The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 7/2/2015 BUILDING PERMIT o& t%ORTH ED X64"YO TOWN OF NORTHA OV 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received C U Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION \J Print PROPERTY OWNER Print 100 Year Structure yes 0 MAP PARCEL.�" /._. ZONING DISTRICT: Historic District yes (no F7— Machine Shop Village yes ono o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 19-Crhe family [I Addition El Two or more family 11 Industrial M-A rte-r�at io n No. of units: El Commercial El Repair, replacement 0 Assessory Bldg D Others: El Demolition 11 Other d"I"'J"' E'll, ®r 0 DESCRIPTION Of WORK TO BE PERFORMED: C,�oSj Identification-lease Type or Print Clearly OWNER: Name: Phone: �';l Address: Contractor Name: Phone: 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$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. I" 2 Total Project Cost: $ FEE: Check No.: Receipt No.: NOTE: Persons contractir with unregistered ntractors do not have access to the guaranty fund L n 7T, of ion , ure - ;®RTH Andover Town of 0 . "t No. CIA- WAY 4 - C' LAKE \y ��/Y 9 BASS' I� COCHICHEwKK 7,9 RATED ►P�,�,�� S UBOARD OF HEALTH Food/Kitchen ERMIT L mumok Septic System 1„ BUILDING INSPECTOR THIS CERTIFIES THAT .. °� ` ............... .. .... Foundation has permission to erect ........ buildings on ... !��.� r.l.�� •••••• ••••••• .................. Rough to be occupied as �e� ...... ...... ®gym °........ .J.e.J�fac .!�h.."}........`?....... .. C. Chimney ............2Jo........... 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 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 I 6 MON THS ELECTRICAL INSPECTOR `3 - LESS CONSTRUCTION ST T Rough Service .......................... .. ... ... ...................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Bulldin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. .CFRrti TOWN OF j�ORTff AND OVER OEEICE OF _ :'1600 D4009,Six-eat & g20g-Sate-36 7�p��ayxa a�`yd5 - ..•Noith..Andovox Massaclzns(tfa 01845 LI Gerald A,Brown - Toleplbne(91)698-954-5 Inspeetorof)Bl ftdings O - a (978 689-9542 WMEMERTICENSE MMMPTIOX . DATE: J v/ JOB LOCA.' . DN,' oN 6 ZM Numb or map/�ot Name Homo l ORO WozMhone � PRESENT MSG ADD.RMSS o�.�i'I'e==m fihe current exempfion dor"fiomeowr!exs°'Was extended to��1u�e ou�uex ooct%�ied&vomngs to UV()units•qz��ss and fo al1oI5ucho?r�ca.rers to engage audiVaQ�aal.Ior hire rho does aotpossess a lieDog e,pxovided fat the ovtuer acts assupers77sor). ,�#a�e3�ti(dzng (Cflde�eat?on.7.0S,3,�.�� DEMITION OFROMEO'WMP , Persons)Who vns aparcel ofland on N rfjlcft koffieresides or zuteuds to xeside, DU Which-Fhere is,or as infended to b6 a one or-Gv1a�az�ly struetuxes. .t�.person,tulto constructs mote that.one home xn,a tY10�earpczzod sha71 not�e considered ahomeowner, Tba undersigned"ho�ste�iwner"assumeszesponszbxli�yoz cbmp7iaRces�,vzFlt tietateBztztdang Codeantl other A:pplica�blo codes,,b laws,tales anti-xegalations. Therxvdersigned"homeownex"cextzfzZas that he/shevndexstauds the Tow o oxfh,AndoverDuilding DeaxEment minim"minspecfsonproceduresand xeclu' ezx�ontsandthathelshow.illco ply ifb;saidpzaceduresand xeguireanentst , A-UROVAL OF 33WDMG Qli'p'IC T Re'visesi 7 2009 " )FozmSomecoWnerssxemption 3QAI}O-FAYpRAT_Q KRR-oIW �nrranntr m Y= The Commonwealth of Massa.chusetts R Department oflndustrialAccidents tl 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH ED WITH THE PERIVHMNG AUTHORITY. Applicant Information / Please Print Legib Name(Business/Organization/Individual): (;o'5"��/ Address: yl� City/State/Zip:A)A4JA6/--'A VW- 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. modeling any city—,[No workers'comp.insurance required.] � 9. F1 Demolition 3.[ " 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. 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.F]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 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. 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-contractors have employees,Ificy must provide their workers'comp.policy number. I am an employer that isprovidingrtvorkers'compensation insurancefor my employees.'Below is thepolicy and job 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 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. Ido hereby ce•tify under thepains dpeva 'es ofpeijury that the hiformationprovided rabove is true and correct. Si nature: Date: .J✓l �� 1 � Phone#: Official use on k.JDo not lvrite 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#: