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Home My WebLink AboutBuilding Permit # 8/31/2015 BUILDING PERMIT �oRrH q. TOWN OF NORTHV - � �. � - APPLICATION FOR PLAN EXAMINATION Permit No#: jk Date Received A �gssAcNus�`��y Date Issued: /IMPORTANT: Applicant must complete all items on this page LOCATION 1 Print PROPERTY OWNERC-11-11-41A KL , ." P 'nt 100 Year Structure yes no MAP IC1 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ O,pe family ❑Addition iwo or more family ❑ Industrial ❑AI ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r r //ri, r i /,_., I �, /, 1,/ /' ,)/l/,i � r r 1 Ir / / / / r❑ Watersh � / a efla ds , � ❑!W d lain/ r r r ttc W / i / � � // ✓ i ori � � r ,r � �f��%��/ DESCR�PTION OF WORK TO BE PE ORMED: t� iL Identification- Please Type or Print Clearly OWNER: Name: i, 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: $ 364 Check No.: Receipt No.:_C !� NOTE: Persons co ztracting witl reregistered contractors do not have access to the guaranty fund 7-7 of �. AOR Tm-ftdover-town of An� ® _ i'' a^ ® �.KE h h ver' Mass, 0. COCMICMl WICK q S V BOARD OF HEALTH PERMIT LU Food/Kitchen Septic System THIS CERTIFIES THAT ....................51A ....... ............... ..................................... BUILDING INSPECTOR ..®.... .. .... .' Foundation has permission to erect .......................... buildings on ...................A. ......... ............... Rough to be occupied as .. . ....... ..... .. ..................... ... . � . ..... ... .... Chimney provided that the per n 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 PERMIT1 ®NTS ELECTRICAL INSPECTOR 40 UNLESS CONSTR ® RTS Rough Service ..... ...... .. ... ..................................................... Final BUILDING INSPECTOR 7 GAS INSPECTOR Ccup� ney emit Required to Occupy BuilCli 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. -ftp,Commonwealth of Massachusetts Department gflr�d�si��aiAccr�e�ts I Congress Street,Suite 100 °t -Boston,MA 02114-2017 Vit www mass.go-v/dia V'ol:kers'Compensation insurance Affidavit:Builders/Contractors/Flectrzcaans/PX>�mbexs• TO BE MED WITR THE PERW CI TING A.UTHORITX. A.plilicant Information Please Print Le 'bl Name(S,.lsmess/Oxganizationffndividual): Address: 2,,m �, , ._ p City/State/Zip: Phone Areyou an employer?Checktheapp'ropriate box: Type of'project(required): 1.❑I am a employer with . :.. : employees(full and/or part time)." 7. ❑New construction 2.[]I araa sole proprietor or partnership and have no ernployees working for me in $. �4erm delirig 3.[a capacity [Noworkers'comp.insurance required.] 9 Demolition I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 10 rl Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. 1-Will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roofrepairs These sub-contractors have employees and have workers'comp.insurance 14.El Other 6.E]We are a corporation and its of�cers have exercised their right of exemption perMGL c. 152,§1(4),andwe have ncr employees.[No workers'comp.insurance required.] 'Any applicant that checks bar#i must also 'o out the section below showingthe irworkazs'compensafionpolicy,nformation. i Homeowners who submit this affidavit indicating They are doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that check this box mush attached an additional sheet showing the name of the sub contractors and state whether or not those entities have employees. if the sub conlracfors have employees,they ri,ust in their workeis'comp.policy number. lam an employers Mat ispiavidingworkers9 compensation insur^ancefor my employees.' Below is tZaepolicy aPdjob site info,-rrcation. Insurance Company Name; Policy# or Self-ins.Lie.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers' conapeRation-policy declaration page(sho-wing 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 Offaco oflnvestigations of-the DTA for insurance coverage verification. --Ydo iteteby cert ndel•t/ie pains andpenaZties ofpetjmy that the information provided move is true an t c"rect. ;Signature: �� W Date: Phone 4: Official use only. _90 not write in this area,to he completed by city or town official.. City-or Town: Permit/License Issuing Authority(circle one): 1.Board or Health 2.Building Department 3. CiWT'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: 4+Q TH TOWN OF NORTH ANDOVER 0, OFFICE OF BUILDING DEPARTMENT ro ay 1600 Osgood Street Building 20, Suite 2-36 AVID North Andover, Massachusetts 01845 CHU Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: Cil- 92 Cft 'jI. Number Street Address M /Lot HOMEOWNER CT Name Home Phone Worlc Phone PRESENT MAILING ADDRESS_ 2,Q t- City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 structures. A person who constructs more that one home in a two-year period shall not be considered a horneowner. The undersigned"homeowner"assumes responsibility for compliances with the 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 C-1 APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535