HomeMy WebLinkAboutBuilding Permit # 10/21/2015 BUILDING PER ITotkORTy q�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit Nod. °s' Date Received �Ao"T
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Date Issued:
I bRTA.NT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER .�� r -�; ,
Print 100 Year Structure LnoMAP PARCEL: ZONING DISTRICT: Historic District yeMachine Shop Villag:—yes
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: Erl ommercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
r� ficationP�lease�Te or Print Clearly
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OWNER: Name: C � pPhone: ( ,
Address:
Contractor Name: C - S Phone: 01
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Email: - `, r . , � - � , 24 % r
Address: ").m, o c)
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ <D FEE: $
Check No.: -1 p
Recei t No.
NOTE: .Persons contracting with unregistered contractors do not have access to th guarand
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T' O �'. h ver, Mass,
.40 COCKICKEWICK
AERATE c)
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BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ........ Ic7 �, .„�,, ,�;,Lf�,,,, �r,� �' BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings oncT�. (2 o..... .... .1. ..... .........................
,'. Rough
to be occupied as .. .. . ........ .. Chimney
.. ............. ..........5 .......e.�?s�...... .......� ,.a ..c�r�l,
provided that the person accepting t Is permit shall in every respect conform to the ter 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
PERMITIES 1 MONTHS ELECTRICAL INSPECTOR
3W LESS CONSTRUCTI STS Rough
Service
............... ..... ...... .. ............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to ccupy By Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathingr Dry Wall ToBe Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of Massachusetts
. f4 Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston,M4 02114-2017
www mass.gov/dna
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIITTING AUTHORITY.
Applicant Information Please Print Le0bly
Naxrle(Business/Organization/Individual): , g r r`-� ' f✓� L
Address:
City/State/Zip: A.v Phone
Are you an employer?Check the approprlafe box; Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. E]New construction
2.�1 am a sole proprietor or partnership and have no employees working for me in 8. r]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ®Demolition
IF1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10®Building addition
4.Q 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. 12.0 Plumbing repairs or additions
5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors trade employees and have workers'comp.insurance.t
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14Other
152,§1(4),and we have no,employees.[No workers'comp.insurance required.]
*Any applicant that checks b6x#1 must also fill out the section below showing their workers'compensation policy information
i Homeowners who submif this 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-contractors have employees,&li must provide their workeis'comp.policy number.'
!am an employer that is pi ovid6ig workers'compensation insurance for my employees.'Below is thepolicy and job site
information.
Insurance Company Name: AAA,,'PPC, , _ ,-/p`e-L<— CQ ry -"A a'A °P y
Policy#or Self-ins,Lie. Expiration Date: I t t 1
Job Site Address: (DO "\ City/State/Zip: N, 1i( �
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 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.
p do hereby certif under the ains a yd penalties of pea jury that the information provided above istrueand correct.
Signature: Date: f K f e-,)
Phone#' Gy. — V Gr c;'
Official use only. Do not write in this area,to be completed by city or town of-cial•
City or Town: Permit/License#
Issuing Authority(circle one): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
Constructi
Reston
ricted to:Supervisor
Unrestricted
than
5, -Buildings of an
less than 35,000 cubic feet y
space. Y use grow
(881 cubic p which Contain
Meters)of'enclosed
Failure p.
State B�►d g Code►s nt it- of
curve ed'
DPS Licensin Cause for the Massac
9 infoppation visit: revocation of this►►den s
� WWA4ASS. se.
GOV/ppS
MJ assachusetts Department Of Public Safetv
Board ofBuilding Regulations and Standars
License: CS-005712
ConStructionSuperv- r
2�
STEVEN cmATsS^ «
202 SUTTON s
NORTH VER ? ° \
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Commissioner �% i
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