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Home My WebLink AboutBuilding Permit # 6/9/2015 11 BUILDING PERMIT ®��fl°T TOWN OF NORTH ANDOVER IN APPLICATION FOR PLAN EXAMINATION o Permit IVo# Date Received �Rp�RA4EU i �„ �SS<1CHLJ5�'C Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION S /G ✓✓ //,// PROPERTY OWNER �.� �j �Print /e� Pint 100 Year Structure yesno MAP "'" PARCEL/ ZONING DISTRICT: Historic District yes �"no `�' fl Machine Shop Village yes rio I f� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ebne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Tlt,lepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r rG,+ rui;iiaii r r.,, /„f„/lJ / I /n ,// J/ r, �, , ,o ; r,..// �/ %/,, I 11 /Watershed D stFicf/ r //i;, Flood al. ❑Wetlands ( /❑ r ,r�r 1 r1/,J,” 1( J" �� „/r/iljr »ir /f r/ / ;I � r �, � � rJ�, DESCRIPTIO. OF WORK/TO BE PERFORM D, Identification- ase Type o Pri t Clearly OWNER: Name: � J r� 1�1 < f .. ex Phone: " .- Address: h6r ,Ie'I'l- 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:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ / , � FEE: $ � Check No.: Receipt No.: c. ��„ NOTE Persons contracting with un egistered on ctors do not have access to the guaranty fund Ml,,'0"'Z/1'k �BORTH Town of ndover ® 0% �.K. h ver, ass, COCNICHt WICK y1. S u BOARD OF HEALTH Food/Kitchen rERMIT T LD Septic System 09 THIS CERTIFIES THAT .............. ....... 6 BUILDING INSPECTOR has permission to erect buildings on $.I Foundation Rough to be occupie .i.. ..... ..............................:............................. .............. Chimney provided that he perso ccepting 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 E I I 6 ®NTS ELECTRICAL INSPECTOR ® LESS C T C S TS 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 Approved by the Building Inspector. Burner Street No. Smoke Det. L/ riot' up'l- Fn 1 Too Q ------------- Qj ------- I kAj 11 LIN. C) Sj- I-c- Wag! jvq;10 Fv 0 o- L. F! of�°ar fi�Y Tom'O NORM, OVER • Na �ne 1600 D400d,9tze0tBuff ding20,•,S`vjfQ?36 ,. _ `J'pp�R'�7%n FBF,.(CJ ••'NoithAndcvexg Ma.-sachus otta 01845 �'S�13CHl15�� Gerald A.Drown � Telephone(978)688-954-5 pertor of Buildings Fax (97-8)688-•9542 a� xt PFIPMT AXPLICAMN 1'leaseprL , DATE- SOB LoCA.TYbN, f �. / N'um'ber StreetA dress 1vIaplLot Ide 2--l' _- //'// L171W dame. . Home&De Workl?hant; PR39ENT MA6NG ADDRRSSLY� Z/m Zl-�,ir �� - ,Sfate• - zip Code The current exempfiou for"homed wirers,teas extended faiaQjude ow.nex 00olipied divowl�gs to two units-QT 08A and fo,a.IIOW Such hon7P0,?rer8 to engage an?�div;dual•for hire Vho does not possess a license,provided Matthe,ovrxer acts as supervisor), StateDuiiding (Code Seation 108,3,5.1) DEMITION OFROMEOWC`BR , ersou(s)who gwus a parcel of land on WRO'.he/she resides or intends to reside,au which there xs,or is xnfeuded to 7�eaaoneortWo aruilysfzuetures. .A.perso.awkconstructsmore thatonehomei .atwayearperitidshallnotbe cozisidered ahomeownez; , The underszgned"homeow.nex"assumesresponszbzlztyfo�-coznpliaz�.ces-tvzFlt tie State�3uilding Co ,Applicable codes,by-laws,razes antl-�regaZatious. de anti other The uudexsigned"homeownex"cerlifCes that helsheundexstands Me Town of gorth AndoverDuilding Dol azfinent ml„i,,,um impeofion procedures and roqukamonts and that helshe will comply with;said pxacedures and recluixomeuts, . 110AMOWNIUS SIC-NA.TM APPROVAL OF PU,rD OFFICIAL Revised 7.2009 Form Siomeowners)Exemption $OARD OFAPPBA7S 688-9541 COhrSERVAMN 685-9534 DEAM1688-9544 PLANNING 6889535 The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia ODM S��v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plum ers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Please Print Le 'bl A licant Information Name(Business/Organization/Individual): Address: Y �S Z/ // Phone#: �/�'�� City/State/Zip: /'TLh Are you an employer?Check the appropriate box: Type of project(required); 1.F1 I am a employer with-employees(fill and/or part-time).* 7. F1New'construction yees 2,❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling capacity.[No workers'comp.insurance required.] 9. ElDemolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q B ' ding addition 4.lam 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. Zunabing trical repairs or additions proprietors with no employees. 12. repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance3 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. 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is pr'ovidingworlter's'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: 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. c v hereby certify r the ins an peva of perjury that the information provided above is true and correct Date: Si ature• Phone#- official #•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#•