HomeMy WebLinkAboutBuilding Permit # 5/1/2015 tkoRTH
BUILDING PERMIT of
TOWN OF NORTHA V 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received rEV
�ssgCHU$
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION --,).,/,
Print
PROPERTY OWNER e
Print 100 Year Structure yes no
MAP PARCEL. ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building /N�One family
11 Addition [I Two or more family 11 Industrial
P(AIteration No, of units: 11 Commercial
El Repair, replacement 11 Assessory Bldg El Others:
0 Demolition El Other
m,yeg gg//,� 4/11�(1111'f "W"","
Ino mit gjl
.........
�'r�,Jl tc. n a� 1, .�1 ��� i, w �f �, ! � +� �/ 1+ �l��,i�Jl��i�r�f/>a�
DESCRIPTION OF WORK TO BE PERFORMED:
'77- A-
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: 4 Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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- $ 1�1400— FEE: $
'_J -_ - -
Check N6.Y. Z
���...Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
...........
IAORTH
'Town ofAndover
-No. r
0 .
0%
Y '
Is_00
ver, Mass,
BOARD OF HEALTH
PERMIT T LD Septic System
BUILDING O.
THIS CERTIFIES T A:
t
has •, Foundation
• • • _ . Rough
to be occupied Finalprovided that the person accepting this permit shall in every respect conform to t e erms of the appli...SAW_ Chimney
1
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and PLUMBING INSPECTOR
Construction of Buildings Town of North Andover.
Rough
VIOLATION of the2oning or Building Regulations Voids this Permit.
Final
ELECTRICAL INSPECTOR
PERMIT EXPIRES IN i' MON S
1 ,X RoughT
t
Service
Final
BUILDING
O.
INSPECTORGAS
O. p t i �`a l ed j j d r Rough
Place 1 .
Final
Dis ! 'a • 1 �'
DEPARTMENTFIRE
The Commonwealth of Massachusetts
f Department of IndustrialAccidents
a i d 1 Congress Street,Suite 100
-_......_._._.__.____... . _._ _._......_. _.....__.._.-.......__.__......_...._Boston,_1VIA...02114-2017_._....___._____..
Sy °� www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PiMAUTTING AUTFIORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual): z f��y /27—
Address:
City/State/Zip: Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.F-]I am a employer with employees(fall and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. NN Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10[]Building addition
4.❑1 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. 12.0 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.$
14. Other
6.N We are a corporation and its officers have exercised their right of'exemption per MGL c.
❑
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.
$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 ant an employer•tliat is providing Ivor lfers'compensation insurance for•my ertiployees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 rider the pains andpenalties of perjury that the infor•rnadon provided above is true and correct.
Signature: Date: d F S f
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#:
----------------------
MRSS husetts -Depirtmentbf ublic'Sdf $- :-
Board of Building f cg.ulations and Standord.�
J
CdnsttucfionSu ey.isor i�
I : License: CS-026854
PATRICK S C®iVF`� ' e �•�. '����� i„�
89 Ames St R
Methuen MA 01844 V, g I
Expiration
Commissioner 061231201E