HomeMy WebLinkAboutBuilding Permit # 4/23/2015 BUILDING PERMIT o���pT bgtio
TOWN OF NORTH ANDOVER $'� " "
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received ArED
gSSAC HUs��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION `Z .
Print
PROPERTY OWNER
Print 100 Year Structure yes no
ITO
MAP PARCE( 0 7 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
'"ew Building c J�l`1 ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
entificannt��'on- Please Type or Print Clearly
OWNER: Name: -J ov�VL Yl' Phone:
Address: ILI he +
Contractor, Name: Phone:
Email:
Address,-
Supervisor's,
ddress:Supervisor's Construction`License: Exp. Date:;
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
)Total
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Project Cost: $ FEE: $
Check No.: j Receipt No.: 'P
DOTE: Persons contracting w'h re,'istered contractors do not have access to the guaranty fund
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑
well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank, etc. ❑ Permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENT'S
i
CONSERVATION Reviewed on Signature
COMMENTS
,rd
HEALTH Reviewed on Signature
COMMENTS
—,\
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Seger Connection/signature&hate Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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fown of
Andover
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COCNICIIEWICN 1'
RRTED
U
BOARD OF HEALTH
PER Food/Kitchen
Septic System
THIS CERTIFIES THAT ........... �� ,,,,,/ ;; 1C ......... BUILDING INSPECTOR
has permission to erect ... '
.......................... buildings on .....�. ....... ��" . .............................. Foundation
Rough
to be occupied as .............A��a
....... . ...................�..�.............................. Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT E I IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTION ST RTS Rough
Service
................. .....Gtr„�.���„ '......... -;---�,
BUILDING INSPECTOR Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises - ®o Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
4 �toKry TOW OTS`N0R'a H ANDOVi p
OFFICE OF
R �
-.160 0 Dsgoaa StraetBuilding20 •Suitp,2-*36
7 ��� n F4��5 • '
North Mdo-vox,Massachusetts 0l 845
Ssrcau5�
Gerald A.Brown Telephone(9 78)588-9545
7nspeefox o $uildzngs _ pax (978)689-9542
ROMEO'WWN"ER LICENSE RXEYRTION
Ai!) Lr TCATfON
please print
PB LO CATIbN:
Number SlxeefAddress IVMp/Zof
Name. �.
dome phone Woi-Maone
r r`
)?P,E8ENNT MAZ[sIIqGADARES,S �`� �'��i � - .:. •
t
fu tynn. Si'tom. .
a dip Code
The cuzrenf exemption for"homeowazers"was extended to inelude owner occti ied
fo allow su h homPo,� - p divelin�s to t�vo units o'r;ess 2nd
uers to engage an L`C"Viaual•forhire who does n.otpossess aBeflnse,provided that fTie,owner
acts as supervisor). Sfafe-Building (Code Section 108.3.5.7)
DEFMI.TION OFROMEO`WNE1R
Persons) who awns a parcel of Jand on which he/sloe xesiaes or intends fo reside,on which there is,or is infended to
J�•e,a one or two family structures. A person,w�.o constructs more fhat.one home xn.a'Ewa�earpeziod shall not'be
eaz�sidered a horneownez.
The undersigned"hotrtedwnez"assumes responsibilifyforcbmpliances wifh the State Building Code and other
.ApplicabJe codes,by Jaws,xules and xogulatiom.
Theundersign.ed"`.bomeownex"cextifies tlzaf lre/she understands the Town ofNoIxfh.AndoverBuzfdffig De�arfinen
3niriimuzn inspection procedures and recluirezrzen and that h /she will comply with;sand pxocedures anfd
xequiremenfs,
BION.LEOWN ERS SIGNATURE � M
PP.ROVAL OE 13TJJI,DMG OF.p`.ICL4j_
Revised 7.2009
Fonn plomeovmers Psxemption
r Y;
'Z30AR))OFAPIPFA7,5 688-9541 CONSERVAMN 688-953o
TMALT.H 688-954o PLANNING 6889535
The Commonwealth of Massachusetts
M F Department oflndustrial'Accidents
{ : = µ f X Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE Fff ED WITH THE PERMTTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/O-r7gia'nizationffndividual):
Address: ko f 4.
City/State/Zip: LA W�ueMPhone#:
Areyou an employer?Check the appropriate box: Type of project()required):
1.❑I am a employerwith 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. am a homeowner doing all work myself[No workers'comp.insurance required.]t
100,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 withno employees.
12.E]Plumbing repairs or additions
S. 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.insnuance,t
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.
X ain an employer that is providing ivof kers'compensation insurance for 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 WORD.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 der thq,pains and penalties ofpeijufy that the information provided ov is true and cors ect.
Si nature: f C� Date: o2J
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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: