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HomeMy WebLinkAboutBuilding Permit # 4/27/2015 04 00"Tol quap IT 0 BUILDING PERM TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received lb Date Issued: I MORTANT: Applicant must complete all items on this page 1,,,,, I ,r�, / r/, ,,1 f � ,,,r /ri`: r/ �/ < //, /r/ / ,r, �,, v/,,. r r),r f1 /�, l� i", rh;., r r,, „� ,,,, ,��i,��r„ !-, l,l�llv,�r, �� o- ,/ i ,r r,r,,��� r, ,,,r,i©r ,, /.,l/ ri /� rl, r/i/i, /. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building .`One family El Addition El Two or more family El Industrial XAlteration No. of units: El Commercial El Repair, replacement El Assessory Bldg El Others: El Demolition El Other M, OR fly” b, Identification Please Type or Print Clearly) OWNER: Name: A/ sz&z 2t� Phone: Y'?F— Address: o20 2Ldl S7 Nage74 14ydal."ems WX. aIF4-s- NONNI, .......................... ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 19" )00 FEE: $ Check No.: �2 2— Receipt No.: 'P N/0TE- Persons coAfrectigg with unregistered contractors do not have access to the guaranty fund g n t 0 { Andover C% LAKE ti ver Mass, COCNIC Hl WICK A. P \ RATED '' '�C) U BOARD OF HEALTH Food/Kitchen Septic System 4*THIS CERTIFIES THAT........ LL.*.. . BUILDING INSPECTOR P.Nd . Foundation has permission to erect .......................... buildings on ,k).... ...�. ......... ...e................ V � Rough to be occupied as ..........................................................dooem% ..... !4.11-...t... ... .... 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 PERMIT EXPIRES IN 6 M0VTW I ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO Rough Service ................................. ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingor Dry Wall To Be One FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. y�o ery To "OF NORM AND OVER OFIFICE OF • ' ,t� v <, :'160D 10sgooaStroctBuff&9209-Suxto,2••36 r K Rao eoviceix`,? `I.S AA}lrb h4�.[5 - •--Xorth Andover,Massachusetts 01845 S.sct�us�. Gerald A,Brown - Tolephone(978)688-9545 1aspeetor of'Buildings Vx (978)688-9542 HONMEOWNER.'LICENSE EXEMPTxON • 1'leaseprint SOB LOCATION i� ,d Number StreetAddress Map)Zot Name. . Home Phone Work Phone -'RESENT MAILING ADDRESS / � Citi'Pn _=m vfw• 7i (`or7 The current exemption far"homeowners"was extended to incItitde owner occupied divelings to tvo unifs-or:ess and 'co allow tsubbh horneo.iem to engage an jnCbidual.foz dire-Who does notpossess a hemse,provided that the owner acts as saper-visor). ,gtateB3iiding (Code section 108.3.5,7) DEFINITION OFROMEOVMR Persons)who Qv1ns a parcel of land on which he/she resides or intends to reside,an wMch there is,or is intended to bi;,a one orfwo family sfzuctares. .A.persotttvho oonstrucfs more that.one home in•atwo yaarperzod shall ztot'be considered a 70meowner, The undersigned".homeowner"assumes responsibility forcompliances with the State Building Code and other .Applicable codes,by-laws,rules andTogulations. The uudersigned"homeowner"certifies that he/she understands the Town of North Aadover Building Department Minimum iuspection procedures and requirements and that he/she will comply with.;said procedures and requirements, . S�ON.IEOW.I`7'.LRS SIG�7ATTll� ' APPROVAL OF BUff D)NG OFFICIAL Reyised 7.2009 FDam SSomeowners Exemption 'EQARD OF.APPEA.T S 688-9541 CONSER•VAUON 689-9530 DBALTH 688-9540 PUNNING 689-955i The Commonwealth of Massachusetts Department of In(lustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E4 lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: a?o 73-1 i i- CiV/State/Zip: Noltl_lr' 4ya�avel2 Phone#: R.5—.3 — 7 Are you an employer?Check the appropriate box: Type of project(required): 1.[]1 am a employer with employees(full and/or part-time).* 7. E]New construction 2.[:]1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling --A any capacity.[No workers'comp.insurance required.] 9. Demolition 3.;C I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.[:]1 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 I LE]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.[]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]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. 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. Iaman employer Haat is providing workers'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 verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: 5— Phone#: 074— 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#: