HomeMy WebLinkAboutBuilding Permit # 3/2/2015 �►ORTH e
BUILDING PERMIT o R�LEo
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION -
64 w" Date::Received '3s A°agrEo PPP°
Permit No#.� �SSACNus�
11
Date Issued
'IMPORTANT: Applicant must complete all items on this'Mage
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building N One family
El Addition El Two or more family [I Industrial
Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Id tibcation- Please Type or Print Clearly
OWNER: Name: �� Phoned� '
Address:
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
1
FEE SCHEDULE;BULDING PERMIT,:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED-COST BASED ON$125.00 PER S.F=_ )%
$'.
Total Project Cost: $ FEE:
� � �
Receipt No.:
Check No,:
NOTE: Persons contracting with unregistered contractors do not have uccess to the guaranty j� cnci
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t/Signature„af AgenOwnerr/,,, ,����/ � /, �r, „ �, �.����r,,,�,�,,,���!„rU��rr✓,,, >>
NORTk
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Town of � � ¢ Andover
No.
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1h ver, Mass,
C0C"1C"t WIC#( 1_'1.
gDRA7ED Ilk? 5
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U BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT ........Aat`. BUILDING INSPECTOR
....... .........
M ,,
has.permission to erect.......................... buildings on ... :........VN- 'l r .. .. .. .................. Foundation
Rough
to be occupied as ...L1.1. ... .......... ...¢...........2).... ftt�,................................ 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
qUNLESSou
CONSTRUCTIO ST TS Rough
Service
................. . .. .... .................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
C o 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 of IndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02114-2017
UV
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): M a SIC �Z"
Address: �. ,C� G��� `�`1 (IL
City/State/Zip: (D Phone#: lam U
Are ou an employer?Check the appropriate box: Type of project(required):
1. I am a employer with__employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 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.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.#
6.❑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.
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.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 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.
I do hereby certify de I ft!n an/�enalties ofpefjury that the information provided above is true and correct.
Signature: ✓ 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)OarciOtirusetts .Depart
partment
Licens tif"ll S"9 Rperl i,ons and . a€e,t
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