HomeMy WebLinkAboutBuilding Permit # 8/25/2015 BUILDING PERMIT 01 LED
NORry q.
TOWN OF NORTH ANDOVER 0 =
APPLICATION FOR PLAN EXAMINATION
H
Permit fVo#: ` Date Received �gssgrED
cHus���5
Date Issued: i
IMPORTANT:Applicant must complete all items on this page
LOCATION c
P int
PROPERTY OWNER
Print100 Year Structure yes no
MAP ®�b PARCEL: 150 ZONING DISTRICT:IRI Historic District yes
Machine Shop Village yes <Jo
TYPE OF IMPROVEMENT PROPOSED USE
Resid ntial Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
aAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Se tic ❑UUell ryy ❑ Flood Iain ❑Wetlands % ❑ UVaterslied District r ,rr
Water/SewerJy±'r� �m C � � ���' � ry"' I74�z.���,�'/rg`�„y�X` rfv`,at�:R✓,yy�X FY%,�` r 5 a N�' ?'�,g �^` `}.fry' ,C �r�w.,,a
DES RIPTION OF WORK TO BE PERFORMED:
Identificatio - lease Type or Print Clearly
OWNER: Name: `. Phone: e• ®o
Address: L
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.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ ' 2�. FEE: $
Check No.: Receipt No.:
NOTE: Persons contractin with un iistered contractors do not have access to the guaranty fund j
FORTH
A-%, W Art -v r j,% -a
ndur V VF
_T
BAKE h ver, Mass,
COC K ICHt MACK
g1,9 A®RAreo PPa��S
S t]
BOARD OF HEALTH
L)
Food/Kitchen
Septic System
THIS CERTIFIES THAT ............................... BUILDING INSPECTOR
............... ....... ....... .... ....... . . ..... ...
has permission to erect buildings on .......... Foundation
......tt................. ..... .. .... ..... Rough
to be occupied as ..... . lam.... ......... .. . .. ......: ..... .......................... . . ....................... Chimney
provided that the person accepting this permit shall in every respect conform to the term-4f 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 EXPIRES61NM0'fTS ELECTRICAL INSPECTOR
LESS T S Rough
Service
.. .............................................
Final
BUILDING INSPECTOR
GAS INSPECTOR
ccupancV Permit Required to 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 Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
04�aKry � TOS'OF RT�PHAND OVER
OFFICE O-V
x� e 1600 0390QarStrootBuff&gg20,-SjjX,te+2-36 r
�.Q CC[+cfi[Y..rt2 Vi •• •
NoithAnJo-vor,Massaahnseltd 01845
�AC{;tS5�
Gerald A.Brown _ Telepl.ono(979)688-9545
I'nspeetorofBuildingo Fax (978)688-•9542
pleasepzinE _ '
DATE:
SOB LOC rnb: , �' SW49gr
uzn'berizeet dress Map Dt .
ame HDznel'hone Work hone
'RESENT MAUL7NW.ADDRES - • . ..
Tmm
The current exempfion for"homeowr!ers"txras extentt�d to?�clude owner Occupied d��ellings to i, o units ox 1�s5 and
oa11DINsubhhoamD,rerstoengageanLpcj.,1;{O�uaZ•fOr�1LTS WAOC70B5nDtpOSSBSsa7i0G315C,provided tbattbProwner
acts as snpaz-t7isoz�. Sia�e��.ilcling (Code�ectio�a.
bEM.ITION OYHOMEOVINB ,
Persons)who grans apazcel oflazttl on or intends to reside, on which thero is,or is xnfended to
T��,aDneoz € D amilysizueEuzes, .A.person.` koconstmotsmomffiatonehonzexaaE�ZD-yeazpezlods�aTZa,o�be
considered ahoaneowner
Tho undersigned"ho nesiwner°'assumeszesponszbiIi€y oz compliances-, ifh the State Building Codoa-ad other
Applicable,codes,by-law;x0es andxegoatzons.
T3aeurtdexsignetl"I�omeov�nez"cez es that lielsheunderstaudsMe,TOWUof1`T0r&AndoverBuilclingDe�aztmenE
urn impeotio'u procedures and requirement.-and tlhathe1,lie will comply with said procedures and
xecluiranients, ,
HONMOWMMS SIGI*1•.A.TURE
APPROVAL OF BMDWG OFFICIAL
Reyised 2009 -
�ozznS�omeoyTnersExemptian
30A I)n-9AppPAr-,zzKQQ_oj�dr
_
1
-------------
Ii a
tl
OcAl
j E i i
� r
-a_
I
I
i
l
f i
I
®x H 1S 1
The Commonwealth of Massa chusetts
. Department oflndustrialAceldents
1 Congress Street,Suite 100
' Boston,MA 02114-2017
s� �r www.mass.gov1dna
Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH TEE PERNIITTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual):
Address:
City/State/Zip: 0 Phone#: 2C
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with : employees(full and/or part-time).* 7. ❑New construction
2.❑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.Vam a homeowner doing all work myself[No workers'comp.insurance required.]t
10 F1 Building 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.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.❑Roof re airs
These sub-contractors have employees and have workers'comp.insurance.#
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 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.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 am an employer that is pioviding workerscompensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins,Lic.#: Expiration Date:
fob 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 certif der t e ins andpenalties ofperjury that the information provided above ' true and correct.
Si nature: Date: 7921
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#: