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Home My WebLink AboutBuilding Permit # 8/24/2015 t%0RT#1 BUILDING PERMIT F D 6 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#:2 -L' Date Received TED PX Date Issued: CHU$ IMPORTANT: Applicant must complete all items on this page LOCATION 130 -PPint PROPERTY OWN ERK\AWE- Print 100 Year Structure yesOno MAP D37 PARCEL06(6! ZONING DISTRICT: Historic District ye no 0 Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family 11 Addition 11 Two or more family 11 Industrial 0 Alteration No. of units: 11 Commercial N Repair, replacement [I Assessory Bldg 11 Others: [I Demolition 0 Other N 115 / / / � / E 1 ESCRIPTION OF WORK TO BE PERFORMED:'11� r (1,lArl,A)Idb AL-5 t 4 14 LJ Lit N/Clo t,�,6 J )�4 Re ,)i ,e (4) 5 -�LGJ Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: b - Contractor Name: 'Joa, cck+f-� Phone (4>(,;J Z Email: ('-� w e,-j M Address: fu+l Supervisor's Construction License:-L6 ()G1:)39 q 1z 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: $ 4J 115, 000 FEE: $ Check No.: -362° Receipt No.: 2-n NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund na ign ne -7`5 too)R i H own of 2 E ndover 0 No. aa('V -� oh ver, Mass, 9- A4 I V C.C.4.1W1CK y1' A0%ATED P.P .c5 S V BOARD OF HEALTH Food/Kitchen rwERMIT T LD Septic System THIS CERTIFIES THAT ............................. ... .. ..� . .......... ... ... . . ...- ........................ BUILDING INSPECTOR . .... . . Foundation has permission to erect .......................... buildings on ..... ...... ... . . . ................. to be occupied as I.&. .... ... . � .. .. .. ..... ...... ....... . 9. ..G. ..... .+4r ev ... . .... LA°ney provided that the person accepting this permit shall in every respect conform to the terms of the application 7FRal 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 CONSTRUA . TS Rough Service ........ .............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. of NORTH q TOWN OF NORTH ANDOVER ,,to , , OFFICE OF A BUILDING DEPARTMENT jv 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 ,SSACHUS Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Sheet Address Map/Lot HOMEOWNER 6�i i� / 7 p S OY3 -)L- N )L. Name Home Phone Work Phone PRESENT MAILING ADDRESS �—�- 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,provided 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 110.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 APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Iradust�ialAccidents ;, . ; •d X Congress Sheet,Suite 100 Boston,MA. 02114-2017 •y. www mass.go-v/dia sy, Workers'Compensation.Insurance Affidavit:Builders/Contractors[Blectricians/PXumtbers- TO BE FILED WITH THE PERARTTING AUTHORITY. Aplilicant Information Please Print Legibly NaMe(Bixsiaess/Organization/Individual): Address: -J City/State/Zip: A/, AVPOV- it M-1-- Phone#: l 7 - ��/0--a Y Are you an employer?Checkthe appropriate box: Type of project(Vgquired): 1.❑I am a employer with employees(full and/or part-time).* 7. []New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition IE]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 FJ 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.ElElectricalrepairs or additions proprietors withno employees. ft FJ Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs • These sub-contractors have employees and have workers'comp.insurance. • � 6.Q We area corporation and its ofcers have exercised their right of exemption per MGL c. 14.[+Other 152,§1(4),and we have uQ 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 submif#his affidavit indicating they are doing all work andthea 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-coniractors have employees,tfiey mast provide their workers'comp.policy number. lam an employer thatispfovidingworkers'compensation insurancefor my employees.'Below is thepolley and job site information. Insurance Company Name: Policy#or Self ins.LiG.#: ExpirationDate: Job Site Address: � City/State/Zip: Attach a copy of the workers' eompensation•policy declaration.page(showing the policy number and expiration(late). 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 certify under thepains andpenalties ofpeijuiy that the information provided above is true and correct. Si nature: Date: Y / Phone# 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#: