HomeMy WebLinkAboutBuilding Permit # 6/4/2015 %AORTII
BUILDING PERMIT 0 'J�FD 1616
TOWN OF NORTH ANDOVER 10
APPLICATION FOR PLAN EXAMINATION 4t
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Permit No#. Date Received
101 'SSs
clius
Date Issued: Its
WPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER R,
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building One family
WAddition El Two or more family [I Industrial
El Alteration No. of units: 11 Commercial
D Repair, replacement El Assessory Bldg 0 Others:
RIDemolition El Other
e,
DESCRIPTION OF WORK TO BE PERFORMED:
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OWNER: Name: Identification- Please Type or Print Clearly,zAL Phone:
�- 6-�
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 0 6 ac, FEE:
Check No.: 116 Receipt No.:
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NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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F-111111111111 A'S FORTH
' i 'own ot nclover
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No. W""!�- '
LAK. h ver, Mass,
COG HICHEW,CK ��•
A°RgrE® Jk4���5
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BOARD OF HEALTH
Food/Kitchen
PERMIT LD Septic System
THIS CERTIFIES THAT BUILDING INSPECT®R
has permission to erect .......................... buildings on Foundation
Rough
to be occupied as .r`' " r..... ...
.... �. .. ... , ......6%',.(C(.............................................. 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
ITEXPIRES MONTHS ELECTRICAL INSPECTOR
UNLESST T S Rough
Service
................. .. .. ..... ........ ...................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Islay in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
-7 Z
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North Andover MIMAP May 20,2015
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Interstates
—SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
— Roads Meters Data Sources:The data for this map was produced by Merrimack
It►ORTH Valley Planning Commission(MVPC)using data provided by the Town of
6..r Easements Of Flu '4� North Andover.Additional data provided by the Executive Office of
MVPC BoundaryaEnvironmental AffairslMassGIS.The information depicted on this map is
ny
L for planning purposes only.It may not be adequate for legal boundary
Parcels N "" A definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER
~ MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
{I * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
�f oo .,." ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
11 ropb AYID
"" p�` THIS INFORMATION
�SSACHus
1"=45ft -
TOWN OF NORM ANDOVER
UFIFICE OF
' Q � :1600 D,9kooa,9tx-ootBwIdiug20,Su%tQ 2-3 6
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Gerald A.Brown � 'I`elepI.one(.9 79)688 9545
InspeetarOf$uiIdings F'ax (97-8)688-9542
,. - -• �z��Ea��.'zxCEN�E��zv�Txo�r - -
Damnprint ,
DATE: 46 /7, 15
,FOB LOCA.T�ON;
Number StreetAddress Map)Lot
IXQ' M0WMR ^.,. (Sus,�l� �?� 1 -31S-1211 _181-31S-12�`�
Name. Home I''one Work Phone
'RESENT MA NGADARESS, tad b-,,, .41 V�11 . ..
c� T�,� � .
ip Cods
The eurrent exemption for"•'homeowners"'was extended to i.Ghzde owner-occupied dwellings to two units•ox>ess and
%o allow subh'o7nPo,vnersto mnga¢e an.in Uvjdual-forliire wino noes notpossess a 71eGnsm,provided that the,owner
acts as sapuVisor). 9fRfe3u?Iding (Code Secfion.108.3.5.7)
DBFMITIOX OYHOMEO'W;NER ,
PerSDn(S)who Qwns aparcel ofland on whic"lle Bheres!Uas or intends to reside,on which(hero 79,or is intended to
7��,a one or two family structures. Aperson wlto constrnets wormmat one home in atwa yearperiod shall not 6e
considered a'.omeowAer.
The utzdersigned"homeowner"'assumesresponszbiI%ty£orcomp7iances wiffi the Statal3uildiug Co
do otT�er
Applicable codes,by laws,xWes and--egalatiom.
Theundersigued"'homeowner"cmHi es that-hQA DunderstandstheTownoflqorthAndo-verBuildingDeiiartwant
Minimum.inspection procedures and requirement--and that helshe will comply with;sand pra cmdures and
reguirerneuts, ,
R0�0�RS SIGNATTipE '
APPROVAL OF BMDMG OFFICIAL
Revised 7.2009
FoxmSomeowners Fsxem�tian
Y3OARDOFAPPBAM-688-9541 CONSE2,VA'RON6889530 �•~
P7EAL�1688-9540 PI;ATTNiNG6$8953a
The Commonwealth of Massachusetts
F Department of Industrial Accidents
a i d I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contr•actors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/OrganizationAndividual): ..1 ''ic:V–
Address: P-A
City/State/Zip: Vk;L ,alb Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
l.❑I am a employer with employees(Rill and/or part-time). 7. FJ New construction
2.❑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. gDemolition
3.dI am a homeowner doing all work myself,[No workers'Comp.insurance required.]t 10 VBuilding 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.E]Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.❑1 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) 14.✓Other {X-
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.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
eet showing the name of the sub-contractors and state whether or not those entities have
$Contractors that check this box must attached an additional sh
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing worker's'compensation insurance for my employees. Below is the policy 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 Herebycert�rder the pains andpenalties of per jury that the information provided above is true and correct.
Signature:
Date: 5-Lz zdir
Phone#: -7 1-3 W-R 1U
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#: