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Home My WebLink AboutBuilding Permit # 9/9/2015 T v�%ORTH BUILDING PERMIT o& <<T.D 16 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o ' x Permit No#: O "L Date Received Sys RATED PPP��y SACNus� Date Issued: e IMPORTANT: Applicant must complete all items on this page LOCATION Prn) ;F _ PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building `One family [I Addition ❑Two or more family 11 Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other o"R❑ Septic ❑Well ❑ Floodplain ❑Wetlands '❑ Watershed District d ! Q�r1�(a�eNSeyue`r •� �t, , , ; , , ,•' , „% , ,,. w :;., w : , DESCRIPTION OF WORK TO BE PERFORMED: w) Cl �y Id ntification- Plea T e or rant Clearly _ OWNER: Name: � �� . � Phone: ' a Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: I Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ = FEE: $ Check No.: Receipt No.: -13` F,3 NOTE: Persons contracti ith nregistered contractors do not have access to the guaranty fund I -To'wn oftAORTH '2 _E _ �' Anctover p +. Ool -.2010 �O LAKE h y ♦ er, ass, coc"Ic HEwtcK S RATEO V BOARD OF HEALTH Food/Kitchen PERMIT T Septic System r� A THIS CERTIFIES THAT ............. .....h!1... ... ............��................................................................. BUILDING INSPECTOR .. ...... Foundation has permission to erect .......................... buildings on .... .. ........Uf-..11�r.................1.&0000 Rough to be occupied as ......... �. !Q Chimney . provided that the person accepting this permit shall In every respect conform to the terms of 1he 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 q,& PERMIT E I S I ONTH ELECTRICAL INSPECTOR LESS CONSTRUCT S S 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 or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. °F NORTH 9 TOWN OF NORTH ANDOVER to � �? eats` • " 6 °L OFFICE OF ° lip A BUILDING DEPARTMENT 1.�e b 1600 Osgood Street,Building 20, Suite 2035 North Andover, Massachusetts 01845 ACHUS Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: G JOB LOCATION: Number Street Address Map/Lot HOMEOWNER �o qcL& •-1qP ame Home Phone Work Phone PRESENT MAILING ADDRESS r(A-b% � � k ® 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,provided 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 110.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/s e unders ds the Town of North Andover Building Department minimum inspection procedures and req uomen and th /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 The Commonwealth of Massachusetts Department of IndlusiWalAccidents 1 Congress Street, Suite 100 Boston,MA 0.2114.2017 •. i�`.•;• Sy,(f4t www.mass.govIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Flumbers. TO BE FII ED WITH THE PERMITTING AUT)IORITY- Applicant Information Please Print Lepribl Name(Btisiness/organization/Tndividual): � Address: l VT City/State/Zip: `F � d\ �tT�I W hone#: b Q —33Y-1 '76 T Are you an employer?Check the appropriate box: Type of prosect()Vequired): 1.❑Zama employer with : employees(full and/or part time)." 7. ❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for mein 8. [1 Remodelhig y capacity.[No workers'comp.insurance required.] 9. El Demolition 3.. I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 ❑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 withno employees. 12,F]plumbing repairs or additions 5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors ha4e employees and have workerscomp.msurance.t 6.Q We are a corporation and its officers have exercisedtheir right o£exemption perMGL c. 14.FJ Other 152,§1(4),andwe have nQ employees.[No workers'comp.insurance required.] ''Any applicant that checks box4l must also fill out the section below showing their workers'compensation policy 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-c6n6ciors have employees,%ey moat provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees'Below is the policy andlob site information. Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers'comp ensatiou'policy declaration page(shoving the policy number and expir anon(late). 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 foam of a STOP WORK ORDER and a fine of up to$250.00 a day against the vi lator.A copy of this statement may be forwarded.to the Office of Investigations of the DIA.for insurance coverage verifica ion. X do hereby c r i u r tri ains andpenalties ofpe�jury Haat the information provided above is true and correct. Si ature: / Date: J Phone# I ��( 7� 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#: