HomeMy WebLinkAboutBuilding Permit # 6/29/2015 BUILDING PERMIT A��o oT e��o
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APPLICATION FOR PLAN EXAMINATION _
Permit No#: Date Received �yA0 Arco PP��cS
V ssaca�us
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Date Issued: (s7
IMPORTANT: Applicant must complete all items on this page
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LOCATION
12,1 t' . A~ -.oA I, r,
Printmm
PROPERTY OWNER,,' 2 t( 1+tXA
Print 100 Year Structure yes no
MAP PARCELI 0 1 ZONING DISTRICT: Historic District yes no
Machine Shap Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
DESCRIPTION, rn
OF WORK TO BE PERFORMED:
1,111,12 Vq. 'b
Identification- Please Type or Print dearly
OWNER: Name:,,, Phone:,.
Address: "
Contractor Name: ( . Phone:
Email: t UZ '� �
,�rw
Address: o ecow 5.1 14 if iI e P Q1 A 5*
Supervisor's Construction License: A,1 Exp. Date: �r
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: $1Z FEE: $ In
C� �Y
_Receipt No.:No. x C
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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FORTH
Town of z . � _E ndover
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No. I � �/ *IV_ _ h
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h ver, Mass, Jew
A- CoCNIC.t WICK
7�ADR�TED NPa �'Cy
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BOARD OF HEALTH
Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT .....PERML11T
......................................................... ................................................
^�
has permission to erect .......................... buildings on ..� ...... . ...... Foundation
`�!►.clmok
. .... .. . Rough
tobe occupied as ............................ .. i11AQt .. ........................................................... 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
UNLESS CONSTRUCTION STARTS Rough
Service
.. ... .. ... ,... ...................... Final
U DING 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
ntil Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
TOWN OF NORM AND OVER
.1600 DsgnaaStzeofBuffding2Q,-Snjtc 6
R'
.••KbithAndovor Massachusctg01845
PiWr-
Gerald.A..Brown - - `I`elelihone(97e)688 954.5
I•nspectorot'Bi ldings . Pax (978)689-9542
' pleas��z�� • ,
AT,C- Ad' ,1&' �_ r
Id'uml�cr
Rome,Phone
. �ixeet�.ddress IVSap/�ot
t WorkWhone
PRESENT MA6NG ADDRESS
Cot
t f'I'e�T • L ate• -
' i Cods
The euxrent exemption for" omeoWrzexs"'Was extenaW 4o inph1do owner-occtip'zed 61-Wolffi',gs to tvo units or fj s �d
to allow sabh hamPoliTmexs to engage an 1�diidual.toxire zvno does nopossess a IicGnse,pxovided that the oWatex j
acts as supexv?sor). 9fatoDO,ding (Code Section.I08,3.s.1)
DEFINITION O:V)aOMEO'W.t`7 R
Persons)who gw.ns aparcel ol:land on Which 11e(sheresides or Mends to reside,on WhiclZ sere xs,oris Mended to
be,aoneortWo ara�ilystcuetures. .A.personwkoconstructsmore,fat.onelWmeinatze eaxpe,1odshallztotbe
considered al�omeownex.
The undersigned"hozrteowner"'assumesxesponszbxlzty oxci�mpliauces v�itlZ th StateBuilding Code autl aner
.Ap.plicable codes,by laws,rrlles and-regulations.
Tbeundexsigned"homeowztex°'cer esthathelsfetutderstands eTowuo 7orEhAzdoverButclzngDe azttttent
o'7nxmum inspecizon procedures and requirements and that helshe will comply with said pxo cod-ares and
requiromouts,
.APPROVAL OF 131UDWO OFFICAt
Revised 7.2009
P'orrnS�omepyynersFs�emp�ion
Y3D.ARD OFAPP.EAT 688-9541 CONSER,V.A`SlON 6M9530
1iEAT.T.E1688-9540 1'I.A14t1IN•G 689-9555 .
The Commonwealth of Massa chusetts
Department of IndustrialAccidents
r . . X Congress Street,Suite 100
Boston,MA 02114-2017
sy;w�t www nass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
NaMe (Business/Organization/Individual): "� C_.
Address: C� V
Ci /State/Zi t° v C Phone# ...
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.❑I am a sole proprietor or partnership and have no employees working for me in $, emodeling
any capacity.[No workers'comp.insurance required.]
3.�I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. ❑Demolition
10 F]Building addition
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
• 12,E]Plumbing repairs or additions
5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have na.employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 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.
$Contractors that check this box musfiattached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-coniractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lic.#: Expiration Date:
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 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.
I do hereby certify under the pains and penalties ofgrjury that the information provided ab ve is true nd correct.
Si nature: ( �t Date: w° rtl ts
.
Phone#: t C ` (W
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#: