HomeMy WebLinkAboutBuilding Permit # 12/5/2016 tiyOR-F'y
BUILDING PERMIT RI.
QF�T, o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 4C
Permit No##: 5_21
P Date Received-11L _ 2_ �SsAel3us���c
Date Issued: t - S '
IWORTANT: Applicant must complete all items on thzs page
LOCATION pfin t
PRQPERTY OWNERo0
Pnnt 1 Year Structure YeS rio
PARCEL ZONING DISTRICT Historic D�stnct yes ria
Machine ShopY_es r
:. ... m R
TYPE Off' IMPROVEMENT PROPOSED USE Non- Residential
Residential
❑ New Building ❑ One family
D Two or more family El Industrial
❑Addition ❑ Commercial
❑Alteration No. of units:
C]Assesso Bldg ❑ Others:
�Repair, replacement rY g
❑ Demolition ❑ Other
❑ peptic ( Well ❑ Floodplain ❑Wetlands ❑ Watershed District
p VVaterl�Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name:
Phone:
Address:
� 11C� c� �z 1V - ry)
Contractor Name: 1._� Phone:
Address:
Supervisor's Constr etibn%.License Exp. Date
Home Improyemerit`License Date
ARCH ITECTIENGINEER Phone.
Address: Reg. No.
FEE SCHEDUI E.SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
r 3 notal Project COSI: $ a'�+ FEE:
Check No.: Receipt No._
NOTE: Persons contracting wr i unregistered contractors do not have.access to the guaranty fund
S��gnature of AgentLOwne.r': Signattare of contractor
4 FORTH
.41
Town of Andover
® `^ X41
No. IL
C, h ver, Mass,
O ►wxe �
COCMIC k4 waCK y7'
0RaTED
U BOARD OF HEALTH
PERMI
Food/Kitchen
T T L D Septic System
............. .. ..... . ....,......C.
.. ........................................
THIS CERTIFIES THAT ...AV
BUILDING INSPECTOR
has permission to erect .......................... buildings on J .... ............. ........... Foundation
► ..... ,. Rough
to be occupied as ..... . .. ..... .. ........... .... N. . ....................... . 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 C®NSTRUCTIO USTARTAV Rough
AV
Service
.......... ..... ............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy hermit Required to Occupy_Buil� 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.
tk0RT#j TOWN OF NORTH ANDOVER
0 OFFICE OF
BUILDING DEPARTMENT
120 Main Street
Arsp North Andover,Massachusetts 01845
CHU
Donald Belanger Telephone(978)688-9545
inspector of Buildings Fax ()78)688-9542
HOMEOWNER LICENSE EXEMPTION
BuildingArmit Application
Please print
DATE:
JOB LOCATION: M0eJaLj
Number Street Address Ma /Lot
HOMEOWNER (j_)(-1'.S CC sel-_6 ..........
Name 1-Ionic Phone Work Phone
PRESENT MAILING ADDRESS i
U�„
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
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 fit 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 requires nts and that be/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massaehusetts
_ Department of IndusirialAeeldents E
r Z
congress street,suate 100
&osto ,MA02114-2017
�r www mass.gavldia
i
a�hers'Coz�apen atio�ab suranc6Affidavit ��dexslC��aT�Os1T�
� trzcYansl��u�nbe�rs.
To BE MJ FQD'W UDITH PFMRTT'N Peasei'xint
A ' ji antWorm.ation
NaMO(Businesslbig
.Ad&ess: t� Mch �w � ►
Phony
clzty/Statdzip:
Type o-project(Mtlixed);
Are you an employers?ChecIr the appropriate box:
em lcyess(fn73 andlor part tame).e 7. El Ne`W'COTStt�lCtio73
1, 1 am aemployer with p
2.�T aur asoleprapxietororpartnarship andhamno employees Working forme irr &. ❑Reruodeling
any capacity.jNovdorkexs'comp.insurance required 9, ❑Demolition
3,v�l am ahorrreawrrez doing allworkmyseii~NOVoxkers'comp.insurancerequircd.]' l0❑Building addition
4.❑I am a homeaWner andwiil be hiring contractors to conductall Wolk onmy propezty. 'w']' IL
❑E1e04ICal Ipppxs of addit]9ps
ensure that aU contractors either have workers'compensation insurance or aze sole _
� L��Pliunb g repairs or additions
proprietors with.na employees,
enerslcontractozaad1havehizedthesub-contractorslistedazttheattachedsheet. 11�RoD£rapairs
5.�Iamag ,t,. -. /
These sub-contractors have employees andhave woxkera'comp.insurance 14,MOther In/,' n'" -
�,F1e are a eoxparailnn and its officers have axernisedtheir right oi'hanxee mptian peder MCrS o.
15e §1(4},and we have no employees.�Io workers'camp.%nsruarequit
atim
*may apphcantthat cheeks lrb �€1 n_iust also£r3.[° e e domglaU work andthenhiro on side cmonizactors must sub pr
rtmaneu affidavit iadicatiuug such
t homeowners Who submitthis affidavit indicating y
Coxrtractors that checkil?is 13o1c must attached an additional sheet showing the name of the sub contractors and siatg whether o r not fhose entitte ave
employees. 7fthe Sub—) have eraplayees,they must protide their workers'comp.policy number.
arrt ars ern foyer that is providingaxlce�s'compensatiarx icszcrance far my employees. below zs t/iepa�icy aradjo site
P
i�forrraatiorx.
Insurance Company-Name:
• ExpirationD�.tez
Policy 6 or S el£im.
City/State/Zip:
lob Site Address:
caxapex�satzonpolicy declax'atiorr.page(showing t7aeplz
oeyxiumEbex axr.d exph'at3.a�.date .
Attach a copy o£tb.e-worl>vexs' MC
500.40
Failure to sage coverage ag required.an d ivy enaltiesZ�n.the form o�a,SmTOP WORK.ORDERIand a fine of p to $250.00 a
and/or one year imprisonment,as well as p
day against the vzolatox.A copy of-[big statement may be forwarded to the O££tce o£Investlgdti