HomeMy WebLinkAboutBuilding Permit # 3/10/2015 %AORTH
UILDIN PERMIT o`�T F.D
TOWN O NORTH ANDOVERy q'
APPLICATION FOR PLAN EXAMINATION
Permit Nod µ
Date Re_ceived>
�RRTED PPa
Date Issued
IMPORTANT Applicant must complete all items on this'page
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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
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: O--sm(c- rio Phone: )--7Z9—G9`W
Address: IJ- S!
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ARCHITECT/ENGINEER Phone:
Address: Reg No:
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F=—
Total Project Cost: $_ (n 1006, 00 FEE::$' m� . w
Check No.: Recei ip
G t No
NOTE: Persons contracting unregistered contractors do not have access to the guaranty jc-'—irind
Signature of Agent/ ) er Signature,of,con#raetor,,^,,
NORTH
M ,own 0"0'
Andover
®
66_ I6 -�
h ver, ass
O LAKE 1 1
COCKICME WICK
�S.9S RAreo %1- Cl
U BOARD OF HEALTH
PERMIT T Food/Kitchen
LD Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
has permission to erect ....... buildings on ...... M ,R •••• Foundation
Rough
to be occupied as151ftis.h... :!':b..w........�I...... ... .I.ir. ....... r
•• ..® Chimney
provided that the person accepting this permit shall in every respect con orm 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 MONT S ELECTRICAL INSPECTOR
UNLESS CONSTRUCT& S TS Rough
Service
....... .............................
BUILDING.
INSPECTOR.
Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Building- Rough
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.
Q4 arH rSy To OF-WORM ANDOVEP,
01UCE OF
BEffIDING DEPARTMENT
.1600 Osgood.Str03tBuxldan920 -rS-dto`-36
North Andover7.Massachnsetts 01845
Garald A.Brown. Telephone(978)as-954s
InspeetorolBuildings . Fax (978)689-9542
. -SOMEOWNER LIQENSE EY
ENIP Tlo t '
BM2)WG pE T A-PPLZCAUON
pleaseprtnt ,
DATE; 3 1
Q-B LOCATION,,_a ,J
-------------
Num7�er Sfreetddress 3.VIapJot
3�10A/MDWt BR
lame. Home Phone Work Phone
PRESENT M(M N•G ADDREss
0
ps-
. • ��.P Cods
The current exemption.f'or"homeowners"Was extended to inolude owner occripied c--iVeRugs to Uvo units or less on_d
fa aI1oT such horneo„rem to engage an? divid�aal•for dire who does n.otpossess a homise,provided that the owner
acts as supervisor). gtafe.Bo,ding (Code section 108.3,5.1)
DBF I.TION OFROMEO WNER
Persons)Who Awns aparcel o land on which he/she reslaas or intends to reside,ort Tymah there xs,or is intended to 9
Tie,a one or two Family sfrucfures. .4.person,tvho constructs mote that-one dome in•atwe yearperiod shall ztot'6e
considered a homeowner.
The undersigned"homeowner”assumesresponsibility for compliances with the 9tateBuilding Code and other
.Ap dicable codes,by laws,xules andzegulations.
The undemigned"homeowner"certifies that he/she&(lo Lauds the Town of North,Ando�verBuilding Dc)� finenf
iairuuminspeciionprocaduresandze eats at7ae/slzetvillcomplyy�zthtsaidpxoceduresand
requirements,
HOMEOWNERS SIGNATURE �
APPROVAL OP BUMUNG QRFICIAG
Revised 7.2009
]Folin Tlomeovn,ers Fsxemption
'EO.AM)OFAITEAT,S 688-9541 CONTSER'4A'RON 688-9534 =
HEALTH 688-9540 PWTNLNG 689-953i •
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 021142017
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): t, e1-
Address:
City/State/Zip: Phone#: 701-W-4-0<3y
Are you an employer?Check the appropriate box: Type of project(required):
1.F-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 $, E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[_1I 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.r]Plumbing repairs or additions
5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance J 13.F-]Roof repairs
6.❑We are a corporation and its officers have exercised their right ofexemption per MGL c. 14.Q 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.
#Contractors 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 tliat is pr•ovidirrg ivorlters'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 veri ton.
Ido herecertify and 'the ins and penalties of perjury that the information provided above is true and correct.Si na l/ 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: