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Home My WebLink AboutBuilding Permit # 11/17/2015 NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION * - H Permit NO: Date Received „ �•9 °j►wva°•vQ'�,c5 Date issued: , CH 55 IMPORTANT:Applicant must complete all items on this page / ,, N %%// / rrr �/ ,i �/iii ,,,, �% i„ ,,.,,,;;,,,�, %%„ „,,,„��, �e/i✓„r / ,;;,,,,,, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 1-1 New Building ❑ One family ❑Addition VTwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition (( ❑ Other p W' F oo p{art%rr > We`ll/ ,,// ❑; 1lUafiershed Cistrict Dili �/,r/ y Identification Please Type or Print Clearly) ' !_. (; OWNER: Name- `c � � -- .. .%�; �%.,,� Address: r �'j ,3)oc” c µk D 1 fu ,) ' / r rrr /oiiii %///, r / r �, / / rr rrrrr r r/ ,e r,�/ �i/�r✓�r�j _//i ...,rrrr„r / ri/ „ //! r r r / r 1 / r P r / / r / , / lnt/ ARCHITECT/ENGINEER Phone: Address: Reg, No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I coo FEE: $ Check No.: Receipt No.: NOTE: Persolfs lontracting with registered contractors do not have acce u anty fund Sima`ure of Agent/Owned w , signature of contractor NORTH Town of Andovell ® 7 (D. o L^K& h ver, Mass, S COCMIC.E." 1'AO� R��r.9 RATED PP C7 S V BOARD OF HEALTH Food/Kitchen PERMImT ]�F� LD Septic System THIS CERTIFIES THAT ..� . .. .. .......... " -_.�;,,,,,,,, ., BUILDING INSPECTOR ......... . �++ .................... has permission to erect . buil4nson .. Foundation Rough to be occupied as ... ... .1.. .. `w�l ... ......... Chimn.......... . ... .. Chimney provided that the person accepting this permit shall i 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESST I ST TS Rough Service .............. ...... ............................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r all ® Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER � OFFICE OF - _ A BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 �'1s nAT.o'P"icy r North Andover,Massachusetts 01845 1 SACHUS� 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 Str et Address Map/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS w � - 60,\k. ,/c4 A 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 am t he/she,MyujIL comply with said procedures and requirements. ' f HOMEOWNERS SIGNATURfr' 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 Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Worriers'Compensation Insurance Affidavit:Builders/Conti•actors/Electricians/Plumbers. TO BE FILE WITH THE PERMITTING AUTHORITY. Applicant Information \ Please Print Legibly Name (Business/Organization/Individual): f � \�,Y 6a 5 ��'1cF Address: 1%s �`7 City/State/Zip3 40AOC`0\k Phone##: q ,�'g `12 3 22(Y,2 Ape you an employer?Check the appropriate box: Type of project(required): 4:11 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.p 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 Demolition 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.dam a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.Q 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.$ 6.0 We are a corporation and its officers have exercised theirright 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. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoptractors 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,they must provide their workers'comp.policy number. I ant att employer'that isproviding iporlrers'compensation irtsuratice for niy employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 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 uanl repair t enalh ofpeijury that the information providedf above is true and correct. Si natut ✓- Date: Phone#' Official use only. Do not white 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: