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Home My WebLink AboutBuilding Permit # 11/24/2015 4 Wv iiUVW-w V L-aimss , a APPLIG3ATION FOR PLAN EXAMINATION 1 Permit Date Received4 — N Date Issued:0 test complete-ail items on teas ofwe PROPERTY OWNER Print PARCEL _2 N 0 -4 U OMNG STR RACT� istedic-Diswd VoN V— Q�U IOU, i V New Building 0 One family 0 Addition [I Two or more family i 11 Industrial – 10t mtjnn It No. of units: Commercial )(Repair, replacement 11 Assessory Bldg ❑ Others: El Demolition 01 Other - UWN E R.- 6 1 a rn e.- o Phone: `� Address: Supervisor's Construction License: Exp. Date: FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED C T BASED ON$125.00 PER S.F. GO h ec-1K 1K--J Recelpt N'O.: NOTE: Persons contra 4tingwith unr isteread co _tnractors do not have ac t1[e'-fuWantvjhnd tAO TH ver Town of Ando 0 q .,�,. .fit•' No. �AKt ver, ass, s� COC wc..1WICK D 1 -r.9 A �AT BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............................ BUILDING INSPECTOR has permission to erect ........... buildings on &L"Aw Foundation ............... ......� ........ ® * ........ Rough to be occupied as ... .. . ... ........ .. ... ......... ( .................... Chimney provided that the person accepting this permit shall in every sp t conform to the term he application Final on file in this office, and to the provisions of the Codes and By- s 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 IT EXPIRESI 6 MONTHS ELECTRICAL INSPECTOR LESS C T CT STA Rough Service ............. .. .... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy .hermit Required to Occupy Buildinz Rough Islay 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. �oRTN TOWN OF NORTH ANDOVER 0 OFFICE OF } ABUILDING DEPARTMENT a 1600 Osgood Street,Building 20, Suite 2035 ,�gATIO��Fy•5* North Andover,Massachusetts 01845 CHUS 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 Street Address Map/Lot HOMEOWNER �� r�J� C, L-b 6� �1� 1�)- Name Home Phone Work Phone PRESENT MAILING ADDRESS 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 require is and that he/she will comply with said procedures and requirements. `�U S � HOMEOWNERS SIGNATURE 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 Massachusefts Department oflndustrialAceldents 1 Congress Street, Suite 100 ='e Boston,MA 02114-2017 www mass.gov/dia sy Workers,Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE TILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legib Name (Business/Organization/Tndividual): .Ad.dress: \ �G City/State/Zip: W( ��V� � Phone#: 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.Q I am a homeowner doing all work myself[No workers'comp.insurance required,]t 10❑Building addition 4.b4I am a homeowner and will be hiring contractors to conduct all work on my property. I will censure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.F1 I am a general contractor and I ha-ye hired the sub-contractors listed on the attached sheet. 13.Fq Roof repair's These sub-contractors have employees and have workers'comp.insurance.t - 14.[]Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGI.c. 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information T homeowners who snbriiif Us 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-coriiractors have employees,'they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for nzy employees.'Below is the policy artd job site information. Insurance Company Name: Policy#or Self-ins,Lia#: 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 certify n r thepains a'n endMes o perjtuy that the information provided above is true and correct. 1 ` Signature: Date Phone#: 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 S.Plumbing inspector 6.Other Contact Person: Phone#: