HomeMy WebLinkAboutBuilding Permit # 6/4/2015 t%ORTH
IIILDIN PE MIT o&,=LE° ,�q�o
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TOWN OF NORTHA V R 0 -
APPLICATION FOR PLAN EXAMINATION
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IPermit N®.{¢: " Date Received �9 Q�RATEO
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SSACHUS�
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION v /y'`
.� Print ....
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: zlclZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
(ZWAddition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
t 'Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
ya
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: M 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: $ 0 o a t FEE: $
t No.:
Receipt Check No.: p
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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07,M5,57-5
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NO"
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NORTH
own o t x ndover_ w..
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No.
�o E h ver, Mass,
COC NIC Nl-CK
�9S RATED
U BOARD OF HEALTH
Food/Kitchen
T LD Septic System
THIS CERTIFIES THAT
PERMLT
11A1t tJ BUILDING INSPECTOR
�.. � t ., Foundation
has permission to erect .......................... buildings on . .�. �.... ..... �...........w�1�.........
Rough
tobe occupied as ......... �.. .. ......................................................................... Chimney
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
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 IN 6 MO THS ELECTRICAL INSPECTOR
UNLESS CONSTRUC T 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
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
u 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
4 SJ�v
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le ibl
ApplicantInformation
Name(Business/Organization/Individual): -
Address:
City/State/Zip: "
P\/ A rely Phone#: G� 7
Type of project(required):
Are you an employer?Check the appropriate box:
em to ees full and/or Part-time).* 7. ❑New construction
1.0 I am a employer with P Y ( P
2,❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling
any capacity.[No workers'comp.insurance required.] 9. ElDemolition
3.nJ am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition
4.❑I 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.[]Plumbing repairs or additions
5.F1 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.t 14.[,Other
6.0 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 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:
City/State/Zip:
Sob Site Address:
olicy declaration page(showing the policy number and expiration date).
Attach a copy of the workers' compensation p
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$25anc 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 hereby certify under the pains andp`enalties ofpeijury that the information provided above is true and correct.
Date
Simature
���2''✓
Phone#: 7 9 6'
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#•
TOWN OF NORM ANDOVER
b;l�y • �Y� OFFICE OF - -
• a
..'1600 Qsgood.StrootBuffding20 -Surt�2-'36
Mith Andover,Massachusetts 01845
Gerald A.Brown TelepI.one(9V)585 MS
I'nspectorofWidiags fax (97S)685-9542
. oMEaw�E LICENSEBYRYPTION
MLICAMN
' pleasebring - -
DATE:
Number Map)l of
Name. . ROMP—Phone worlcPhone
'P,E,SEMT MINE 9G"DRWSS � Y . .. • '
✓ Ao4
z1LA 4
C. `offim • ,sqt�fP. tip Code
The eurrent exempfion f'or"•homeowners"was extendod to jolude owner occupied d��telings to i�3ra units or;ass an_d
fa allow such, ,o,neo;reqs to engl��B a37.3Cj�1¢uaI• Or 71T�w(lO C7oeS�J �70s5eSS d 71CG31Se,Provided that tho ownez
acts as supe�isor). ,�tiafe3j-ildzv-g (Cflde lection.Z�S,3,�'.�) -
DBMITZON MHOMEOWNER
PMSDn('s)who awns aparcel ofland on wMel3•lickheresides or intends to reside,an which there xs,ox is xnfen.ded to ,
be,a one or two arntly stracfures. Aperson wlio Wmtmots more that onehome in•atwa yearpor%od shall not be
considered ab.omcowxder,
Tho uuderszgned°`lzozrteowner"'assumes xesponszbxlity oz compliances with the State Building Code and other.Applicable codes,by-law;rules andx-egalations.
The tindexsigned``homeowner'certifies that lielslie understauds the Town ofl`7oxth Aado�erBuilding]]eliaxbnent
ml-limum mspecfion procedures and requirements and flat lie(she will comply with;said procedures and
requirements,
HONMOW7.BZ2.S S.fUXA.TME
APPROVAL 0Y BU L IN-C 0F'.FlCTAT,
�Zevised 9.200 -
1~orrnSomeowners 1 sxem�tion
Y30ARD OFAPPEAM 688-9541 CONSERVA'RON 688-9530 �-"
13EAf.TH 688-954Q RS,ATiNWG 689-955i •