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Home My WebLink AboutBuilding Permit # 8/20/2015 p TaORTII ®F PERMIT BUILDING TOWN OF NORTH AOVER o APPLICATION FOR PLAN EXAMINATION ^- Permit No# Date Received ��s ArEDCHU �5 Date Issued: MP TANT: Applicant must complete all items on this page LOCATIONP n t Print 1 '� I 100 Year PROPERTY OWNER p Structure yes not yes no MAP PARCEL: ZONING DISTRICT:_ Historic Distric Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition El Two or more family El Industrial "'Alteration No. of units: [i Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other /� ..,i,.,,,, i �i:,. ❑/VV.:at�. .Sh r ,. , OOd laln., / i, u r ri,/r. ✓, / /1 cJDI.lir,_. r W J�%/�/ N /!, �%i /elm,/�i�,!„!%�,:.i�/�%�1i/%�i/, DESCRIPTION OF WORK TO BE PERFORMED: Id cation- Please Type or rint Clearly �„ 66 OWNER: Name: �..� a �� Phone: _ a.m Address: 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 COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ � Check No.: ? Receipt No.: NOTE: Persons contra ting with unregistered contrac ors do not have access to the guaranty.fund t%®RT#1 Town of ndover ® 0% K _ / o �.K. h ver, ass, COCHICNlwICK 0R�+re® PPa� •(`� BOARD OF HEALTH Food/Kitchen PEKMIT T U Septic System 0 THIS CERTIFIES THAT ........... . ,,,,,,,,,�,,, „�, BUILDING INSPECTOR .... .......... .. ...1................... . . . . . . .... .. . has permission to erect .......................... buildings on Foundation ...... ..................... . .. .......... .. Rough tobe occupied as ... ............... ....... ........ ... ...... ... .. .�.�... ...... ........................... 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOXTT Rough s Service .................... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupanc-V Permit Required t® Occupy Buildin 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. O� NORTH TOWN OF NORTH ANDOVER �o OFFICE OF OWN BUILDING DEPARTMENT it , , *__ * �o 1600 Osgood Street,Building 20, Suite 2035 �+gssKieo nP��y North Andover,Massachusetts 01845 ACHus / Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION 13UIDING PERMIT APPLICATION Please print DATE: ., .w .. JOB LOCATION: a k,e w Number Street Address Map/Lot HOMEOWNER Z/ „ �C w ... ' �...._ �� ` w. ., Cj Name Home Phone Work P ne PRESENT MAILING ADDRESS k City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided that the owner acts as supervisor. 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 dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with 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 lip' APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 I I 1 The Commonwealth of Massachusetts Department ofIndustrialAccidents f4 I Congress Street,Suite 100 Boston,MA 02114-2017 vwt www mass.gov1d1a Workers,Compensation insurance Affidavit:Builders/Contractorg/FIoctrieians/.Plumbers- TO BE MEJ)WITH TBE PERMTTING AUTHORITY. Aplilicant Information Please Print Legibly Namo (Biisiness/organization/fudividual): L -7 Adch-ess: l I � VCMAPh6city/state/zip: Are you an employer?6eckt&app*r'opriate box: Type of project()required): LnIam.acroployervith employees(full and/or part-time).* 7. F1 Now construction 2.U I am a sole proprietor or partnership and have no employees working for me in $,, Remo any capacity.[No workers'comp.insurance, required.] 9. wDemolition 3.[J1 am a homeowner doing all work myself.[No workers'comp.insurance required,] 10 F1 Building addition 4" lam a homeowner and will be hiring contractors to conduct all work on my property. IviU ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors with no employees- 12 h Plumbing repairs or additions 5.❑1 am agenexal contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs Thesb sub-'contractors have employees and have workers'rkers"comp.insuranceJ ce 14.FJ Other 6.E]We are a corporation pnd its oMcqrs have exercised their right ofexemption per MGI.c. . i" '� - 152,§1(4),and we have no,.9pploycep.[No-workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below shoving 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 ave employees, * it provide their)�orkeis'comp.policy humber, employees. if the sub-contractors h '' ployees,'diey must I am an employer that is pidpiding workers compensation insurance for my emplbyees.'Below is th ep oficy 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 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,of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains dpenaIt' o ejyuiy that the information provided above is true and correct. les �f,T. Signature- Date: I< Phone 4: 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#: