HomeMy WebLinkAboutBuilding Permit # 4/15/2015 BUILDING P �ORTy
MIT o� O , �N
�� h�4x rb g6 � III
TOWN OF NORTHA
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received °°o'`�`Nµ'pa
� cwus�c
Date Issued:
IMP RTANT:Applicant must complete all items on this page
/
„
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
Im w o'.ml /, i..i, ,,.-. ,ir, , �„ ymra A�r I N+ lafl.. .r, /"„ rf..,rl Y ikr✓/.. r,„r ,„r li ,; l 1 , re4'/, flir' Y� o11�wInV"'r�d
�� �, I food�I in'I i Wetly dls �� ❑ e�s�r e w ��,n,, ��/
DESCRIPTION OF WORK TO BE PERFORMED:
entificatio , Pl ase Type or Print Clearly
OWNER: Name: Phone: Vn
Address:
I
I' I.
r ` r
� aY+Ce � ✓ �c,
I p I
I
,Im
ARCHITECT/ENGINEER Phone, "
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$9200 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F_
Total Project Cost: $ FEE: $
Check No.: Receipt,No:;:
-NOTE-: -Persons contracting with,unregi gntractors donothave:access-to-the-guaranty fiend___
/7rio
P,,.l�� �{, rr as l .. r ✓7T�' r�'I .,!,.l /T r,r ri/�//I/,. //Ti/ ,.. v 7 r„ t
�.�o,.g.,���.,�, ,�og,o� .�a�>u_/�.�z�� / �,r✓�g ...r�e� ,�.,�,Ir �_«.,,m;,r_,���, r 1,,,�,� I
F N®RTH
Town of t EAndover
No. d�— - _
r, Mass14
ve ,
COC
HIC"
t
Nl W.CN
S V BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT .....................�v ....... ..... ..................................
� .'•... .... Foundation
has permission to erect.......................... buildi gs on ... U.1......... .........•.••.
................................................... Rough
to be occupied as ......... .l. p 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION TA S Rough
Service
..................... .. .................................................... Final
BUILDING INSPECTOR
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.
TQC OTS`NORTff• OY{ .VJ4s.�y{,y�
4L•❑ Y fT T
�Z OFFICE OF
BUffiDINGDEPARTMENT
• ' �Q��e`'x :z600 IQsgoodStreetBuild `
g20,-Surte 2-36
ygS�inn 5 5
North Ando-var.,Massachusetts 0x845
ACHt1
Gerald A,Brown 'Telephone(978)688-9 45
InspectoroTBuildings _ fax (978)688-9542
H(MEOWNBR-LTCENSE EXEMPTION
please print
DATE:
JOB LO CATIfON: // - BA.,q kek ,
Number %34A.ddress Map/I,ot
Name. Rome phone W ork 1'llone
PRESENT MAILING ADDRRS 81/!
['-i y`P =m. �fafw
Zip Code
T.he cuzrent exemption for"homeowners"was extended to
nclnde 0wr1
er0 rc"PIed divellings to two units•DX;ass and
Ica allO}y b-h ho-mao"Tmers t9 ei3ga,e an:hffi(1 di1al. Orl]]Se yy(�o d08S 7Dt17055e$s a 1Ce31se,provided t7iattthe oy,mer
acts as suPDzv1sor). State3uilding (Code Section.108.3.5.7)
DEFINIITON OFROMEOWNER
Berson(s)wSlo awns aparcel of Xand on
bb which he/she resides or intends to reside,on which there is,or is intended to '
-'a one or two Family structures. A person who constructs more that one hOme in.a tyre
coyearperiod shall not be
considered alaomeowner.
The undersigned"homeowner"assumeszesponsibilityi'ozcbmpliances with the State Building Code and other
Applicable codes,by-laws,zules and'zegalations.
The undexsigned"homeowner"cextitxes that llelshe yanderstands the Town oTNorth Andovex3uilding DearEment
3ninimum inspection pzocedures and requirements and that Tae/she will comply with,said pxocedures and
requirements,
-UOAMDWN.ERS SIGNATURE
A PROVAL OF BUtI D)NG OFFICIAL
Revised 7.2009
Form Homeowners Bxemption
'fidAR'D OFAPPEATS-689-9541
CONSERVAITON 689-9530 DBALTH 688-95$0
PI,-WING 688-9535 •
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston,MA.02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lel=ibly
Name(Business/Organization/Individual): 9 0� 114
kA
Address: /1/ BAPS
City/State/Zip: Aq. Aqd6 V(--A0641- Phone#: 7 6-
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.Q 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. ❑Demolition
3.N I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]Building addition
<1 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.Q Plumbing repairs or additions
S.❑I am a general contractor and I 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.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
have no employees.[No workers'com
152,§1(4),and we p.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,lhey must provide their workers'comp.policy number.
Iain 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.#: 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 cer ' under theandpenalties ofpeljury 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#:
