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Home My WebLink AboutBuilding Permit # 4/23/2015 BUILDING IT �,oRrH TOWN OF NORTH ANDOVER oma' APPLICATION FOR PLAN EXAMINATION y "yak my / R Permit No#: Date Received '� poR�reo rpa ccs ' gSs 9CH11S Date Issued: I PORTANT: Applicant must complete all items on this page p ti✓ 1 11 II � !r � ( I" r I `�,` ^ u� ,., ,,I, t Q r�1W�' { ��1++s w�yf WII !""" ON i WN'➢9 .. �..t' Y�'�Y 1 J I I I p a. I ...nt. �./,�, !�� rrr I J� ✓rr n,d,,lluro TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ,P-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r nr ./.o �,,,1,,nlIorfrnd";,fdr, -,l 11��1rrr 1 i J Y�rro�,a,,�,m6mx.ior°e'/%/rr✓ro,1k�C�lfflfl(ff06 ri-,,(/kl�1�f(!�I�)�r!I1 4/r J,�,,. ��Y!I��I rii,l!�l/�.,'�rrf'�"1 Q`�,.(L,.(P,�r.l<rlf,brf&,Adr.r,�e arf�,or.jY�,'P,Yi,.:,..�/,K1jII('a./'C/c�/„(Nf�n1U(O�/�//Jj Jl/�,��j��r .>f DESCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: " Identification-kS "PleCboType or Print Clearly Phone' Address: , 111 Il f 11,I W,, "I1'� f,11 N , �h �" �ii Y u� �, �,Y;•, rro i I�(r, �'.r; �I�, o a 1� Y� � , ��Y I,u �i � ,h IiF�I u � ��l�� t nu,„I 11 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ I ,,- C ° FEE: $ Check No.: Receipt No.: ' f” NOTE: Persons contracting with unregistered contractors do not have access to the guaranty,fund ,Signatureof Agent/Owner �,,,,� Signature ofi,,contractor ,,, ,;,�r,,, /,,,,�� r�,/�r/ rip tg®RT H own- of And clover 0 O ® f•t_ O LAMS h Ve>l'' d.SS COCIIICIIl WICK AERATE® P•PL D�`��(� � u BOARD OF HEALTH Food/Kitchen PERm Septic System ' <..c,�.� ... '� THIS CERTIFIES THAT ..... .:��?......... ��`/`'� BUILDING INSPECTOR . ...... ... . .. has permission to erect ,.,. Foundation p .......................... buildings on s�,�,� / to be occupied as �.-,�„?ec �/� .... :�'1 ... `�'�,5 � r� ....... Chimney ....... .................. ...,,�.�r.:7!I :.. ........ Rough hey 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESSTARTS Rough Service .................................................................. ..... Final BUILDING INSPECTO GAS INSPECTOR Occupancy .Permit Required t® Occupy Buildin„z 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. 04 ar �y TO"CDFNORTH AND own 01 TICE OF :BUffiDING DEPARTMENT 1600�Jsgood e Building 20 Suite?36 yy Str e� • '"G` ITS LCGV4iEitkKK , • . 'f NorthAndo-vex Massachnsetts0x845 ss�ct�us� ° - GeraTdA.Brown Telephone(978)6$8-9545 3nspeetorof$uildings _ Fax (978)689-9542 -HtJM-EbWMR LICENSE BY,EMP TION BMDG l;'"EPM- T ARPLICA.TIO • 1'IeaseprinE DATE: �OB LOCATtN: 2,31 6v CA Number SlxeetAddress Map)x Ot IMMOWNER Name. Eozue phone Fork Phone PRESENT MA6NG ADDRESS 7 "tyTnTm - 7ipC�ds The current exemption for"hoaneotAazexs"Was extended to nchtde ownex occupied divehings to t4vo units or,,e apd fo alloy such oanPo suers to enga¢e an div;a-Hal.for hire-WAD does ao�possess a iicDaisa,provzded hat ate Mwr acts as snp5n4sor). 9fateDOcling (Code Section DLEMI.TION OYROMEOYM Pexson(s)Who QWns aparcel of land on wluc7x Ite/she resides or znfends to reside,an wzicla there is,ox is xnfended to h ��,a one or two family straetares. A person Wlxo contracts more that one home in•a t za yearperiod shall not be eomsidered a homeowner, The uuderszgned"homeowner"assumesrasponszbilztyiorcomp7iances�vatEz tie stateDuzlding Code aRtl other App73cable codes,bylaws,razes andragulatiom. Tho undemigned-homeowRop certifies that he/she lnderstauds tl1e Town of Borth Audover33uilding Do�attment inspecfion prooedures and requirements and that he/She will coraply With;said procedures and requirements, 3EIOME0•t rMRS SZGNATM APPROVAL OF 13UT�[LD)NG OFFICIAL Reyiseti 7.20Q9 P'orm�omeowners rsxemption • • ')3DA2tD OF'APP,EAM 688-Ml CONTSER,VAMN 686-9530 - S3EALTH 688-9540 PLAT7NING 689-953i • The Commonwealth of Massachusetts ' f Department oflndustrialAccidents E a 1 Congress Street, Suite 100 Boston,MA 02114-2017 ti< ,y; t wwwanass,gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERIVL[TTING AUTHORITY. Applicant Information Please Print Legibly NaMe (Business/Organization/Individual): 5"c o- Address: 3 � D-e- vut4 R City/State/Zip: Phone#: Are you an employer?Check the apliroprlate box: Type of project(required): l.rJ 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. F1 Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.hlsurance required.]t 10 Q 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.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ t 13.0 Roof repairs These sub-contractors have employees and have workers'comp.ins�.uance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employces.[No workers'comp.insurance required.] , • Fi *Any applicant that checks b6x#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-cbri6actors Tuve employees,they must provide their workeis'comp,policy number.' X aim an employej•that 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: ` t City/State/Zip: / t �( y Attach a copy of the workers'compelrsation policy declaration page(showing the policy number and expiration c[ate). Failure to secure coverage as required under MGL o. 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 S'T'OP 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 DTA for insurance coverage verification. I do hereby certify under the .nsa enafles ofpeijury 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/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Ste'` �jc'�l Cal � - -'° J