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Home My WebLink AboutBuilding Permit # 4/24/2015 ............ %AORTH BUILDING PERMIT o�RY4�D ,4�ti O TOWN OF NORTH AN OVE �m- APPLICATION FOR PLAN EXAMINATION � a Permit NO: Date Received ^D " Date Issued: . ��Ss A'rvo IMPORTANT: Applicant must complete all items on thisa e LOCATION ° / 0 , , ? 517 , 'PROPER77",,' OW EFS , %I Print Maph�rte storlc[��stnct � yes on ago, yep. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family �ddition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ,�, Well � ❑flpodp�lain�� ❑111/etlar��s � 0JWatesF,0 E 1?Uaor/ dwer. , , ,, I,, .2. ev c Identification Please Type or Print Clearly) OWNER: Name: T UvGC.,_D Phone: 60—oZ7s--T3`7q Address: CT CgNTRA QR" Name 0 n e Adldress Superu00r,s Construetlon Lig nse hxp ; D Hme irrprcumenE laden , Exp: Dat 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: $_ . Q 00 FEE: $ Check No.: L Receipt No.: ? NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne ^Signature of contractor t%O R TH Town of EAndover Zo LAKE h ver, Mass, COCMICHEWICK 1' Q \ S V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT .......!�.�:.�!:`�..... ��;�y r�1��.......................................................................... BUILDING INSPECTOR has permission to erect................ .... . ............... Foundation .......... buildings on .� � ... ... .°� :Yf ? `.....L�. ::'.�1 F ,p 3 Rough to be occupied as ........ .� i. r r??c� ................. �,,r�� .. �?�� ................. 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough Service .................. ... . . .. ..... Final c�� BUILDING INSPECTOR GAS INSPECTOR Occupancy-Permit Reguired t® Occupy Buildinz 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. "°RTa TOWN OF NORTH ANDOVER or a - OFFICE OF BUILDING DEPARTMENT a 1600 Osgood Street Building 20, Suite 2-36 �Qsaerau5��y North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 HOMEOWNER LICENSE EXEMPTION Fax (978)688-9542 EXE Please print DATE:_ !I /==q I is- JOB SJOB LOCATION: a/c2- Number Street Address l _ Map/Lot HOMEOWNER �]5H&) gnu Q,) 7 s 3 3 79 Name Home Phone Work Phone PRESENT MAILING ADDRESS V49-f /f/G¢ 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 comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents a , d 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 LeLZibly Name (Business/Organization/Individual): -7, v' Address: ( City/State/Zip: dot, • u� Phone 1. 7S'3 3.7.7 Are you an employer?Check the appropriate box: Type of project(required): 1.Q 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. Remodeling any capacity.[No workers'comp.insurance required.] 9, El Demolition 3,[311 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑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.Q 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.] IL '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. #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 am an ernployer that isproviding ivor'kersl compensation insurance for niy employees. Below is the policy andjob 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 thepains andpenalties ofperjury that the information provided above is trite and correct. Signature: Date: i Phone#: c c�� 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#: t{t{\\ W j V \, J� : r �[