HomeMy WebLinkAboutBuilding Permit # 7/30/2015 %AORTH
BUILDING PERMIT ,, F.D ".61 �
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: lA Date Received
,?Are C,
C
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION -3 CuAes�&-
Print
PROPERTY OWNER (\AA9\< qQ-TOIT64ED
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 11 One family
El Addition Li Two or more family 11 Industrial
Ll Alteration No. of units: El Commercial
XRepair, replacement El Assessory Bldg El Others:
Li Demolition El Other
ESCRIPTION OF WORK TO BE PERFORMED:
ACC.
Oil
Identification- Please Type or Print Clearly
OWNER: Name: MAA C'are f30-0 Phone: '7 F1 7 0
Address: (t\4 0 194:S-
Contractor Nqme: i�eQq,�S JRrvtCt5:3 Phone: 77el -7 CO
Email: q420\, (e0- ileXtiscp,
Addres �- ?.O. T2o2L-- 282.3 VIO'bikYe-N
Supervisor's Construction License:.CS.--739'r` I Exp. Date: 417]Zoi
Home Improvement License: 1ZJ Exp. Date: 7 0
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: $ 211, FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting W11 unregistered contractors do not hoc,ace the arantv fund
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%AORTH
ndover
Town of
2 _E. ...'.�.
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ocHICw.c. 1'
AORATEo
S U MEMNON& BOARD OF HEALTH
Food/Kitchen
PERMIT T
Septic System
% iw BUILDING INSPECTOR
THIS CERTIFIES THAT . "' """
.... . .. ..............
��. ., ........ Foundation
has permission to erect .......................... buildings on ... � ... G4 •• •e
•.. Rough
... . Chimney
to be occupied as ... 1 ..�....... .e�. �`.�..........�.. .. ..., � c ' ev
provided that the person accepting this permit shall in every respect conform to the ter(s.
of the a licatlon Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTST TS Rough
Service
................. ..... ................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occup-y 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth ofMassachitsetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
fvivul mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
� 4
Name (Business/Organization/individual):
Address: 0 Bcv<
City/State/Zip: �d�t�� lrte-OJ Phone#: ��
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. I am a general contractor and I G ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
y p ty. � 9. E]Building addition
[No workers' comp.insurance comp,insurance.t &AC e-
required.]
5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L Plumbing repairs or additions
myself.[No workers'camp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other `
camp.insurance required.] ,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inform on.
t Homeowners who submit this affidavit indicating they are doing all work and then lure 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.
I atit att employer ilial is providing workers'compensation insuratice for»ty employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify larder the pains and penalties of perjury that the hiformation provided above is true and correct.
Sienatttre Date , [2_6l
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
G.Other
Contact Person: Phone#:
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PpLNC►E96ECANCELLED BEFORE
IN9LL BE DELIVERED IN
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iasuhua -Department of publ'a
o Safety
Board of Buildilig Regulations and Standards
Lw cen .CS-0739"91
23 GLNDiA1 EhR "e
DANVERS MA t�1923�
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° 041g'atiWl
7/2096
Craraimissioner
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a, CtfOee of Cuasumer Affairs&Business Regulation License or registration valid for individul use only
" before the expiration date. It found return to,
,6 OME'IMPROVEMENT CONTRACTOR
" egtstration: 129177 Type. office of Consumer Affairs and Business Regulation
Expiration: 7/15/2015 Individual 10 Park Platt Suite 5170
F a� Boston,MA 02116
Gerald White
t
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Gerald While k
r 2 "Glendale,Or
Oadvers,SNA 01923 Undersecretary - trot valid rvltirout signature
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