTHTOWN OF NORTH ANDOVER
,,1 14 ;6
0 OFFICE OF
0
f- M BUILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
North Andover, Massachusetts 01845
S C us
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
GUIDING PERMIT APPLICATION
Please print
DATE:
A4
JOB LOCATION: /147 , /g/ A io-1 J tte e e
Number Street Address Map/Lot
HomEOWNER �,, .Ir.44'L,�,",e
3 2J 7 Yd 6 V
Name Home Phone Work Phone
PRESENT MAILING ADDRESS AAe&itj,'wAc x
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 videcl
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"certif ics that lie/she understands the Town of North Andover Building Department
ininhilum 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 Floineowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
`LThe Commonwealth of-Massachwvetts
Department of IndustriaZAeczdents
n I GYongress Street, Sritte 100
Sosto,a, N.1A 02114-2017
= n � www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contxaabers.
TO m,-u%E17 WJi_TH T :PI,PEI RMt` LING.AUTiTOR1TY' ]?lease Print Le •b3
A.a' licant Znfarmat"'
"
Name, (£izisiness/I�igataizationllndividaal):� �^ 1
Address:
Lh Phone
Type of project(Xequixed),
Are you an employer?6hecle.the appropriatebox-
em to ees fiiA and/ar part time),* 7. �N&W'd6nstriiction
l.[]Z am a employer with-_____.__ p y
2,[Ay l 1 am a sole proprietor or partnersbip and have no employees working forma in $. MOMM00lition
an ea�acity.[Naworkers'camp.insurance required.] 9.
3.Nlamahoineownerdoingalkworkmyself:LkToworkers'comp.insurance required] I 10[]Building addition
4,[A Z am ahomeawner and will be hiring contractors to conduct all work on my property, 1:will �f 11, p,
Llecirical xe alis oradclitio�s
ensure that all contractors either have workers'compensation insurance or are sole 1
ployees.
Q.10 PlxDlxbing repairs or additions
proprietors with no enrt
5,F]l am a general conttactprand I hirve hired the sub confronters listed ur the attached sheet. 1 , l�bof reliairs
These sub-contractors have employees and have workers'comp.insuranCo$ 14.[1 Other_.
g, We are a aariroraticlii and its,nftieers have exercised their right o£'exemptiorx per MC L G.
1.52,§l(4),and we have no employdes.iNo workers'Comp.insurance required,]
_ — .--
*ACy applicar-tthat eln$ck3s bbl#i roust also fill out the section below showing their workers'compensation policy in£nrmation;
i Homeowners who submit•this"davit indlcatingthey are doing all work andthenhire outside,Contractors must submit a new affidavit indicating such
tCnntractors that claeckmi Hod must attaCkied an additional sheet showing tbo name of the sub-contractors and statg whether oz oat fins®,entities have
employees,they must provide their workers'comp.policy number.
employees. I£tho sub-contractors have e
X a ra e2arr mployer that is providilig-Wo,-IcePs'eomliensation insur•ancefar°nay employees. Mow is thepalie arrd nab site
information.
Xnsurance Cozxapanyl�arxze:
' � f?,xpirat%anI)ate:._, J
Policy##or SeI:E ins.Lia, :-. --
City/State/Zip:�
Jab Site Address: _
Attach a copy of fixe woxiccxs'compensation,policy declaration.page(showing the policy number and expiration date).
is a e by a flilb Up to M500.00
i♦ailuro to secure coverage as required Linder MUM o. 85,§25,Ain ire farrrr of a SxOPual z Ox��on pORDERland fine Of UP to $250.00 a
and/or one xmprisozmzent,as well as civil penalties
fthis statement may be forwarded to the Office ofl'nvestig tions of the DIA for basurance
day against the violater.A cagy a
coverage verification. _
X da hereby certify un r°tliepairz clpenartres of perjary that the information provided above is true an�carrec�
ate
Si : "�
�Officical use only. Da not in this car ea,to be completed by city or town official,
• Perrnit/License ii
City or Town-
Xssuing Authority(circle one): i
1.Board of eal(h 2. Building l7epaxtraextt 3,Ci1.y/Town Clerk 4.Electrical Znspectox 5.1?lumbing lnspeetox
6.Other