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Home My WebLink AboutBuilding Permit # 8/18/2015 ORTH BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received Date Issued: SSACP4us WORTANT: li App , I �I I I I - 11 1, , 'cant must complete all items on this page 7' 7777777777= 7777 7-7 77 LOCATION NO pflh -4 -PR ' N S -OPERTY,--, W tin TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ri New Building One family Addition D Two or more family 11 Industrial D Alteration No. of units: Ll Commercial 11 Repair, -replacement U, Assessory Bldg El Others: E Demolition E Other 7 CA�4� i2 01-Y 5e_ v3A, 02 ILI' d Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: K) CONTRAOTOR r. g, 1�22�m J Exp tk�ten a) ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.-$12.00PER$100o.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00PER S.F. Total Project Cost: $ d — n 420/e�v Cl/ Check No.: 7- FEE: $ ,2(,-L) Receipt No.: NOTE: Persons contractingw, I!`tl, unqgistered contractors do not have access to the guaranty fund Si nat f-A J In. g Wn. of-contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swiinming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS C®NS RV PION Reviewed on Si nature -4 )41-�Y cv�I COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Tomp Dumpster on site- yes ho° Located at 124 Main Street Fire Dep�rtrrient sigrAaEure/date COMME14TS i IAORTH Town of dover IT,, V% ►i/ �O q w h " ver, ass, coc"ICHEWICK ��' �•9 A0" ATEo 01?��5 S U BOARD OF HEALTH Food/Kitchen PERM* IT T LD Septic System THIS CERTIFIES THATBUILDING INSPECTOR ............................................................................................................................ Foundation has permission to erect .......................... buildings on .. ......�.. t11 .1�,..f....... ............... �f ... Rough to be occupied as ........... . .. ................... . ..t...... ? .a� 1 ... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCI STAT Rough W49 Service ............. .r ...................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired t® Occupy Building Rough Islay 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 of Massachusetts Department oflndustrialAccidents X Congress Street, Suite 100 Boston,MA 02114-2017 J•,. www.mass.gov/dia w Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PEPJHTTING AUTHORITY. A licant Information Please Print Le ibl e Narrle (Business/Organization/Individual): r/ Address: / tvi l�, t � City/State/Zip: ir. Phone#: 2-- Are you an employer?Check the appropriate box: Type of project(required): 1.f—1 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.n I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 uilding addition 4. I 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.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 152,§1(4),and we have no 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,they must provide their workers'comp.policy number. I attt att employer tliat is pr'oviditig iporlcers'compensation insurance for'uty 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 verification. I do hereby cerci y,-under the ins and ettalties ofpeijuty that the information provided above is true and correct. Si nature Date: Phone#• 7 7 % e Official use only. Do not write in this area,to be completed by city or tows:official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a� w TOWN OF NORTH ANDOVER OFFICE OF I BUILDING DEPARTMENT P 1600 Osgood Street Building 20, Suite 2-36 e , , w" North Andover,Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: / /A Number Street Address Map/Lot HOMEOWNER z 2 6"' —3113 Name 1nome Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF tl1'1pf•.64,LS 688-.9541 CONSF RvKrFI;YN 685-9530 iVF.h.C'M P!0-9540 1'I„hNNING 688-95:35