HomeMy WebLinkAboutBuilding Permit # 6/22/2015 NORTH
BUILDING PERMIT ® _@U
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APPLICATION FOR PLAN EXAMINATION
Permit No#: L Date Received "
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Date Issued:
I PORTANT: Applicant must complete all items on this page
LOCATION 0 t t
Print
PROPERTY OWNER PC, W i
Print 100 Year Structure yes n
MAP PARCEL: ZONING DISTRICT: Historic District yes n
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building rpOne family
❑Addition ❑ Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone: io
Address:
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:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ `,.. � FEE: $
Check No.:
Receipt No.:
NOTE: Persons contracting °h unregistered contractors do not have access to the guaranty fund
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t] BOARD OF HEALTH
Food/Kitchen
PERMIT T LU Septic System
THIS CERTIFIES THAT q t � '� BUILDING INSPECTOR
.................... ,................. .............................r......................................................
Foundation
has permission to erect.......................... buildings on ... ......... ►.i'�. .#�. . . .A.
...... ....................
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to be occupied as ...... +... .............'f..... .. . ..............'!!<o°! }.J..:. ... 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
10% PERMIT EXPIRES IN 6 THS ELECTRICAL INSPECTOR
UNLESS TIO T T Rough
Service
............... .. .......................... ................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Displayin a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall oBe Done FIRE DEPARTMENT
Until Inspected and Approvedy thin Building Inspector® Burner
Street No.
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NofthAadovoxg Massadhu otta 01845
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Gaxald A.Brown Telepl3.one(978)6889 '45
Ynsvr-ctorofBuildingo _ Fax (978)689-9542
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—ROME( AMR LICENSE BXEZ1 R TxO 1
PB LOCA.TfON,' c
Nuxnhez Stzeet Address map/Lot
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C� ''�'ot' • , te• - . stip Cod s
TAA current exemption f'or'lomeownexs"was extauaM to iuohlde owner oom% llod ftamgs to tvo units.03'1,00s and
to allow subh homeowners to engage an Ldivaduat for hire Vbo o7oes a tppssess a JI0031se,provided that the owner
acts as sapery?sor). gfafoWl cling (CoaoSactipn -
DEMITION OFRO:EOWMR ,
Pexson(s)who gW.Us aparcel ofland on wl�icl3 helshexeszdes or intends to zeszdc,on wl3iclr fheze is,ox zs xnfenderl tp
he,aoneortWo amilysfzuetuxesw .A.persortwho comtmofsmore tTiatouohomexnat�o�earpeztoclshallnotbe
eoz�sidezed al3omeownex ,
Tho vnderszgned".ho3steownez°' With alio StateBuilding Code and offer
.Applicable codes,by Laws,Mes and-xegulafzons.
The uimu ersigned"bomeownex°'cex; es aEke/sh)unclexstandsMoTown ofIgorth ndoverBuzldingBeliattraent
�vin sper,tzon procedures and roquiromeuts and that hey&he txtlll compbr with;sald procedures and
rer�ulzexnents, r
ROMOWMRS STGN'AT E ,
.APPROVAL OF BTTff-DWG OS'.�'.ICIAL
�2eyisecZ J2Q09 ,
)FIDIm eowners Bxem�tion
30ARDOFAPPBAM 688-M41 CONSFR`t�',t�.`S�ONfi86-9S34 BEALTH689-9540 PLANt`7tNG6189953:
The Commonwealth of Massachusetts
Department of IndustrialAccidents
M ": X Congress Street,Suite 100
Boston,MA 02114-2017
O M 5y'y
wK www.mass.gov/dia
Affidavit:Buildexs/Contxactoxs/Electricians/k'lumbers.
Workers' Compensation insurance Af
TO BE FILED WITH THE PERMITT'NG A7JTHORIT'Y. ase Print Le 'bl
A licant Information
Nalco (Business/Organization/Individual):
wad
A-2 hz
Address: a
CiCity/State/Zip: Phone#:
ty/S :. . . .. :
Are you an employer?Checlt the appropriate box;
Type of project(required):
em to ees fill and/or part-time).* 7. Q Neer`construction
1, am a employer with P y
2.Q I am a sole proprietor or partnership and have no employees V✓orking for me in 8. emodeliing
any capacity.[No workers'comp,insurance required.] 9, Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition
4.❑Tam a homeowner and will be hiring contractors to conduct all work on my property. I will
1 L[]Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12.Q Plumbing repairs Or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,0 Ko6f repairs
These sub-contractors have employees and have workers'comp.insurance) 14.0 Other
6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c.
152,§l(4),and we have no employees.[No workers'comp.insurance required]
*Any applicant that check's bbx t#1 must also fill out the section below showing their workers'compensation policy information.
i 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 checkthis box must attached an additional sheet showing the name of the sub-contractors and state whether or not those,entities,have
employees. I£the sub-contractais have employees,they must provide their workers'comp.policy number. - -
X am an employer tliatispr•ovidingrtvorlcers'compensation insur•ancefor•my employees, .Below is tliepoXicy andjob site
information.
Insurance Company Name:
Expiration Date
Policy#or Self-ins.Lie.#:
City/State/Zip;
Job Site Address:
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 WORD.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.
X do hereby certify under'the pains andpenalties ofper;jury that the information provided above is true and correct.
• � ,,�"" .• Date:
Si ature•
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:
