HomeMy WebLinkAboutBuilding Permit # 6/30/2015 >1
BUILDING PERMIT 01`A°oT 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: �L�� Date Received
I.9 TEO
SSACHUS�
Date Issued: a
IMPORTANT:Applicant must complete all items on this page
LOCATION l 's- qoud
Print `
PROPERTY OWNER -
__ C +� 14 r, , Cit tq d
r ® Print 100 Year Structure yesno
MAP PARCEL: ZONING DISTRICT: Historic District ye no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building IKone family
Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
DwSe tics' Well' ❑ Flood laml ❑WetlandsrWIN
teshedrDstnc
DESCRIPTION OF WORK TO BE PERFORMED:
'/d/
t
V '/ /q P _ ck eti /c/,v-L
Identification- Please Type or Print Clearly
OWNER: Name: / r Phone: 97 3/ y 7q,?
Address INS- �
Contractor Name: l Phone: , / L�
Email:
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$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ ��5 00 , FEE: $
Check No.: ��7/ Receipt No. _
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
` 1
JAOR'1 H
Town
_E.....'.I,
Andover
®ofto
No. OM- 2.0 1 - _
z h ver, ass
O COC NIC aw �1
X9,4 A�Rgreo
0.ea�.(5
S U BOARD OF HEALTH
PERI T T LD Food/Kitchen
Septic System
CTHIS CERTIFIES THAT ..............!.... ....61—Y J.,Gt......Y../!!..G... ...���. . ............................................ BUILDING INSPECTOR
`y � ®®� �''� Foundation
has permission to erect .......................... buildings on ..1..!.. . .............. ..... ..................................
Rough
to be occupied as .... �. .!` I. ........ ..... .. .....:............................................... 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EI IN 6 MONTHS ELECTRICAL INSPECTOR
UN
LESS C STR CTIO ST TS Rough
01 �_Z� Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Puildin Rough
Islay 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 y the Building Inspector. Burner
Street No.
Smoke Det.
04 mor TO OF NORM.�ANDOVER ,
OFFICE OF
-.1600 DskOOdStrootBuff diug20$-Surto—?-'36
�'�#�'�3txn FY��d5 ••'�CST��t�5].dQVE,x �a5'S'3.C�7.tI5P..tt,4•`�}�,�QJ�'
' �s�fiC�1115�"4 8
GaraldA.Brown ` olopIkup-(978)688-934-5
InspeetorofBliffdings fax (97-8)688-9542
please print ,
DoE LOCAVON: (V 5--. C� W
5 P
Numbe): tree ddress xY.Iap)Zot .
_ 4
Nam. Homo Ilhone �1orICI'hane .
VAcliMIAat - v j
'I'.�e cuzzent exemption�'az"•I7,Omeo'4vnexs"'tivas e�tend�d io?n.�Ittde ownez-o cclipled d�Yellings to t4vo 7.i7�lts•oT I�sS 2tt d
cQ allow su�T,3,o meo„�exs io eng%e a17 dividsaZ.foz hire zvno cloes aotpassems a license,pxovided fiat fihe ownez
acts as snpezvYsoz). Sf fe3uilding (Code ecfion ZOS,3.5.�
DBMITION OFROMEOWNEtR
Person(s)Who awns aparael of land on wl�icl��efsltexesicles or intends to reside,an wl�ic�t tl�eze is,or zs xnfended fa
��,aoneortwo aroilystrucfuzes, ApexsonvlltoaonstructsMora f7iat.oue omexnatylayaazperzodsballAotbe
coz�sidereda7�.onteowner, •
'Elis undersigned"homcdwuae,assumesx-esponszbiIit rJbTaompliances with vio sfateBuzlcliug codoand ofkr
APTEcable codes,by laws,tales and-xagalatxons.
Tbe�mdersigned` iomeownex"cuesthat ifie,TOWnofgorfh..A.nclove-Buil&gDe& ent
nvnimu7nzns_peotionpzoceduresand xec�lli�e eats dfhatltefsitetrlllaompZywztlz;saidpxaceduresaud
requirements. .
RONMOWMRSPIGNATM '
APPROVAL OF)BMDMG OF'.PICIAL
Revised 7.2Q09
x'oxzn�ozneowners Exemption '
3OARD OFAPPBAT-688-9341 CONSEVAHON 688-9530 BEATX1688-9540 6ts g;q�i
The Commonwealth of Massa.chusetts
Department oflndustrialAccidents
d I Congress Street, Suite 100
Boston,MA 02119-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMIT.TING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: 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 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑DemoIition
3.Kl am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 E]Building addition
4.❑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 have hired the sub-contractors listed on the attached sheet.
❑ 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.#
6.F1 we are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ Other
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.
(Contractors 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-contractors 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,Lie.#: f Expiration Date:
f
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 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' under the pains and penalties of perjury that the information provided above is true and cor'r'ect.
Si nature: aZAV� Date: 6 3 Q S
Phone#: / Z
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#: