HomeMy WebLinkAboutBuilding Permit # 12/8/2016 BUILDING PERMIT4Q ;�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: a Date Received ^
*N74D
�SSRCHU �t
Date Issued: ti vo
LwORTAN :A licant must com. fete all items on this' age
LOCATION � ,,. _ ` :i �L4NC
Print
RROPtyR,TY'OWNRR �
Print i Rel Year Struckure yes no
MAP .:' F?ARGEL. ZONING DISTRICT. _l-listarc District yes no
Machine Shop Villi ge yes no
TYPE OF IMPROVEMENT PROPOSED USE
_ Residential Non-Residential
❑New Building XOne family
0 Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: __- ❑ Commercial
Repair, replacement o Assessory Bldg ❑ Others:
❑Demolition ❑ Other
0 Septic ❑Well ❑ Floodplain ❑Wetlaricls ❑ Watershed bistrict
0 Water/Sewer
nn DESCRIPTION OF WORK TO BE PERFORMED:
I- OA) j0Q9Cfj
clen#il*ication- Please Type or Print Clearly _
OWNER: Name: U/LI Pltone:9 `� 3�' . - a
Address:116 �i�c�S��® ,C,qw :
Contractor Name: Phone:
Address:
Supervisor's Construction License Exp. Date: _
iriome Irnproverraertfi License: Exp. Date =
ARCHITECTIENGI NEER Prone:
Address: Reg. No.
FEE SCHEDULE.BULDIN G PERRIT.$92.00 PER$1000.00 OF 714E TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
,Total ProjeGit Cost:: $ 3-Yoo.o D FEE: --
Check No.. I d Receipt No - C _�
PeI s s ;rata acti ng with urtregis#erect contracfars do not have access to the guarantyfund
re ofgeritlOwr�er Signature caf cahtractar:,
NORTH
own of
0 . . - : 0
i h ver, Mass I
OLAKI 1 1
gyp_ COCNICMe'WICN
°RATED
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ......1.01 .I. ........... .., ` ..........................................
......,i BUILDING INSPECTOR
has permission to erect .,........ buildings on ......I.J.bFoundation......C. .�. .�,. ,�.w........, i
Rough
to be occupied as ................ ........° ' ! ......... !„&.4.r Nli.. ......,......,...... 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 CONSTRUCTION S S Rough
=Wmb.................. ....... .&....W.................... 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 Wali To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
tkoRTH pN TOWN OF NORTH ANDOVER
OFFICE OF
0
BUILDING DEPARTMENT
120 Main Street
0 0
North Andover,Massachusetts 01845
'SACFiUS
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Pleas ?rine
DATE: Id — 6 —/
JOB LOCATION: //(/ A AI =
Number Street Address Map/Lot
— &Ll_-- , 8--5 3 -
HOMEOWNER,I
Name Home Phone Work Phone
PRESENT MAILING ADDRESS C.,q//47 dC-- LA
Vl:--To C19 9.2-6a.2
City Town State IZip 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 in a two-year period shall not be considered a homeowner. (780 CMR
Section 110.8.5.1.2)
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/she will comply with said procedures and
requirements.
HOMEOWNERS
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Fonn Homeowners.Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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Policy#or S elf ins.Lic.fob
#:,
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AffchSita Adrh'css:
.l�fta ;i rapt'a;fi3xovP�xkcxs'cauxpensatianpoi;icy dcciuxaiioxtpagi�(sliawirtigtlxei3alicyxxrtxizi7ax•and expuaiJaxx tItita).
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and/or o�i0•ycaa•ixnprisortrziont as'woil as civil pean€ilUes in tho form of a S7'Of?Wf7 () ll1:lZ.>axtii a i do o�'uli is $uxaa a
day agtifnat iszo viokatox.A copy of"'sf:€f»M`at mvy bu i'biwarded to the f).fftcs offnveafig€tions o:f'lx0)'A-br insutaTzGo
co-vemp verifioation.
correct
Ido hereby cerh;fy r er tl'separxrs(it'd"Oil cltdes ofperjury that the ztlfnrnzatfonpr ovided above is fuse correct
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DfficBat use Doty. Do not'Yvrtte in t1lis area,to be conVteted by city or tower official
City or Town: rerMwUct3nse#k
Usuing Autbaa•iiy(circle ox(e): ` ectox 5.1'Intmbiao ectox
.xioar€i o l asiltl3 ?,.S3uif€[ing l0epgxfmtant 3.Citfyffovvn Clerk 4.7u+lecUlcal bsp g
6.other
Contact Pexsoxa.
The commonwealth of.Massachusetfs
{ Department offndusirialAceldents
I tang esv Rreet, State 100
tl Bostoiz VA 02114-2017
2017
w www.rnass.go-v/dia
'Q•a�M Sy'y9
-Wq kers' Compensation MED W�THT �EIt1VIII'x NG AU7[�Os cxansl 'Xu nbexs,
TO REL :lease print Le 'ToI
AP iicant Infoxmation
Na1771.e(Bus9nessloxga�iizatxonlZncli�ridual):.�V �
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Adaos : 6-3 y35�
� 01 Poona : 7 ;
City/statelzip: ;: .:. .. . i_.PQ: " ed
• -: Type of proseef.(xegaj )_
epnn meanployer?Cftacktkaappropxiatabox:
I.�X am aempIoyer��- employees(lull and/or part-f
7. ❑NdW'd6R9t46ii0n
andhaven0 employees working forme in S. ❑Rem0da1iiig
2.Q I am a sale proprietor or paztnefghip - 9. ❑Dem0litioa?
any capacity [ItiTa�vozkers'eorap.imurartce required.
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3.E]Y am ahomeowner d0i19 all work myself[iso wozkers'comp.insurancerequired.J 10 El I3uil diiag addition
4 I amahomeowner and will be luring contractors to conduct all work on my property x will
ena haat all contractors eitherhave workers'compensation.insurance or are sole
13.[ Eleoixical Tepails 017 ad.ditinp-s
proprietors-with no'employees. �2�KjPIi W119-repaixs or additioxr
13. ]Raaf re'airs
S.❑ am a general eontraofoz and X hate hired the sub-contractors listed oathe attached sheet. N�@tom
These sub-oozrtra0tors have eisaployees andhaPe workers'comp.insurance 14.14 Me � 9
(,❑We are a corporation and ifs oflYcersbave exercisediheir right afbxerupti0n perMG c. !A�
and vre gave no employees.[No vrorkers'comp.insurance required] STDG a0
-kers'Go
Y applicant that cheolcs hoz#1 niusttasfilig they are doinganwork andthen hire outside a ntractaas moust submirtma Aew af�davrt rndreatirrg such
T l'lomcowners who submit-tb�aMd-
r:.
tCnnizectorsthatclsec3Cihisboxmustattachedtn� �must etheir workers'rcomp.policynumber.andstateuhetherarnotthoseentitiesDave
employees. 7fthe suh-contractors hEL employco, Y
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I am anerrzpToy that is pr ovic7ing-Wo,-kers'compensation irrsurarzce for^my employees Berm is t/ispolicy arzd o i site
information.
jwuraace Cam-panyNaxrre:
Expiration Date,
Policy#ox Self iw.Lite.
City/S lata/zip:
a roT�SiteAddress: e Showingthepolicpnwmbexandexpzzat�iondate).
Attach a copy of he axJ exs' caxapensationpolicy-declarationpag
500.00
d Ttailure to sect?to covexage as regnixed utxder M IL o-enalties in the form o a STOP Ol'WOE ORDER and.a fine ofnl to X250.00 a
and/or one-yeaX imprisollrnent,as well as civil p
9 day against the violater.A copy oftTvs stateme�.t may be forwarded to flag pace ofha-vestigations of the INA for iasutance
j coverage•vaxiftaation-
a ils and peaatties ofperjury Mat the information provided move is true and correct
I do laer e�y certify urzder<tliep
Date:
Si atu ro:
Phone it:
Official ase arzly. Do notes ite in M&a:ea,to be completed by city or<torvrx official
• l'erxaitl�,ieerxse#
City or Tovn-
IssuiugA.utharlty(circle one): P ector
1.Board of Eealtla. 7.BuIld�ing Depart neer, 3.CitY1Tn 4vn Clerk �.E+Zectxxcal pns ectox 5.Piurrtbzng Snsp
is 6.Other
Phone#•
Contact Pearson: