HomeMy WebLinkAboutBuilding Permit # 12/8/2016 ORT
BUILDING PERMIT N,�.�,ED
of� o
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
� Date Received
A7E0 A .
Sy~ACHUS
Date Issued: �
(JR T:Applicant must complctc all items on this page
LOCATION
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PAR ,,EL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT _ PROPOSED USE
ResidentialNon- Residential
F1New Building ❑ One family
❑Addition ❑ Two or more family 11 Industrial
❑Alteration No. of units: _ ❑ Commercial
C7 Repair, replacement - ❑Assessory Bldg El Others:
❑ Demolition ❑ Other
❑ Septic ❑ Well ❑ Floodplain 0 Wetlands 0 Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
60
Ile
le
cleat ilicatioxa- F'1 ase'I' c'car Print Clearty .�,.
OWNER: Name:_ ,� Phone ,
Address: •., ��e, V__.... = ----
Contractor Name: Phone.-
Address:
Supervisor's Construction License: Exp. date,
Home Irnproyern-ent License: Exp. Date:
.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.' $ 50 FEE: $
Check No.:
Recei t No,,:
�__�-=--- -- _. p -�
NOTE,: -lel",sons contracting ith an.registered contractors do not have.access to the gzrccranty f aid
Si M7ature of Agent/Owner ° Signature of contractor ,
-Mmension
Number of Stories: Total square feet of floor area, based 6-n Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast,or service drop.,requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA— (For department use)
9 �v
❑ Notified for pickup Call Email
ate Time Contact Name
Doc.Building Pon-nit Revised 2014
'Town oft%ORTH
_ : over
0 ;�- 16
No.
h ver, Mass,
p L[1L NIi pW1CR y�
°'�ATE 0 t P� '�C3
L1 BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
AAvftTHIS CERTIFIES THAT .......... ...... .,.. ....,.. .•... ......— .. ...............................
rid Z— BUILDING INSPECTOR
.
Foundation
has permission to erect .......................... buildings on .. .
Rough
to be occupied as .... ,. .,. Chimney
provided that the person accepting this permit shall In every respect conform to the terms of the!pplica ion Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the In n,Alte a on
Construction of Buildings in the Town of North Andove 6S ® PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Vol s Pe
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CS NS Rough
Service
.......... Final
ILDING INSP TO
I�
GAS INSPECTOR
Occupancy Permit Required to Occu Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Null To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
t%ORTII TOWN OF NORTH ANDOVER
OFFICE OF
0
BUILDING DEPARTMENT
120 Main Street
.4— North Andover,Massachusetts 0184
5
Telephone(978)688-9545
Fax 2
Donald Belanger (978)688-954
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Building;Permit Application
Ele
,Ilse print
JOB LOCATION:
Number Street.AdcessMap/Lot
-5j
HOMEOWNER
C,7 4 $ 5,
Name Home Phone Work Phone
PRESENT MAILING ADDRESS.-
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,pKqyided
that the o slaervis
owner acts a, ar,
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" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/shQ-wil I comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE_,,
APPROVAL OF BUILDING OFFICIAL_ ------—
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 689-9541 CONSERVATION 688-9530 HEALTI-I 688-9540 PLANNING 688-9535
0, Commonwealth of massachasetis
1
Department o f IndustriarAccidents 1
1 C`ongTess Street, Suite 100
d
Boston,.1V.1A021,1,4- 01
F` www mass.go•P/dia
w
. �garl�ers' Compensation Xnsrrrancei A,flicla'vit:Bui�dexs/Gen`tractoxs/�XectrXcitansl�'1nymTaexs.
TO SiiTXEDWffj7T1EJ'F121',�T.'rT` NG AMjIO:l2S'�'X�. TeaseX'rint YePAl
anon
licantlnform ,
Name,(Businesslftanizaiion/In
Adch-ess:— - - - - 57 116 D old
----
__ =---
T
ypeoject( ecltxired);
' ro rlate box:
�e you an employer?Checl�f1i e app p 1.❑Iamaemployerwithoyees( tll and/az part-fitno).,�I atn a sole proprietor or partacrship andhave no employees vvorkin'g fez me inurance re wred] . n olitiarr
any capacity.[NO Worker"camp.ins q
3, I am a homeowner doing all work myself[No workers'camp,instuance zequirecl.]r
to Building addition
4•� operty. X will I am ahomeowner andwill be hiring caniractors to conduct all work on my pr
11.E electrical:repaixs or additions
ensure tltat all contractors either bane workers°eompensatkon insurance or are solo I N L F: u ab g repairs or additions
proprietorswithna empliryces.
13%[ l:offr4aiss
5.�l�a general aontractox and I;hava hired ttto sut7-canfracfors listed onthe attached sheet. _.__.
These sub-confzactors have employees and have workers'comp,insurance-t 1.4.�Other_
rn
6.-]We are a rorporation and its,offiednhave o welkel,comp.i insurance required.��I c.� ���
152,§1(4),and we bave no empldydgs.[lT — otic information.
compensationP Y
y applieantth ks boX l must atsci xll ontthe Boo doing dIt showing
l3otneowners vakrct hdokk:bis afbdavit irtdicaiing thcY are doing all work and then hire outside contractors must submit a uew affidavit indicating h s o
tContractha
ozs that akteckthis IN;Box roust attaclied'an,add h0nus h et she heirtwa kers'comme of ae policy number.
e sub-contractOrs d state whel3rcr of otflsose„entities laavc �
employees. lftho sub-contractors bave employce_ _s_r f 1 �—
-- —=—•..
_ Pm to Pes• .33elow zs theporzcy and oh szte
I arra an employer'that.zs pr'aviding warners'corazpensation irasurancc for my P y
information. _ ----�”
[rrsurancc;Company Name:
policy It or Self ins.Lia.
City/State/Z,ip:____m — —
Jab Site Address:
tacb,a co o:tthe`s Q4: ers' olicynumber and expiration date).
coxnpensationpolicy declarationpage(slrovaiolat'anpun hablobyaft� eta$:1,500 00
g the P
At lr� �5A is a.crimnlal vx 1
Failure to secure aovera�e as required under 1V1Gla o.7.52,§25A
' or ana� eax imprisonment,as well as civil penalties itr the form ai a S'J'Op WORT"-
-we
OI�:C�t7T.�UEIt and a ane of txli'to $250.00 a
and/ y t s 'll statement may be forwarded to the O ita o Chtvestigatians al the pfA.For insurance
day against the violator.A ca Y
coverageyericatian. _ �__ __�
enalties o er as that
tTie zrafarrnation pr ovzded above is true d erect
Xdo hereby under{thepai andp .f`p� .T rJ'
one#L
pfficz� ar use vol of tvr ite in this car ea,to he completed by el y ox°town official.
PermitfLicense _
City or Town: -
7ssuingA thoyity(circle one): ector 5.Plumb•ingfUsl�ector�
7.Board of ilealtlx 2.Brxildang Uepax fico ent 3.C.ity/Town Clerk 4.li lectrical Jnsp