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Home My WebLink AboutBuilding Permit # 11/15/2015 BUILDING PERM ITOORTH �O TOWN OF NORTH ANDOVER 10� APPLICATION FOR PLAN EXAMINATION a Date Received SSgCwus� Date Issued: �ITM;PXANT: Applicant must complete all items on this page r Year Structure yes nog r Print 100 MAP PARCEL ZONING DISTRICT Historic District ,.yes n M - ; ,; ` ` achene Sfiop Village ` yes ; riot TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑1/Vetlands ❑ Watershed District . r ❑ffl6ter/Sewer DESCRIPTION OF WORK TO BE PERFORMED: a� c [)o Y-C'h c'nd PC,rc V-, S LL I r s r'd d/-) P u (z 0n J0 -- �.%c0 ��ct1 v , d n � - . aur t Id tiiication- Please Type or Print Clearly OWNER: Name: ' - & ' H) LdbV Phone: Address: I`c� (P�yo5\J-e viC)-c /V- Contractor Name. ..., J ; Phone: Email., . Address. Supervisor's Construction License xp a e Home Improvement License � ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: Check No.: Receipt No.: � NOTE:E: Persons on >ac zng with unregistered contractors co not have access to tle ivarantyfund Signpupe of Agent/OWwef--, /' Signature ofcontractor, %AO RTHtown of A"11.doY1 T er No. oh ver, Mass, COC NICK@WICK �A �V �•9 °R^Teo S U BOARD OF HEALTH PERMIT T L &O Food/Kitchen Septic System THIS CERTIFIES THAT 4-� 'DS ,,,, i �'� ,.,, BUILDING INSPECTOR ........ . .. ... .............I.............. ................................................. Foundation has permission to erect .......................... buildings on ... ........kq�*V�:h�L........ ..... ....... Rough tobe occupied as .... ......... .....` ........ ............................................................................................... Chimney provided that the person ac pting 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 PERMITl IN 6 MONTHS ELECTRICAL INSPECTOR LESS ST IONVL 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER q t`ED6 -1V OFFICE OF p BUILDING DEPARTMENT it X 0 * �a * 1600 Osgood Street,Building 20, Suite 2035 ��SsgE��h North Andover, Massachusetts 01845 c►+us Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: I l JOB LOCATION: Number Street Address Map/Lot HOMEOWNER c fit' n Vv k b 1 I e�/ ��. Lt��a ��X, j/) t S,e s 2> k) I ct f1 Name Home Phone Work Phone /U J PRESENT MAILING ADDRESS j)S V y)c) y- A&r-c 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 requilemepts and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNAT JRE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 -he Commonwealth of Massachusetts .'� Department ofYnd-ustr"ialAccidents E 1 Congress Street,Suite 100 v Boston,MA 02114-2017 www mass.gov/dia zJ• Workers'Compensation insurance Affidavit:Builders/Contractors/Elgctricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/lndividual): Address:_l —�1 D_S/(?tnnrL City/State/Zip: FP . Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employerwith : employees(full and/or part time).' 7. Q New construction 2.❑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. Demolition 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole , proprietors with no employees. 12.F]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the atsheet. 13.F Roof repairs These sub-contractors have eiriployees and have workers'comp.insurance.t 14.❑Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and wo 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 submiti this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors 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,tliey must provide their workers'comp.policy number. I am an employer that is pNoviding workers'compensation insurancefor my employees.'Below is the policy 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_ . f do hereby er•tify oder•thepains a enalties of perjury that the information provided above is true nd correct. Date: Si natur J Phone#: Official use only. Do not Ivrite in this area,to he 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#: