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Home My WebLink AboutBuilding Permit # 4/21/2015 ,.w..................... V%ORTH "ID, ."$6 "� ., BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received U Date Issued: T 1*PO ems on this page �%/,�/////�111�1,�1�� r , f , , �r,�l J u��lll Jf�� l� 1� f � � �/rl�, �� , � j i � / � / � Ofit r r � /;�%/ ;YA f W TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building *One family [I Addition [i Two or more family [I Industrial Alteration No. of units: [I Commercial [I Repair, replacement [I Assessory Bldg [i Others: [I Demolition [I Other KENN "fi MA f Irl�y f . �� , r�r I J��„�1e��i��1��f �,.�� ,��1,,��f�� >�� r Identification Please Type or Print Clearly) OWNER: Name: vilo A4, Phone: Address: 5ke6f ARCH ITECT/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: $ 66( - 00 FEE: Check No.: ' PL3 C,-'— Receipt No.: NOTE: Perso7s co; acting with unregistered contractors do not have access to the j#arantyfund S.J( 'n, , JAORT-k. Town of2 e ndover a, -t `T®yamNo (] ® 4 O LAO(& W t+l' C `LSS, COCMICKCWICK �A- �,4 a°RATED `S U BOARD OF HEALTH L D Food/Kitchen Septic System PER BUILDING INSPECTOR THIS CERTIFIES THAT .. .... . .................................... ................ ��.` Foundation has permission to erect .......................... buildings on .. ... . .... 1{I ......... ... ........... ... Rough ... . ........................................................................... to be occupied as ......: kaft..... 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 v PERMIT ES IN 6 ELECTRICAL INSPECTORI - S .. RoughCONSTRUCTIONService UNLESS . Final BUILDING INSPECTOR GAS INSPECTOR O ecu ancy Permit Required to scup atRough Display in a Conspicuous Place on the Premises — Do Not Remove Final r all Be Done FIRE DEPARTMENT No Lathing Until inspected ve the Building Inspector. Burner Street No. Smoke Det. 0ORN TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 0 North Andover,Massachusetts 01845 CHUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: Ll JOB LOCATION: Number Street Address Map/Lot A HOMEOWNER i'll 07- 3?0 - Name Home Phone Work Phone PRESENT MAILING ADDRESS 16 A?n 150 �2ee Jt NO/I 4nGlom 440- City Town State Zip Code_ The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will compP.Awith said procedures and requirements. < HOMEOWNERS SIGNATURE `-_ APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF AIIPFIMS 088-95,41 CONSEI2VA HON 6H-9530 I*AL 1-H 698-9540 PLANNINGi 689-9535 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 1 Boston,MA 02114-201 r� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/l lectricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. A 1><cant Information Please Print Le>TiblY 1 Name (Business/Organization/Individual): 1/1 Address: 9 '.fa�an City/State/Zip: a /1( ®t it /r Phone#:�� Are you an employer?Check the appropriate box: Type of project(required): l.Q 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.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.VI am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.(]Plumbing repairs or additions 5.Q 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'camp.insurance.1 14.Q Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 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 aan ari employer that is providing ivorlreas'compensation ia:sur'aaace for'my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: i 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 paints and petialtie of petjnly that the i►tfor oration provided above is tr' a a�ad cow ect. Date: �A Si nature: �. 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): i LLI.Boardof Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector erson Phone#; Q- \.-q Ci ON, >lr Al GA-1