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Home My WebLink AboutBuilding Permit # 8/10/2015 00RT#J BUILDING PERMIT 0. C TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: It Date Received 7RpDRH7eDWPp R5 Date Issued: to 14 IMPORTANT: Applicant must complete all items on this page LOCATION 1 i"L/<2 c/q-tMJ(" W1 I/, 5 I PROPERTY OWNER W; P& Print 100 Year Structure yesQno MAP PARCEL:00�e2 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 101 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building One family [I Addition U Two or more family [I Industrial El Alteration No. of units: [I Commercial $-Repair, replacement El Assessory Bldg [I Others: El Demolition El Other DESCRIPTION OF WORK TO BE PERFORMED: 41,10 WC 41 0 V11)Cx jaw I-T-01 12, New, Fly, 1entifitation- Please Type or Print Clearly OWNER: Name: W1 1 114 kqT ze Phone: , �,-6 S 3 ...9F0 ,, Address: C / 0, Ao; o Contractor Name: Phone: Email: 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 CO T 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 fcontract6r OT town of 77" Andover 0 ��• .�' ® _ ® T - =_"f17 (N 21 �� Very iaSS i S COCHICHtWICK. BOARD OF HEALTH Food/Kitchen PER"IMIT T LD Septic System *- THIS CERTIFIES THAT ................. BUILDING INSPECTOR has permission to erect .......................... buildings on ....... ..... ............................ ...... .................. Foundation Rough to be occupied as .............. toa.... .....z................ ........ ......N .. ... ....... . ..� ............® Chimney u 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 UNLESS CONSTRUCTIO STARTS Rough Service ........... ... ... . ......../ -.................. Final BUILDING INSPECTOR GAS INSPECTOR Ccupaney Permit Required to Occupy Buildin Rough Display in aons icous Place on the Premises — Do Not Remove Final Lathing at or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. _ Burner Street No. Smoke Det. The Commonwealth ofMassachusetts Department of IndustrlalAccidents R. 1 Congress Street, Suite 100 Boston,MA 02114-2017 �. :.s�;�•�` www.rnass.gov/did Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMIT TING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/lndividual): � Ill �� ? / �1 Address: 3 04 t,C il 1`1\° 0 City/State/Zip: A&A Aolw& Z, M# dIF9S Phone#: d ? J-6 Cl Are you an employer?Check tine appropriate box: Type of project(xequired): 1.❑I am a employerwith employees(full and/or part time).* 7• F1 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. FA Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3-Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.&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.KPlumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insruance.1 6.Q We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have n4 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. T Homeowners who submit 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-contractors have employees,ley must provide their workers'comp.policy number. I am an employer that is providing workerscompensation insurance for my 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' compextsation 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 WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce" under the pa• s andpenalties ofperjuiy that the information provided above is true and cor'r'ect. Signature- Date: — /Z7 t 0 t Phone#• C� cls "7 )�,o � Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 04 br TOW'O:u opaff ANDOVER OMOROF - ~�^• .AL1' M P TAW1.'t T r •'1600 OBkODRStr00fBu fdk92,0,-SU.tQ 2-06 Wbith Andovaxg.lMassachtzse#a 01845 , �RC�iIS5� Gaxatd A.Brown ToXopliono(97$)688-9545 luapeetorofBuildings Pax (978)689-9542 -R@NMQVMR LICENSEBYMYR If ON ` 1'less�rint . V , OB LOCA1..C4_IN., L � Q,/)/v 'i7 d 0` Number ke Acldzes --� Map) o �IOAMOVMER Name . ozne Phone W orkRhone a TM PRE-SWT MAMiNGADMES, . zip Ca_ T$e current exemption for"Izoaneol zexs"tx�as extendod fo?n�ltzde owner occupied divel'ugs to U-vo units or;�s5 an d to allow sabh hoanao,�auers to engage an iaidividual.for biro who&PS nDt possess a ,provided that the owner acts as snpex-v sor). 9tatei3uilding (Code Section DBFI -ITIOX OYHOMEOW,N R Person(s)who gwns aparcel ofland on whicb.7xelslaereslaes or z atends to resido,on which fbere is,oxis xnfended to be,a axle ox 10 aiaily sixuetcaxes, Aperso Lwho constmots Mora tbat onebomein atwo-yearporzod ka'ztot'be eonsidezedalaameo�+nar. _ • Tho undersigned"Ifoxneci�yner"assumeszespansibitit3rtoz comp7iazxces %t�tietate$uzld%ng Code . and other W:Qcable codes,,by lays,rales andxegulatzons, dTbevndexsigned"homeowner"camesthat lzclslaeuudexstanclaf eTo T74 of Nexfb. ndoverBuRdiugDo&ffinent Minimum inspection pro coduz-es and raquiramenfs and tTiat fackhe comply with,sald pxacadures and xecluixexnenfs, ,' t .HOMBOWMRS WONATMW , APPROVAL OF J3WDSNO OFF.ICM . Revised 7.200 " x'oxxu�SomeovrnersTsxempiion ` ^ 3DARD0FAP)PBAT-6H-93$X CONTSEft`4rAUON688-95.34 WALTH689-9540 PLANNING 689-9555