HomeMy WebLinkAboutBuilding Permit # 7/2/2015 t%0F?TF1
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION ev e- .L ly s7-P, ct-,?
Print
PROPERTY OWNER 77FVCW DEX00-16/Z
Print 100 Year Structure yes
MAP PARCEL: 3 ZONING DISTRICT: Historic District yes 1-0
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Li One family
[I Addition [I Two or more family 0 Industrial
El Alteration No. of units: El Commercial
S�Repair, replacement RAssessoryBIdg 6140-46r El Others:
0 Demolition 11 Other
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fe
0,
DESCRIPTION OF WORK TO BE PERFORMED:
el C T- T 6-1 /,�P,4 G F
Identification- Please Type or Print Clearly ce-M —77a-1-216 -,S_07(9
OWNER: Name: '-J"'EVC",,yV Phone:
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.
Total Project Cost: $ 50 , 0 0o 00 FEE: $
Check No.: lqo f —Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
TOTS'OF WORMAND OVER
b it w�b OFIBICE OF
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Gerald A.Brown. - Telepllona(979)699.954-5
ha-peefox•ofBi ldings arc (978)688-9542
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please p:M .
DATE: Y-31 �
YQB LOCATION., 9C 3:E nz!n K S-j2&-t�7 33
Number Txeet A ddzess Map/Lot '
IXOAMC)WNER g�tti �t"j2�Cff�2 WS-2S�'2,774 - 77Y--.2/H=.Sn78
• Name. Homo phone ane CEZ,L
TRE-SENT MAMCT ADDRESS ,56 CV 69 LY M C-r7 - -
A104TV A"Davtk %yIRSS p/gi1S,
. . zip Co_
TAB ouxrent exemp9on:(or,%Moow enr was exterdcd to:badludfa owner ocotipied&VOM1 gs to two-uor;�s5 anr�
to allaW such 1?ome0,Wexs to e33gage an?r--Ebi ial•fox hire Viio does notpossess a IicG3ise,provided Mat tT3e owner
acts as supar-visor). Siate3uijding (Code Seotion
Pomon(s)who gwns aparcel oflan.d on tvldeh halshexesz es or zutends to reside,ort wh1ofi there is,ox is infeuded to
70b,a o)ae or two familysfruefums. A person who coz�stracfs3noxefat ouedome a t�va yearperiod s�alZ ztot 6e
cc�usideredahomeownez;
The undersigned°`hoxneciwzzer"'assumesresponszbilityfoz compliaztces v�zflt the SfatuDuildiag Codeand otT ar
.Applicable codes,Toy lam,rules and-xegalations.
The,nuclo sigued"homeowace'eerffies that h4fa&dexstaudathe Townof146Ah,AndoverRaildingDo&fineuf _
jll97�nxn and requiromonts and that helsha 1.M comply with;said pxocedures and
xeciuizexf33eufS,
ROAMOWNMS WONAATME
A-PPRO AL Off'`33TTXDWG OFFICIAL
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3DARD OFAPPRAT 688-9541 CONTSBRYAWN 689-9530 BEALTH 699-9540 M!s. NING 686 953-
The Commonwealth of Massa.chusetts
Department of IndustrialAccidents
- : d I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information M,,U Please Print Le ibl
Name (Business/Organization/Individual):
Address: 4576 25 EV&-R F67-
City/State/Zip: N097t /i/y.'D Oyt2 Phone#: 7 7 V 78
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. Q New construction
2.❑1 am a sole proprietor or partnership and have no employees working forme in 8. F1 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 E]Building addition
4.N 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. 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.Q 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.
I 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-conh'actors have employees,they must provide their workers'comp.policy number.
I ant an employef•that is providing workers'compensation insurance fof•miy employees.'Beloly is the policy 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.
I do hereby certifynder the par and penalties ofpeijuiy that the information provided above is true and correct.
Si nature: �t�U� Date: 7/,?
/
Phone#: 7 7 y-.� 19-Sd 7c5
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#: