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Home My WebLink AboutBuilding Permit # 10/9/2015 i OORTp. BUILDING PERMIT ®��eD ,b16 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION �- oq coc��2�ew�o��1• Date Received pDRNTED �j Permit Nod: Acaous``� Date Issued: p. ll I ORTANT:Applicant must complete all items on this page de LOCATION � w....... �� PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_ istrict ye no Machinstorice Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building .One family El Addition ❑Two or more family El Industrial [I Alteration No. of units: El Commercial .,Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r "�a r r,r;a..n, ra v r � Nr Gfa,r✓i%G,(%8 l r, 1J r+arxwX�4 r�ti!" �rtfxr�IJ( d�M'lG/Ii i/li7 / : r,r /a//;G/ho,r/F.kl,,, p ,! /, ,J,/1l 1, N r ,/ / r n ct, r„ro nr� ;r� r«ve.l ,/ /UI//,<, /cr r�/(/ I//Ii nr,/,✓/ / /�lr.„ir;:. �,fr r�, aterrJ.h ed.D�St , ./ �/Nrl�,� f ,r;, �f. n,.. �;�,;� s r/,/��.,, r,f r❑�`rYW ,,,r,,, r/,/ ,rl,, /��/, .Y ,r,��% � ood I m �❑,Wetland,/ �� , I� �/�% G / �y�❑ ��..,i/r,rlrr�rr„i I�t(Se tic� ,❑,Weil I/; �,:/f� /r/ ,�,;rliNG �+no/I a��,�1/// 'I/r %//,//// , /%//� I ! �r��i;%i ,/ .,✓l !!!' r!.'1/�,rr%r'��✓ �/,, ('/, i. r1i/�� ;//J�",r%�Jrl / „r�, ! �� 1��r/r „�rr��rl( r DESCRIPTION OF WORK TO BE PERFORMED: Identification- Pelse Type or Print Clearly , OWNER: Name: ° ....� 7 Phone: Address: 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$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $_ Check No.: Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund — — gaatu IF ®RT lown Of ndover 0 No. A'% -EEE2b1V �. h ver, Mass, 10;'�7 O LAKE.44 o COCKICHEW/CK V % x.95 RATED 5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD r� Septic System THIS CERTIFIES THAT ................................................ BUILDING INSPECTOR .. �—�� Foundation has permission to erect .......................... buildings on .... ......1� ..... .......... ...... . ..............,................ .......................................... Rough to be occupied as ........ ...... �... ....:: .... ............. -: ........ .. Chimney provided that the person accepting this permit shall in every espect conform�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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT E I IN 6 MONTHS ELECTRICAL INSPECTOR qb LESS TRCI S Z Rough Service �...�._... ........ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy.BuildinRough 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 Massachusefis Dpartment of I'ndustr'ialAccidents 4 � Y 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia y� Workers,Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY- Applicant UTHORITY.A licant InformationPlease Print Le 'bl Name(Business/Organization/[ndividual): 4 " Address: � - City/State/Zip: x,1-11 �, ~- Phone#: �_M t Are you an employer?Check the appropriate box: Type of project(required): L❑1 am a employerwith : employees(full and/or part-time).* 'l. ❑Now construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3,'K 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.FJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 Roof repairs These sub-contractors have ernployees and have workers'comp.insurance, 6.Q We are a corporation and its offigers have exercised their right of exemption per MGL c. 14.F1 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#his affidavit indicating they are doing all work and then hire outside contractors must si bmit anew 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-conlracfors have employees,%ey must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees.'Below is'thepolicy and job site information. Insurance Company Name: � ,✓ Policy#or Self-ins.Lic.#: l ExpirationDate: fob Site Address: o showinr thetatolicrpnumber a expiration date Attach a copy of the workers compensation policy declar atr n page(showing policy P )' 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 WORD 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 certify under thepains and penalties ofperjury that the information provided above is it-tie and correct. " Sr nature: ✓" r" ✓ - - ...,• " ''�"- ""7 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#: NORTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 �SSpC U Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER 11 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,provide 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-or 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 110.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