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Home My WebLink AboutBuilding Permit # 7/14/2015 rg0 RTpi BUILDING PERMIT o� ,.FD 16��.0 L> T O THA 46 APPLICATION FOR PLAN EXAMINATION urw"�" Permit No#: Date Received A�RgTED pp' C LIS Date Issued: a. �SSg IMPORTANT: Applicant must complete all items on this page LOCATION y L " .. Print PROPERTY OWNER Print 1 OCT Year Structureres Ono MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building W One family VAddition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other / / �, / y , f / , and ,la „ i❑Wetlands/ ! /�` //� W tershed District, / //, MDEC IPTION OF W RK TO B E PERFORMED: m r° -, Identification- Please Type or Print Clearly OWNER: Name: _ , `.. Phone: „ - Address: C �� Contractor Name: C1,)4r Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER L wc/ `° i Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$9200 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ( OFEE: $ 0 ;) Check No.: Receipt No.: Q, Flo 6 NOTE: Persons con ratting with- _ gistered contractors do not have access to the guaranty fidnd 4� a nr,. Flans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Flans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dulmpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - D FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on (P Aa Si naturWK COMMENTSU 4 - i��o L11 C I_0,- C /V 4- -L-- HEALTH Reviewed on Signature COMMENTS All Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Seeger Connectionisignature & Date Driveway Permit DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE,DEPARTMENT'- Temp Dumpster on site yes no L'ocated'at,124 Main Street Fire ®epaoment signature/date COMMENTS VXOR E 1, Andover Town Of0 :1 No. — ��y �, - h h ver, Mass, O� L 111 �. COCMICNf wlC It\y AERATED �P��y BOARD OF HEALTH S U Food/Kitchen Septic System PER ......................... BUILDING INSPECTOR • ./ J�'• •.... Foundation THAT �►�R'....'�.... ... THIS CERTIFIES •••• • •••' • ' ' .............&air..... Rough ••,,,,•,,,•.,.....,buildings on .. :.... .. .......... has permission to erect ....... • Chimney ............... ' e �•` • �••• • application Final to be occupied as ... ... . res ect conform to the terms of provided that the person accepting this permit shall in ry p PLUMBING INSPECTOR to the provisions of the Codes and By-Laws relating to the Inspection,Alteration an on file in this office, and p Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ELECTRICAL INSPECTOR PERMIT E I 1 MONTHS Rough LESS CONSTRUCTI TA Service Final '• • INSPECTOR _ ................... •• BUILDING GAS INSPECTOR Building Rough ccu anc Permit Required to ccupy Final Place on the Premises - Do Not Remove FIRE DEPARTMENT Display in a Conspicuous all To Be Done No Lathing or Burner e an proved y the Building Inspector. Street No. Until Inspected Smoke Det. The Commonwealth of Massachusetts 64 Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 ,�p www.mass.gov/dia y��M SV�V Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A licant Information Name(Business/Organizationdividual): ? ' /In ` Address: r3,9 ,/�n�rs+�C_/ Phone#: City/State/Zip: � C - Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with ( em to full and/or part-time).* '7. ❑New construction p Y ces 2.❑1 am a sole proprietor or partnership and have no employees Working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12. Plumbing repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F j Roof repairs These sub-contractors have employees and have workers'comp.insurance# 14.Q Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 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. tContractors 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. lam an employe;•tliat is p;•oviding ivm•Ite;s'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: ompensation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers' c Failure to secure coverage as required under civil penalties inthe form of STOP 25A is a criminal violation ORDER and a fine of up to$250.00 a and/or one-year imprisonment,a P 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 cert' e tli - a'ns andpenatties of pe;ju;y that the information provided above is true and,correct Date: Signature: 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 Phone#• Contact Person: TOS OF NORM ANDD OVER 41 OMCEOF "'1600 DBkODd StreatBuf& g2Q -Mte 236 r • `Q.jl YCcwtxntw%K�b "��a p Fey"�� •Wofth..Anaworg Massadhusetq 01845 Garald.A,Brown Toll- -ue(978)658-9545 I'nspeetorofBi ldings a (978)658-•9542 �. - - - x��awl�E�:x�x�E�r�E��z��rxC��r • • . • p1e.___ase roriuE DAM II 70B LOCMYON., lumber Ixeef Address Map)Zot ' HMO. ionze Phone Work3hone CORY Alma The current exemption�'or"homeowners"Was extended is h�.o7ude owuex occtip'xed divelLings to t�vo units�r less an %o allow subh�oznPowue%s to engage an�tiVidaal.forhire ono does aotpossess a 7icGnse,pro vided That the owner acts as supelvisor). Siate3uizding (Code'0e0fion 108,3.5.0 I]EFMITION OYHO1MEQW.NEtp. , Porson(s)Whoawns aparcel of land on which Itelshe resides or luteuds to reside,on which there ls,OAS xufended fo 'bt,a one ortwD family stracfures. .Apersormko constructs more fhat.onehome in:aiwo-yearpmi d shall not bn considered ahomeowrten The Mdersigned"hoxsteciwnez"'assumes responszbxlz€y oz cs�mp7iances with,the Mate Building cad anti otT�er .Applicable cocles,ley laws,tales anal-xegulaflons. Tbevndersigned"!homeownex"'cerE; es that IlelslzetuzdersfandsMOTownofMuth A7doverl3uilclzngDe�azfz mt i,1,�771'lum xnspeofion procedures and roqukomauts/ancl fhathelshe-willcomply Wzih.;sald Pzocedures attcl reL1,711rerllentS, .. ,1 �j- �' HOIMOWlBRS;91GX .T APPROVAL OF BMDSI G OFFICIAL Roylsed 7.2009 xorrngomeoumers Exemption ' - F•-Y!i 3DARDOEAYPEA-688-9.41 CONTSERV'.�UON688-9530 MALTH699-9540 pr.arrtrmrr��u�o;a�