HomeMy WebLinkAboutBuilding Permit # 9/17/2015 ttORT11
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:-�N,
Date Received
,Date lssuedAS C"Us
s
EWPORTANT: Applicant must complete all items on this page
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(TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
C ❑ New Building 006e family
I I Addition I I Two or more family E Industrial
[I Alteration No. of units: 1: Commercial
Ft epair, replacement El Assessory Bldg E Others:
11 Demolition 11 Other
ce Location
Dat
NO. ik"?
TOWN OF NORTH ANDOVER
C ficate ® Pepm't
erINER: Name: FeeBuilding/Fra
,,,J,Iress: Foundation Permit Fee
Other Permit Fee
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TOTAL
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Check#
Building inspector
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ARCH ITECT/ENGINEER NWT"Ill"",�-- ,,�,,,,.,-,,,�,,,�",-."-,--, Phone:
Address: V Reg. No.
I.
FEE SCHEDULE.BULDINGPERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
FEE:
'rotai Project Cost: $'t oo- -
Check No.: I�� $Receipt No.:
,NOTE: Persons codtroctingVith unregistered contractors do not have access lo-AeVu"arantyfund
rim tkORTH
I own of Andover
®
No. s
SAKE h ver, Mass,
COCHICKEWICK y7'
�,9 A�R�►TE o PP�,`'��
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
•
THIS CERTIFIES THATte, ... ... .. ... .. BUILDING INSPECTOR
................. .® ..... �.... ........................
has permission to erect .......................... buildings on ...... . Foundation
. ......... ... �. .......
Rough
tobe occupied as ..... ...... .......................... ............ .. ..... ....... .............. ,.. ......®.................... 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT E I IN 6ANTS
ELECTRICAL INSPECTOR
® LESS Rough
Service
........... ............................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
ccupancy Permit Required t® Occupy Buildin 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.
00ffT#j TOWN OF NORTH ANDOVER
OFFICE OF
0 0
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
AC
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:A,
JOBLOCATION:
Number Street Address Map/Lot
HOMEOWNERa US 6_0S"i I'll/ct-)K--
Name Home Phone Wo vk Phone
PRESENT MAILING ADDRESS I(I
S+
o V, o i
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 homeowner.
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. A
HOMEOWNERS SIGNATURE,_
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OFAITEALS 688-9541 CONSERVA110N 688-9530 11VALTIT 688-9540 PLANNING 689-9535
The Commonwealth of mlgssgc �esett�
. Department of IndlustrialAccidents
X Congress Street,Suite 100
_'oston,Aft 02114.2017
www.mass.go-p1dia
Wovkers'Compensation Insurance Affidavit:BnRdexs/Contractors/EZgctricians/.Plumbers.
TO BE FILED WfTk[THE PERMtTTI NG AUTHORITY.
AI)li icant Information Please Print Le�xbly
NaInc)(Btwiness/oiganization/xndividual): _...,.
.Address:
City/Mate/Zip: Phone##:
Axe you an employer?Checkthe appropriate box: Type of project )Vequired):
1.❑I am a employer with employees(M and/or part-time).* 7. [1 NeW construction
2, I am a sole proprietor or partnership and have no employees working for me in 8. „R euro delilig
any capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3..6 am a homeowner doing all work myself:No workers'comp.uisuranee required.]t 10 0 Building addition
4.❑I am a homeowner andwiil be hiring contractors to conduct all work on my property. Iwill
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors withno employees. 12. plumbing repairs or additions
5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. ]3.[J Roof repairs
These sub-contractors have employees and have,workers'comp,insurance.T
6.❑We are a corporation and its ofCcers have exereisedtheir right of exemption perMGI,e.
14,❑Othbr
152,§1(4),andwe have naemployees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information,
T Homeowners who submiti this affidavit 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. Nthe sub-contractors have employees,tliey must provide their worlceis'comp.policy number.
T arm an employer thatispi'ovidingworkers'comperrsatiorz insurance for my employees.'Below is thepolicy arzdjob site
information.
Insurance Company blame:
Policy#or Self-ins,Lic.#: ExpirationDate:
Job Site Address: i City/State/Zip:
Attach.a copy of the workers'compepsation•policy declaration page(showing the policy number and expiration slate).
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 DTA.fox insurance
coverage verification.
I do hereby certW under the pains andpenalties gfperjury that the information provided above is true and correct.
Sign are: lk A-)
Date:
Phone#•
Official use only. _Do not write in t/iis 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/X'owa Clerk 4.Electrical Inspector 5.Plumbing Inspector •
6.Other
Contact Person: Phone#: