HomeMy WebLinkAboutBuilding Permit # 6/15/2015 BUILDING PERMIT0 V%ORTH
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TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received .yssO"Ar Eo
qac Hu
Date Issued:
IMPORT icant must complete all items on this page
LOCATION
Print
PROPERTY OWNER -,.1 '0
I Print 100 Year Structure yesno
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes bno
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building '�Kpne family El Industrial
19 Addition El Two or more family
El Alteration No. of units: L1 commercial
El Repair, replacement ri Assessory Bldg 0 Others:
11 Demolition El Other
''a
Ing- W
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone: I (f
Address: S 3 1-1 Vt, 1-J ti r L
Contractor Name: Phone:
Email: 01
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: $ Cr 0 C) FEE:
C'
Check No.: Receipt No.: J
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
...........
tkoRT H
Town of over
® �{ -
�^�� h ver, Mass,
coc..IcKaw.c.c
ADRATED
S u
BOARD OF HEALTH
Food/Kitchen
IT �T� D Septic System
THIS CERTIFIES THAT .......) ... l ...................... BUILDING INSPECTOR
has permission to erect .... .................... buildings on ... .... .............. .......... 14'.4Foundation
..... .............................ikA a
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 E IES 1 k�,_
ELECTRICAL INSPECTOR
® LESS CONSTRUCT T , -Rough
Service
............................. . -.v ................
�r 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
�4 prH TOS'OFWORTH ANDO +R
OBRICE OF
lit
'A Ju l .LJ.Y Ed, r
600 Qsat StroetBuffd�]g 0a � `
go - 6
"°R n F`�5 •WofthAndmry Massachuseta 01845
Gerald A.BrownTelephona(978)688-9,545
InspeutorofBuildings _ pay. (97,8)689-9542
d'lease�rinE
DAM
' �um'6er Slxeet.Address �llap/�ot
Name. Hozne phone ►Nozkl'hone
TRE-SENT:llMMG ADDRMu"' . - - . .. • ,
GTm State - ,�
zip Co_s
The was extended to?n�luc�e ownex❑c�t%pied diVellings to t vo units.g_ less and
to allow Sub h homf-0 minus to engage an in C. msal-for hire Vil0 r7oes notpassess a 7ieonse,pyo Aded AaE tT e,oymez
acts as snpezvisor)> gfiate3ulding (Code ection 1�$,3.5,d
D)MMITION 0-FROMEO P 4
I'ersou(s)who awns apazoel ofland ou which e/slieresides or intends to reside,ort wMdfi-Ehatf,is,ox is xnfended to
��,aoneox o arnilystzaetures. .A.persoxGwltoconstructszaorethat.onehomDivatwoyearpexzodsltaUnotbe
�onsidexed al�.oxneowxzez; •
Tho undersignod.°`homodwnej,,assumes responszb7liEy hoz Goanpliauces with the StatoDuilding Code anti other
Applicable codes,by-laws,reties andzegulations.
The un.dersigued"homeowiam?,cexHes Me,Towzzof11'oz1EtAndoverBuildingDpe a�tent
aninimum xnspeetion procedures and rogairamoats and that helsha vdH comply 1,yi-th.;said pzoceduxes and
xecluixexxients, ,
XIONEO),YMRS S.ICr�'.A.TURE r' '
.API ROVAL OF J3UJ .DWO Op'FICJAI,
Peyised 2009 "
�'orrn�omeownersFsxBmption w
3DARD OFAPPEATS-688-9541 C0NSBR,V',AUON 688"9530 MAT,TH W-9540 1'LA.NN-mO 689953i
The Commonwealth of Massachusetts
f Department of 1lndustrial Accidents
; . . I Congress Street,Suite 100
d Boston,MA.02114-2017
www mass.gov/dia
ODM 5Yf
Workers' Compensation insurance Affidavit:Builders/ContractorslElectricians/Plum els.
TO BE FILED WITH THE PERMUTING AUTHORITY. Please Print LqqLbl
A licant information _i
Name(Business/Organization4ndividual):
Address: 1S 1 �A '�
City/State/Zip: N 0/� p `�` I�' Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
em to ees fiill and/or part-time).* 7. ElNew'donstruct[on
1.❑I am a employer with P y
2.❑I am a sole proprietor or partnership and have no employees working forme in 8. F1 Remodeling
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.M I am a homeowner doing all work myself[No workers'comp,insurance required.]t 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
11.E] repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
ect
proprietors with no employees. 12.FJ Plumbing repairs or additions
S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,,0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance# 14.❑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 cheeks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submitthis 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(hose entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lie.#:
City/State/Zip:
Job Site Address:
ompensation policy declaration page(showing the policy number and expiration date).
Attach a copy of the workers' c
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
enalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
and/or one-year imprisonment,as well as civil p
may be forwarded to the Office of investigations of the DIA for insurance
day against the violator.A copy of this statement
age
covexverification.
c v ragehereby certify under tliepains andpenalties ofpejjury that the information provided above is true and correct:
Signature
�—ti�, ( Date'
�. _
Phone#: 1 ,
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#•