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Home My WebLink AboutBuilding Permit # 1/5/2016 t%ORTH BUILDING IT ®FRKL�o ,b�ti� TOWN OF NORTHV 5 APPLICATION FOR PLAN EXAMINATION o r Permit Not#: ..' (J; Date Received oR^r¢o aeay.t`� �SSAC HUSH C Date Issued: I I POkTr NT: Applicant must complete all items on this page LOCATION b `"7— Print PROPERTY OWNER �� - Print 100 Year Structure yes no MAP PARCEL: ,� ��w ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Res' ential Non- Residential ❑ New Building , ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: li4emolition ❑ Other r 1kf�1YKJ.h➢1 � , i,,, /(o /l // /// f �A/l 11,/r1(//K1.%/// I( , K/ (/%7Y/1, Iri r%I/ 1 1 rrf(r,�✓,(AK 4lrlr�ll!/K( (, u(/rl» / // J DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: t� �'T - ;�� Phone:` �d ` � 7 Address: Contractor Name: J _ �7 _ Phone: ` 1 - '�S , Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•MOO PER$1000.00 OF THE TOTAL ESTIMATED COST EASED ON$125.00 PER S.F. Total Project Cost: $ `� ' r FEE: $ Check No.: o Receipt No.: >. p 1 ^ . NOTE: Persons eontracc registered contractors do not have access to the guaranty fund /rOli///% �, �f F N®R7'�1 ' i ,own ot2 : EAndover ® ..mow"' •y '1 ® 'S i ver Vw O LAKE [OCNICNl WICK RAreo nP�`,��(5 U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System MENIM% LA 1"43 THIS CERTIFIES THAT O. . ZQ r� BUILDING INSPECTOR ...... buildings on ........................ Foundation has permission to erect .................. . . ..... ..... .... ....... ..... ...., u Rough tobe 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO , ARTS Rough Service ............ .... .... .. .................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Displayin 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. NORTy TOWN OF NORTH ANDOVER 0 OFFICE OF A BUILDING DEPARTMENT A ; 1600 Osgood Street,Building 20, Suite 2035 7 ppRRT�p�PP4y* North Andover Massachusetts 01845 1SSACHUSti'C Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print ,r- DATE: 12S ur S JOB LOCATION: _3—v 0-cl? Number Street Address Map/Lot o HOMEOWNER 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, rop vided 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. n 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 y`he commonwealth ofMassa.ehusetts Department oflndus/rAd Accidents h I Congress Street,Suite 100 - r y Boston,MA 02114-2017 ~' www.mass gov1G ra 7orkexs'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PXumbers. TO BE,FILED WITH THE P ERMTU G ATJTETORI.TY. A licant Information _ Please Print LeAb Name(BIasiness/organization&dividual): � . C w a y .Address- Cx /State/Zip: ff 'hone#: Areyou an employer?Checlr the apl'opriate box: Type Of project a employer with employees(full.andlorpart-time).' 7. �Now construction ct7'lorl 1.❑T am am a sole proprietor or partnership and have no employees working forme in $. Remodelirig y capacity.[No workers'comp.insurance required.] 9, Demolition '°' < " f farn a homeowner doing all work myself[No workers'comp.insurance required.]t 10[j B��gaddition m a homeowner and will be hiring contractors to conduct all work on my property. Twill 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.E Plu bing repairs or additions 5. I am a general contractor and I haye hired the sub-cointracfoxs listed on the attached sheet. 13.E]Roof iepaits 'hese sub-contractors bade employees and have workers'comp.insurance. 19. Other 6.E]We are a corporation and its offiggrs have exercised their right of exemption per MGL G. 152,§1(4),and we have na employees.[No workers'comp.insurance required.] - any applicant that checks liox#1 must also till out the section belowshowingtheirworkers'compensation policy information. i Homeowners who suliriiit phis affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and stake whether or not those entities have employees. Ifthe sub contractors have employees,they must provide their workeisI comp.policy number.' X am an employer tTiat is pi'ovidirzg wor'lrers'compensation insurance for my employees'Below is the policy and job site information. Insurance Company Name: Policy 0 or Self-ins,Lic.#: Expiration Date: � .,: City/State/Zip: fob Site Address: .Attach a copy of the workers comape declarationiox policy page(showing the policy)Cumber and expiration.date). Failure to secure coverage as requited under MGL o. 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 ofup 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. do hereby certify under epains a penalties ofperjury that the information provided ado a is..true and correct. .✓`� Date: Si nature: Phone 0. 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 ffealth 2.Building Department 3.City/'t'o'wn Clerk d.Fffectrical Inspector 5.Plumbing Inspector 6,Other Contact PersOn: Phone#t: NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: (Location of Facility) Figna\dre o Permit Applicant Date i � � 2 4 ree