HomeMy WebLinkAboutBuilding Permit # 7/10/2015 NORTH
BUILDING PERMIT az'-FD
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TOWN OF NORTHA VE -
APPLICATION FOR PLAN EXAMINATION ® ` p
Permit No#: Date Received 'h Q°RATED Ppay�S
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Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION (90 A
i kid , l4
PROPERTY OWNER / ie- . e 3-n
Print 100 Year Structure yes o
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
. Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Other
El Demolition
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D SCRIPTION OF WORK TO BE PERFORMED:
Identificaflon- Please Type or Print Clearly
OWNER: Name: r.�l ±d Phone: 76 0 7-
Address:
Contractor Name: �, r Phone: —�
Email:
Address: d
Supervisor's Construction License: / Exp. Date: ,' '1
Home Improvement License: / �// Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 3ovo FEE: $
Check No.: Receipt No,;, Y Af y
NOTE: Persons contracting with unregistered contractors do not have access t lie ara fuz d
- - - — 71
V4®RTH
AIL
Am
MR
Town of ndover
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C' f h ver, Mass,
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COCNICNEW,CK
A04ATEID
BOARD OF HEALTH
Food/Kitchen
E R mmm I iF llu LD Septic System
THIS CERTIFIES THAT ,,,, ,, , ,,., BUILDING INSPECTOR
................. ........... .. .�. ... . ...............�SZ,G.o o.
. .. yK
Foundation
has permission to erect .......................... buildings on .. a 4
.... ............. ......®..........
10
to be occupied as ..L... .AS.. ... .... ...... :!I; .. ChimneyRough...... ...... t.�r ...�
provided that the person accepting this permit shall in every respect conform t e 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
WARTSUNLESS CONSTRUCTI Rough
Service
.......... .... ........ ........ ....... ...�.. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required 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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massa chusetts
Department oflndustrialAccidents
d I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.goh/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERI4IITTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual): av" /
Address: (�j � �nn P(-e'Wl1t?
/�' t 6�JAz
City/State/Zip: / �� � Phone##: q7 'Z
Are you an employer?Check the appropriate box: Type of project(required):
L❑1 m a employer with employees(full and/or part-time).* 7. w•construction
2. 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.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10E]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. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
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'ran.
ust 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.
tConfractors 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-contrac{ors 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do herehy cert'y and •thepaWs an penalties ofperjury that the information provided ab ve is true and correct.
Si nature:
Date: /
Phone
Official use only. Do not write in this area,to he completed by city or town official..
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
. ,�yVd1"<PO4JUJ7t 2JGLl1P,CGGC�O��G JJad',,,JeCC1
!L\ Offiee'of Consumer Affairs&Business Reg t ^nse or regi �c-t tion valid for individul.use only
—
�OME IMPROVEMENT CONTRACTOR:
re expira$aaai'date. If found'retura to
egistration: 1;08511 `type: 01ire of Consumer Affairs and Business Regulation.
>1=x0irat1on: :8/'19/2016 DBA i0 Nrk Plaza-Suite 5170
UT&�ton,AVIA 02116
SMITH CONSTRUCTIONCO.
KE 'ri Smith -
63 INGLEWOOD ST
N'Andover, MA 01845 - Undeise,cretary --- —
Q9-val' _wit out signature
Massachusetts -Department of Public Safety
Board or Building Regulations and Standards'
C r"ru Cii67 Sul viS01
License: CS-102589
KEVIN J SMITH
63INGLEWOODCS 4 99
North Andover Na 0
Expiration
Commissioner 03/05/2017 '