HomeMy WebLinkAboutBuilding Permit # 6/29/2015 BUILDING PERMIT OORTH
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
assC
Date Issued 4;IMPORTANT: Applicant must complete all items on this page
LOCATION V! 02-zWL-/ I&A'11'
Print
PROPERTY OWNER 1�1&- -
Print 100 Year Structure yes no
MAP PARCEL:e�P,60 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building KOne family
[I Addition Li Two or more family Li Industrial
Iteration No. of units: 11 Commercial
Li Repair, replacement Li Assessory Bldg Li Others:
0 Demolition Li Other,,,,,, t'g
TO,
9,91?4,1,
Wk�
IN
DESCRIPTION OF VYORK TO BE PERFORMED:
s a Jk'0 aa 4 AcO 4h,��r
V
entification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: 7L-3C-t4-6-1010 lsltA
Contractor Name: 1411 -eid Phone: 'k3 s—
Email V -J,2�;,,)
Address:
Supervisor's Construction License: 65 60Z 71�� Exp. Date:
Home Improvement License: 2- Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE;BULDINGPERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00PER S.F.
Total Project Cost: $ A'A 40—OL
FEE: $
Check No.: Receipt No.:
NOT Per ns contractim-a with unregistered contractors do not have access to the guaranty fund
e
FORTH
Town of ? . .� a ndover
...1,, .
® .. to
No.
- 11h
O ver/ ass,
LAKE
COC KIC.IWICK
S �
BOARD OF HEALTH
11 A
PERNII I T L D Food/Kitchen
Septic System
THIS CERTIFIES THAT A4 BUILDING INSPECTOR
has permission to erectFoundation
.......................... buildings on .......!C,��t�-�?°:9.... ....{. ...... .........................
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
IT EXPIRES MONTHS ELECTRICAL INSPECTOR
UNLESS TI T Rough
Service
.............. ................................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® OceupV BuilclinRough
Display in a Conspicuous Place on the Premises - ®o Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedy tht Building Inspector. Burner
Street No.
Smoke Det.
OMCE OF
f• 71 r
' �Ra •" . X600 D.goC,9StrootBuxlding20,-SmftQ 94-3 6
_ 7�a��srxn ae� d5 Kbit Ando-P'fxg-Massadhusata 01-84;5
Gexald A.Drown Telephone(978)698-954,5
1'nnpeetorofDIIdings Fax (97-8)689-9542
R@MF-QWMP,MCENSE RYKEI&TfON '
pleasepr:m ,
PB LO CAI�OM-2 0
�umbex Street A ddzess map)Z of
Name. Home Phone •WbrlkAone
M-SENT MSGADDxXS - - -
`i�'I-4, - o f - `q cr�r71
Tho current exemption for"homeowners"was extended to:Laolude owner--occupied diuelin�s to tvo uzzits or less ani
eo allow such,homeo„meas to engage anLdj-y;duaZ•forhire,-�:no�1oas aotpossess a�ceuse,pxovldetl that the owner
acts assnpexvzsox�. ,��iate3u?Iding (Codeuection•x�8,�•5.`i� - °
DEFIMTxON OFHOMEOVMER .
pemon(s)who gWAs apazcel ol:land on which helshe resides or intends to reside,on which there is,ox is xufended to
'bb,;'one or two family sfroetares. .A.persmwho constructs more that.onehome in atwoyearpe46cl shall Aotbe
eonsidered a homeowner.
The uttderszgned"h oxneciwner"'assuznesxesponszbilztyfoz comp ances with the State l3uijding Code and ofiar
Applicable codes,,by-law;tales and--egaXagons,
The rxudersigned"homeowner"certiffes that helsheunderstands the Town ofNorth Andoverl3uildingDeliaefinent
miullu um inspsefion pxoccdures and requiromaats andthathe(she will comply with;said pxocedures and '..
xeciuixernenfs,
HOAMOVytbT$RS;31GM.A.TrlR7;
APPROVAL OF l3TT.[C,DWG OFFICLAL
Raylsed 9.�Q09
Fonngomeowners Exemption
-Y
3DARD OF.ApEEAM-688-9547 CONTSERVAUON 698-9530 YMALTH 6'89-9540 PLANNWO 6889535
The Commonwealth of Massa chusetts
Department of IndustrialAccidents
s I Congress Sheet, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
Applicant Information g Please Print Legib
Name(Business/Organization/Individual): ! kd f 3 ��/4.-��-A.)z)
Address: --- :Z �J � �� 6'4y r(
City/State/Zip: ; e /4.. � Phone#: 97 ��l &A e2,S-
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am.a.employer with employees(full and/or part-time).* 7. ❑New construction
2.F1 I am a sole proprietor or partnership and have no employees working for me in 8.,KRemodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.MI am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.F]I am 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. Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5. I am a general contractor and I hhired rethe sub-contractors lid the et
ors steon e attached she .
❑ 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.E]Other
152,§1(4),and we have no.employees.We 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.
tContractors 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-con}raciors have employees,'tliey must provide their workers'comp.policy number.
lain an employez'that is providing workers'comp zzsation insurance for nzy employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lia#: i Expiration Date:
Job Site Address: >�c�fa '�r� Vi/� l�l�,'f City/State/Zip:A/, 4J //2`dd o9cA—
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.
I do hereby cert'y u d r the ins a dpenaltles ofpezjuzy that the information provided above is true and correct.
Si nature: /- Date:
Phone#: �' a
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#: