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Home My WebLink AboutBuilding Permit # 9/8/2015 ii BUILDING PERMIT �oRra TOWN OF NORTHA VER APPLICATION FOR PLAN EXAMINATION - H Permit No#: �. Date Received �RA°RnreoW �SS�ce�usEc Date Issued: I PORTANT:Applicant must complete all items on this page LOCATIO190 5FjLEtj SiME N ` Print PROPERTY OWNER .) �; Q � A V--LAP i Print 100 Year Structure yes gno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE *ne ential Non- Residential New Building family Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,,,,, , rr (/!'yM W/�.k fP i .,�� !AC.G.d , ramirriF + ro / iii C -i vrU i./ uir'1•,,riYlY(Xdi% „r i r! .y ✓�fi�(%N�r?r 21f(1j K i it ll�((re Idrrr errfo. ✓lGr, ✓i, 1, i //, „ , r I � ,� O�Water hed ure 15trICt! �� rr iit after/Sew�oir k v P� ' '�»,a „ ; � 1, 1 i DESCRIPTION OF WORK TO BE PERFORMED: P ,T 1 14per. Identific do nPlease Type o early C OWNER: Name: HP �... Phone: s r Address: O L d L.L. L k,,j Contractor Name: 6 f-(Ot” A , ` QPhone: �� ` I� 6 7 — 7(c) e? Email: r Address: O ` ,. Supervisor's Construction License: CS- '7 8'16, Exp. Date: 1 O w a it '' a Z .r VrD Home Improvement License: Exp. Date: ARCHITECT/ENGINEER L Arte06D rki Phone: (9 7 1 Address: tw,4 Im A Reg. No. �. 7(v FEE SCHEDULE:BUNG PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ y Check No.: ��, Receipt No.: NOTE: Persons contracti ith unr ' to e o ctors do not have access to the guaranty fund -- i o®RTH S7 Ifa ¢ U" 0 v ve r is O ver LAN. � Mass, COC NI CNl WICK A°RATE. � U BOARD OF HEALTH M Am T LD Food/Kitchen rER Septic System i 61l T`,f�// BUILDING INSPECTOR THISCERTIFIES THAT ... .............�....................................................................................................... Foundation has permission to erect .......................... buildings on ./Y4?... C�. . . .. .. .............................. Rough 4)'Vi4 4z�m 611"1 tobe occupied as .............. ... ......................................... ... ............................................................ Chimney provided that the person accepting this permit shall in every res ct conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By aws 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO S RTS Rough Service ............. ........ .. .. Vii.................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Puildin 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 Approved by the Building Inspector. Burner Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 9SSACHUS�� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: T_ ;z 6 JOB LOCATION: Number Street Address Map/Lot HOMEOWNER �0.40 V CA H r t(, , q I S- &5 t- m<1/0 Name Home Phone Work Phone PRESENT MAILING ADDRESS 19 0(0 I CLA-`_,9 tam �OkTt4 /.X) NJ k, S S 61/ ISP 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, rop vided 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 thate understands the Town North Andover Building Department minimum inspection procedures and requir ens nd that he/she will co ly with said procedures and requirements. HOMEOWNERS SIGNATURE . APPROVAL OF BUILDING OFFICIAZ Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth ofMossachusetts Department oflndush4alAccidents 1 Congress Street,Suite 100 `=•'F .Boston,MA. 02114-2017 °t www-mass.go v/dia 5y' Workers'Compensation.Insurance Affidavit:Builders/Contractors/Elgctrzciaus/-Plumbers. TO BE FILED WITH THE PERMTTTING AUTHORITY. A licant Information ® Please Print Le 'bl Name(Business/Organization/Individual): 0 v-4 �i I A14 RLAA, l t-L Address: `� ®l.® 14 e LCAG f Lg.v City/state/Zip: IN of714 16po y Phone#: %7 - r36? 6®/ Areyon an employer?C&e Ictho appropriate box: Type of project )Vequired): 1.❑I am a employer with : employees(fulland/or part time).* 7 ow construction 2. I am a sole proprietor or partnership and have no employees working for me in &. Remo delilig any capacity.[No workers'comp.insurance required] 3..Q T am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10 rl Building addition am a homeowner and wilt be hiring contractors to conduct all work on my property. I wiIl ensure that all contractors either have workers'compensation insurance or are sole 11.C1 Electrical repairs or additions proprietors withno employees. 12.FJ Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance./ ' � 14.[�Other 6.Q We are a corporation and ifis ofpcers have exercised their right of exemption perNiM c. 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] ''•`.Any applicant that cheeks box41 must also fill out the section below showingtheirworkers'compensationpolicy information. T Homeowners who submit this affidavit indicating they are doing all work andthen 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-coniractors have employees,they rluft provide their workers'comp.policy number. I am an employer that ispioviding workers'compensation insurance for my employees.'Below is the policy all d job site information. Insurance Company Name: Policy#-or Self ins.Lic.#: Expiration Date: Job Site Address: / ® J A(f City/State/Zip: /V��'� AL06091 Attach a copy of the workers'compepsation.•policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under MGL o.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 certify and t7 pa0*79 — Offilcial eryuiy Haat the informationprovided above is true and correct. 0 Si nature: Date• A" �Phone#: 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: