HomeMy WebLinkAboutBuilding Permit # 9/2/2015 BUILDING PERMIT
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TOWN OF NORTH ANDOVER � -
APPLICATION FOR PLAN EXAMINATION ® `
Permit No#: Date Received r9D Pp4��5
Ss�cHus�`
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION ! / 2 f �0 , J ) /
Print
PROPERTY OWNER Cl,
Print 100 Year Structure yes "�j .,
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yeso
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
[I Addition El Two or more family El Industrial
El Alteration No. of units: 11 Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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❑ F /
DESCRIPTION OF WORK TO BE PERFORMED:
J
Identification- Please Type or Print Clearly .IT
OWNER: Name: Phone:
Address: A2
,�. ° ..
_ Phone j'
Contractor Name: �� /�""�� ��� `���
Email: ,g o,;
Address: h- 1-71,114a 6/? ,1/ Rey a 1 17'
Supervisor's Construction License: -31 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.. ER S.F.
Total Project Cost: a 0 FEE: $ "
Check No.: p
Recei t No.:
NOTE: Persons con ratting with unregistered contractors do not have access to the guaranty fund
1
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector fifes No
DANGER ZONE LITERATURE- Yes No
MGL Chapter 166 Section 21A—F and G m1n.$100-$1000 fine
NOTES and DATA— (For department use)
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® Notified for pickup Call Email
Date Time Contact Name
Doc.Buildiug Pennit Revised 2014
vtORTH
To' wn of 17"
ndover
O a6l
® AC
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CC1C aIIC 14t WICK
RATE[> P .`C,
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ..........7 ....... ... .......... ............... . .. . BUILDING INSPECTOR
has permission to erect ... ........ buildings on ........... ..... .. .. ........ ........ Foundation
Rough
to be occupied as .... A.......a&1.0-0�44... ... ............ ........ ... .... ..... . ..... ....... 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
�0 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS T I Rough
Service
.................. . ....... .............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing r Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusefis
Department of Ind.•usttriaZAeczdents
1 Congress Sheet,Suite 100
== Boston,MA 02114-2017
www.rnass.gov/dia.
SJ+ Workers'Compensation.Insurance Affidavit:Builders/Contractors lElectricians/PI tubers.
TO BE PILED WITH THE PERMITTING•AUTHORIT'X•.
A licant Information Please Print Le ibl
NaMe(Business/Organization/Individual):
Address: ��� �� n �� 0
city/state/zip: 0 hone#: F/7)2
Areyou an employer?Check&e appropriate box: Type of project()Vequired):
1 maemployer with —employees(Pill and/or parttime). 7. El Now construction
2. 5 am a sole proprietor or partnership and have no employees working for me in 8. o delirig
any capacity.[No workers'comp.insurance required.] 9. Demolition
3.Q I am a homeowner doing all work myseIt[No workers'comp.insurance required.]t
10 E]Building addition
4.❑I am a homeowner andwill be hiring contractors to conduct all work on my property. Iwilt
ensure that all contractors either have workers'compensation insurance or are sole 11.[❑Electrical repairs or additions
proprietors with no employees. 12.[I Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs
These sub-contractors have employees and have workers'comp.insurance.,
6.Q We are a corporation and its officers have exercised their right o£exemption per MGL c.
14.F1 Other
152,§1(4),and we have noa employees.[No workers'comp.insurance required.]
t.
'-Any applicant that checks box4l must also fill out the sectionbelowshowingtheirworkers'compensation policy information.
T Homeowners who submit#his a£tidavit indicating they are doing all work andthen hire outside contractors must submit anew 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-contractors Have employees,Viet'mast provide their workeis'comp.policy number.
lam an employer thatispidviding workers'compensation insurancefor my employees.'.below is thepolley and job site
information. /
Insurance Company Name: /I
Policy#or Self-ins.Lic.#:__ �-�l �✓ Expiration Date: �
� z7—�
Job Site Address: /e-, z 0 City/State/Zip: ���V ' %T
Attach a copy of the workersco. p nsation•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.
X do hereby certify uy der thepains andpenalties ofpetjufy that the information provided above is true and correct.
Signature _ _ Date: ® �
Phone# 279 — 5
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 Ifealth 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector -
6.Other
Contact Person: Phone#:
�" �f7,G�LLrrvn2o�rGcoe�C/t-n���%!/GCCJ�IGC/acCDeL7i.L -
__ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 147818 Type: Office of Consumer Affairs and Business Regulation
Expiration: 8/9/2017, DBA 10 Parti Plaza-Suite 5170
i;. P
Boston,MA 02116
DINO'S CONSTRUCTION
DEAN MCCOMISH JR
46 KENDALL POND RD; �J/✓ v �y
DERRY, NH 03038 Undersecretary Not valid without signature
off, Of A�e �rf�>ioiuteci
DME I RO���Affairs / �Cll,
MP &Business
s 9Strdtion; 8N8 CONT Regulation
'.EXpiratio 147 RAC7
DING S2015
CONSTRUCTION DSA Type.
j 6 K N A�OMISH jR
DERRY, NH 0 038 RD :
4�
UOderseCretary
Massachusetts -Depair-nen,of Public Safe},.
Board of Building Regulations and Standards
Construction Supcn'isor
!icense: CS-082835
X7.5
DEAN L MCCOW--SH JR
46 KENDALL POND RD
DERRY NH 03038
o mason r 04/27/2016