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Home My WebLink AboutBuilding Permit # 9/23/2015 t%ORTH BUILDING PERMIT 0.1<(,FD TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION en Permit No#: 9 Date Received A H Date lssuedj,� ORTANT: Applicant must complete all items on this page LOCATION P int PROPERTY OWNER Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family 11 Addition 11 Two or more family [I Industrial El Alteration No. of units: 11 Commercial J ,kRepair, replacement F1 Demolition 01fl Locationkta IDESC� No. 2 J" L c") Date X41 TOWN OF NORTH ANDOVER Z /I ldldfti is Certificate of occupancy $ T/ OWNER: Name: Building/Frame Permit Fee $ Foundation Permit Fee Address: Other Permit Fee Contractor Name: nke,,e-le- TOTAL Email: Address: Check# Supervisor's Construction Licenss .................... Building inspector Home Improvement License: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 0-o FEE: Check No.: " t `41 M Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - --------- Signature of Ac /O Siqnature of lentwneW- t%®RTH Town 0 0% ® `ANF h ver, ass, 0 COC LAK WICK 4q• RATED S u BOARD OF HEALTH Food/Kitchen rwER Septic System 4 THIS CERTIFIES THAT .............. ...... .... .. . ....10.... .. ... ...............3....................................... BUILDING INSPECTOR has permission to erect buildin s on �', ,�,, ,,,,,(�, Foundation p .......................... .... ............. ........................ ® Rough tobe occupied as ...... . . .......... ...... ............ ...... ... . ........... . .......................... Chimney provided that the person accepting this permit shall in every respe onform 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ® UNLESS CONSTRUCT ST 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massa chusetfs Department of Industrial Accidents z.> 1 - '— Office of Investigations i_1 ,t 600 Washington Street ;` •� <<_r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Coutractors/Electrieians/Plumbers Applicant information Please Print Le ibl t Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: 3�� -3O' Are you an employer? Check the approp ate box: Type of project (required): 1,P-1 am•a;emplOyer with 4. ❑ I am a general contractor and I employt:es(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have o_ ❑ Demolition working me n an for icapacity- employees and have workers' y � q. ❑ Building addition tiNu workers' comp. insurance comp. uisurance.l required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box ill 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 and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate 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: t/1 td, X9160 Policy or Self-ins. Lic.#: t� ` - � +�� t � Expiration Date: :" t Iob.Site Addie'sa. �� Ci y/State/Zip r� Attach a copy of theworkers' compensaliollpOhCy declaraiion page(sIhowirigthe policy number-and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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_ Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under e pains and penalties of erjury that the information provided above is true and correct. Signature: �� , Date: B' 1> Phone#_ ��`" I Y� 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): I. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: ism Massachusetts -Deoartment of Public Safety Board of Building Regulations and Standards Construction supervisor -License: CS-068461 NIICHAEL J OKE)tFE 21 Francis Street North Reading 1 Ii 018 Expiration 02/24/2016 commissioner &Xs �Ponvriwiscuea�C�i a�C�// Office of Consumer Affairs&Business Region e OME I MPROVEMENT CONTRACTOR egistration: r:� Expiration 5/1-1467226722 Type: DBA EEFE CONSTRUCTION - 21 rrL O'KEEFE NORTH 'IS STREET 'SING, MA 01$64_ Undersecretary