The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 2/6/2017 V%ORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:_L?'� Guts Received A Dat issued: RTANT: Applicant must c221E!e��page IMP In LOCATION__jj�) Print PROPERTY OWNED MAP NO: c District yes n Machine Shop Village yes n ........... TYPE OF IMPROVEMEN PROPOSED USE Residential Non- Residential I New Building 11 One family I Addition Two or more family Industrial —1-1 Alteration No. of units: i1 Commercial I Repair, replacement I Assessory Bldg I- Others: I DemoRion Cther FM&�d- 0 Septic f.-I Well [11 Floodplain 1D Wetlands Watershed District 0 Water/Sewer Identification Please'rype or Print Clearly) OWNER.- Narne- Phone- Address: CONTRACTOR Name: Phone: Address: Supervisors Construction License: Exp, Date: Home Improvement License.- Exp, Date., ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE-SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. "notal Project Cost.- $ FEE. $ Fu Check NO.: F2 Receipt No., NOTE: Persons contrac-tilnIg with unregistered contractors do not have access to the guaranty fitnd Signature of A 16`40wner Mllk 'Signature of contractor r-im*qq AD ®RTH Town 01 " 6 nclover 0 C,� ,[, . h vers Klass, � CO[Mt[NC wKx �' 'A40 P�%y BOARD OF HEALTH Food/Kitchen PER Septic System Aft THIS CERTIFIES THAT .. .,�... . , Ir{.. , .!! OMy .................... BUILDING INSPECTOR has permission to erect ...................... buildings on .�, ,� Foundation r"00 APEVA .00 AD Rough tobe occupied as . .f . ..... ....... .. . .... ............................................................. 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 LD VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT Final IT I I T ELECTRICAL INSPECTOR LESS C 1"( I Rough ZS /2'ft__.ffi0 Service "' Final UILO INSPE OR GAS INSPECTOR ccul2cancy Permit Required to Oeegpy BuRough 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. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114M2017 www.mass.gov/dia sy Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Le ibI Name(Business/Oxganizatiordlndzvidual): 6�V 16 to A- -e (A Address: 1 1&)1 k1( City/State/Zip: OV fPAh M 5 Phone##: 7 Are yon an employer?Checkthc appropriate box: Type of project(z@quired): 1.❑I am.a.employer withemployees(full and/oz pari time).* 7. LJ New construction 2.F1 I am a solo proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. L1 Demolition 3.F]I ant a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4. S 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.Q 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.[J Roof repairs Thede sub-contractors have employcos and have workers'comp.insurance) 6.Q We area corporation and its officers have exercised their right of'exemption per MGL c. 14El Other I S2,§1(4),and we havo na employees.[No workers'comp.insurance required.] 7. 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. $Homeowners who subitik tans affidavit indicating they are doing all work and then hue 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 have employees. If the sub-contractors have employees,tkioy must provide their worlo5m'comp.policy number. I am an employer that is pi•oviding-ivorlrers'compensation insurance for my employees.'Beloit/is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job 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 fire up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forms of a S'T'OP WORK ORDER and a fine of up to$250.00 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. s I do herebycert, under thepains andpenalties o er au that the information provided above is true and correct certify p p fP j y f Signature Date: Phone#: I Official use only. Do not write in this area,to be completed by city or town official- City or Town: Permit/License# Issuing Authority(circle one). 1.Board of Health 2.Building Department 3.City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a TOWN OF NORTH ANDOVER u OFFICE OF BUILDINGG DEPARTMENT VV. 1600 Osgood Street Building 20, Suite 2-36 �� North.Andover, Massachusetts 01845 S u,� 'S: Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please int JOB LOCATION: IVjIV V-�� VU _.— .__._...---.-._._..-- Number Street Address Map/Lot HOMEOWNER lQxWK . CrSal�c .r r� Name Home I one Work Phone PRESEN'r MAILING ADDRESS Noffl City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.'1) DEFINfTION 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 I'amily structures. A person who constructs more that one home in a two-year period shall not be i considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the 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 rninimurn inspection procedures and requirements and that he/she will comply with said procedures and requirements. i IIOMEOWNERS SIGNATURE r APPROVAL ROVAL OF BUILDING OFFICIAL c � � Revised 10.2005 Form 1,lomeowners Exemption i &'lr)ANtI3 4;F A N'FFlLS 688-9541 C ONSL:i(VA HON 688 9530 1IFA[A 11 d'iUY 9540 I'[.A'NNI'N6 688_9.535 I a i