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HomeMy WebLinkAboutBuilding Permit # 5/12/2015 %AORTy BUILDING PERMIT of AK,FD ,6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ Permit No#: 4 ( ` Date Received RTED �ssgcwus�c Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION '�5-o 0- Print PROPERTY OWNER AQ L 1'VV)le f: Print 100 Year Structure yes gno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial RIkepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ._yewv� r �r-i' ✓, In% /I, t/// �. Ifoil /i ,/ /�x < lP,,v,a/u��1 rtat[f Y ,. .��I�,�.fr'I�lr�,.N//� c, . /,1,/i P r1G �� � l,�i /fr- 4 /� !, / � /„ ® edsa Wate shed sIn.' /� ,� �I�; .W � � (�fi ' r�alnl �l' / 1 1 f r,, ,r(i�1 ,�P) , rf/�kk „� / ESCRIPTION OF WORK TO BE PERFORMED: Identification-- Please Type or Print Clearly OWNER: Name: 'DAu C-::- Phone: ` 7�Ke 0 C) Address: 15-0 �-�ACG°”a C Contractor Name: Phone: Email: Address: ' Construction License: Ex Supervisor's . Date:p Home Improvement License: Exp. Date: 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: $ 1700 FEE: $ c Check No.: Receipt No.: Z NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 0n 'ii",,,;/ ,tl/„m:,�r r /�:;, / / ,c> lG,ii% ,✓., ,/ ,, ,"�J/.. / ✓ ////,, /�/ �%/ D/,/ //%/%i//,.//„ r/ r rG r' Ira tAORTH E. :..'.A, ® ♦ e ® .:`.. . . ro LAE h ver, ass, S ? /� COC q,y�• � Rm U BOARD OF HEALTH Food/Kitchen Septic System . PE ITT LD THIS CERTIFIES THAT ......�'k.ef...... r.................... BUILDING INSPECTOR /� G�' �l( ,''c � .................... Foundation has permission to erect .......................... buildings on .. ............................�l....4�:...:.:....... Rough ............... to be occupied as :.1:.�.�.1�..J . �..... .................................................... .................. Chimney provided that the person accepting this permit shall in every respect conform to the : ..... ........ e 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 UNLESS CONSTRUCTIONS.3ARTS Rough Service .............................. .. .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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 ntil Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. TOWN OF NORM AND OWP, a .,.ra OFFICE OF • ' 3�r, €1by :1600 DskaDdSfz'eetBuff ding203 Suite36 •p cccvcn...zR . . - "1 b�R3}7b F4�•`•(5 .••MithAndo-vex Massaausetta 01845 . �'SSliCHtS5�� g h , Gerald A.Brown `telephone(978 68$-9��5 hnspeetoron,;Rdings Fax (97$)689-9542 . �©W:NER:LICENSE ME&TION ' pleasep Ln ' DATE: aB LOCAT�ON; a�IA C{ Iumhez SlxeetAddress Mapl.Eot uozvzGEa 224,u Nam. ionze l'hon X71 ark Phone -PPXSRNT MAUL�NG ADDRESS 5�Z7 c iV I f1 r of zip Code TAC euxrent exempfion for'-Homeowners,was extended to inchide owner occupied dwellzngs to two units or€ess an_d fa allow sr7bh homeo,,ners to engage aa. .dividsal•for hire wno r-10(3s uotpossess a 7 ceazse,provided that the,ownez acts as supuxv sor). Stafe3ui(di'ng (Code section,lOS,3.5.7) , DEIi'.TNITION OVEOMEOVMR. Person(s)Who Awns a panel of land on which he/she resides or intends to reside, on which there is,or is infended to + aoneortWo amilysfzuetures. ApersonwAoconstmotsmoretAat.onehomeinatwayearperiodshaRnot be considered ahommwnen Tha undersigned"hDmcdwner''assumesresponsibi tYforcompliances with the State3uilding Codeaut�other Applicable codes,by Im.,mies andTogalations. The-Imci rsigned"homeowner"tames•thatRe-AghevndexstaudsiTieTownOfNorthAndo-ver33uiletingDeO tment m7xiinxum inspection procedures and requirements and that helshe will comply with.;said pxacedures vad 'recl'u�lr�e,�z'n�te.ut.-, 'p�t('i �t ' .C7.0-IY.LCU YY�.'1�.lZ.0 IJ�V�� TU.kZC APPROVAL OF 33MDMG OFFICfAL Revised?209 FonuSozneowners Fxemp[ian - xY BOARD OFApI BAYS-688-9541 CONSEUAMN 6SO-9530 YEALTH688-9540 P7,A'N�Tmira�Q�_a;a� The Commonwealth of Massachusetts Department of IndustrialAccidents . 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 PER1vHTTING AUTHORITY. Applicant Information Please Print Le0bly Name (Business/Organization/Individual): U r 1 Wt ,4 1 � Address: Iso c � rL_ , r q City/State/Zip, � �AID. A NDD(� U LW hone k-(6� � �`� L � Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. F1 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. L1 Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F]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 It.❑Electrical repairs or additions proprietors with no employees. 12, umbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.M Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6.Q 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. i 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 am an employer tliat is pf'oviding 4vorlcers'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: 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. Ido here under the pains and penalties ofperjury that the information provided above its true and correct. Signature: - Date: � / S 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#: