HomeMy WebLinkAboutBuilding Permit # 4/24/2015 t%O R TH
BUILDING PERMIT o*�t.ED
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION A
Permit No#: � Date Received
�SSAc HUSE�c
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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Machine Shop Village yes � no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New BuildingOne family
11Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
JI-Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septics ❑Well ❑ Floodplain FWetlands ❑ Watershed District
DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: tra
Contractor Name ,Phone '
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Home=Cmprouernent License ' , ,: r ,, Exp 1-s -
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: $ 4/3/00 0 FEE: $
Check No.: ' Receipt No.: ,
NOTE: Persons contracting with unregistered contractors do not have access to ranty fund
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Signature of Agent/Owner Signature of contract r
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h ver, Mass,
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BOARD OF HEALTH
PERMIT �T�
Food/Kitchen
%J L Septic System
THIS CERTIFIES THAT ......I1:.c .. :'�1...F.:........................................................................................ BUILDING INSPECTOR
has permission to erect ................... buildings on �� �Sc;? Foundation
......; g ......... ......... X-" ........ .............................. Rough
to be occupied as ..... ...�.`�. ,� 1 :..'/.. �� s .. .: ��F / 6
�°•• f. �.�:i�� Chimney
provided that the person acceptin this permit shall in every respect conform to the terms of the application r�� 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 COSTRUCTIO TARTS Rough
Service
.................. . . ............................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
Department of Industrial Accidents
i d 1 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 Le ibl
Name (Business/Organization/Individual): 'T
Address: e
City/State/Zip:
r�'/ �%� J �j Ph ne#:
�
Are you an employer?Cheek the appropriate box: Type of project(required):
1.F1 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 $, ;Remodeling
any capacity.[No workers'comp.insurance required.]
9. Demolition
3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]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.❑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. Roof repairs
These sub-contractors have employees and have workers'comp.insurance) ❑ p
6.
1%—
We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]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.
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.
lam an employer'tliat isprovidingworkers'compensation insurancefor my 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 certif n�der thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: 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#:
V.,massacosetts -Depr rtment bf Public Saf y
Board of Building Regulations and Stanrds
Cd115t1`uctioli Superl,i..sol
* .. z
License:CS-026854
PATRICK S CONSTell
89 Ames St `f
Methuen MA 01944 a: i
l
�A Expiratior
Commissioner 06/23/201E