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Home My WebLink AboutBuilding Permit # 10/21/2015 BUILDING PERMIT t%ORTH TOWN OF NORTH ANDOVER 4, APPLICATION FOR PLAN EXAMINATION 00 Permit No#: Date Received 'O"ArED S CHUS Date Issue , 'd I IMPORTANT:Applicant must complete all items on this page LOCATION y I Print PROPERTY OWNER,-be,,/?/1;,-S - e,5,-Ju- (-I??'-� Print 100 Year Structure ye no MAP PARCEL: )/Z- ZONING DISTRICT: Historic District es no Machine Shop Village le s no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building One family El Addition 11 Two or more family 11 Industrial El Alteration No. of units: 11 Commercial epair, replacement 11 Assessory Bldg 11 Others: D Demolition 11 Other DESCRIPTION OF WORK TO BE PERFORMED: 4e Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: c 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: $ ca. FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractor v do not have access to the guaranty fund n u re tk®RTH ' town of Andover ® - �� ry t to No. 564"" - 64� LAKE h ver, ass, Coc"ICMf WICK � U BOARD OF HEALTH Food/Kitchen Psl= KMI I I LD Septic System THIS CERTIFIES THAT .. BUILDING INSPECTOR . ... has permission to erect .......................... buildings on .��. .. ...... ....�... �. ............ ............... Foundation i �— n Rough to be occupied as ...... ?............ ....... ..............�............ ......... —.... ..... ...... ..... 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 EXPIRESPERMIT IN �+T ELECTRICAL INSPECTOR LES 1T 1 671 T Rough Service ..................... ...................................................... Fina BUILDING INSPECTOR GAS INSPECTOR ceupancV Permit Required to Oecupy BuilclinRough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be ®one FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. pORTH TOWN OF NORTH ANDOVER OFFICE OF ° , p BUILDING DEPARTMENT �o 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 �SSAC14 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: U0 �c < jj\\ Number Street Address Map/Lot HOMEOWNER./)e/tn;,� Name Home I'llone Work Phone PRESENT MAILING ADDRESS -S 9fi- 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,provided 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 I IO.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 6 - 11& ,6,_ I APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts z . F Department of IndustrzalACCidents _ = 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PEPMITTING AUTHORITY. Applicant Information Please Print Le0b Name(Business/Organization/Individual): /`f/2!S• S L'.�( /'y Address: City/State/Zip: L,¢ 72 Y��'" �� 11d S Phone Areyou an employer?Check the appropriate box: Type of project()required): I.l I am a employerwith employees(full and/or part-time).* 7. New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El DemoIition 3_VI 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. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 1.2.F]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors Have employees and have workers'comp.insurance.t 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we.have nq 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 sulimif 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-coniradors have employees,they must provide their workeis'comp.policy number. I am an employer•t1iat is providing workers'compensation insurancefor my employees.'Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: 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. I do Hereby ce tfy under•thepains andpenalties ofperjury that the informationprovided above is true and correct. &.a `, C1 Date: Phone# l 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#: