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Home My WebLink AboutBuilding Permit # 6/4/2015 I %%ORTH BUILDING PERMIT 0 CS TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ry 1VL V Permit No#: Date Received —A4 US Date Issued: iVP-0VRTANT: Applicant must complete all items on this page 2 117,10 LOCATION V Print PROPERTY OWNER Z U F m(ou's Print 100 Year Structure yes (n 'L MAP PARCEL: ZONING DISTRICT: Historic District yes 0 Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [I New Building [] One family El Addition 11 Two or more family 11 Industrial Li Alteration No. of units: [I Commercial A4,Repair, replacement 11 Assessory Bldg 11 Others: 0 Demolition 11 Other 04 �m:r �l f � �'�, � � U� �� , �r � �±, ��f�� f �""a ers etl Dista ��%� e DESCRIPT 0FW1 RK TO BE PERFORMED: Ila L/ Identification- Please Type or Pfl}�� Clearly 9 ZA o;,)ie J ECL Phone. OWNER: Name: X–oc,i Address: 5�,.3 (!��a/7 1 V Le,—// Contractor N rn): d- 1)116 6� Cl-IrielC Phone: 7.r"') Email: �e /�?, � -, &,0"7 Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDINTERMIT:$1Z00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Cost:Project GUL. 1000 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund tkORT H Town of mi'%Idover ® - �^�� h Ver, Mass, E 114 / sw 0 COC 104tWICK 5 U BOARD OF HEALTH Food/Kitchen PEr% MMMIT T D Septic System THIS CERTIFIES THAT ........... .. .... . .. ..... ....... .. ......F-:4.6-P.. .................... BUILDING INSPECTOR has permission to erect .......................... buildings on . ....... !.....`. ............................. Foundation ...... Rough to be occupied as ..... ................ ....... .. ............. .. ..... .... .......................... Chimney provided that the person accepting this permit shall in every respect conform to A 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES, S ELECTRICAL INSPECTOR RTS Rough Service ......Z .. ...... .......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or all o Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. �4prti � TOW'OF NORM. OVER K 01TICE 0F. 1500 DsgooaStroot%ffding20,•Svxt�?36 7�p��37xL FQF�.LrJ .••Noith.Andovoxg Massaahusetta 01845 Gerald A.Brown - Telephone(978)688-9145 InspectoxoT3uildings -fax (97.8)688-9542 MICAMN pleaseprint • . DATE: SOB LOCATfON: 92' Number � Streft dress — Map/Lot MEOTER „e /f?G�'17��1 /—C� ��0✓� ��d' o�.� �/ Name HOMOphone Workllone PRR-SFNTMA.6XG.ADDRES (S� � //'/ /� �/�•: ' Cad�r�T=m • ��tP• - zip Cojo"L-- The current exempfion hoz"homeowners"teas etencled toowner occupied divellivgs to t4vo units or less and co allow suchomPo;�ers to engage asdzviduaZ.forhire-who does aotpossess a IicG31se,provided that the owner acts as snpowlsor). 8iate3o,ding (Code ueotion,108.3.5.1) DEFIMITZON 0-MOMEOWNER , J'erson(s)wha awns apazcel of land on tvhicl��e/slzeresiiies or zutends 4o reside,on wlziceze zs,or is xnfendedo ��,a one or two family stzuctures. .A.person who Constructs more tliat one homD in•a twoyearperiod shall not o eansidered al�.on=teownez; • Tho undersigned"Izorzteownez"'assumesxasponszbility orcbmpliances With the state Building Code and other Applicable codes,by-laws,rules and-xegulations. Tfie undersigned"homeowner"oerHfes that he/she understands the Town of lgor h Andover3uilding bo&ffwent ruiniznum inspection pro ceduxes and ragairezttents and that helshe wi11 comply with;said procedures and xequirements., TSOIV.LBOWN,Bl2.B UGHA.TT7 ___.. _...... APPROVAL OF l3•LT.IT..DWG OFFICIAL $avised 7.2Qo9 1~oxzn�omeownersTsxemp�ion - , BOARD OFAMAT,S 688-9541 OONSFRVAMN 686-953o BEALTH 688-9540 M - �.TTNINO 688 9535 The Commonwealth of Massachusetts Department of IndustrialAccidents i ; a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia 6^M SV.V Workers'Compensation Insurance Affidavit:Builders/Contr•actors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant Information Pleas Print Lerbl Name(Business/Organization/Individual): ,� (J C / °r 0`"1I6;1_J Address: � City/State/Zip:/(/0. � "/"?_.__f ') Phone#: ✓�� , 71 Are you an employer?Check the appropriate box: Type of project(required): l.n I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.FJ I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition IN 1 am a homeowner doing all work myself.[No workers'comp.insurance required,]t 10 Q Building addition 4.0.1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑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.insurance.t 14.Q Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL e 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 am an employer 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: 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 da her^eby certify ander the p ins;and penalties ofperjuty that the information provided above is true and correct. -- µ.,..._.. .,..._. Date: J-/ Z Sinature: 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 Cleric 4.Electrical Inspector• 5.Plumbing Inspector 6.Other Contact Person: Phone#: