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HomeMy WebLinkAboutBuilding Permit # 3/23/2015 BUILDING PERMIT of NORTH q� Z�t.�LED.Fg a6'Ve TOWN OF NORTH ANDOVER,,'-. o APPLICATION FOR PLAN EXAMINATION Permit No#: / DateReceived`;. ° .... �.4 q°RRTEo PPa�.,(� SSgcHus�� Date Issued: IMPORTANT:Applicant must complete alf items,on this'page r . 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 �� e=tic � ��Wellx��'"��< � ❑ Floodplain ��ft❑VI/etlantls �' Y� 1 �s�Wafe rshed�District �, .. �. �4 `g`.gig, /���"�'Il✓.,✓,^i..-��"`p ufrcr"" � � �L�,��, .e"�p�4s��` .t�-�f�T„ ��f �i42� P r6'.Kl ,.� � -;; r Wa e /Sew��3�{,� �"*,_'��"ec �,� rh��, �✓t+" r��'€r ��� f� i? r .yj�` ,, �r"` ?����� ,� ��r���Ir'��n�r ,' DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly' _ OWNER: Name: e_ 4 v e Phone: yA , Address: A �° AL1 t� �r� f ✓ v C �i ,,,a-.., _ r; '. _�•-,,c'r�€��j,Y2.;.,"'� s✓r'.r:�"r {` r✓,rn° '�` �, ,f��'i1 x;r `.?"'..� J dry- ���i{�x�`t,�:�, .S „rt.,,,ate: ,�£"""r'`.,'.:,✓ �[n;b :: r ..'�, .^r,`�.°� � � 1 .,�. .- ,,. �at�� ,<'�„->fj`�"��i`" ir�'�l. ,�, J; r �F;d � �.:tX� r` t!�sr;;�r �:; ,�, �r h„="�,'w.'z ��,,,,�<r,�`�;v���,'� 7r�✓�.r°�",� , y.. ,ter !' aJ✓r .�" � '�rr. ,'�r'/ '`"��`. - ✓'rr -��.,a u,r `'S"r�rr ,.. ,�:�r-9,',�.'�'��rf-{ tr"' r,�r�,r�'��� ?f"r �' ,9r.�'�rzr" � 1 ?' -r� rE rr .. ✓''���„ '` .��..' x�r�r.�a�. � -.r'v'���Y� -rTar�:�✓r"�r.�, u` r f�� ''" � � P.'�" °��, �,.,. ARCHITECT/ENGINEER Phone: Address: Reg-NaIr FEE SCHEDULE:BULDING PERMIT:$9200 PER$9000.00 OF THE'TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ i c� FEE . Check No.: :, f Receipt lVo �r I� NOTE: Persons contracting ith tin ist`e ed contractors do.'tiot:liaveiaccess to the guaranty fund Signature of Agent/Owner Signature�of�contractor . FORTH Town of4 :. ,, Andover ® — 0 . 115 S$c " .�- Mmu�: LAK. h ver, Mass, �®A�R�ITE c) Ll BOARD OF HEALTH ff Food/Kitchen i7ERMIT T %j L OL10 Septic System THIS CERTIFIES THAT �, ... . . ..... ........................................................... BUILDING INSPECTOR L" Foundation has permission to erect ...................... buildings on ... ....... .��'rA.�a,��:....... �..� .... ..... Rough to be occupied as ...... ........... d:zo........ .........j .... 7: .................................................... Chimney provided that the person accepting this permit shall in every rct 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 1 _ PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR r LESS CONSTRUCT S Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancy 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. The Commonwealth of Massachusetts E Department of IndustrialAccidents M I Congress Street,Suite 100 Boston,ALL 02114-2017 "t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name(Business/Organization/Individual): �'�'� L l��l l "l�ti�f Address: a � L' r�&-o1 A City/State/Zip: N 6 d-k (vk6 y` I P- Phone#: Are you 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.F]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling a"pacity.[No workers'comp.insurance required.] u,-�,/ 9. ❑Demolition 3. 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions S.❑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.t 6.Q we are a corporation and its officers have exercised their right of exemption per MGL G. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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 insurancefor my employees. Below is the policy and job site infoswiation. 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer under the pains and penalties of per jury that the information provided above is true and correct. Si nature: _ --- -- Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �4K ar fi'�y TOWN OF NORM ANDOVER. ORFICE OF BUMID:MG DEPARTMENT • ' a ,� X600 OsgoadRXeetBi lding20,-Svzto 2-36 7$�3 b�4�`�5 •NoitZ Anzlovex'y Massaohusetts 01845 t'rexaId A,Brown Telephone(978)688•-95'45 Iuspeetorot:Bi ldings _ Fax (978)688-9542 . R(D-MEO)MR•LICENSE E ,P-WTION BEDING)MMMTAWLICAzTION pleasepr2nt DATE: Number Slxeetddress Map/Lot Name Home P:houe W orlt Phone PRESENT MA:ILIN•G ADDRESS c 3Zip Codo fihe current exemption fox"homeowners"was extended to?nehide owner occupied dtvelings to t4vo units oa less and aallow such homPa,yuexs to enga¢e an.in,dividsau• r lire w:no does notpossess a license,provided that the owner acts as supervisor)• 8-i oDulding (Code Section D-UM-ITION OFHOMEOVM Persons)who awns aparcel of land on which he/she resides or intends to reside,on which here is,or is inteuded to ' be,a ane or two araily structures. A.person.wlio constructs zaoze tTiat.one hOMO in atweyearporiod shall not'be considered a hDmeDWnor, The uuderszgned"AottteciWace'assumes respousibilityi'ox compliances with the StatoDuilding Code and other applicable codes,by laws,.xWes and-iegulatxow. The undersigned"homeowner"cexti,�es that he/she imdexstauds the Town of14orth AndoverBuilding Dq�artment nlnimum inspection procedur:11,1101' ents and thathe�she will comply wzth,saidpzacedures and requirement.-,HON.[EOWN;E;RS` , A2'I'.lt.OVAL OF BUMDMG OFFICIAL Reyised 7.2009 X oOnn l:lomeowners Exemgon ')30AIZI)OFAPPBA75 689-9541 CONSERVAUON 689-4530 - BEALT,H'688-954a E1;:3.NWNG 689-9535