HomeMy WebLinkAboutBuilding Permit # 10/5/2015 14R
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BUILDING PERMIT 0 , #6 +
16
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued: °'
IMPORTANT: Applicant must complete all items on this page
LOCATION A* ez W A• CA b/&,<)
Print
PROPERTY OWNER Ke$Z 'do g,
Print 100 Year Structure yes no
MAP /079 PARCEL:,VP
ZONING DISTRICT: I/if Historic District yes
Machine Shop Village yes 6�20—
TYPE OF IMPROVEMENT PROPOSED USE
I--, Resid ntial Non- Residential
"ew Building Rr6ne family
[I Addition El Two or more family El Industrial
El Alteration No. of units: El Commercial
El Repair, replacement El Assessory Bldg El Others:
El Demolition El Other
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DESCRIPT19N OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: e,
Contractor Name: 4
7�' &I r- JPhone:
Email: Pg,1,4me Aw-,"g e,14
Address: )1.1 4-ye,"- 4,yre, 30 A6z, xwdo� ,Pozl
Supervisor's Construction License: C 5; Exp. Date:,
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.0t)PEq S F
Total Project Cost: $ -1-11,� C// 5 FEE: $
Check No.: Receipt No.:
is e
NOTE: Persons contractingit unre t d contractors do not have access to the zu my fund
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BOARD OF HEALTH
Food/Kitchen
Lvv%PERM Septic SystemTHIS CERTIFIES THAT BUILDING INSPECTOR
....... ...... ... .�.... ................................ ...........
. .. . ... ....
�"{ -36 Foundation
has permission to erect .......................... buildings on .. .. ........ ..... .:'....�....................................
I ............................................ Rough
to be occupied as .............. 0. .... 1�1............. ......! `�......... ....... ...... chimney
provided that the person acceptin s 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. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMITI MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION tSTRTS/, Rough
Service
.................... ........................
f BUILDING INSPECTOR Final
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
- Department oflndustrircIAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Business/Organization/Individual): el(Z(6 of e, ;Ic .
Address: 10 ���P�7'.'C 4
City/State/Zip: 100 n 4�m vie-•C , <Q Phone#:
Are Ypu an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. P"fam a general contractor and I 6. [ 'New construction
employees(full and/or part-time).* have hired the sub-contractors
2,❑ I am a sole proprietor or partner- listed on the attached sheet.t ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9, C]Building addition
[No workers' comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.F1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL. 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
q � 13.❑Other
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 this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:. SD�t�1{�� ✓!1��y�E'S 6�1ri r �O�v1P/t��
Policy#or Self-ins.Lic.#: (BGG SW-.SO,* 1,3'W Expiration Date:
Job Site Address: &.Z, ta( NO Ar,-j01-0OGo 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 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.
I do hereby certify under the pains
a'nd pet alties ofperjury that the information provided above is true and correct.
Simature: ! ✓ Date: /D 161.5
Phone#:
ol
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.PIumbing Inspector
6.Other - -
Contact Person: Phone#:
Massachusetts -Department of Public Safety
Board of Building regulations and Standards
LUld)L1 It 1.Ll l/ll Jtd�J l:d l.'S 111Fw
License: CS-0753.02
BENJAMIN C Os Op ''
69 Old Village Lame
North Andover r&A 01845„-1
Expiration
Commissioner 12/04/2016