HomeMy WebLinkAboutBuilding Permit # 10/8/2015 _7
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BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit NoM ✓ Date Received C US
Date Issued: t ell
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER Al)�
Print 100 Year Structure1yes, no
MAP PARCEL: ZONING DISTRICT: Historic District '-��es (ff�o
Machine Shop Village yes (� n(v
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family El Industrial
,KAddition 0 Two or more family [i Commercial
KLAIteration No. of units:
0 Repair, replacement El Assessory Bldg [I Others:
El Demolition El Other
DESCRIPTION OF WORK TO BE PERFORMED:
_OE4�7--
Identification- Please Type or Print Clearly
OWNER: Name: Ad y44&, Phone: W1 44
Address: 6,f ee rJ v-1 IV e-
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ eelo, 00 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
qT-JAC -
IAORTH
town of Andover
0 . to
No. _-
OO LAKE ver,
�.SS9 V
COC CHEWICK
QDR�TE D
S u
BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
DTHIS CERTIFIES THAT BUILDING INSPECTOR
/°_ Foundation
has permission to erect ....:..................... buildings on ..... .. ........ �.�d.�.�.... . .. .
Rough
tobe occupied as ........ .. ...............� :...... ... ......... ..... ............................................ Chimney
provided that the person accepting this permit shall very spec=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 EXPIRESI 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIONARough
Service
.... ..................... . ................. Final
BUILD I INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy PuRough
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.
t; I-f
4 � 719
lc
FM
E FU E
546 SM
K
#56 SgSO Sq.ft 19L Sq.
�4 24 24 24
173
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North Andover MIMAP October 8, 2015
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Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
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—SR Meters Data Sources:The data for This map was produced 6y Merrimack
F►ORTN Valley Planning Commission(MVPC)using data provided by the Town of
Roads p'F t�su 'qM North Andover.Addillonal data provided by the Executive Office of
Easements
�� yob a Environmental Affairs/MassGIS.The information depicted on this map is
¢ter } ,y 10
Parcels for planning purposes only.If may not be adequate for legal boundary
definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
# * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
oN4TIO dry THIS INFORMATION
S$gCHUS
1"=47 ft «�.
The Commonwealth of Massachusetts
z . Department oflndustrialAccidents
X 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 PERMITTING AUTHORITY.
Applicant Information Please Print LeOb
Name(Business/Organization/Individual):
Address: G C X 0 r�,J
City/State/Zip: A)V, 400 ell Phone
Etre you an employer?Check the appropriate box: Type of project )required):
1.❑I am a employer with employees(full and/or part-time).* 'l. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remo delhig
any capacity.[No workers'comp.insurance required.]
9.
3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑Demolition
lO�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 with no employees.
• 12.[]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors lid thtth
ors steon e attached sheet.
❑ 13.[1 Roof repairs
These sub-contractors fiade employees and have workers'comp.insurance.t
6.E]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[J Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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 contractbrs must si'bmit 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. Uthe sub-c6n6ci&s have employees,lhey must provide their workeis'comp.policy number.
X am an employer•that is providlhg workers'compensation insurance for my employees.'Below is the policy and)ob site
information.
Insurance Company Name:
Policy#or Self-ins,Lia#: 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.
Ido lien certi y r tliepains andpenalties ofperjury that the informationprovided above is true and correct.
Si ature• Date:
Phone
Of la use only. Do not write in this area,to be completed by city or town official..
City or Town: PermitMeense 0
Issuing Authority(circle one): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbinglnspector
6.Other
Contact Person: Phone#: