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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 _ .... V&ORTIJ BUILDING PERMIT ° TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Date Received ?A ED Pe�R�S Permit No#: saclau�`� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no /4 •c District yes no ZONING DIS TRICT: Histan MAP PARCEL: Machine Shop Village yes. no TYPE OF IMPROVEMENT 9 !Residential ROPOSED USE Non- Residential ❑ New Building 0>01he family ❑Two or more family ❑ Industrial ❑Addition ❑ Commercial NcAIteration No. of units: Bldg [i Others: ❑Assessor ❑ Repair, replacement y ❑ Other El Demolition N,rr v r 1 Watershed Dstr ct ©a;�y ,r„ ;���i,S���Yi/, eF;ir�i%�''��/" p a ❑ Sept'c ❑Well Se �,ro - DESCRIPTION OF WORK TO BE PERFORMED, Identification-. Pleas e or Print Clearly Phone: yP OWNER: Nam � ,. Address. Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Horne Improvement License: Exp. Date: __:::::::::: ARCHITECT/ENGINEER Phone: Reg. eg. No. FEE SCHEDULE,B ULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. II FEE: Total Project Cost: $ / $ No.:- Receipt No.: Checkaccess to the guarantyfund NOTE: Persons contracting With un g tere�l contractors cla not have g fIr asm- a . it t,ORTk Town 2 EAndover ® - .:�.. t o h ver, Mass, COCNICNEWICK'yIt. ADRATED S 11 BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System iFs�- ���� BUILDING INSPECTOR THISCERTIFIES THAT ...............................................................,.... ................................................ 7 � / Foundation has permission to erect .......................... buildings on ..................! �1'....... v................................................. ^f, Rough to be occupied as ..............dl.... �:!. .....SI.YL.<::1. ..................................................................... Chimney � e provided that the person accepting t#Sis 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS Rough �................... Service ................. ...... . 1.................. Final BUILDING INSPECTOR GAS INSPECTOR Oeeupaney 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. The Commonwealth of Massachusetts Department oflndustrialAccidents =; „ F tl 1 Congress Street, Suite 100 Boston,MA 02114-2017 Vt www mass.gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Ap plicant Information Please Print LeOb Name (Business/Organization/Individual): Address: 41 C J-11 , City/State/Zip: !/�� / Phone/#: 54'5_7 (O 3 Zy Are you an employer?Check tAe appropriate box: Type of project()required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.[J I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling eIaay capacity.[No workers'comp.insurance required.] 9. ❑Demolition3,4� m a homeowner doing all work myself[No workers'comp.insurance required,]i 10[f Building addition 4.F1 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.❑Electrical repairs or additions proprietors withno employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ g, 13.[�Roof repairs • These sub-contractors have employees and have workers'comp.insurance,# ; , 6.❑We area corporation and ifs officers have exercised their right of exemption per MGL c. 14Uther V �n I S� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks b6x#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. 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-coritractors nave employees,they must provide their workeis'comp.policy number. Y nm 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,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. .fdo lzereb!wcef-tify under the tins and penalties ofpezjuiy that the information provided above is true and correct. Sign re: ��J dl D '� Date: f��_ 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 04 pr TOWN Off`NORM ANDOVER 011-TICE 02 .'1600 Osgood,9ty0ofBuff&g20,-Suxt,?3f3 N. J. ofthAndovax J.Y..Iaw`ddhusata o O4J s�r�cau5 Gerald A.Brown Telaphone(978)6gg-954.5 1•nspeutorofB;fdzugo fax. (978)688-•9542 B' )'G SF T Al?)?LIC.A.TfON 1'2ease rin-E PB LOCA�dDN., 6,/ V �Tuznl7ex �_ 'et.A.d ess 1VSap�Ct ' Name. Homo Phone WorkPlzone PRESENT MA69CY AbARMSS zip Coila The current exemption for"•,homeow-n-a s"was extended to?�elLtde n1�lnex ocetipied d�vell�ngs tC i�vo unifs or;ess and Focts as s a's susut oaneo.vers io engage andJdi Vadnal.for hire-ho does Rutpossess a 7iconse,provided Mat Me,Dvjmor apervisor). R afoBol ding (Code uectio� DEP. ITION O-`HOMEOWNBR , Pexson.(s)who awns aparcel ofland on ujhich helshe resides or zurtends to reside,Cu Which there is,oxis xnfended to ��,a Cua or tWn amilysfroctuzes. .A.persoU.Who comtfadErmore t7iat onahomeiu:ajwo yearpexiod shall notbe Ponsidered ah0 eoWnez; The undersigned"ACzne6wzRe1" with alio Mate lmlcling Corte and other Applicable cordes,by-laws,tales andxegaxatzons. The-lmdeMign6d"homeov�uex"ce esthaEl-ie/sfie"3nde"tauds oofNorthA.adoverBuilding Dr,iatfmojLt MininaumansperfzortPro a0(lures and roquirowenfsandtliatlte eWIU comply yitlZ;sazdpzaceduresancT regnixezneuts, � . .HONEOWN`131i'S .APPROVAL OP$3=))WG OF'.EZCAL Revised 9.�.Q09 " Fozzn�SomeovtnersE�Bm�fion ^ 3OARD OFAPPEAM-689-M4z CONTSF.ft IA'HON 696-9530 .r MAL'rR 6$8-950 -PS.AT7NWG 686 953a •