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Home My WebLink AboutBuilding Permit # 8/10/2015 OORTH BUILDING PERMIT ®� TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION PermitNo#: Date Received TED se Date Issued: CHU IMPORTANT: Applicant must complete all items on this page LOCATION Lk, s Print PROPERTY OWNER AL&!a + �IL PNnt 100 Year Structure yes P 1- 0 MAP PARCEL: ZONING DISTRICT: Historic District yes rio Machine Shop Village yes li2°� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building El One family Li Addition El Two or more family 11 Industrial F1 Alteration No. of units: 11 Commercial H7R-epair, replacement [I Assessory Bldg El Others: El Demolition 11 Other WV, 0 01 qg,i, 31 1111,11V,11),,w,,-t ",eg,ei e dr�Distit DESCRIPTION OF WORK TO BE PERFORMED: A/C UD 4� Identification- Pl�ase Type or Print Clearly OWNER: Name: ntes �- r-wN,L J-� I'A))A�eli Phone: `0�-U 7 Address: (z t, Contractor Name: VVkkk2tF4te-KiJrA.. Phone: q 71 5 60 - 61�i LA Email: Address: Supervisor's Construction License: L, 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: $ co FEE: -n Check No.: Receipt No.: W-5 1 Pi on contracting with unregistered contractors do not have access to the guarantyfund + %AORTH Town of Andover 0 . , ® ® 2AIY _ �� q COC o9 0 ;AKQ 7� Ch@WBC 6c V 0"�.ATED t) U oS° � BOARD OF HEALTH Food/Kitchen PE Septic System THIS CERTIFIES THAT .......... l t!.l,r! BUILDING INSPECTOR has permission to erect buildings on ....... .. . .. �,� V.. c..L„ ..Q .. ..... Foundation ..... .. .. . . . . Rough to be occupied as ....... ... . . . 0 ..... ........... f.........&--Nfb'b............ �. 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 Rough 41T T LD VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS I T Rough _ 10 Service .... .......................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildi Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final Lathing at in or Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. _ Burner Street No. Smoke Det. TO". 0MORTHANDOVER 4J..0°.. CR A1C' ` UMI DEPARTY&NT " r b til]Dlsgoa9�t 00tBuffdi g20,-Silzt��36 'c jig _ N'oith.Andvvar,Mass-adhxsetta 01345 GoyaldA..Brovvn o " Tblapll.one(979)6SB-9545 lnspeetax of 3r�itdings • -Fax (978)6899542 -H@MEOWNER LICENSE MW If ON , BS C pE f T"PLICAMN 1'.lease�zi�-E DATE,--- el TOB LOC—A-TfO , --�J cti l ` ' .�'um'bex �ixeet.A_ddz'ess �ap/�o� ' EOE . -Al i �h � � �l'ame. . :dome hone "�N'oxiC�'hpne . SPE-8E-T MMNG ADDIMS,Aeto - . .:. . ' .. , 0It, - . ti CodkA T.lte eurzen�e�empflon fox"-hozneo�zexs"'was extenttpd fo�plac7e nv�ner-occx%pxed divelvgs fa f�Up unifs•fix less an 1 is nTlo� such?omPo,vnexs to engage anL-`C"riauax for hire-Wfto does notpossms a 7ieeaam,pxovidad f iaf file oWncr acfs as sopezvysor. gfa ce:Ml ding Code ectlon x�S,�<5. DIM-1110:9 OYHOMEOVMR Pbrson(s)Who PUq apucel of lana or iatends'to reside,on WHch fhere zs,ox is 7nfended fp b��a one ox GWo rami(psizuctuzes. Aperson,who co=tmofs mora ffiat ona homDxn atwo yearpmr 6a shall notbe �oalsiaereda7�.oaneownez; Tho Mdersigneci io teownar"'assuraesresponszbxli y oz comp7iauces wiffi tho sfataBuild ng Codeand other .Apylica-ble codes,ley laws,xules ana-jegulafions, e nndersignet "bomeowztex"cues that ReMat dexstands e.Town of NbTffi AadoverRaRcling T e��enf �inirpuzn xnspeefioz�procedttresandrequirementsandt athekhDWM comply'wila.;saldpracaduxes and rer�uisemezzfs, . . , RomDWMR.B SICYNA.TME AZ'PROVAL OF J3Dff-DMG OFFICIAL , , 2eyised�X009 . , �oxzn�Someowners�sxem�tion DARA OFAPPEAM 685-9541 CONTSEMT,tS ON 686-9530 The Commonwealth of Massdehusefis Department oflndustrialAceldents 1 Congress Sheet,Suite 100 Boston,MA.02114-2017 gy;wat www mass.govIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electrlcians/3.'lumbers. TO BE FILED WITH THE PERMIT"TING AUTHORITY. Aplilicant Information Please Print Le 'bl Name (Business/organizafion/Individual): t iou r Address: CiCy/State/Zip: 0 " ' . ( L(` phone Are yon an employer?Check tine appropriate box: Type of project(xeguired): 1.❑1amaemployer with employees(fulland/orparttime).* 7. []New constr action 2•❑I am a sole proprietor or partnership and have no employees working for me in 8. f"Remodeling any capacity,[No workers'comp.insurance required"] 9. El Demolition . 11 am a homeowner doing all work myself[No workers'comp.insurance required.]t � 10 �Buildhig addition 4.L�1 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.[]Plumbing 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.insurance.t 6.Q We are a corporation and ifs of�cers have exercised their right of exemption perMGL c. 14.E]Other 152,§1(4),and we have nn empl�yees,[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit#lis 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 fiave'employees,they must provide their workers'comp.policy number." I am an employer that is pio'viding workerscompensation insurance for my employees.'Below is the policy and job site information. Insurance Company blame: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compeMation"poliey declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o. 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 ofluvestigatlons ofthe DIA for insurance coverage verification. I da here y rtify and the pan s andpenaldes ofperjuiy that the information provided above is true and correct. Signature Date: Phone Official use only. Do not*write in this area,to be completed by city or tolvn official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of.Health 2.Building Department 3.City/Town Clerlr. 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone R.: