HomeMy WebLinkAboutBuilding Permit # 6/4/2015 i
. i
BUILDING PERMIT Q�
�otarH
�t
16
TOWN OF NORTH ANDOVER Q. y� ,
APPLICATION FOR PLAN EXAMINATION _
Permit No#: '' Date Received ..ArEv
SSACHU!"
Date Issued:4W14M0yR_T
ANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER I
Print e I . OI
J Print 100 Year Structure yes n
MAP �°'! PARCEL: ZONING DISTRI T: Historic District yes
Machine Shop Village - yes)
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
ARepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic/fr `❑f ,W✓ell2� vsJ l+e lfl„`4 1 ytYi!F`�l,oF od(p✓lan x t�`yetads1✓'
hed Distract,
f
DESCRIPTION Oi WOR TO BE PERFOR D: c
�1
Identification- Please Type or Print Clearly
OWNER: Name: 1!' Phone:
Address: I C)
Contractor Name: Phone: "�� '�� as
Email:
Address j J
Supervisor's Construction License: 0 % Exp. Date: 4,
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$925.00 PER S.F.
Total Project Cost: $ FEE: $
�I
Check No.: �- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
�Sianatu�e of AaPn /Owner
,
rim VAORT H
It own of Andover
0 .
&_ I
`• , e�
. ® 4
ver, Mass, JS—
COC KICK@WICK
BOARD OF HEALTH
P R mmm T Food/Kitchen
Septic System
. �
THIS CERTIFIES THAT ............... .. .. .. ...... .......... ... .............. .....--Y?. ................ BUILDING INSPECTOR
Foundation
.................... buildings on .
has permission to erect ..... ........... -�. . .. ........ ..........................
Rough
to be occupied as ..� .1.. ..............f..� ... .>... .... L IJ ..-......I........................... emn chiy
`
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
PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
�
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMITE l ELECTRICAL INSPECTOR
UNLESS TI 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 r Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
z Department of Industrial Accidents
d 1 Congress Street,Suite 100
Boston,MA 02114-2017
5V,JW www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERA11TTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 6,�
Address: �� C>
City/State/Zip: Q_.A Phone#: 1561k l b! it
Are you an employer?Check the appropriate box: Type of project(required):
1.F1 I am a employer with 6_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. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 EJ 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.F1 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)
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.]
IL
*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 am an ennployer'that is providirng workers'compensation irnsarance for•my employees. Below 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'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.
I do hereby certify r e the p 'is an dpenalfies of per jrrry that the information provided above is tr rr and correct.
l
Signature: Z , � Date / f
Phone#: Ss�2�S—d —
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#:
' �ss1C se s -vepar r�eri
n 0
rfY '
i su idirsg wtiaC7 s 'a '
Cs-OW97 ;
yt Titi
MARK F RAE '
130 MARBLERIIDGF
North Andover NR 01845
r
<< xp+raticn
04/24/2016
Comrriiss4oner