HomeMy WebLinkAboutBuilding Permit # 7/6/2015 NoRTM
BUILDING PERMIT o&1,,FD ,6 6
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION o
1.
Permit No Date Received RgrEo PPa��S
�', SSACNUS�
Date Issued: `
IMPORTANT: Applicant must complete all items on this page
LOCATION 1 141
Print
PROPERTY OWNER l(- C
Print 100 Year Structure yes no
MAP - PARCE ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resicjential Non- Residential
❑ New Building One family
[IAddition ElTwo or more family [I Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
olition ❑ Other
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�� �� ���� �J � ,�� r�y ❑ Flootl latn�,�,�❑�W,etlands� ���� � ���❑ 1Natershed District �r� r�.
�❑ Septic, ❑Well, � ���, � pr�x �Y � � , s � r ,� � ��� �,` f� �
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
(-7 YA W J,2-
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ L✓ FEE: $
Check No.: Y;zA Receipt No.:
NOTE: Persons retracting witli unre 'jtered co tractors do no-1.4mve access to the guaranty fund
t%ORT-R. vl,%Idover
Town of
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- 2Ak Mass
h ver,
LUKE Il,
�.'js COC HICNE WICK
A"ATED PQ� y
'9S V1100111116, BOARD OF HEALTH
Food/Kitchen
PERMITSeptic System
• BUILDING INSPECTOR
1/V`�"�!6�a..........................................
THIS CERTIFIES THAT .......'.. "� ""'
....
...............................
.••.......,.•••..•.• Foun anon
has permission to erect .......................... buildings on . .. .......... �... Rough
Chimney
to be occupied a . ----% Chimney
• ••• •� •• • """"""' the terms of the application.'
Final
provided that the person accepting this permit shall in every respIci confor Alteration and
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover. Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
IT EXPIRES IN 6 ®NTS
ELECTRICAL INSPECTOR
LESS C T S TS Rough
- Service
........................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
occupancy Permit Required to QLLEff Pudding Rough
Final
Display in a Conspicuous Place on the Premises — Do Not Remove FIRE DEPARTMENT
No Lathing or Dry Wall To Be Done
Burner
Until Inspected and Approved by the Building Inspector. Street No.
Smoke Det.
-7
TOWN OF j9ORM ANDOVER
L'❑
��( OFFICEO��'R1gn 71e�1Y
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Gerald.A.Brown 6889545
Ins reetox o Buil&go Wax (978)689-9542
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HONMOM ERTICBME IMBI&TZOX .
pleaseyrin-E .
DATE:
' �1'uxnhex i;treetA.ddress N.Cap/�ot -
-UONMOWNBR (
• �7ame. . oxne I?hone orkl'bone
)?p,u-,sw.T mea Ami m 3 �= f
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The current exemption fox"homeow�zers"teas extended to?n�lude ownex❑ceti zed d(vel�ngs to t4vo units•or>� ss am
fa allow subh hormo.�uexs to engage an.Lcividual.for lire-who does noty mwss a license,pzovzded that t7io owner
acts as supex�ysox�° ,81iata3u?.lding (Code�ection.l�8,3.5.�� - ''
DEF.ITION OYHOMEOVMR
Persons)who t Wag apazcel of land on u7l�i ch Itelshe xeszcles or Intends to reside,On which there is,oxis xnfencW to
7��,aoneortwofamilystructures- .A.person,wkoconstructsmorathatonehome.inatwoyearperiodSha.71Rothe
considered aliomeownez;
The uuderszgD.ed" onzecivrzzer"'assumesres�onszbili r fozcomp7iances wjfh the StatoDulldiug Codea-Rd other
.Apylicablo codes,by-law,jales anti-xegulations.
Tbevndersigned"hozneowAex"cex;fxosthat hels -n ' dstheTow ofN7'orfhAnd ovarBuff ding De�aztraeat
vznrmuzuinsperfionproccdmusand roquireme andtbatlxelslzewill 0 withrsai.dpxacedwvaand
reguirezneAts,
HOAMOWT`.SR.B SIGNATM
.APPROVAL OF I3TJZC.DMCr OFFICIAL
Reyiset17.2�0� _ ` .
)porn XSomeowners Mdmption
The Commonwealth of Massachusetts
Department oflndustrialAccidents
'f 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 PERAUTTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: L, ok(
:Df AR
City/State/Zip: M6 Phone#: tS
Are you an employer?Check the appropriate box: Type of project(required):
If]I am a employer with employees(fall and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 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.❑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.
• 12.0 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.#
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]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-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. 2,121A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil pen les in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator/.9cop of this stat emen ay be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ce 'y der the pains dndpen ties ofpejufy that the information provided above is true an correct.
Signature- Date: o J
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#: