HomeMy WebLinkAboutBuilding Permit # 7/1/2015 I FORTHBUILDING PERMIT RILED
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#:Id Date Received AYEV
Date Issued:
IMPORTANT:Applicant must complete all items on this page
"'LOCATION e el
Print
PROPERTY OWNER ,'a '7-T Ll�-loz14
Print 100 Year Structure yes COP
MAP r PARCEL ZONING DISTRICT: Historic District yes 281,
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ane family
11 Addition [I Two or more family [I Industrial
ffteration No. of units: [I Commercial
0 Repair, replacement [I Assessory Bldg [I Others:
El Demolition El Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home improvement License: Exp. Date:
ARCH ITECT/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: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contoctors do not have access to the guaranty fund
7777-77-,�777771
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t%ORTH
Town of
® ' Andover. ::
O. V—201 LAKE_- ,--
�, h ver, Mass, -t
O COCNIC twi K 1•
"�OATED JL
S U BOARD OF HEALTH
Food/Kitchen
PERMIT �T L &W Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT ..... ..... ............t..............................................................
��.....'............... Foundation
has permission to erect ........ ................ buildings on ..... .........VV��: •� ........ 4....
Rough
to be occupied aA ........................................................... Chimney
.... .......... ....
provided that the on accepting this permit shall in every respect conform to the terms i the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
30. UNLESS CONSTRUCTION ST-ART Rough
Service
....................... .
... ............................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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 by the Building Inspector. Burner
Street No.
Smoke Det.
04 gaxry � TOW Off`)90RTff ANDOVER ,
01 TICE OF
36 ES .I600C)SgoOdStroatBuff ding 20,-Silxtc2-36
7 p��,�d Fey"�5 •Woith Andovox,Massachusetts 01 845
- �s�r�caus�•�
GaraldA.Brown. _ Telepliono(9 79)688954-5
33 spectorofBildings _Fax (978)685-•9542
ROXWOMER EICENSE 13 EMPT C� .
pleasebnnE .
DATE: K� ,
' •N'umher SixeetAc�dress .• Map/,'Got .
�IOAMCX ER SC ca T 77. o G ✓L
Name. . Homo 'hone W rk 'hone
AX)0 Li4 S oly �t l'
y �t=m • �f - dip Co+?e
The current exemption f'or"liomeowners"was extended io ,�clnc�e ovinex❑cctip'1ed divelings to t�uo un%fs or:cs5 and
to a71ow subh hozneo„reAs zo engagean 1�dz�aaual.forhiro who does notpossess a 7.icG3lse,provided that the owner
acts as supexuisor. 9fafeBuift (Coda Seotion 7�S,3a5• '
DEMIMON OYROMEO•WMP,
Porson(s)whaawns aparael o IaAcl on which he/shexeszdes or znfands to xCoo on which is,or is infended to
T��,a one oz ttuo a=4ilysizuefures. Aporsobwho constructs more.ffiatone,homein aiwo yearperxor.shau Rot bo
consideredah-orneowner,
The uudersxgned"hometiwzrez”assumesresponsibility or compliances with the)State Building Code and other
Applicable cones,by laws,roles acid-xegalataons.
The lmclexsigued"homeowao?cext ftes that hehfia h derstauds the Tow-u ofNorth Andow.03iii1ding Dr,i,,a ment _
m;�;muzn inspection pracedures and roquiromenfs and that h elshe wiff comply wjth;said pxacodmos and
reguireznents, .
APPROVAL OF I3WDMG OF'FfCfAL
Revised 7.2009 "
x'oxm�SozneownersXsxempfion � '
3DARI]OFA-PpEAM 688-M41 CONSER•4AUON 688-953(1 �TAd7TC1 ti�II c�t.itt bT h A7Am rri Jnr.n
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Sheet, Suite 100
Boston,MA. 02114-2017
www mass.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'y 7-r Af"
Address: / /-/�q-i7 r,?u t.J 6 # /_/
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.F]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. Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
10 Building addition
4.�I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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.
thi
t Homeowners who submit s 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 jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 of perjury that the it formation provided above is true and correct.
Signature• Date:
Phone#: 77/ — S
Official use only. Do not write in this area,to be completed by city or town official..
City or Town: Permit/L,icense#
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#: