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HomeMy WebLinkAboutBuilding Permit # 2/26/2015 FORTH BUILDING PERMIT O� ��LEu ,g + TOWN OF NORTH ANDOVER 46 APPLICATION FOR PLAN EXAMINATION / Date Received Ar Date �Pp° Permit No#: ®0 �SsgcHUS��� Date Issued: IMPORTANT: Applicant must complete all items on this page , l r � �� ,,. ;r'rriwrpr ,/l ,.:'J r.. r}�rrr r,�ryrtarrY�>tnrrrK�,,,,,rilrar,rwa,i u�r+.��wu� � (•, 11ir!,,rN�vyirVlue� r �l(l;:�rr.�' �WIN Gi 1 r ori ! 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 r ��,/ r �1! � ///, , // /, ,� ,, r r ,,, /�,�„„///, �❑ W to s ed'Drst pct /, / Se tic ❑ / / , , , , / , „ „ , ,/i„/,r , �! rr / „ a ,y,Al ,'f�ll�I 1/ r (( I � ( f l % /!�rr✓ �>�,� 1 � � 1 4r�� �j/ � ED: � .DESCRIPTION OF WORK TO BE PERF i Id„ntiica�tion- Please Type or Print Clearly' Phone: OWNER: Name: w.. Address: f I h� 1➢l? � r,, ,J rr 1, �,� � s �' , ,ral"f �� Nl�'y yr��! '!r`J�'/, �y Ir) ///� y �r,ri 1 rt 11 rri , � I� ' �! '!� �f r I � Y lr � p l,... ry��� � r ,.ur'��.../.l �, ulf��rfl�r/irYv✓�Ir�wn- _ __ �troiai,A,rJA...�m„Dr ae .uY/� �t111�1/i�d�,1��, C�sn?w�N>��IGo rS,a;J.rR� &m'U,�.!noYsanYr�r i� ARCHITECT/ENGINEER Phone: Address: Regi. 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: $ ) 066FEE: $ Check No.: Receipt No,: NOTE: Persons contracting ith unre ' tered contractors do not have,-access to the guaranty fund Signature ofAgent/Owne Signature of cbnttactorr r. t%O R TH Town of s E ndover • NN - T _ Ah ver, Mass, a la& COCHICHIWICK ATEO U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .. Foundation has permission to erect .......................... buildings on . '4a.... '......... to be occupied as .. .. . .........a.®...#W� � ... .....� ... ....1r ...... ... 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 CONSTRUCTIO ST TS Rough Service .. ................... ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit required to Occupy Building \ Rough Display in a Conspicuous Place onthePremises — Do Not Remove Final No Lathing or Dry all To Be Done FIRE DEPARTMENT YY Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH AND OVEP, OBFICE OF • ' �£•o���•",� . :�_�J©Q OSgOQ[�t�-'�XU'e�B11T�dlllg2�'M EN.e. y �3YRp.e�"y North Andovor,Wassachaset-t8 01845 • �s�FSCHLiS��^� r '.. Gerald A.Brown - Teleplzone(978)6$8945 Inspecfoxof$uitdings _ Fax (978)689-9542, RO-EOW.hTER-LICENSE BXBMPTION BTT ' BIVIz` `AtPLIC.A.'zTZO N • .pleasebrint , - DATE: � ��. � • JOB LOCATION.,—. 931A .. Number SireetA.ddJr— ress fSap/ of '�10YMOWNER C, _ Nam . . Home phone - . ' WorltPhone ' PRESENT MATLMG ADDPMS y Sf3fw• dip Code The current exemption for"•homeowners"teas extended to 4 to allow subh homacg - g ¢ nGlnde owner occupied divelings to f�vo unifs or less and ueas to en a�•e an individual.forhire-who does notpossess a 7ieGnse,provided that the,owner acts as supervisor). Stafe3uiiding (Code SBCtion DB.F.IN.ITZON OIIHOMBOVMP, Persons)who gwns a parcel ofland on wbich Ire/sloe reslaes or anfends to reside,on w�ixcli Fere Vis,or as xnfended to cabb,a one or tWO faudly stmefures. .A.person who constracts more thatt me dome in•a fwo;yearpeiso shall not'be nsidered a homeowner. The undersigned"hozneawner"assumesxesponsibiIify foz-coznPIiauces WIfh the,State Building Code and other Applicable codes,by laws,xules and-xegulations. The undersigned"homeowner"certhes that helshe undersfands the Town ofNorfh Andoverl3uilding De'arfraent zuinizuum anspecfion procedures and re wire fs and t1i lielslze Will comply With;said procedures and p xeclniz eznenfs, r HOMBOWN�ERS S.IGNA.TME APPROVAL OF BUTLD)"G 0.Y'FICTAB Revised 9.2909 Fon Homeownersempfion 'BOARD OFAPFEALS-688-9541r • C01�SR.R,VADON 688-9530 LIEALTH688-95}0 . PLA..NNWr,689-95s5 The Commonwealth of Massachusetts Department of Industrial Accidents a , 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): _r oca Address: 1 . t?-0 Y) I City/State/Zip l"1 " flrk-, �%``�`�Phone#: . ., Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(Rill and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. FIRemodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1• El Demolition 10 E]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.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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. 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,they must provide their workers'comp.policy number. lam an employer that is pr oviding workers'compensation insurance for•my employees. Below is the policy acrd job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD 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. I do hereb ti r r r•tIi pains andpenalties of perjury that the information provided above is true and correct. I/* Sian Date: 4 Phone#: 1 2V 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#: