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Home My WebLink AboutBuilding Permit # 4/22/2015 �oRTH BUILDING PERMIT °&R``E° '6%6 TOWN OF NORTH APPLICATION FOR PLAN EXAMINATION 0 - Permit Vo#: Date Received .ssacH`use��"�nR`"5" Date Issued: ' PORTANT: Applicant must complete all items on this page KwPrint PROPERTY OWNER w rint' "I00'Year,Structure yes S � � Di"strict" e no Historic' MAP � PARCEL: ZONING DISTRICT: y Machine Shap gY Village es o _ TYPE OF IMPROVEMENT PROPOSED U USE Residential Non- Residential ❑ New Building KOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other p III g IPili�iq P�1",� � Ull ar'r"�iN 'w��(a�w"��id .,. IIIIiW� � .o �ftp a (a�� 7 i�� •; i w a�I� � i�. e e �+ ��W � o� i�tl0(��'u" , ), xtia 1rG DESCRIPTION OF WORK TO BE PERFORMED: a Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address:; Supervisor's Construction License: Exp. Date:' Home Improvement License: Exp. Dates ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE,BULDING PERMIT.$12.00 PER$1000.00 OF T STIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ - FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i1111,76"Gce ,V7f//g ","P/,'/ %Gii%. tkOE3TH Town of -Andover ? *, - 0 . ver, ass, coc.'C.Ewecz �a �,9 A°R�r�® S � BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............................... BUILDING INSPECTOR has permission to erect buildings on Foundation Rough to be occupied as ............ .. .. ........... ...... . ..... . .. ...................................................... Chimney provided that the person acceptin is permit shall in every respe nform 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 I ELECTRICAL INSPECTOR Rough Service ............. .... ....... g Final ® BUILDING INSPECTOR GAS INSPECTOR ccupanc-p Permit Required t® Occupy Buildina Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. TO"0MORM ANDOVER [OF-Fx-C�jE OF �wJ^,+' � " Y-�.—+.a—s-� .K�aL�H W.%-��.+.A-.e.'F.�-x.P.LL'I.a.♦� ' 4 1500 Dsg0aaStz-00tBuxXcZrn 20,-Soft —?-'36 r "pRatxn FQ 4�t5 MithAn lover,-Massacusetts 0x 89.5 �SSRCNUS�� tl h ' Gerald A.Brown - Telephone(978)699-9:545 lnspectorot:Buildings _Fax (97-8)6889592 M"ter+,pFIT"PLICA.TION s :YOB LOCAT�ON.' pleaseprint - , Wuznber gfreet.Address Map)�ot Xamo..._M ooze l?l�ozz orT Phone PPMONT MAUiNG AMMESS c"Z clr&Y�' m ip Co� TAB current exemption fox"lloxaeownexs"was c tended to Glude owner ocDupied ditlli_ngs to two units-q-rims and fa allow such ho-rneomax-sto erngage anlncividual•for lire�rhn does aDtpossess alzce�ase,Providedflaatthe owner acts as supervisor,). u�tulfe3Vilding (Code Seotion,108.3.5.j) - I) WITION 0YROA00WER :Person(s)who awns a parcel ot'land on wlz%eh hdshe resides Dr intends to reside,on which fhere Vis,or;.S xnfended to bb,a one or two f'am ly straGtares. .A persoimho constructs more tSiat one:home in at�vo earpeziod sha11 lot bp considered ahomeow11er . Tho undersigned"hDmeownez"'assuanes xesponszbility orcbmpliauces with tha StateBuilding Code aRrl other.Applicable codes,by-laws.,tales and-xegalagons. ' Tlaeundersigned"' omeownex"'oert fies that-he/shoiMdexstaud9 MO Town Of North Andovpr Building De�attmeat '�YlYti7TTium inspection.pracedures and requirements and that helshe will comply with,said procedures and '.. req,Virements, . A-PPROVAL OF 33TT.d'.aDMG OFFICIAL RBY;sed 7.2009 - X'DS7ilozneovtrierssempfion 8O,ARD OP'APPBA7-688-9541 CONSPR,VAMN 688-9530 TMA f 688-9540 PLAWNWO 6899535 The Commonwealth of Massachusetts z Department oflndustrialAccidents K = 1 Congress Street,Suite 100 - F 4 Boston,MA 02114-2017 www mass,gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers. TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/rndividual): ( µ, Address: i' �ee 'i_171t City/State/Zip: 4 Phone#: Are you an employer?Check the appropriate box: Type of project()required): L❑1 am a employerwith : employees(full and/or part-time).* 'l• New construction 2.❑1 am a sole proprietor or partnership and have no employees working for mein 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3.'SI am a homeowner doing all work myself[No workers'comp.insurance required.]i 10 Cf 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.[]Plumbing repairs or additions S. 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.insruance.l 6.0 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. 1f the sub-con'traetors taye employees,they must provide their workers'comp.policy number. yarn an employer that is pi•ovidhig worlrers'compensation insurance for•my employees.'Beloiv is thepolicy 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' compepsation 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 foxv✓arded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under the pains andpenalties ofperjuiy that the information provided above is true and correct. p sign 0: ,.. Date f LL� Phone#: Official use only. Do not ivrite 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#: