The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 10/19/2015 lry %AORY 1 BUILDING PERMIT ' 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4t -- - Date Received �Ra0RRreo Pea`y E� Permit N ��CFiuS�R Date Issued: OR-'TA T.Applicant must complete all items on this page LOCATION �� r '� Print PROPERTY OWNER Cv ��(All Print 100 Year Structure yesLno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building 0-066 family El Addition 11 Two or more family El Industrial teration No. of units- El ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 7 „ Jrr,rrt r;,3i, r,ti .a,,,r, e�;rr, , ,,,ffrM/;I% ershed District ,, ,,, ,�a-. ;, rJru¢r,x i r%r..i-r/i,r/%,pr/ %�r..r r., /r r✓,.. ,. % / n❑ W,at ,,rv. .r,.r s ,nf `, ; ,,,,; ��n�� , ,�ar'b� ,l / JY/. � rr �, �,,/�/rr.. �;,,.�,� ,. a ,, � / ❑�Vi V,etlands ....<�, / ❑ Se Jr ,,,'. , /.. ® V V- ,I , r9 /«/%r� o.,� />y,a�� r , ,,�l rr/ r ,r � r��/ /✓�JJNO�..�'/' /�„�rl� / 1:.�, / yl:r ,r J ��y �,r,,unr �/�„r,%,,.r lic<a,;,,, ;, ,,,,.., It DESCRIPTION OF WORK TO BE PERFORMED: eta Ipkcp 6L �� ace. CA t,UIJat.J bo”, x Identifiication- Please Type or Print Cleary � Phone: q76,. f S-2,766 OWNER: Name: U LL P(4VI Address: Contractor Name: Phone- Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Ex- ARCH ITECT/ENGINEER xpARCHITECT/ENGINEER Phone: Address: Reg” No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: Check No.: Receipt No.: NOTE-. Persons contracting with unregistered contractors do not have ace�tot gu r �Iiyfund t s � , Town of . Andover O to ["A No. A .010, IL h ver, Mass, COC NIC"EWICK AERATED V BOARD OF HEALTH Food/Kitchen PERMIT T LD�Q Septic System THIS CERTIFIES THAT ....... �- — , `� BUILDING INSPECTOR ........' ..................................................................... .................................. has permission to erect .......................... buildings on .. .. ::^............. " ........................ Foundation Rough to be occupied as ...!.......... :J....... ......1.. s ......!A.>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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES 16 MMITH ELECTRICAL INSPECTOR LESS C® STCTI ART Rough Service ............... ...... .. ............. ............. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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 Massachusetts xDepartment oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 . .��-.•:„SJ:4yt www mass.gov1dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Awlicant Information (-'tf Please Print Legibly Name(Business/Organltn izationdividual): �c ic. aftsan Address: G T-t Sodem Pt- City/State/Zip:AIK! 4 o.: rl 1416 01 O Y s Phone#: 918-6/b -2 76 G Are you an employer?Check the appropriate box: Type of project )Vequired): 1.❑I am a employerwith employees(full and/or part-time).* 7. El New construction 2. I am a sole proprietor or partnership and have no employees working for me in $, (ARemo deliTig any capacity.[No workers'comp.insurance required.] ' 9. El Demolition 3A`n a homeowner doing all work myself[No workers'comp.insurance required.]i 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.[]Plumbing repairs or additions 5.❑I am a general contractor and I haye hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors fiavo einployees and have workers'comp.insurance.t 6.Q We are a corporation and its of gers have exercised their right of exemption per MGL c. 14.Q 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. f Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must si bmit 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-conlracfors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and,joh site information. Insurance Company Name: Policy#or Self-ins,Lic.#: ExpirationDate: 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 certrf under the pains and penalties ofpez juzy that the information providedfabove is true and correct Sign e: Date Phone#. T78 "w/0. 2-7�',� 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#: „o?Ty TOWN OF NORTH ANDOVER Qhs,. a oL OFFICE OF ° p BUILDING DEPARTMENT n 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 �RCHusk Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: '0f(q f�is JOB LOCATION: Number Street Address Map/Lot HOMEOWNER `x'79 618 --2-_7i6 6 Name Home Phone Work Phone PRESENT MAILING ADDRESS 674 ! AAkM , Ww-Ir 1q,1° 60(0 City Town State Zip Code The current exemption for"homeowners”was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the 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. 1 HOMEOWNERS SIGNATURE ` APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEAI:S,688-9541 CONSERVATION 688-9530 HE AL;1'I1 688-9540 PLANNING 688-9535