HomeMy WebLinkAboutBuilding Permit # 10/3/2016 OOR7 H
BUILDING PERMIT OFTT�en l6�H
TOWN OF NORTH ANDOVER IN
APPLICATION FOR PLAN EXAMINATION
Permit No#: S(c Date Received 16 Y' o 1
sac►+us
Date Issued: 10(3 eat
IMPORTANT: Applicant must complete all items on this page
LOCATION b2 easse-11 s
Print
PROPERTY OWNER Ptaa►01e r Je,144 0
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residentia Non- Residential
❑ New Building � wo
O family
Ll Addition or more family ❑ Industrial
❑ eration No. of units: ❑ Commercial
7epair, replacement 11Assessory Bldg LiOthers:
molition ❑ Other
❑Septtc- ❑ 2MM
❑ Flo4dplaln ❑Wetlands fl Watershed District
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F
DESCRIPTION OF WORK TO BE iPERFORMED: d
ir1 Ar i i`�► 2i!� zx'i o frvcho r g `i�
41 -
ASA Q-6-064 Inc iakJ vtzw � ra,,cabin .$`S� ntW e(L,,_Fric.413 j>1,urnbmj &i
Identification- Please Type or Print Clearly
OWNER: Name: tj, ono(U5 4,) Phone. q-78'2.Z. 6L67
Address: (ol, ,s l 9ac6 A-n r k &OLi
Contractor Name: Phone:
Email.-
Address:
f
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date-
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FRE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ Z O0.oz> '36D 0,6
—FEE. $
Check No.: °� Receipt No.: 30L79
NOTE: Persons contracting with unre 'stered contractors do not have access to the guaranty fund
F tkQRT11 '4
own of 4 n over
o .�... `
No. — �� _ I
:� . h ver, Mass, 10 b y 0
COCN1C"g W1CK 41-
�,A A�AIATED P'4�`,`'�5
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT - T LD Septic System
THIS CERTIFIES THAT �.!C.:h.,¢l.A.S........ ar 2 I �4^�v ....... BUILDING INSPECTOR
has permission to erect ................... , ... buildings on .... C ...,...... ......... .. ,,, �s S c L L....S Foundation
/ I' �- Rough
to be occupied as .... iA .e..�..... `: ...... .. ..`�..II'1�t. ......... .. ... ............................................. 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 CONSTRUCTI N STA TS Rough
lService
......... .... . L.. . ..,.......
. .. . ....................
....... .... .,......
BUILDING. . . . INSPECTOR.. Final
GAS-INSPECTOR
Occupancy Permit Required to Occupy RuRough -
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.
TOWN OF NORTH ANDOVE R
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
North Andover,Massachusetts 03$45
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUI DING PERMIT APPLICATION
Please Print
DATE: 216(
JOB LOCATION: os�c
Number Street Address Map/Lot
HOMEOWNER j Lln liS 9 o0e 1,,0 AJ14
Name Home Phone Wiric Phone
PRESENT MAILING ADDRESS 6 2- Vos<W) St(t(t—
..........
(A AA46V� M01 mg -I'S
City Town state Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwelfings 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 into-ads 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 IO.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 helsho understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that helshe will comply with said procedures and
requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exomption
BOARD OF APPEALS 688-9541 CONSERVATION 639-9330 HEALTH 683-9540 PLAWNG689-9535
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02119
Workers'Compensation Insurance Affidavit
Please Print
Name: 11ic.lnat�t5 �ot�Qlla+tJ
Location:
City NodJO,,kel- Phone
E�am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers'compensation for my employees working on this job.
Company name:
Address
City: Phone#:
Insurance Co. Policv#
Comlaanv name:
Address
City: Phone#:
Insurance Co, Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00
and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature _ Date
Print name 1J CkolaS 90f"a'40 Phone# -2n-547
Official use only do not write in this area to be completed by city or town official' F1 Building Dept
❑Check if immediate response is required Building Dept ❑ Licensing Board
E] Selectman's Office
Contactperson: Phone#: ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION
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