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HomeMy WebLinkAboutBuilding Permit # 8/24/2015 Q%ORT + 19IL IN PER IT m��%LED ,g�'�'O TOWN OF NORTH AVER 0 � APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ATED PP��Ry S�caaus Date Issued: w I I PORTANT: Applicant must complete all items on this page LOCATION " - Print PROPERTY OWNER Print 100 Year Structure yes n MAP PARCEL: ZONING DISTRICT: Historic District yes n Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial . epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r �r�ocr t err r ,F r, ❑ Watershed District Weflantls ain ,, ❑ r /nr , , ❑ Flood I /r. of , � r f / ell r is /❑W P ,, f,f ,Set , / i r o � r � Y � , lfi r/ r 0✓ >, „ r,r r r r/ / / o er, ✓ p r� r / , r r r, t/ / r r, - r, �i r r e r r ���� r / r DESCRIPTION OF WORK TO DE PERFORMED: 0e tific tion- e Type or Print Clearly OWNER: Name: m. � A; `�" Phone: '' Address w µI Contractor Name: Phone: C Email: 4 Address: Supervisor's Construction Licenser 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: $ FEE: $ �I Check No. / Receipt No.: � ' DOTE Pero s con in with unregistered contractors do not have access to the gna an fi�azd - - �� -- - --- t%ORTH IN own 2 � _E. ._ " ver 0 �► h ver, Mass, 7 ° COCNIC t..C. y1' X1,9 A°41rEo S U BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT ..... ....... ...... . BUILDING INSPECTOR . . .... . ...... .... .. Foundation has permission to erect .......................... buildings on ........ ..... .00............ Rough tobe occupied as ......... ..... ... . . ...... .... ... .. ... .. .............................................. Chimney provided that the person accepting this it shall in every resp t conform to the terms of the application Final on file in this office, and to the provisions 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 IT EXPIRES I T S ELECTRICAL INSPECTOR LESS C T C T R S Rough 3P _,,../� Service .. INV ..... ........... ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building 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. The Commonwealth of Massa chusetts _-. . -- Department oflndctstrial Accidents 1 ���t Office of Investigations 600 Washington Street Boston, MA 02111 T r. www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/-Electricians/Plumbers Applicant Information Please Print Le ibl A Name (Business/Organization/Individual): , 4- Address: City/State/Zip: Phone#: r2. you an employer? Check the approprVteox: Type of project (required): l am•a;etnployer with I am a general contractor and] employees(full and/or part-time).* have hired the sub-contractors 6. New construction 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have o. ❑ Demolition working for me in any capacity- employees and have workers' f q Building addition t t?1u wori<crs' comp. irisurancc comp. insurance.t i required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. o workers' comp- right of exemption per MGL y � P- 12 Roof repaus insurance required.] t C. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 rnust 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number_ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: aim "wt Policy#.or Self=ins_ Lic.#:: e( � � 3�1 ���—?-' J _ Expiratioti Date: t `�� Job Site Address: _ Ciiy/State/Zip . Attach a copy of the workers' compensati0l]policy declei-ationpage(showirig the policy nuniber'and expiraliondate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line 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- Be advised that 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 th pain and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone #- -7 , Of 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. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: . ��G' �Y/7L7TLd/ZC(lACC�C� J1CCC�C66G'� - Office of Consumer Affairs&Business Regulation /gYOME IMPROVEMENT CONTRACTOR eegistration: 146722 xpiration Type: 5/11/2017 DBA "EEFE CONSTRUCTION MICE. 21 rp �O'KEEFE NORj- RE STREET SING, MA 01864— ,'- Undersecretary Massachusetts _ DepartMent of Publi Board of S wilding Regwlations c Safety Construction and Standards Liven Supern-isor , se: CS-068461 _ NIIV ris CHAO 21 Francis StreetE'FE ; NorthReading>y� 016,11 i 0 C0+nmissioExpiration P ation ----___ 02/24/2016