HomeMy WebLinkAboutBuilding Permit # 12/11/2015 ILO R Yy
BUILDING PERMIT of tLED ,��tio
TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received QDRRTE76,
�SSACHUS
Date lssued.jr--)�-"Oz�
J76 P®RTANT: Applicant must complete all items on this page
LOCATION
�� Print
PROPERTY OWNER/ "Il _ �;✓�r;�,
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT:_ Historic District yes no
Machine Shop Village yes no
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
❑ Septict ❑Well ❑ Floodpla[n ❑Wetlands ❑ WatersnedDistnct
r >rR r
[�Water/Sewer ,, ,. . .,
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: r,
Contractor Name: O)- dwloro � �� ?e
Phone:
Email: a�.til�� 1 A4
Address: `i uf`1Q v,' 3f
Supervisor's Construction License: Exp. Date: 20 f
Home Improvement License: / / Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASr ON$125.00 PER S.F.
$
Total Project Cost: $ 6) FEE:
j
Check No.: Receipt No.:
DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
----— – - -- - - —--- -----.. .- -..- --- --- ---- — --- ---
ttOR T H
Town ofAndover2
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C, �.KE h ver, ass,
COC HICHEWICK �1`
®S 4A-rED
11 BOARD OF HEALTH
Food/Kitchen
Pr= KMIT U L D Septic System
THIS CERTIFIES THAT . .. BUILDING INSPECTOR
. .. . . . ....... .
OIL
has permission to erect build' on . Foundation
p .......................... .... .... .. ...... ... ...................................
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tobe occupied as ..................... ..................... .................... ............................................................. Chimney
provided that the person accepti g this permit shall in every res t 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 O T S ELECTRICAL INSPECTOR
CONSTRUCTUNLESS T Rough
TML�� Service
............. .... ........................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy BulldinRough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathingr Dry Wall To Be one FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
--- ------------
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pa s
MgaN t
PROPOSAL NO, DATE
BID NO. ARU' TELT
TO PHONE NO. DATE OF PLANS
PKAC-e��
ADDRESSTWORK TO BE PERFORMED AT:
FA
70
/')i Af pej(,4, 0 )-t r-
We hereby propose to furnish the materials And nprfnrm fhp labor necessary for the co letion of
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j f
6
Area below for=dditlonal description and/or
colmpleted
ltpfdork to be performedin accqrdalce with the rawings d submitted for above work and
1a7l)STIT in a substantial workmanlike manner for the sum of
Dollars ($ with payments to be made as follows
ACCEPTANCE OF PROPOSAL The above prices,specifications,and conditions are satisfa0pry and pr6e)rby accepted. You are authorized to do the work as
specified. Payments will be made as outlined above.
'01
Signaturya
Date Signaturb"�,
M.*..adains°N 3818-50
11-12
The Commonwealth of Ma OW Usetts
.Department of IndiustrialAceldents
M P s 1 Congress Street,Suite 100
Boston,MA 02114-2017
5yiy� www.mass.gov/dia
Workers:,Compensation InsuranceA_f:rjdavit:Builders/Contractors/EXectFicians/Plumbexs.
TO BE FILED VfT-H THE PERMITTING A.UTiIORT.TY.
A. lxcan-Information
Please Print Ileaibly
Name($usiness/Organization/ludividual): 9 • 4
.A.ddxess:
G /State/Zi c, Phone#: / �C� ZC P—S V,ty p• •
Are you an employer?Checktlie appiropriate box: Type of project(r;equired):
em to ees full and/or art time , 7. []New, construction
1. I am a employer with •.. _ P Y ( p )'•
2. I am'a sole proprietor or partnership and have no employees Working£or me in 8. Remodeling
any capacity.[No workers'comp.insurance required.] 9. El Demolition
3.Q I am ahomeowner doing allworkmyself[No workers'comp.insurance required.]t 10 0 Biffl(�ing addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
11.[(Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole . .1 proprietors with no employees. 12: _}Plumbing repa7xs-Or additions
5.F]I am a general contractor and I have hired the sub-coiztractors listed on the attached sheet. 13._W Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other
6.F]We are a corporation and its offigers have exercised their right of exemption per MGL c.
152,§1(4),and we have etnpl ky s.[No workers'comp.insurance required.] -
FAny applicant that checks liox#i must also fill outthe section below showing theirworkers'compensationpolicy information.
Homeowners wfio subriiit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such.
zContractors 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-contracfozs Tuve employees,they must provide their workeis'comp.policy number.
X that is ps ovidirzg wor hers'eompensatiorz insurance for•my employees.' below is the policy and job site
am an erriployer
information.
rnsuxance Company Name:
Policy#or Self-im.Lie.#: Expiration Date:
rob Site Address- City/State/Zip:
Attach a copy of the workers' compepsation 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 inthe 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 luvestigations of the DrA for insurance
coverage verification.
X do hereby cerci rider th anus rtdpenalttes ofperjurn,�treat the znforrrtation pr ovided above is true �e��
Si nature:
C Date: C. /jj
Phone#:
Offtcial use only. Do riot write in this area,to be completed by city or town official..
City or Town:
#
Issuting Authority(circle one):
1.Board of ITealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Sa,ct44
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Office of Consur,:cr Uaari s&Business Re:;ulation
O�17E.IMPROVEMENT CONTRACTC•
" egistrtion`. 181116. Typa: {
Expiratio:jc' -2/25/2017-- DBA-,
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ANALORO CONSTRUCTION .
JOSEPH ANALORO
51 PROCTOR CIRCLE
PEABODY,MA 01960
Undersecretary