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Home My WebLink AboutBuilding Permit # 6/16/2015 l� o* �oera1 BUILDING PERMIT TOWN OF NORTH ANDOVER o - .:<... APPLICATION FOR PLAN EXAMINATION - Permit No#:19 Date ReceivedcHus �A7ED rr C7 sg Date Issued: PORTANT: Applicant must complete all items on this page LOCATION " c%c/fir. ,20 Prw PROPERTY OWNER '', ` Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition El Two or more family 11 Industrial [I Alteration No. of units: ❑ Commercial [IRepair, replacement ElAssessory Bldg Oth rs: [IDemolition [I Other ...... rf,,, rJa�?I,. ,/.. , , : tershe ,, f /� DESCRIPTION.f WORK TO BE PERFORMED: Identification- se Ty or Print Clearly OWNER: Name _. , 14"�a ��i Phone: 7 Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: __Exp. Date: Home Improvement License: Exp. Date:- ARCH ITECTIENGI NEER ate: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: $ 3� Check No.' " Receipt No.: �"" NOTE: Pers ns contractin with unregistered contractors do not have access to the guar77777, anty fund /i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans F1 Sw�:iug Pool' TYPE OF SEWERAGE DISPOSAL Sewer [Public Sewer ❑ Tanning/Massage/Body Art ❑ SwimmiRg Pools ❑ well ❑ Tobacco Sales ❑ Food Packagging/Sades [I Private(septic tank, etc. ❑ Pennanent Dwnpster on Site F1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature— COMMENTS CONSERVATION Reviewed on, ( Si nature T' ;7 COMMENTS HEALTH Reviewed on. Signature COMMENTS cL U C AC 6? in CVY) Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/s Driveway Permit DPW Town Engineer: Signature: —Located 384 Osgood Street FIRE D E 0,A R ,HENT, 77, Tb'mpeQumpster onsite; ,yes no Located Main Street Fide 0 signature/dale o. ' rW COMMENTS rff,l AM SORT I own of over 0 O h no LAKE ver, ass, (n Its -�ggy COCHICHEWICK BOARD OF HEALTH Food/Kitchen LD rER I im T Septic System THIS CERTIFIES THAT ........ ..... .. AL ,,, BUILDING INSPECTOR .. ..... .. ....... ..................................................... Foundation has permission to erect .......................... buildings on .3q...... .. .... .... ..... .. 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 ® LESS CONSTRUCTION Rough Service .............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy PuildinRough 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. TO"OF NORM AND OVER OMCE OF ' a •e .:-1600 X719koa' _ 7�p�R3txncilu t4�'[5 • Tc�iTz davex lVlassaausa 4Z S45 Gerald A.Brown . Tolep7zone(97$)6889545 I'nspeetorofBl;ffdiugs -Fax (978)6889542 . -HQMEb—VMBR MCENSEEKEMPTfON ' ' 1'leaseyrinE • DATE: *6. - 0/)ADB�,t�Cevin t1 N'um'ber treet.A.dd ess Map)�ot • ame. . �1.ortze Phone W ozk 'bone • 0 I C��fs,TO m a z a • ip ? Thp-current exemption for". omeowners"teas extended to�Glude ovinex❑cctipled d�Yellings ca alloy sub hoznPo„�ers is e3gage an Edi vadual.fox firs ono does aopossess a lice3lse,pxovzded that fi7ia owuez acts as snpazvisor, >��iate3�ildiRg (Codeuect?on Z�S.3.5, ) DEFINITION OYHOMEOWMP, , Person(s)'who 9wils aparcel Of land on which Itefshe xesliies ox lriteRds to resi(je,on which there is,ox is iufeu ded to ��,a one or two Family sfzuetares. A poison Who cumtrticts more that one home xu,aiwo yearpQd d shall uot'be considered a hmacomor. Tho vudersigRed"hontec Wn6l"aSsuraesresgDUSXbzIi y oxG�rmp7iaRces�vzf�t tie fafeBuilding Cocleand oilier A•pp2ca�ble codes,7iy lawn,xWos and-xegalatxoass. The xmdersigned"hozrtoownax°'text; es khatIiels eunders tdstheTOWuOfNorth&doverluilffagDf,i fine Lt iniuzuxn inspection pro cedures and that helshe will comply with;sand pxoceduzes and x'ecluirezneRts, - , .HONEOWNIM SIGNMM , APP.P.OVAL OF I3TT,IL.D)NG OFFICIAL. Revised 7.2009 FozznSomeawners Exemption ` 30A D OFAPP.EAM-688-9541 • Cb7�rS �'t�rZON 685-9530 MAL'IJ3 6$8-954a Px..hlRNG 689-9555 The Commonwealth of Massachusetts . . (0 Department of Industrial Accidents 1 Congress Street,Suite 100 _ - Boston,MA 02114-2017 www.mass.gov/dia OiM 5y�v Workers' Compensation Insurance Affidavit:Builders/Contxactors/Electricians/Plum ers. TO BE FILED WITH THE PERMITTING AUTHORIT X. please Print Le 'bl A licant Information Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Checic the appropriate box: Type of project(required); (full to full anP and/or art-time).* 7. F1New'eonstruotion 1.Q 1 am a employer with em P y 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. U Remodeling any capacity.[No workers'comp,insurance required.] 9. ❑Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4' am 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 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 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 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. d an additional sheet showing the name of the sub-contractors and state whether or not those entities.have #Contractors that check this box must attache employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. worlters'compensation insurance for-my employees. Below is the policy and job site Yam an employer that is providing information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Adch•ess: 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,tviolation RK ORDER and a fine f up to$250.00 a and/or one-year imprisonment,as well as civil penalties in the form of a STOP day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains a dpenalties of perjury that the information provided above is true an, orrect. Date: Si nature: U 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 Phone#: Contact Person: