HomeMy WebLinkAboutBuilding Permit # 7/23/2015 t%ORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit No#: 1(p Argo
Date Issued: !:-�- I
IMPORTANT: Applicant must complete all items on this page
LOCATION 2o F--roPie-E-7 J,)P- to oe-r t+ A&wwree— H,�)- c)1 ?-tt
Print
PROPERTY OWNER J-155 t+ JP—
Print 100 Year Structure yes 1`\
MAPLOaC, PARCEL:Z,(f— ZONING DISTRICT: Historic District y ��O\
es �Jn ,
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building 11 One family
0 Addition El Two or more family Ll Industrial
El Alteration No. of units: El Commercial
F1 Repair, replacement 11 Assessory Bldg El Others:
El Demolition El Other
110"I
DESCRI TION OF WORK TO BE PERFORMED:
6 AS C-"G cgHCtfT R-OCIL C61i-t^r�-
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OWNER: Name: Identification- Please Type or Print Clearly (F hone:""� t
Address:
Contractor Name: Phone:
Email:
Address: 4
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ lo 1000 FEE: $ 12-0
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Check No.: Receipt No.: Oq
NOTE: Persons contracting with unregistered contractors do not have access to the g'uarantyfund
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Food/Kitchen
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THIS CERTIFIES THAT BUILDING INSPECTOR
.................... .. .. .��. .. ..........................................................................� ::I nj &"'+0 YN
has permission to erect .......................... buildings on . ....
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to be occupied as ........... . ...... .......&A:L(V-.jC....d ......K..li�e� ......... ............................ 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
t : UNLESS CONSTRUCTIOT7 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.
LOT I
L T 2o" `"2�
EXFND.
TOF=269.4'
92'
26' LOT
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MICHAEL
0 J.
SERGI
0 Na.33191
pewo
WSURVO
THIS DRAWING SHALL NOTBEUSED BYTHECLIENTFORANY
FOUNDATION L OCA TION PURPOSE OTHER THAN THAT OUTLINED ABOWEXCEPT WITH
THE WRITTEN PERMISSION OF CHRISTIANSEN&SERGI INC.
FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY
CLIENT: ORCHARD VILLAGE, LLC OF CHRIS TIANSEN A SERGI INC.AND ANY UNA UTHORIZED USE IS
THIS CERTIFICATION IS MADE AND I IMI TED TO THE ABOVE CLIENT PROHIBITED.CHRISTIANSEN&SERGI TAKES NO RESPONSIBILITY
FOR THE UNAUTHORIZED USE OF
LOCATION20 EMPIRE DR. NORTH ANDOVERMA. INFORMA TION CONTA INED HEREON.THIS DRA WING OR ANY
DATE.'5/9/92 SCALE:1''--30' 6AsEo ON$CA t ED DA TA ONL Y THE PRIMAR YS TRUCTURE
SHOWN IS NOT LOCATED INA FLOOD HAZARD ZONE AS SHOWN
ON FEMA FLOOD INSURANCE RATE MAP.COMMUNITY NO.:250098
0008C DATE'6&I993ZONEX
PROFESSIONAL ENGINEERS& LAND SURVEYORS
CHRIS TIA N & SERGON, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01630
WWW.CSI-ENGRCoM TEL. 978-373-0310 FAX 978-372-3960
DWG.NO,:06029.001.047
The Commommalth of Ah.vuivhu.fyetiv
Depirtment of Indush-lublecildents
I Congress Street,Suite 100
Boston,MA 02114-2017
ilvivisxiass.govIdia
Workers'Compensation Insurance Affidavit;
'I'()llj:FII,El)Wri'll'14IR PERNIff'FING,AUTHORITY.
Applicant Information Please Print Legibl
Narae Q AXGs H to e- a VA II�Vlz V1
Address: F—ITI P I IQ
City/State/Zip: Phone ii:
__-
Are you ao rniployer?Chetli life aPprotralate box: Type of project(required):
1,nInjuncinplayerwith _cmployers(full and/or part-time).$ 7. n New construction
2,[_]1 am if solo proprietor or partnership and have nocraployce-i working;forme 417 S. n Remodeling
any capacity JNr)workers'comp.insurance required.)
9. El Demolition
>PTJI�'a a hom00%ner doing all work myself lNo workers'comp.insurance required.]t
10 E]Building addition
I nun a homeowner and will be hiring contractors in conduct off work off my propcity. I will
Insure that all contractors either have wrakets'coutpensramn insurance or are sale 11.[:]Electrical repairs or additions
proprietors with 110 employees. 12.n plunibing repairs or additions
I fen gencial Conilactor and Ibavc hired the sub-conabadws listed on rho miotic<I slvaaf 13,F]Roofrepair's
Ilicso sub-contractors have employees and have workers'comp.insurance.! Wj 1-i I^)0 CH
&F-1 We are a corporation find its officers have cxIacised their right of'exemption per MG1.c.
152,§1(4),and we have no employees(No workers'comp.insurance required.)
.Any applicant that vhccks box if I must also fill ouFthe socelloa,below showing their workers'compensation policy information.
I I huncowlts,cum submit this affidavit indicating livy are doing all work and then bin,outside contractors must submit a new affidavit indicating such
lC'0IaT&c0r8 that check this box most attached an additional sheet showing the name of the sub contractors and state whicther or not those entities have
calploy"s have employees,they must provide their workers'carnp.policy miraber.
Join ail Belon,is the policy mol job site
111fornfaliolf.
insurance Company Name: C 1
---------------------
Policy#or Sell'ills,Lie,It: 2>62—o
f E.piration Date:.
ae
Jot)Site Address: -0-6LOVL-1-12—.15
Attach if copy of the workers'compensation policy declaration page(showing the policy rintriber and expiration(late).
Failure to secure coverage as required under MG1.c.152,§25A is a criminal violation punishable by a Fine Ili)to$1,500M
and/or one-year imprisollancill,its well as civil penalties in the form of a STOP WORK ORDER and it fine of tip to$250,00 a
(lay against the violator.A copy of this Matenicrit inity be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
mallies
I do herekI,cerltfy under ter milts ondil qfpeftry 11tal In information prat above Is trite anti correct
Sigjilut jj�p;
Pholle it; t
Official use only, Do col n1rifif In Ibis area,to be conitlVele(I by city or loran qfjkiat
C*i(yor'l'c)wll; , .- —— ---.............
Issuing Authority(circle one);
1.Board of Health 2.Building Departitivitt 3.Cityffown Ckri( 4.Electrical Inspector S.Plumbing Inspector
0.Other
Contact Person: Phone
Op t'o°TH 9 TOWN OF NORTH ANDOVER
OFFICE OF
,y n BUILDING DEPARTMENT
1600 Osgood Street Building 20,Suite 2-36
ass„,,,, North Andover,Massachusetts 01845
S 1C HUSE
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: " z2° f _
JOB LOCATION: Se ./ N - AlOD01164. , 0 6
Number Street Address Map/Lot
HOMEOWNER t " ° AA) " "
Name Home Phone Work Phone
PRESENT MAILING ADDRESS °
Vie— C>f
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
u
HOMEOWNERS SIGNATURE V °
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 6880541 CONSERVATION 688-9530 11EAL:T11 688-9540 PLANNING 688-9535