HomeMy WebLinkAboutBuilding Permit #827-13 - 229 APPLETON STREET 6/3/2013+ BUILDING PERMIT 3� at" »6•,''0\
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATI N y
Permit NO: Z Date Received
�9SSACHtIs ��
Date Issued:
IMPORTANT: Applicant must complete all items on this vaize
LOCA
14
VNl��i Print >J
PROPERTY OWNER
Print
MAP NO: 09-57 PARCEL: 02/0 ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
OWNER: Name:��
Address: 0'2� 5 4�yle
CONTRACTOR Name:
Address:
Identification Please Type or Print Clearly)
otea�; 720 Ph(
Supervisor's Construction License:
Home Improvement License:
x1 xA9V✓1- z �,d O T 1 6
Phone:
Exp. Date:
Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING
PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ Q oco• FEE: $
Check No.: Receipt No.:
NOTE: Persons contracti g wit, Jnr ' to d contractors do not have access to tile guaranty fund
Signature of Agent/Owner Signature of contractor
V . --A
All
Location ;,7 c� A St
No. 12 2"1 � 3 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ a �0=�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #;; �
26462 Building Inspector
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The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: _0,,:'�9 _.41
/State/Zip: A/. /O��D1� ��i'i' Phone #:
7f — 4 Fol- 4/], Y -
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
eglured.]
5. ❑ We are a corporation and its
3. Tam a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance renuired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractor; 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, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Job Site
Expiration Date:
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u the pai naloes of perjury that the information provided ab ve is true and correct
Si ature: Date:
Phone #:
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
''-' I
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: 4-2-1-3
JOB LOCATION: a2
Number
HOMEOWNER
Name
r -f
Telephone (978) 688-9545
Fax (978)688-9542
s0 /one) 07--11
'"treet Address �i Map/Lot
(92YJO�-�W
Home Phone
PRESENT MAILING ADDRESS o;� /' J X11
Work Phone
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)
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 structures. A person who constructs more that one home in a two-year period shall not be
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
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. lZ
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised I0.2005
Foran Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535