HomeMy WebLinkAboutMiscellaneous - 19 HAROLD STREET 8/3/2015 .. l
SAORT!y
BUILDING P ITo�R,,V.Q 6q�o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit No##: Date Received
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C.HU`S
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION �S t, .
PROPERTY OWNER �I not ��,
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p y� �`t Print 100 Year Structure yes no
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MAP PARCE ZONING DISTRICT:_ Historic District ye no
Machine Shop Village yes ( no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
?io d� r ot.j r + skm � a*-+
Identification- Please Type or Print Clearly
OWNER: Name: Krqsir-) Phone: -) 7(aL[7f 7
Address: 1C) 0) 9"rt
Contractor Name: r7 S Phone: 0 7
Email: c-c- 9,-�I. a t/�.a'7 _
Address:
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: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
T.,
� NORT1�
2 s EAndover
p :. - ;`: 0
No.
�O LA 149 " ver, Mass,
CC/CNICNEWICK y11'
A°Rgr,Eo S
S 11 •
BOARD OF HEALTH
Food/Kitchen
IT LD Septic System
Cr •
THIS CERTIFIES THAT �..`� ,lid, BUILDING INSPECTOR
.. ......... .. .. ..
has permission to erect .......................... buildings on .....I.j........ ......�
.� Foundation................... Rough
tobe occupied as .......sli..Y...... .* . .............................................................. Chimney
provided that the person accepting this permit shall in eve 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 INSPECT OR
UNLESS CONSTRUCTIO T
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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
TOW OF NORM AND OVER
OMCE OP
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NDSthAndovbx'�MaSsachusata 41845
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GoraidA.,13rown Texep one(97$ 698-9545
Inspeetox o $uiTdings a (978)699-9542,
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PREBMT MAT6NGADDIMSS 19 Va r-DI
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TAo euzxent exemption Ior"homeo 4vnexs°' vas mtouhd io iuol e o�Ynex oceti 'xe �iveTlings�o ii vo units ox as.and
fura71o"YSUEhhoTmovrB=tstoengage,8d'l.?i(dJv;dh1al•forhiroWftodoe37.ofvOsseSSa.Rcmigo,pxo-videdMat•Nle,omoi:
acts as snpuivizor). 9fafoB 1 ding (Code Sootion
DIWITION OFHOMEOVMR.
I'exson(s)who 9wns apac,61 ol:'land ozx urXi%c7�ltelsliexesicles or intends to reside,on wh ch thore,is,ox as 7nfended to
a ore ox�Wa arnilysfti�etuzes. Apersmwho covet a-0t.-mom ffiatDnf,home,ju.atwo-parper.(odshaunot bo
co�szdered a7�.omeo�vnez;
Tho undersigned 11,hmoawuer"'assuzuesresponszb7lity fox compliances wiffi the StaieBuijcting Codea-ad ottxer
App7sca to codes,,by-law.;rules and-joguxations.
Tho undersigned"homeoxatee,cextj�Ras that true Town of)�Torth AndoverRuRft Deli Dnt
Wfil i77um xn s.peotion.procedures and roquisexnezLfs aMI•fiatholke,will comply with said pxacedma and
x'equlrexnents�
HO�EO'�`LR.B SIGI�•.�TT11�E '
&PPROVAL OF,133MDXt G OFFICIAL
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'own�czneoWners Dxempfian '
D RD OF APPEAM 68 8-9.541 CONTSEMMON698.9534 xu?Ar ��Q_o�,rn brA'kT' —«.r,
The Commonwealth of Massachusetts
. Department of IndlustrialAceldents
:, i. d 1 Congress Street,Suite 100
Boston,AM 02114-2017
www.mass.gov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE Fff ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Nalne (Business/Organization/Individual): y n C—,I A .0—
Address: d S� '
City/State/Zip: di Phone#: �'`� ' (P L( - 71
Are you an employer?Checktlie appropriate box: Type of project(required):
1.❑Zama employer with .. employees(full and/or part-time).* 7. ❑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.]
3.4 am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. El Demolition
4.❑T am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5. I am a general contractor and I have hired tho sub-contractors listed on tho attached sheet.
❑ 13. of repairs
• These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL G. 14.❑Other
152,§1(4),and we have nq 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 subuiif 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.
I am an employer that ispi'oviding workers'compensation insurance for my empl6yees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
pensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL G. 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 DTA for insurance
coverage verification.
I do hereby certify under thepains quad-penalties ofpetjuiy Haat the information provided above is true and correct.
Sinature: Date:
Phone#• 4 8--7 (0`-f -7&--7
Official use only. Do not write in this area,to he 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
Contact Person: Phone#: