HomeMy WebLinkAboutBuilding Permit # 8/13/2015 1
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BUILDING PERMIT �oRrN
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received 74A�R4TEU " 45
�SSAC HUS��
Date Issued: �.
IMPORTANT: Applicant must complete all items on this page
LO 'ATION
n Print
PROPERTY OWNER ( 1� '\C -- -' ` print 100 Year Structure yes no
MAP IJ PARCEL: '1' ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building El One family
Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
r '-� Well ,f, %❑ Ffooc( lam �❑Wetlands� r � "❑ Watershed Disrtrict '
xm
^- ❑ Septic,:. ❑ '.. ��` .k %r / -;lhrr+ k r,: pl ,! r✓;' ".:� y :� �.lrr" t rr� � `^'C '-i"� J%-`l y z�.:
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'' rl�r aerfSeWer„ c �" rr Jf'y� ae r .r �rY, v' 1P, J ✓ ° ;. .., .yr,.A :r a„,7�I,,, zs.nor^:^` ,/-; r.F„=. .,
D S(C�IPTION OF WORK TO BE PERFORMED:
Ide ti i ation- Please Type or Print Clearly
OWNER: me: C Phone:
Ew'm
Address: `l�r LJV to
Contractor Name:.O �JW- hone:
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 PEI60000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ {
Check No.: J I Receipt No.:
NOTE: Persons contracts with unregistered contractors do not have acces the gu, ty fund
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town of �.. �_� Andover
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No. Zo( l
�. h ver, Mass,
® LAKE q.
COC K.CKSW.CK
.9 A°^ArED
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ......................................... ...... .................................. ....................................
has permission to erect .. �C Foundation
. ........ . ........................... ..............
..................... buildings on . I .......
4 l IJnkn Rough
to be occupied as ......... .....6-a-A.................. ............................. ..........................athe
..... ........ Chimney
provided that the person accepting this permit shall in every respect conform to the terms ofpplication 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
UNLESSTI T Rough
Service
........... ... ....T r ....................... Final
BILDING
INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
o Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
TOWN j�ORM AND, OVEP,
OFIFICE OF
�.$�3YX0 F4�,.[ • . .:• Xo:c hAndmx,-Massacbusetlq 01845
,
Gerald A.Brown - TelaVIkue(978)68$9545
I'nspeetaxofBi l&gs - �a� (978)689-954-2
EMP11ON '
BMDUpFPM- T AWLICATfON
1'leasep �
DATE:
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umbex 8txeetAddress Map)�ot '
JOMEC �E . I Z 5 '71 Y 9 6-q `'v. "
mama. -
Rome, one Warlc hone
7,i C do
The cun'entexempiion.for Iomcownerd"wasextendad to��7uc�eovinex oacti�ie�
to allow s T,homPa, OS,am
meas to en age anlJLz aanal•fozblre ciao sloes no possess a iet 3is pxovzded tT�atthe owner
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acts as supezu?�or}. Sr�.te3�i(ding
DmFjMTION OFHOMEOV M-R
PomOn(s)who awns apazceI ofland on V7Mch I.cbheresides or xnteRds to reside,an WMA fiheze is,or is xufended to ,
bb,a ane or two azr�ily sfructuzes. A person wlto constru cts moxe that one b ome xn a two year erzo shaTZ ot be
considered a7�.ontGDWner. , n
The 2zuderszgned"homeowner"'assumes xesponszb�lity�'oz-coznp7laz�.ces�vzt7z t�.e SfafeBuilding Co de anti o��.er
.Apylicablo codes,by-laws,rules and-Xegulatzons.
The,vatdersigned=`bomeownex"ce hesl�a&cTzstaudstToToWnof9brtfiARdoverBnitdingDc�mfmGut
Minimum impecfion procedures an et fs audthatlte(slze will comply With said-Vrocaduresond -
repirernents, .
HOMCO�xj�7�R�SICrS�',A'I'TY.RE-+ I r� .
APPROVAL O:V J3MDMG OF'.li'XCIAL
eyised 7.2009 -
'oxzn�ozneowners�sxemption - -
DARD OFAPPBAM 689-9541 OONTSBR'VAUON 586-953o
MAUR 6$8-9540 �'Z..�1QN[NG fi8�953n
The Commonwealth of Massachusetts
z Department oflndustfialAccidents
1 X Congress Street, Suite 100
Boston,MA.021142017
www mass.gov/d1d
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print.Legibly
Name(Business/Organization/Individual):
Address;
City/State/Zip-- ) • U !k Ot Phone#: �� 70 77,9
Are you an employer?Check the appropriate box: Type of project()required):
1.❑lamaemployerwith s employees(full and/or part-time).* 7. New construction
2.[]lam a sole proprietor or partnership and have no employees working for mein $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. F1 Demolition
3.Q l am a homeowner doing all work myself.[No workers'comp.insurance required,]i
4.fa1 am a homeowner and will be hiring contractors to conduct all work on my property. l will 10[Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
i t
propzietors withno employees. 12. ]Plumbing repairs or additions
5.❑lama general contractor and T have hired the sub-contractors listed on the attached sheet. 13. Roof re airs
These sub-contractors have employee's and have workers'comp.insrrance.t p
6.Q We are a corporation and its ocers have exercised their right of exemption per MGL c, 14•❑Other
152,§1(4),and we have no employees.[No workers'comp,insurance required.] ,
-Any applicant that checks b6x#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must sgbmit 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. kihe sub-c6&actors taye employees,flier must provide their workers'comp.policy number.
X airs an employer thai is providing works rs'compensation insurance for my employees•Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lie.#: 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 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 verific '
Ydo hereby e r fy nder tt epains andpenalties ofpetjuiy that the information provided above is true and correct.
-20/Sign re. , Date: "
Phone#:
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.CityjTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: