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HomeMy WebLinkAboutBuilding Permit # 6/4/2015 �4RTt1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * - Permit NO: Ll Date Received °Rareo Date Issued: Ss U5 ORTANT:Applicant must complete all items on this page /%�i lel ©P)yRT r4 R / // ////r // //rA✓ r r / / Zm I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 56ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other tN�/�r / elf ❑ Icodplsln / ,;[��N #ands r� Watersh e�;fi�WA"' t r/ aur; 1 i o E) /VP d�w �N ' t;'K of'-K /4C Ev'-t /)ZC'J Identification Please Type or Print Clearly) OWNER: Name: r► ►.. . l�e� 14 A&Ti,�AAl Phone:c0 �� 6 r Address: t 9 7 l *V,Y 4 0,5' �_� �� ���;>8�;T14 / //✓/ /i� /i/ r ri / / / J r r fI S &F ! U/ rcen Le;� �Mr��ri�,�fi�►r'��r+��`i�r'�'�-�cens�" �. /AXI[")//I��►te/ ;. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S. . Total Project Cost: $_q j q 6)o FEE: $ A Check No.: 0 Receipt No.: NOTE: Persons contrac in ' ith unregistered contractors do not have access to the guaranty fund f Signature of Agent/Owner, S gnature:of contractor {I t%ORTH A v ui own of nd to ® O LAKEver, ass, COCKIC.awICK �1' ,e .44 RATED S BOARD OF HEALTH rERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT .........C1446.00.\- BUILDING INSPECTOR has permission to erect buildings on Foundation .......... ........... . ....... ... ..... ..........V Aft ® Rough ll to be occupied as `/.!+.In,C w.... ... ... .... }..f;64iA:j:W--t. .... 01 - 40.... ...... I. Chimney provided that the person accepting this permit sha elery respect conform to therms 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 T S ELECTRICAL INSPECTOR ® UNLESS CONSTRUCTION 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. NORTH TOWN OF NORTH ANDOVER O�''~eB o OFFICE OF ° . p BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 �SSACHUSES , Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: �' f JOB LOCATION: l 7 Number �1Street Address Map/Lot HOMEOWNER C �� i SSI,,, r/' T►9�� �I 7e 3,35 -06 16 Name Home Phone Work Phone PRESENT MAILING ADDRESS 37? U i LL i j e- R-0 0 2 rn n le fery MA-ss 0I y City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies t he/she understands the Town of North Andover Building Department minimum inspection procedures and requi a ents and that he/she will comply with said procedures and requirements. r - HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street,Suite 100 Boston,MA 02114-2017 iyww.mass.gov/dia y •Worlters'Compensation Insurance Affidavit:Builders/Co ntractors/Electricians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LetTibly Name(Business/Organizatiordndividual): C- 0 n,131 J.'e +/L T i<.9 Address: � V f ) �t+2 Fls � � — City/State/Zip: fJ I D )e, 'to-v iii $hone#: q 7 e- Are you an employer?Checlr the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8.-'Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C]Roof repairs Those sub-contractors have employees and have workers'comp.insurance.$ 14.14.E]Other 6.FJ 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 I employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer iliat is providing ivorirers'compensation insurance for my employees. Below is the policy and job site i information. Insurance Company Name: i Policy#or Self-ins.Lic.#: _ Expiration Date: Job Site Address: City/State/Zip: j Attach a copy of the Worlters'c ensation policy declaration page(showing the policy number and expiration date). j Failure to secure covera s required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-ye rlsonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agar s the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificafo . I do hereby�cee 1if der the pain and enalties of peijuiy that the information provided above is true and correct Signature: �C Phone#: t•- Date 617. 3 C( Official use only. Do not sprite ii:this area,to be completed by city or town official City or Town• Permit/Lfcense# 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#: is {j .It TH N IAF d69a t �.. r _ 1t ' NE 1�,5gt M 1f Uia1.,� t...: 833 R PEMBROKE MA 023 .3002 DD 02.0172012 R�vo7.15e Iffo alma rrr�n uirs pt � License or registration valid for individu:use 0711 OiTce oTonsumerAtia�rs ia_ss cgu anon g Y before the expiration date. If found return te: i10ME IMPROVEMENT CONTRACTOR TypeOffice of Consumer Affairs and Business Regula.on I� Registration: 80858 t� 10 Park Plaza Suite 5170 Expiration: 1/20/2017 DBA ' Boston,MA 02115 pt PI_S PAINTING PERFECTION , PETER VOUSBOUKIS 33.PARKER RD � --- iL �� — PEMBROKE,MA 02359 Undersecretary Not valid without signature