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Home My WebLink AboutBuilding Permit # 7/24/2015 �O R ry BUILDING PERMIT OF��yeD ,b�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �AY Permit No#: `' Date Received 9�ADRATED Date Issued: e IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNERL, - 1� Print 100 Year Structure yesno MAP V PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Xwo e family ❑Addition or more fa 'ly ❑ Industrial ❑Nteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District E7.1Natec/Sewer DESCRIPTION OF WORK T_Q BE PERFORMED: r Identificatidh- P ease Type or Print Cley — 2 OWNER: Name: � 464k/ r ?w"z Phone: (� Address: Contractor Name: V1 b ft `-APhone: Email: cin 'f t Address: `�c-� �r ,r� j►� �- Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/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: $ FEE: $ �P Check No.: Receipt No.: NOTE: Persons contractin itlt tered contractors do not have access to the guaranty fund X- - - ____o I - - -- „ --- tkORTH own ot ii0over g h Y O L44AK& �� / �.SS' Ira COCNIc HewlCK �•9 A�RaTE®RM I T S U BOARD OF HEALTH DFood/Kitchen P 'Raw, Septic System �'C a BUILDING INSPECTOR THIS CERTIFIES THAT ............ ..O ..... ............................................ ........... ................ has permission to erect buildings on .. Foundation Rough ................................................... to be occupied as .......... .. ................. ........ .. ® ........... Chimney provided that the person acceptin his permit shall in every res t 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 PERMITEXPIRES 1 TH ELECTRICAL INSPECTOR ® LES CTI S Rough Service .............. .. ..... ......................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Buildinz 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. TO"OF"RTH AND OVER 1600D OadrStroatBuff di7]g20,`SujtQ 3 $R 7xn FLS , •Xoith.Andavexy Massachusetta ol845 Gerald A.Brown '�eleplzoxze(978}68$9��5 nspectorot 3uildings a Fax (978)689-9542 M—NMOMMER LICENSE.MMI?TfO H• • y��y��-{�[ �'j�h,y[`yS y^�•,..--y}'��,{ryf�.�e-V�j.y[��+•[��{y��(yj�s-( �•�[-�y'y[/�y(�•�.{y� [j�jj�}/y��yg,}}�� • . J.l'�J.i-�)V�L�.I J,S-'t-..P4iJ.-lei w�—'S.Lr.-1AC1.}.JfO 2'Ieas�prinE . f)ATE: ° eo Al. Number StreetAddress ma P/�ot ^ �OAMOWMR VIr,Ivu - 7a a. Home MQQ0 �1or7��'hone c�V Tff - � The current exemption for'110 meownzexs°' vas extanae;d to iuojudo owner occtipxed dfuelff-ngs to��o units :ass and To allow sub hoanPowucis to engage an�C i vidual•for liire who c7oeS no possess a Gc315e,provided that the owner acts asstu"pervisor). StafoD ding (Code Section7p8,3,5.�,1 DEMITZON OIFHOMEffjTMER , Pmson(s)who Qwns aparcel ofland on wlzicl�lzelslzexes% es or Mends to reside,on which tTlere is,ox is xnfended to l��,a one or•two�"amily structures. -A,person,'w�.o constrtzcfs more that.oxzo�.onxe xn•a two�earpexXod shall not lie ' considered ahomeown..er. , Tho lmdoulgned"hame�iwner"asstzmesxesgonszbiIity orcompliaz�ces with the State13uilding Codeand otter Applicable codes,ley Zaws,rules and--egulatzous. Thevndersig�ed"homeowner"cexti, as thathelshetiuderstauds the Town.of7ortlx AndoverDuilding37eiatEment ;,,;,,;,,,um xuspeotzoR procedures anal requirements and that 1.e1she w.i11 comp ty widr�said pxocedtxres and - IIOAMOWN`.L-I:R.S S.1ON Tl APMOVAL OIV BUILDWO OF'.EZCSA3 .pleyisett 7.2D09 , 'FormozneoWners Esamption , 3DARDOFA.PPEAM688-9541 Co31r8EMrAUON6&6"9530 IEAE S6$5-964Q 3'L?3A2NIAI0689953 The Commonwealth of Massachusetts zW Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA. 02114-2017 °tet www.mass.gov1dia yV• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED'WITH THE PERAUT TING AUTHORITY. Applicant Information g Please Print Legibly NaMe (Bu1 p (Business/Organization/Individual): � " err,��„ yv"�_-y Address: 3,4 City/State/Zip: A",4,�)-e,,. Phone##: r Areyou an employer?Checkthe appropriate box: Type of project(required): 1.❑I am a employerwith employees(full and/or part-time).* 7. (]New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] INJ ama,homeowner doing all work myself[No workers'comp.insurance required.]i 9. El Demolition 10 ❑Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 oof repairs These sub-contractors bane employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14• Other 152,§1(4),and we have nct 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 subrriif 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-contracfors have employees,they rirust provide their workers'comp.policy number. X am an employer thatispiovidingworki rs'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: fob 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 WORD 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. X do Hereby cer fv nd th ans and penalties ofperjury that the information provided above is true and correct. i sign Date. C Phone# �w • 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 Ifealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: