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Home My WebLink AboutBuilding Permit # 8/26/2015 OO RTH �^• BUILDING PERMIT mF� Lro IBy,WQ .�� fir',jr w '1!• ' 5 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received p�RRTED PpP �� Permit No#: � �Ssgcoaus``� Date Issued: " IMPORTANT: Applicant must complete all items on this page LOCATION � w k, � � "1 &&.,t - PROP RTY OWNER "� " "'� Print 100 Year Structure ye no MAP PARCEL: ZONING DISTRICT: Historic District es no Machine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Li Addition [i Two or more family [I Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Weid:§== /d Distract r rM o„/ r- �, r ,r: //� j//// „,re // , , ., � ,,r ,„ r , �,� ,r ,,//,,, /�„_r J„ , //,,F / /,,r :ellW ,� /r i / ,/f / // o1�,/,�, / /Sewer!��',i%%//ri//��i%/%��d�� DESCRIPTION OF WORK TO BE PERFORMED: Identify��C - - Ptease Type or Print Clearly OWNER: Name: CA Phone: 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$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting ivith unregistered con -a to o not have access to the guaranty fund , %40RTH mover _t own of An Ct ® - ;•. �+ ® _ b o ver, SSS, cocwc«l WICK �1' AQRATED S V BOARD OF HEALTH P F=.. R M I Food/Kitchen Septic System THIS CERTIFIES THATBUILDING INSPECTOR ........... �.. ....... .. ..... ......... ........................ ............ . ... K has permission to erect Foundation .......................... buildings on ... . 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES ELECTRICAL INSPECTOR LESS T Rough Service .............. ......................... ....................... 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. t%ORTH TOWN OF NORTH ANDOVER OFFICE OF 0 BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 044T..01"1, North Andover,Massachusetts 01845 1SSACHUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BVIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot o HOMEOWNER 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,provide 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 I O.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 cowly with said procedures and requirements. P — 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 Cormaonwealth ofMass�chusetts Department of Indust ial.Accidents P 1 Congress Street,Suite 100 Roston,MA 02114-2017 www.xnass:go-Pldia ,y. Wevkere Compensation.Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE MAD'WfTff THE PERMITTINGAUTHORITY. A licant Information Please Print LeWb Name(Business/Organization/fndividual): C tylState/Zip: Phone#: C 'g ` " T+LL " Are you an employer?Checictfieappropriate box: Type of prosect(required): 1.Q l am aemplcyerwith employees(full and/or part-time).* 7. []Now construction 2.[]I am a sole proprietor or partnership and have no employees working forme in 8.,6RemodeliAg any capacity.[Noworkers'comp.insurance required-] 9. ❑Demolition 3 am a homeowner doing all work myself[No workers'comp.insurance required.]It ' 10 [J Building addition 4.❑S am a homeowner and will be hiring contractors to conduct all work on my property. Twill ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑Z am a general contractor and X have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs • These sub-contractors have employees andhave workers'comp.insurance.1 6.EJ We are a corporation and ifs offeers have exercised their right of exemption perIAM c. 14.El Other 152,§1(4),and we have na employees.[No workers'comp.insurance required.] St - *Any applicant that checks box4l must also fill out the section below showingtheirworkers'compensation policy information. T Homeowners who submif 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-coniraclors have employees,they must provide their workers'comp,policy immber. I am an employer Mat isprovidingworkers'compensation insurancefor•my employees.'Below is thepolicy andlob site information. Insurance Company Name; Policy#or Self-ins,Lic.4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' cbmpensation-policy declaration page(showing fire policy number and expiration elate). 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. Ido hereby cern under t/iepains and e e ?fpe4ury Haat the informadonprovided above is true and correct. sign 0: ' Date: . 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 Ifealth 2.l3uildingDepartment 3. City/Town Cleric. 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Picone#: