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Home My WebLink AboutBuilding Permit # 10/1/2015 BUILDING PERMIT t,oFf , of�yt�° 6 qua 6 0 TOWN OF NORTH ANDOVER 10a APPLICATION FOR PLAN EXAMINATION Permit No#: r - Date Received �Q"°RArE Date Issued: " / IMPORTANT: Applicant must complete all items on this page p,, ,>,r, r,rr/r/,, „r� �,r/ rrrl/Ir'!/ /i / � rIG I r / / % ! I l �l// % � r l I J / I � �� 1 11 r � ��✓% r 1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family El Industrial [Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,�llWII �G^c��lt�er, IF �r / /r ror/ /rr i/,.r.. ../ DESCRIPTION OF WORK TO BE PERFORMED: 461'r -VIZIM it,CA lk ry /t rtF� Pe .Gc r� c, h"am rrr Iden i ication- Please Type or P 'nt Clearly OWNER: Name: Phone: Address: 021/1 rr r r r r rl11"'21,. / //� r Or i � r ,✓ r,.i r v, / r.r,/, 1 %i //, IYl1� 1 Y t Vr .� Ir / //,/ /r¢. rr ., I i r' 17r r:�l..r � ll� ,l � / rr✓,., r,.. �. r( II 1 � r , � - q K / I 1 'Y I lJl ///;1 a "Y" 112/11 10//, .I:+OIII�✓/4n;,Ni�i�r9t;�Fc�Lr rrt,�alllfifA�,!/pr(f�NrYf�h/✓?,hra;,�l ,Nainr�l�rlA'�nr�xlndl,l//raiNla�rrfrmrini/i ARCHITECT/ENGINEER Phone: Address: Reg. No. Wu 0 PER$1000.00 OF THE TOTAL ESTIMATED COST BASE N$125.00 PER S.F. FEE SCHEDULE.BULDING PERMIT:$12.0 P Total Project Cost: $ "� FEE. $ ,. Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund X-i griature of Agent/Owner , m. Signature of contractor,; G ttORTH ' it -01wn oll2 t ev. "cf% r 41 �® r t T 6 LAKE h ver, ass, coc"ic"awIck y1. �.q A�RgTE® S U BOARD OF HEALTH Food/Kitchen PERMIT T L Septic System THIS CERTIFIES THAT ,_, , ,, , ,50 ,, ,,, ,,, , ,,, ,, ,,,, , BUILDING INSPECTOR ........................ . ..................... . ....... ... ...... .. ,. . Foundation has permission to erect .......................... buildings on .... .......... a.............. �..... Rough to be occupied as ...... .. k.. ...... ...... ............. .................... .. Q�A�.T....1 ... 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. ^d44 PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations voids this Permit. Final PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR UNLESS CTI® AR Rough Service .................... .. ... ...... ... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Massa chuselts Department ofIndustrialAccidents I Congress Street,Suite 100 Boston,HA 02114-2017 www mass.go Idia Workers'Compensation insurance Affidavit:Builders/Contractors[Ei lectricians/Plumbers. TO BE FMED WITH THE PERMITTING AUTHORITY. Applicant Information— Please Print Legibly Nalne (Business/Organization/Individual): ce"�V 7 Address: City/State/Zip: AlqtA4, Phone#: q78-6(67_78(� Are you an employer?Check the appropriate box: Type of project(Teluired): 1.0 1 am.a.employer with employees(full and/or part-time).* 7. F1 Now construction .2.[J I am a sole proprietor or partnership and have no employees working for me in 8. KRemodeling any capacity.[No workers'comp.insurance required.] 9. D Demolition 3.4 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t vodgz 10 E]Building addition am a homeowner and will be hiring contractors to conduct at[work on my property. I will nsuro that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions prop'netors with no employees. 12.❑Plumbing repairs or additions 5.r]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. • Thes'e sub-contractors fiay.e employees and have workers'I rkers'comp.insurance. 13. Roofrepairs 6.F1 We are a corporation and its offlqe I rs have exercised their right of'exemption per MGL c. 14.F1 Other 152,§1(4),and we have no e4l8y-e-.[4o workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit!his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-c ionlract6rs have employees,. they must provide their workeis*comp.policy number.' 1 am an employer that is piovidhig workers'compensation insurance for•my enipl6yees.'Below is the polley and yob site information. Insurance Company Name: Policy#or Self-ins,Lie. Expiration Date: Job Site Address: City/State/Zip:" 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 cert' under the pains andpenalties ofpejjUiy that the it provided above is h u and correct. Date: IdIl Sign e: I a Phone#: C(M 8 — 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 4: t%ORTW TOWN OF NORTH ANDOVER �2ob``�C� � OFFICE OF o A BUILDING DEPARTMENT A a^ 4 1600 Osgood Street,Building 20, Suite 2035 "° 0, 5 North Andover,Massachusetts 01845 �SSACWUS�R Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please prin DATE: -a)// If w6 JOB LOCATION: ' �, = Number Street Address Map/Lot HOMEOWNER < ft Cr fc " Name Home Phone Work Phone PRESENT MAILING ADDRESS , 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-m•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 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. 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