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Home My WebLink AboutBuilding Permit # 9/21/2015 OORT H BUILDING PERMIT R1"ffp ,6�ba TOWN OF NORTH ANDOVER0�/ APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: IORTANT: Applicant must complete all items on this page LOCATION rL 4 t7`d u"° Print PROPERTY OWNER Print 100 Year Structure yes o MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration Repair, replacements ❑ Demolition Location � i ❑ Septic ❑Well ❑Water/Sewer � � � No. :�� , �� nate DESCRIJ « TOWN OF NORTH ANDOVER Certificate of Occupancy �� $ Identiiica Building/Frame Permit Fee OWNER: Name: 1Izi .l Foundation Permit Fee � $ Address: 3 t Other Permit Fee $ TOTAL $ Contractor Name: 1 704dd `. Email: j1A �c � gra Address: ! t Check# �,w�� .. Supervisor's Construction Llcem Building Inspector Home Improvement License: t ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$125.00 PER S.F. Total Project Cost: $ le-V' FEE: $ ._ .. Check No.: Receipt No.: DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor �--�-- F NORTH Town of s EA' ndover ® No. - 0000, o h ver, Mass, Q coc"'C"f_.CK ' AERATED /•P�`�.�5 S IJ BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT AsullpsomA ............................... . ....................................... BUILDING INSPECTOR has permission to erect g .�, " Foundation .......................... buildings ....�1� .....��.�.lfir•��.�.............. . • � � • Rough to be occupied as ... .� �....... ... .. �. ... ..... ........ Chimney provided that the erson aft ctin this ermit shall in eve respect conform to t e terms of the application p p p 9 p very p pp 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 VIOLA ON of the Zoning or Building Regulations Voids this Permit. Rough Final ? iPERMIT EXPIRES IN 660NTU ELECTRICAL INSPECTOR UNLESS CONSTRUCT 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. The Commonwealth of Massachusetts Department of IndustrialAccidents " = 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information / Please Print Ledbly Name (Business/Organization&dividual): �� tf7/ Qr.iT7 j�yE� Address: l6 120vAge-z- �kw fcO- City/State/Zip: f9 .ter Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.A I am a employer with .I— employees(full and/or part-time).* 7. ❑New conshuction 2.F-]I am a sole proprietor or partnership and have no employees working for me in 8. jaRemodelirig any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.E]Plumbing repairs or additions 5. t h d h tt th d li t b h d hi I am a general contractor and I have rethe sub-contractors listed on e attached see. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: 6f, _ )Uy )46. Policy#or Self-ins.Lia#: k0d 5-W 657 7i Expiration Date: Job Site Address: City/State/Zip:.14.J11i oduigtz_ ,c+, Attach a copy of the workers' compensation 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. I do hereby cer ify under the painand pen ties ofpeijufy that the information provided above is true and correct. Signature: Date: Phone 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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: e o��a��zC�uoecc�f�1/944"1aC/(1,;e i Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ARlegistration: 118501 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/27/2017 Individual 10 Park Plaza-Suite 5170 k':Z , Boston,MA 02116 KENNETH J DIAMOND KENNETH DIAMOND 10 DOVER HILL RD TOPSFIELD, MA 01983 Undersecretary Not va id without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supers icor License: CS-019192 KENNBTH J DIAMOND , 10 DOVER HILLRD TOPSFIELD MA--01983 Expiration Commissioner 01/13/2016