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Home My WebLink AboutBuilding Permit # 7/1/2015 VIII BUILDING PERMIT %AORT11 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date ReceivedAr.. Date Issued: "7 ,( CH IMPORTANT: Applicant must complete all items on this page Lx PROPERTY q gg arlStructure,,/,,,,, t"""w ric,pis NG,"DISTRIC M 1-, 1yes n cr, Machine"Shop';Village yes` o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Z One family 11 Addition El Two or more family El Industrial [I Alteration No. of units: Ll Commercial "Iepair, replacement 0 Assessory Bldg El Others: Demolition El Other P'Sbptic,1- EIWell 11 Floodplain , 0 WWetlandsEl Watershed Water/Sewer ,,,,, DESCRIPTION OF WORK TO BE PERFORMED: 4F�oe 5162/,1,6 OvA/ :3 7-)0 U e-, ,/C-t, Identification- Please Type or Print Clearly OWNER: Name: ,-- vZ-eJA Phone: !2?,Y 66ys-0,6, Address: 9, 5';' -5-L�177wltd - Avp�L-6-f Contractor Name ; � , -,Phohe. A- 7 p,'v A 7, 11 041" 'Ad," rr 0 W 7, r"', mv OF Y,6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: C;—�qj()S— NOTE: Persons contracting w la unregistered co tractors do not have access to the guaranty fu d Signature of Agent/Owner', Signature of contractor FORTH Town of ndover 00 L... h ver, ass, -COC KICMIW.CK A°RATED P4�,`,t5 V BOARD OF HEALTH �JD Food/Kitchen tjERM �T T L Septic System THIS CERTIFIES THAT ��;1 G:lZr: BUILDING INSPECTOR ....... ...... .... . .......................................... n , Foundation has permission to erect .......................... buildings on .:t�Gf...: G.?............?.!....... ��........................ 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMITI E IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO S',ARTS Rough Service ............`...... ... ......... ....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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 Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts „ Department of IndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 �� www.mass.gov/dia svv Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le:sibly Name(Business/Organization/Individual): Address: �l f S✓l�'y POP City/State/Zip: /U ovT Phone#: j 7 f' ly� Are you an employer?Check the appropriate box: Type of project(required): 1.�1 am a employer with__:__employees(fall and/or part-time).* 7. ❑New construction IF]I am a sole proprietor or partnership and have no employees working for me in $,remodeling any capacity.[No workers'comp.insurance required.] 9• Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will pairs or additions ire tElecrca ❑ ensure that all contractors either have workers'compensation insurance or are sole 11. 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.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 14.❑Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] * applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Any 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 mustattached 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 insurancefor my employees.' Below is the policy and job site information. Insurance Company Name: 14 f z Policy#or Self-ins.Lie.#: �� ,�Z— Expiration Date: Ems' ( $vj'7�t/ �ItGCCi�ty�/State/Zip: /" Job Site Address:_ —�T y 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 certify e'tli pains andpenalties of erjur t t the information provided above is true and correct. Si nature: Date: Y7-1 Phone#: 7 2 �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.PIumbing Inspector 6.Other Contact Person: Phone#: License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature v�G'�QO%IL77L0%L(UCCL-Gt�L Ol�/(�CCLdJCLC�CLJCfCJ Mee of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Type: egistration: 165887 xpiration: "4/5/2016 DBA l TMK REMODELING THEODORE KELLEY ' 214 SUTTON HILL RD. _ga NORTHANDOVER, MA 01845 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-105086 THEODORE M KELLEY 214 SUTTON HILL RD ' NORTH ANDOVER MA 0185 j cJ '&IF Expiration 10/08/2015 Commissioner