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Home My WebLink AboutBuilding Permit # 8/25/2015 V%0RTJ1 BUILDING PERMIT 0. TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received— A Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Old mm Q Print rint PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District ye Machine Shop Village yess s no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 5 [i ,� e New Building , ;W—n,, family 0 Industrial [i Addition 11 wo or more family Alteration No. of units: [i Commercial [:]'Repair, replacement Li Assessory Bldg [I Others: Ei Demolition El Other �, 'M C pi ........... DESCRIPTION OF WORK TO BE PERFORMED: A- V �s V i-P 0o') ldenfificati9n- Please Type or Print Clearly OWNER: Name: q�e]S r Liil'-(1,0464Phone:C Address: 1w1.1),,rK RV-..: Contractor Name: ��A,A Phone: Email: CAK0,4 3) JrA LL") . ...... Address: Exp. Date: Supervisor's Construction License: 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: $ ro o FEE: $ Check No.: Receipt No.(9 NOTE: e'er ions'%coi;trActing with unregistered contractors do not have access to the guaranty fund nati ire of contractol t%®RTH Town of nclover ® - "ah ver, Mass, O LAKQ coc.. Mt WICK rE O S u BOARD OF HEALTH Food/Kitchen P E M T LD Septic System THIS CERTIFIES THAT ........... .. .....ft CA-'0'0 ....................... ............................................................... BUILDING INSPECTOR . .. has permission to erect. ..... .................. buildings on ..... .. ....... ... .. ......... ... ....... . .. ... Foundation Rough to be occupied as .... .................. .. .. ... ....... .. .. ..0........7:4.00.4,! ........ Chimney provided that the erson accepting this permit shall in very 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 PERMIT IN 6 MON T S ELECTRICAL INSPECTOR UNLESS I rA Rough Service Final BUILDING INSPECTOR GAS INSPECTOR ccupancV Permit Required to OccupV 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER 6 ,- OFFICE OF 0 BUILDING DEPARTMENT IWO 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 CHUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: NX,4f) -Rli CX)JU- JOB LOCATION: Number Street Address Map/Lot HOMEOWNERj (I,' Name Home Phone Work Phone PRESENT MAILING ADDRESS �,�- n�c "Wh 018w)` 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 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 APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 T-;he Commonwealth ofMossachusetts u . Department oflndlustriaZAccidents s s 1 Congress Street,Suite 100 tl F< Boston,MA 02114-2 017 �q syyv`�t www mass.gOP/dia Workers'Compensation ZnsuranceAffidavit:Builders/Contractors/Blectricians/ lumbers. TO BE FILED WITH THE PERIMTTING AUTHORIT'Y'. A licant information Please Print Ledb NaTTle(Fittsiness/Oxganization/lndividual): .A.ddress: e°.. City/State/Zip: Phone#: , Are you an employer?ChecI<tTxe appiopriate box: Type of project(required): 1.F1I am a employerwith employees(full and/orpart time).* 7. ❑Now construction 2.[]I am a sole proprietor or partnership and have no employees working forme in 8. [1 Remo delhig any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself[No workers'comp.insurance required,]f 9. Q Demolition Building addition.10[❑Build 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 ILE]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. Roofre airs These sub-contractors have employees and have workers'comp.insurance. p 6.C]We are a corporafion and its officers have exercised theh right of exemption perMGl e. 14.[]Other 152,§1(4),and we have nq eriiplayees.[No workers'comp.insurance required.] , *.Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. T Homeowners who subro lois affidavit indicating they are doing all work and then hire outside contractors must si bmlt a new affidavit indicating such. ?Contractors tbat check this box must-attached an additional,sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees,tliey must provide their workers'comp.policy number. I am an employer that is pidviding workers'comp ens tion insurance for my employees'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the 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. f do Hereby certify under thepains andpenatties ofpeijuiy that the information provided above is true and correct. a� I- Si nature: Date: asjC Phone#: ..�/ .. Official 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#: