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Home My WebLink AboutBuilding Permit # 1/31/2017 .......... TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 17 Date Received 01 Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION . . . rent PROPERTY OWNER , .,.:�. ,�� Print � r� 100 Year Odd Structure yes MAP NO PARCEL I� 'ZONING DISTRICT Hrstanc Distract yes Ma - chine Shop VilFage yds TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition <Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D.S ❑Well D Floodplain ❑Wetlands ❑<Watershe Distract ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: -77 S A�1 ,61 r" (4—LIC mlx 4 o Identification Please Type or Print Cleary) C G OWNER: Name: Phone: � A—Clo 44 Address: �S� r • CQNTRACTOR Name. Phone.:; Address.. Supervisor's Construction License a Horne Improvement License: . Exp Date,: ARCHITECT/ENGINEER /U®A.(C Phone: Address- Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON5.00 PER S.F. Total Project Cost: $_ C�� 44y FEE: $ 9 Check No.: /0 Receipt No.: 7 NOTE: Persons contractin with unregist ed retractors do not have access to the guaranty fund S�gnafure of Ag r�tlOvtirne gil. ure of contractor:. Plans Submitted ❑ Plans Waive Certified Piot Plan ❑ Stamped Plans ❑ tAORTjHj own of s_ 1� 4 ndover ® �- "` va No. IL z h h �ver Mass , I 0' COC ML W IC K OATED S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ BUILDING INSPECTOR ....�. " .............�-. �..t.. .......�L.a.............................................. has permission to erect .......................... buildings on ....... .....1!�,u,T�R M�1/......A4.VC... Foundation . Rough to he occupied as ......vo W, !, *61t*#..... .,.. .�....,. ... . .... 10% .................................. ....... Chimney provided that the person accepting this permit shall 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.- LESSCTIYT Rough Service .. . ....,.....................,.......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy .,hermit Required to Occupy By Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final g No Lathing or Dry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts f Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers,Compensation Insurance Affidavit:Builders!Contractors/E lectricians/Plumbers. TO BE FILED'' IT$THE PERMI'T'TING AUTHORITY. Applicant Information Please Print Le ibl NaMo(B€isiness/Organizationitudividual): Address: City/state/Zip: ' 0 Phone#: Are you an employer?Check the appropriate box: 'Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in $. KRemodeling any capacity.[Ido workers'comp.insurance required] 9. Demolition 3. I am a homeowner doing all work myself.[No workers'comp-insurance required.]t 10 [J Building addition ❑ 4 I am a homeowner and will be hiring contractors to conduct all work on my property, I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12,❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repair's These soh-contractors have employees and have workers'oomp.insurance.t • 6.E]We are a corporation and its officers have exercised their right of exemption per MGL C• 14.El Other 152,§1(4),and we have no.employees.[Ido workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing theirworlcars'compensation policy information. I Homeowners who submit this a fCdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities bave employees. If the sub-contractors have employees,tlioy must provide their workers'comp.policy number. .I am an employer that is providingYvorlcers'compensation insurance for'my employees.'Beloo is the policy and job site information. Insurance Company Name: .Policy#or Self-ins,Lac.#: Expiration Date: 3 lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 a and/or one-year imprisonment,as well as civil penalties in tho form of a STOP WORK ORDER and a fine of up to$250.00 a a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. .I do hereby tify u er 11 p ins a pe /ties ofper' y that the information provided above is true and correct. Si a Date: Phone#: �/ Official use only. Do not write in this area,to he completed by city or toren official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk d.Electrical Inspector 5.Plumbing Inspector G.Other Phone#: Contact Person: a of NORTH TOWN OF NORTH ANDOVER t,`•° "o OFFICE OF BUILDING DEPARTMENT 120 Main Street North Andover,Massachusetts 01845 MCRU �� Donald Belanger Telephone(978)688-9545 1 Fax (978)688-9542 Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Building Permit ARelication Please]rine DATE:—_ Al JOB LOCATION: N1irnber Street Address (` Map/Lot HOMEOWNER A/,/ LV'&�lllJ �lJ' Name Home Phone 'Work Phone PRESENT MAILING ADDRESS c� 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, rop vided 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 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 he/she understands the Town of North Andover Building Department miniinum inspection procedures and requirements and that he/she will comply with said procedures and requirements. ---- &!� HOMEOWNERS SIGNATU:R1__ APPROVAL OIC.BUILDING OFFICIAL Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSEaRVKI*ION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i I