HomeMy WebLinkAboutBuilding Permit # 6/9/2015 ......
i
BUILDING �aorarn
IT o� OOR t
TOWN OF NORTH
APPLICATION FOR PLAN EXAMINATION _
Permit No#: Date Received
SSACHUS�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION - � ' "r,
Print
PROPERTY OWNER ` `" ` °� °' � �
b Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District ye no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
r f,r, ,,, , _ � i �/ ,, it /, / r/ ,, ./r // ,/ r/ ,/ ! ✓ ,
l u,��„-, �� , ///,// / // �,/ �,r r , �rW tla,dsr/ � /�/ r ❑ oblate ,ed>C�is�nc#/ , ,, ��,
� r / ❑fWe , ,///„i ,r/ ��❑ ood a /❑ „ , n / r
DESCRIPTION OF WORK TO BE PERFORMED:
s � w
Identification- Please Type or Print t Clearl y
r r
OWNER: Name: , �,, °° Phone:
r ;
Address: X-1
Contractor Name: Phone:
Email
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone: f
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: $ Soon FEE: $ Qko
�;
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund p
r
t4ORTH
S E 1
vmdover
' town of
0
® Sf_
O LAKE h ver, Mass, �a
COCKICKEWICK �It
�®ADRATED p`PP��y
� Ll
BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ....... _V-4k
INSPECTOR
has permission to erect buildings on .jq1 ,,,,••............................ Foundation
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 MONTHS ELECTRICAL INSPECTOR
LES CTT RTS Rough
Service
..............S
......... .......................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® 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.
TOS'OF NORM AND OVEP, ,
Q
,M■ �(� j��k`ICE OA.�RAWrr
' Q :•1600 DYkooaStreetBuff ding 2Q, ?36
I S•
US •Noith Andover,Massaahusetta Of 845
�SSACH �� '
Gerald A.Bxovrn - 'Telephone(978)688-954.5
ofBuildingsa (978)689-9542
` HQMEC7 ERTICENSE.tYM OPTION-
pleaseprin-E °
DATE:
uml}er StreetAddress Map)�ot
YO'MEOANER :CAN (-\ A\!()-;�ti IT C,®1 L-70 �1•0
l�7ame. .
Homophone, Work Phone
PRESENT MAUiNG•ADDRESSY,
, nor �/1 GCzs � S
t'f�i'I'etm V fate - lip Code
The teas extenaod to?nclude owner occupied divelings to iwo units or;ass and
fa allow subh homed;vers r o engage an.? (,!ivid,1al.for lire-Wino does notposses9 alicc3nse,provided that the owner
acts as snpexv?sor). 9tate3uRding (Code Seofion
DEMITION OYEOMEO WMR
PE;xson(s)who awns a parcel of land on which.h6he resides or intends to reside, on which,there xs,or is infended to
'he,aoneortwof'aamflystmGtures. A.poison,who constmotsmore t7iatAnehome,in;atwoyearpczxodshallnothe
consideredal�.ozneowner, _
The undersigned"homeowner"'assumesresponszbilityfoz cbmp7iances wzFh the tafeBuilding Cocleand other
Applicable codes,by-law;xules and-xegulations.
T`heundonAgned"bomeownex"'certifiesthat.he/slleuuderstaudafideTownofl`7orf6.,AadoverBuil&ngDe�a Dnt
minimum inspection procedures an d roquirements and that helshe will comply with said pxa codures aad
requirements, ,
H'OAMOVM)3RS SICYNATME `
APMOV.AL 0E BUff I) G OF'F'ICIAL
Reyxsed 7 2oQ9 _ "
)'oxmjjomeowners Exemption -
)3DARl)OF'APPEAM 688-9MI cohrsER�rAnoN 5859530 TEAL 6$8-951p FL.
ATtNWG 688--9531
The Commonwealth of Massachusetts
F Department of Industrial Accidents
N 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
davit:Builders/Contractors/Electricians/Plumbers.
Workers' Compensation Insurance Affi
TO BE FILED WITH THE PERNUTTING AUTHORITY. please Print Le bl
Applicant Information r
Name(Business/Organization/Individual): J56 V_
Address: VeAc
-70-
City/State/Zip:
Are you an employer?Checic the appropriate box: Type of project(required):
1,Q I am a employer with employees(full and/or part-time).* 7. ❑New'construction
2.Q 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
3.0 I am a homeowner doing all work myself,.[No workers'comp.insurance required.]t 10 Q Building addition
4.Ear—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
S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Ro6f repairs
These sub-contractors have employees and have workers'comp.insurance i 14.Q Other
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.
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. Ifthe sub contractors have employees,they must provide their workers'comp.policy number.
orlcers'compensation insurance for my employees. Below is the policy and job site
X am an employer that is pr'ovidingw
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lie.#:
City/State/Zip:
Job 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$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.
It
hereby certify under'tlrepains andpenalties ofpeijury that the information �ed�bJ i istrueand correct
Date:
. �
Si ature: _
Phone#: �l `S _7 C
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#: