HomeMy WebLinkAboutBuilding Permit # 7/14/2015 %4®RTF/
®�Rt4t° Ig'1RJ®
6 0
BUILDING PERMIT
TOWN OF NORTH ANDOV 0-
APPLICATION FOR PLAN EXAMINATION -
C.
Permit NO: _ Date Received °+a<•ATOP
����' •,.^
Date Issued: 20 I -
I ORTANT•A licant must cam lets all items on t is
rr 1
1 1
r
i
� r
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑ New Building ®-One family
11 Addition 11 Two or more family 11 Industrial
11 Alteration No, of units: 11 Commercial
[ Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
ME/
nil
Identification Please Type or Print Clearly)
OWNER: Name: ► � c� " Phone: ( -7
Address:
GJ m
1 /
1
1 ,
ARCHITECT/ENGINEER Phone:
Address: Reg. No,
FEE SCHEDULE:BULDING PERMIT:$92A0 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F.
Total Project Cos": 1 FEE: $
Check No.: Receipt No.:
NOTE: Persons contrac,ng 'th unregistered contractors do not have acc s to the guaranty fund
r,
t
V-01-9 Irm tkORTry
"11dover
' town of
O 0
No. o6o.abiler .s . _- . �. 1
o h ver, ass, 20 1
L^K.
COCHIchEWICK
A°RAT E o PPS
S u BOARD OF HEALTH
Food/Kitchen
t: RM IT Septic System
t BUILDING INSPECTOR
THIS CERTIFIES THAT ............U......... ... ....
T� i ...............ik-r4.....................
has permission to erect ............ buildings on
5 .. Foundation
. Rough
to be occupied as ..... .�.�. ........ . ........ ...h... ........�.... chimney
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
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES 16 M T S ELECTRICAL INSPECTOR
LESS C ST C RTS Rough
Service
......... .... ............................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BulldinRough
Islay in a Conspicuous Place on the Premises — ®o Not Remove Final
No Lathing or all To Be ®one FIRE DEPARTMENT
Until Inspected and Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
Department ofIndustrialAccidents
1 Congress Street,Suite 100
Workers'
AM 02114-2017
www.mass.gov1dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers.
To BE FILED WITH THE PERMITTING AUTHORITY.
ADDlica :Information Please Print Letribly
Name (Business/Organization/Individual): JArn..C_
Address: e 2z-
City/State/Zip:
z-
City/State/Zip: ANcv,.e)r Nei Phone, 9 4-
Are you an employer?Check the appropriate box- Type of project(required):
1.641 a employer with_J_2_.mplcyees(M and/or part-ti-4- 7. F1 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.] 9. ❑Demolition
3.0 i am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition
4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. lwill
ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions
proprietors with no employees. 12.n Plumbing repairs or additions
5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet
13.r-I Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.[tither
6,0 We are a corporation and its officers have exercised their right of'exomption per MGL c.
152,§1(4),and we have no employees.[No workers'comp,insurance required.] -F�u'A �5( D/AJI
*Any applicant that checks box#1 must also fill Out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
tContTactors 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 alit an employer that Is providing workers'compensotion insurance for my employees. Belolp is the policy and job site
111forination.
Insurance Company Name:
Policy#or Self-ins.Lie.#: j:, /r_. Expiration Date:
Job Site Address: S14' 22o"A GXA 5r -City/State/Zip: JQ 4kAW_�C
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 certify under tliepains andpenalties ofpejYury that the information provided above is true and correct.
Date:
Si_na�ture:
Phone
Offlelat use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License V
Issuing Authority(circle one): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
12014 3 : i6 : 55 r'M 8740 CA 02/02
i;`ER u Off_ CA-\TE OF L«_321 UTY 0H81 U—G'A-PRAsI� ► � 1
09 f t;�i lFIGATS 18 ISSUED AS A.MA-11e,0€N.ORMA710M ONLY Aim CONFERS AID RIM-41Z UPON 749 CEPI IFIDATS HOLDEPL WHS
GToP�C1GA`iff 1;e NOT l FL�:F�Ir:'t`1UlaLY f3P.WHOA,l NsL Y Al1l-0,01 NIS, OR Abate�'71���D1I�I=;��:lP��PE��BY T POLICIES
BELOW. MIS G1nP�f°IOME OF Ii SUPAI�IGE EjQjS 1410 Gi WSrjlil#`Iia ri �0I 1�C`I�.A I Sail EW ME ISSUING INSi (S),AUS®E' D
If' POR TANTa IF the esrtlf`feals holder Is aR ABDMf f l-INSURED,the poftq{ies)r usitc he endorsed. If SUBRO(DA►`ION 18 WAPM.sub eez to
Me terms and cot:flldone otthe pollef,@wWIn pariales may raguim an endomemartL A swien.ent on this rargRa ie does not confer sights to
Up-
cardfloate holder 111.ReH 07911011 eltdDrse,•rtent(S).
PRODUCER 06,963-00i
FATFA Insurance Associates l�G ia���to.2�t: t9787�s2�87oC "�"a�� {978)68%-w79
X326 05gooditesz Iat
Worth"Mir?otrer,FrAOIC49 an,la�s:
alaunatal amurfaa0wa aGa "Aloe
tllsum t•AsunEP A• A,MT1.RRuai insurance Company 33 viz
.tovt:h Andouav Building Camp txsu s:
20 Box 182
.Tarbh Andover, ZM GIS 15 t`aUtiCv D:
tr�ttr=z i:-
it allBea-
�t51J P�{i�faS D 1.11GAms 14Urw'I;C-R: i1IL{WER:
'r?•IIS IS TO C51171FY TFLAT—NE POLICIES OF INSURR rce LISTED BELOW HAVE SEEN ISSUED TO'I INSURED ISAVIED ABOVE FOR iT E FOLIGY PERIOD
IN01CAT:D. NOTL ,HSTANDINe ANY RBOU1RErfiENT,,=RM OR CaNDntlaiq OF ANY CONIRAGT M. OTIHER DOCW{EN 1 Wiim P.ESAECT TO VlirtlCli w$
CErFMMGAir MAY 8E ISSUED OR MAY PER Ai I4,irlE INSUM1110E AMORDED FY TNE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL Tre TM-KSS.
ff"%CLU81O,\'S 41D MWMONS OF SUCH POLI 0118,WIT, SHOW,I1'ftAY HAVE SEEN RHOUCEO BY PRID CLAM&
It`' 1"',rE®FG?8URA4{GE ppdo ', ! F ai'1PA aR LV6ii5
L,r iNSR 1�^fD F91IC1?UIu$-. T
GV-SRALf:ASUJiY tED
CCUMMIGE S
COWAIE LYcL AL GZMAL UAMLRY CL, ?S1rJ_ F(Arrfdnalawn) IS
PER=11AL0All VIJJURY IS
GBIEO-1AGGRWATe IS
t-WLAGG?EGtA'TE�Ll?X1 A"'LJEESP , PRODUDTs•COAL30Pf.QG Is
rnLtCr t li�i I r00
�UI'Q1d0316aLI,lER� cor.+auvto�r�Leuaur
HA,YYAtrfO AiWAUt 0 SCHMULED ecaLYLYJURY(ftrpusnn) Is
nAL o9 AUTOS MILY IWIM..Y tRarweidanQ I S
ECRM AUTOS t�N GU:'
5 PROPE?T t7AtA5 .
nIT,'0Faratddaut S
10,
S
UmaRr"LLA U49 OCCUP. EACH OCCURREWE I S
xa=U3 LJSe I I CirlfdBErrL'7= AGGREG a
II KKrf��O II R----,er.IONS t �,y�� I S I
Fif DEtAF'LOY �I61YY ril 3t 1-OP�L mmal IS
t, ole--lc r-�L�o G• nyE r
{flandator,+in t ELEWHACCDar:
HH) lir' •Is iOD,dTD!).sB
f I I9.LDISEASE-F-A,R 1OYEE)S •01),E1UD.Q0
�`t.ND0%P P-ATMIs;r;�: i I ;:t_alsE"�-!~_tcYutrr, I s SDU,d7DII.oD
t
2cCt1N,[OH ar`OPia?.A?la}SI LaCATfOH81VciICL'v{lfetaehACDRD 9Gi,�dNanal Rcnarls�eBul:,IFnotesgasLtsr.nntrt!)
NORTIF:G-AtSNOWI SI, �t t
! �Y,@[1L7aitJYOFTrtiAA3DVsAl;a"CP.IBk'fIPQIICI�B';CR1'GELLERBa�,E
174E EXPIPWIDN DATE TFIEPff0=, NOW= I1:7LL BE Ml IVE,®r'7i W
ACC9RDARGE MATH TIDE Poi.CY PP.OVISIOFIS.
O 19t{D 2D 710 ROG025 v0,R'M UR ll®ll.l�II3Icsits rv�samle i.
lG0F�D2$(2010108) ;:te>GC:',I3 Flafia7aavid i0g0 era I�glsieradt:iaarlfso7�CDnD
:10-Ird Of SLIiICI;Ilg Pr.,gtj
CS-982816
JOHP,T ja Lr"wNAK-JR
70 PffLLofq pGAD
MILMN MA 0,2106
E
OOY1612016
Llai
Offpce of COI-Isl ner Affairs and ]Businesse a.•ta<
10 Park Plaza S�-�i�:e 5170 on
Boston, Massachusetts 02116
Home InTrovement Contractor Registration
Registration: 137552
NORTH ANDOVER BUILDING CORP. Type: Private CofApr Tall
C;c�iration: '19/26/20.16 T'f' 260459
JOHN LEEMAN
P.O. BOX 132 _...
N. ANDOVER, MA 01845 _.....
SCA @ 0 2oM•oS/t@
Update Address 2W,@•e@@@ral Ca@@'d.Ivi['1@'@L reason fog-Change.
�.`.� Address ....� Rea@e'wal )'u@@@y@ley@@@CY@@L05t e1@'d
�._�