HomeMy WebLinkAboutBuilding Permit # 4/16/2015 .Y...,.,.w , U1Ll to FI=KMI1 Noo
TOWN OF NORTH ANDOVER ° �►
APPLICATION FOR PLAN EXAMINATIONb`
Permit O: Date Received
115
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Date Issued: .�
IWORTA.NT:Lk2pficant must com fete all items on this page
LOCATION Vi a"
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PROPERTY OWNER A M
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MAP NO " PARCEL `ZONING DISTRICT: Historic District yds a
Machine Shop Village ye 0a
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building N,One family
❑Addition ❑ Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
47I � � fJi ' ?_
Identification Please Type or Print Clearly)
1 C Phone: >': C 0(
OWNER: Name: -sf' ` � .:.. • �' � ... J
Address:
CONTRACTOR Name: Phone:
Address:
'LAJ �"J(-J tve
Supervisor's Construction License: Exp. Date:
Homo Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. 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: $ I 5 0() 0 FEE: $
Check No.: r_- A Receipt No.:
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NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner ?'� t� �i` ��1
T�Signature of contractor
NORTH
Town of
2 s Andover
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OLA ah ver, Mass, IN
A
COCNICHCWICK.
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BOARD OF HEALTH
tiERM-IT T LD Food/Kitchen
Septic System
In
THIS CERTIFIES THAT .......... .. . ... . ......... i :�.1. ..........................................................................
BUILDING INSPECTOR
...�. Foundation
has permission to erect .......................... buildings on ^�........ .40.!4...... ...........................
Rough
to be occupied as ............ .... r. ..t ......n.................... :... ..... .:n...........:............................... 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
PERMITI ES IN 6 MONTHS ELECTRICAL INSPECTOR
1•
UNLESSCONSTRUCTION S Rough
Service
................... .... ......... .:................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Bu Rough
Islay 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.
�4K,Ao ur j y TOWN OF NORM AND OV P,
OFIRICE OF. _. -
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• ' Ana :1600 Ds9oaaStrOotBuffding2Qo•Surtc,236
XazthAnd vex,l assac usetts of 845
Gerald A.Broun - Telephone(978)688-954.5
Ins
peetorofBuildings Fax (97-8)689-9542
H aWNERTTCENSE tYEzvfP'�xol� .
BNI�J[N Tdt7C'�`A7PPLTCATfON
1'leaseprtnt
DATE: -
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SOB LOCATION,, 5)
umbex Stu-'aAddress . Mago�t
OME0 �1ER '` 6Jl G t 1 r C� J J L� (4r)
Name. lozne l?Itone Workl?&ne
PRESENT MA6NG ADDRESS �' /�7~� • � . ..
C' r tm -
ip Cods
The euzrent exempfion for llomeow�zexs"txras exfenclad to elude ownex occupied divelu a v =- 1
to a71a, subT�Romeo,, �s to i�.o units ox,oss am
suers to engage an?Jdivid-aal.for lire w:no does not possess a license,provided that the,ow.uez
acts as cape visor). Rfafo)301 cling (Code Seotion 7.o8.3.5.`t)
IEF. ITION OYHOMEOWNER ,
persons)who awns aparoel ofland on urhich he/shexesi�es or intends to reside,on ubich-there is,ox is iafended to
7�e�a one ortwo fazpily st�ucfuzes, "A.person �a constructs�oretriat ane�onzexa a G�voeazperAod shall z�ot7�e
eoz�sidered alsomeo�nex,
The undersigned"homeowner"'assumes�esponszbiTi€yox compliances uTzfh tie MateBuilding Code anti other
pplicabla codes,by laws,,xules and-xegalations.
Therzadersigned"homeownex"cexfxles that he/sTie ndersfands the Town of North AadoverBuilding Dq�a ent
xnmuuum ins
peofion procedures and requiroments and that h0kho will comply with;said pro cedures and
.requirements,
HOIVMOWNLR.S SIGNATURE ,
A)'?,ROVAL OF 13=D) G OFFICT_A_L
Revised 7.2009 _
Farm Romeowners Exemption -
8OA'RD OF.APPEAM 688-9541 C01\19EK,A.uoN 688-9530
YMALTH689-9540 PLANN)NG6859535
The Commonwealth of Massachusetts
43) Department oflndustrialAccidents
a l 1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dna
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE TILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeObly
Nalne (Business/Organization/individual): d4w q k . -�_/'1'J d
.A-d(hess: 0/ Pa v I.s S4- ) ,%l dli A to d c"i c
City/State/Zip: kcrl� 4014.1'<,I^ 1' , Phone#: 315/- AL1
Are you an employer?CheckAe 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.;�J 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
10E]Building addition
4Y1 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 1 l.❑Electrical repairs or additions
proprietors with no employees.
12.F]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.F1 Roof repairs
• These sub-contractors have employees and have workers'comp.insurance,l
6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑OthOr
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.
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-c6niraciors tave employees,they must provide their workers'comp.policy number.
X am an employer that is providing workers'compensation insurancefor 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 certify-under the pains and penalties ofperjuiy that the information provided above is true and correct.
Signature: Date:
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Phone# v� o CJ Hyl '
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#:
u\
00
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