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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 i i `AORTH BUILDING PERMIT o&.11 F TOWN OF NORTH ANDOVER �` CS APPLICATION FOR PLAN EXAMINATION Permit No#: ® Date Received �19A�Rareu Pea��S SSACHus� Date Issued: -IMPORTANT: Applicant must complete all items on this page LOCATION /� -�I���S®� Ax• h4dloene 6 &�6-19 Print PROPERTY OWNER v o� Print 100 Year Structureres tn MAP PARCEL: �60( ZONINGDISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑AI ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other fl 'u,'�':`u �,r,�.ce r , i� yr r= ;� 4l x Se' .t ry 1Nell ❑ Flood lain L711/etkartds, x❑ Wath, h_ ed.Restrict xt r,,. e�a�•✓`r;/,y �,,,.,,: I`.,r'n`r�, ��;ss. �a��1x}�y,�,l� 1. .'`. f� „5, � ,%',"„�<��'.`(;r�`����,^�a�s�''�`'yr �-%�✓.f,,�?���`.r�����w � %�,�d.. -., :� ..:,�,, '��„- �- '�v �r�'F�/a s m. .�r,,.-aa,�.,ate. ,,.�,,...1, ..M,r.w.._ x�.�'�a� .1�,r.����.i ;,,.,�r r�r��,�"i��t_r's ,,,�i;F:,.Fr, �.,`x ...,rv,✓�r��' -s ..,.,�.� � �.�, ..rx'._, .xxh.r,.7 _ k` ,&.n...<i"Jr r„1 '7.�:� DESCRIPTION OF WORK TO BE PERFORMED: yQe���c� ��� /a x/� bac������ o� ber�ee� o•¢,�'0.9 � ���ri'-y. Ident' kation- Please Type or Print Clearly OWNER: Name: vfti C-o a 0 Phone: Address: /(Pq-d411s0h �1`• n �de� Contractor Name: pfWA1, C (&"oo Phone: -.3.AA -el(:;,e Email: Address: R" *,C.0 low e oy ez. Supervisor's Construction License: eS-O?X 38 Ii Exp. Date: agl�k Home Improvement License-42 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS ASED ON$125. PER S.F. Total Project Cost: $ FEE. $ Check No.: Receipt No.: NOTE: P sons contract' with un gastered contractors do not have access to e guara fund FORTH ndover Town of 2 1,. ®. �, h ver, Mass, O LAKE A. Coc"ICHEWKK\y ,9S�� a TEDUP BOARD OF HEALTH PERSeFood/Kitchen ptic System MIT •.• BUILDING INSPECTOR • ................................... THIS CERTIFIES THAT . �•• • Foundation .. .............. has permission to erect .......................... buildings on ....... .U. .••••••• •• Rough J(�n /fJ Chimney ® �cc ..J..71G1�... . ... . .�.� ..... •�u... ...... .. to be occupied as ... ..... ct conform :!! lice ion Final provided that the person accepting this permit sh s every respect Laws rel tmg to the Inspection Alteration and on file in this office, and to the provisions of the Code By -Laws INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ELECTRICAL INSPECTOR PERMIT EXPIRES IMONTHS Rough UNLESS ST CTI S RTS Service ................ ................................ ....... Final BUILDING INSPECTOR GAS INSPECTOR EFFin ccupancy Permit Required to Occul�y Building is lain a Conspicuous Place on the Premises '— Do Not RemoveFIRE DEPARTMENT Display No Lathing or Dry Wall To Be Done Burner Until Inspected and Approved by the Building Inspector. Street No. Smoke Det. The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El Please PrintLggLily er A licant Information Name (Business/organizatiordindivvidual): Address:___/_V City/State/Zip: �t� �ti�d/� d Phone#: 9 7ff Type of project(required): Are yo n employer?Check the appropriate box: general contractor and I [�6. New construction 1. I am a employer with 4. ❑ I am a g ❑ — * have hired the sub-contractors Remodeling employees(full and/or part-time)•' 7. ❑ listed on the attached sheet. 8 ❑Demolition 2.❑ I am a sole proprietor or partner- These sub-contractors have _1 ship and'have no employees workers, comp.insurance. g, ❑Building addition working for me in any capacity. [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their required.] right of exemption per MGL 11 3. repairs or additions 3.❑ I am a homeowner doing all work c. 152,§1(4),and we have no 12.❑Roof repairs myself. [No workers comp. employees. [No workers' insurance required.] 13.❑Other comp.insurance required.] ' rmation. *Any applicant that checks box#1 must also fill out the section below showing their workerscompensation policy info ating such. Homeowners who submit this affidavitaan additional sh eg showingowing the name of the sub-contractors and their workers'all work and then hire outside contractors must submit a comp.policy information. achedformat on. tContractors that check this box m tt I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �� Insurance Company Name:. 4��/1� �`D I/eQS ..l�asUP �G - Policy#or Self-ins.Lic.#: �� Ql>.,5^fid 73�l�apl 1# ExpirationDate: 7 / /3� City/State/Zip: /Vc' Job Site Address.. / _ S Attach a copy of the workers'compensation policy declaration page(showingn lead to the imposition of criminal penalti s of a Failure to secure coverage as requiredunder Section 25A of MGL c.152 ca fine up to$1,500.00 and/or one-year imprisonment,aswell a civil openalties f this statement mthe ay f forwardedTOP. to ORK ORDER Office fd a fine of up to$250.00 a day against the violator. Be advisedcopy Investigations of the DIA for insurance coverage verification. Ido liet eby cert fy toder the pains an enalties of perjury that the information provided abov is t ue�nd correct. Date: p/`s Si ature. Phone rofficial use only. Do not write if'this area,to be completed by city or town official. Permit/License# or Town: ng Authority(circle one): ng Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 1.Board of health 2.Buildi 6.Other Phone#: Contact Person: - - - Rodd Injury by Accident 1.000,084 each accident The lirrtits eI liability under Petfi Two are: Bodily Injury by Disease $ -- 1,000,000 policy limit =i,ggq�}pq aach ernployea Bodily Injury by Disease - C, other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B C. This Petiey inctudes these Endorsarrtents snd Schodulss: SEE SCHEDULE 4. The premium for this policyi�will be i verification Ond��nr3e by udit classifications,Rates end Rating Plans. All Information required be - -Hates Cta&sifications $1 Estimated Per Code Estimated C$ Annual No. Total Annual Remuneration Premium Remuneration -- INTRA 285696 SE CLASS CODE 3CHEDU E ! INTER --- _ $4,217 - - Total Estimated Annual Premium $1 086 Minimum Premium $575 Deposit Premium Q®V i Gov MA Assessment Chg. $128 STATE CLASS MA 5ti45 $3,778.00 x 3.4000% 0713112019 This policy,including all endorsements,is hereby countersigned by — Autiioatxati S!gnature Date M P Roberts insurance Agency Service Ottice: 1060 Osgood Street 54 Third Avenue North Andover,I1.`IA g1845 Burlington MA 018013 WC 0q 00 01 A(7-1 1) tnctud©��opyrtghted material�i9 the National Cuurctl o peessarton in urer�ce, uae'd k'0h!!2 parr,?1-02-t,Rkt. 2 e'CS • �, 1.oe ,gyp -i C 00S AIV�Uage�1 +� 'y %r AXP` 69 pNa °veY r, ��. All, )) J Co