HomeMy WebLinkAboutBuilding Permit # 6/4/2015 BUILDING PERMIT .1,VUED !jAoRT116
TOWN OF NORTH ANDOVER 6
0
APPLICATION FOR PLAN EXAMINATION
C,l Date Received
Permit No#: rED f?
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER—/ 'Z
Print 100 Year Structure yes no
MAP (7- PARCEL: ONING DISTRICT: Historic District yes C62
Machine Shop Village yes, no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building )dOne family
11 Addition 11 Two or more family El Industrial
VAlteration No. of units: 11 Commercial
KRepair, replacement [I Assessory Bldg 11 Others:
11 Demolition [I Other
I S
101 IIIA (-.Ir
P
DESC1,PT ace
_AF WORK TO�BE PERFORMED:
C—
Identification- ease Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: z ,(,?s 11"e AC 9" Phone: -7
Email:
Address: Z'Z- C
Supervisor's Construction License: Exp. Date:
Home Improvement License: Ex.p, Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDINGPERMIT-7$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ –°�C)'o FEE: �5 6nQ
Check No.: Receipt No.:
NOTE: Persons contr cill with unregistered ntractors do not have access to the guaranty fund
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Town of M. nclover
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No.
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41 Al
COCHICNEWICK ��
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BOARD OF HEALTH
Food/Kitchen
. PERMIT �T� LU Septic System
THIS CERTIFIES THAT .............. BUILDING�'�.......... .....d......!. A . ......................................................
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 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 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT RTS 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Q4 11URTH TOWN Y Y.Lq OF NORM 7O;- JC��3{_���tt. ANDOVER
OF
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n `.1600 USgDOC `$ree Eu11C1ia1g 0, S i —9-36
"�R3 n Fpa` NoithAnJover,Massachuselta o 845
GoralclA.Brown ° - Tolophone(9 79)6889545
lvspeetorof$uilcTings Iax (978)685-9542
M;RMOMMER ICENEEEXEMPIfON • .
pleaseprinE
'YOB L0CWd0N:
+�1'uzn'bex 8freetAddress �I'ap/Lot -
Name. . lonzel'7�one ►Noxkhone
PIM-SENT MAMG 4G ADDIMSS /2 S,iq vJ��� 2 ° /✓il%�'// ✓�'w i� i'f Y�
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—7m Code
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'I b e eurtezzt eempfion fax" omeownexs"was extended io?noJude ownex ocetipied di�eilings to t4�o uxufs or Tess and
to allow sub T,?,mPommexs to e-,Iga¢e an Lelb;dsaf.for hire-wino do us not
possess a 7ieGuse,pxovided that ate owner
act as s>spe�?sor�. ,�iais3tilding (bode�ect?on ZI)8,3,5.�) - -
DEFINITION OYHOME0VMP ,
parson(s)who awns aparcel oflancl on which Ile/Ae resides or Mends to reside,on wmc;h-here xs,or zs iwanded to
��,a one or$wo family sfnicfures. .A.persoxtwlto comtmots more t7iat onehome xn atwa parperztid shall not'be
considered ahozneownez;
T`he tmdez-szgned".homeowner"assumesresponsibilityforeompliances with the,SfateBuilding Code anti outer
Applicable codes,Tey laws,rales and-xegulatious.
Tbevztdexsigned"homeownex"cext;Resthat�elsheitnrlerstarttTsthe Town ofNbz-tb.Ando-verFuzldingDe�atfinent _
iY17Ti77Tluzn inspection procedures and roquiramenfis and'thathe/size till comply wit�h;said procedures and
recluireznents.,
API)ROVAL O.i Y )LDMG Oh ia. IAL
�ieyisecT 7.20x9 y
FoxznS�ozneowners�sxemption "
30ARD OFAPPBAT 688-9541 CONTSEt,VAUON 698-9530 RUATTH M-9540 PLA.NNING fibs 9535
The Commonwealth of Massachusetts
44 Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dna
Worizers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMMITTING AUTHORI�Y. Please Print Le 'bI
Applicant Information
Name(Business/organization/Iudividual): E= / r!tib
Address: 2L� l2 d
City/State/Zip: AJ01- t-I 1,�WooV e,v�- )Oi 4- Phone#l:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(frill and/or part-time,).* 7• ❑New'donstruction
2,❑I am a sole proprietor or partnership and have no employees working for me in 8. JxRemodeling
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 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
11,F]Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12,Q Plumbing repair's or additions
5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 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 o£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.
tContractors 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.
X am an employer that is providingtvor'Irers'compensation 111surance for'my employees. .Below is the policy andjob site
information.
Insurance Company Narnc:___,(,6�r�-"
Policy#or Self-ins.Lie.#:
Expiration Date-
Policy
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
d under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
Failure to secure coverage as require
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.
X do hereby e 1t fy nd 'thepa!ns andpenalties of per jury that the information provided above is true and cor'r'ect.
lis^.Z.z'U'vd Date:
Signature: i
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#: