HomeMy WebLinkAboutBuilding Permit # 7/6/2015 T#1
BUILDING PERMIT thORD
1
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit NoW), Date ReceivedQO�q TEP
C-1
SS�acHUS
Date Issued:
�WORTANT:Applicant must complete all items on this page
STE 4/0��_r
LOCATION —r7 40 /�—
Print
PROPERTY OWNER V,1' /A—
Print 100 Year Structure yes no
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MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building El 0 amily
El Addition Two or more family El Industrial
1� Owo C
0 61ation No. of units: 11 Commercial
,otepair, replacement El Assessory Bldg El Others:
0 Demolition El Other
I'M 1, Wetlands ,"'ershed u,y"".
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U11 2000LIUAIAF%
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DESCRIPTIONF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone: 22—y—zx ,2
Address: 7
Contractor Name:
0-1— Phone: 7fl
Email:
Address:
Supervisor's Construction License: Exp. Date: e7
E f-- a
Home Improvement License: Exp. Date: Sclo
W-4/ARCHITECT/ENGINEER a Phone:
Address: Reg. No.
FEE SCHEDULE.BULDINGPERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 2 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with ul"iregistered contractors do not have access to the guaranty
,M1117,
7,777
,AORTH
Town of
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h Ver, Mass, IJ�I 15
T OLAKE
COC
MICME WICX
AoRATED Pkl?
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BOARD OF HEALTH
Food/Kitchen
PE IT U Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
.............. 1... ..J ............. .. .2. e. ..............................................
.....
has permission to erect .......................... buildings on .. . ............f. .... :(.:L>1:�....... ....... .. Foundation
y� Rough
tobe occupied as ............... .... ..ti! ..... .... G ....................................... Chimney
provided that the person accepting this permit shat i&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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
. PERMITE IN 6 MONTHS ELECTRICAL INSPECTOR
LESS. C T TS Rough
Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
ccupancy Permit Required to Occupy Puildin 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
1icK��7Iy6(r_.■���_gfiY�d�OMCEOLL}FwN
°QK 'u ^X600 QsgoodSix-eotBuilding20,-MfQ?36
. •Noxth An ver,Massaahusetto 01845 ,
�RtE11S5�
Gerald A.Brawn TeZepltone(978)588••954-5
l'nspectorO;rBuI&,gs Fa7c (97-8)688-9542
SUM.EQLW LICENSE EXRYkT�C7�
Pleas rin E
QB LOCATION:
Number Map)lOt
Name. . iorne 'hone WO&Aone
PREOENT MAMGADDRESS 'r /�/i?vU)
. i
C-11-137 NI)a
a dip Cods
TAO euxrent eKemptzon for"- 0moownexs"Was exta'Ad to?nolude owner occupied d VOMIngs to t vo units or I�sS d
i:Q allow sub�,hoaneo,�raeAsto enga¢e an�.dz�ad,,zai•foz-�ire�vao does aa�possess a�icGnse,pxo�vzded tl�att7�e ow�x . •
acts as supra-d9or). Sta oDO,ding (Code Spot! jou.5.
DMMITION O:VHOMEOVMBP,
l.'exson(s)WILD awns aparcel ot'land on or zntends to reside,on wZzich fihere xs,or zs infended is
b�,a ox�e oz Ewoarnilysizuctures. A person who constr¢atsmore tTiat oneonxexn atyva-yearperzod sa7Z not be
considered artaonmeowner
The un.derszgned."•homeowner"'assumesx-esponsibiTity'f'o_z-complianGos with the 8tataBuiiding Codd and other
.Applicable codes,,by laws,Tales and-xogalatdons.
The uUdersigne-d"homeowner"cremes that I.effia tdexstands ffie Town ot:NDA AndoverB-a!Id:ng D e&ftont
msnimuxu znspecfion pro ceduz es anal reclnirements and that he(she will comply witlx,said pxacecluxes and
xegulxexnentS, ,
-UONEOWN:BRS
APPROVAL O:V BULMNG OF'FZCTAL
ReyiseH 7.2409 .
�ozzn�omenwners�ixem�fion ^
3DAM)OF.AP)?.BAM-688-9541 CONSERVAUON 688-9530
DEAL' H688-9540 S'�,A.TII�TING6889535
The Commonwealth of Massachusetts
Department oflndustrialAccidents
.r; 1 Congress Street, Suite 100
Boston,MA 021142017
..��,�"t www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � � •� L
Address: -7f; Z_e-y
City/State/Zip: �- ��� G U e-- 41 PhoneV?" 1��� f
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.]
3. I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 1 Demolition
❑
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. Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
oyees.[No workers'comp.insurance required.]
152,§1(4),andwe have no 1141
*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.
tContractors that check this box musttattached 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.#: 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 cer 'y under the pains andpenalties ofperjury that the information provided above is true and correct.
t
Signature: .� Date: /�—
Phone#
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#:
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