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Home My WebLink AboutBuilding Permit # 1/7/2016 BUILDING PERMIT o�-j-TM t, �t� D �6 ti TOWN OF NORTH ANDOVER �� :`'` 46 ° APPLICATION FOR PLAN EXAMINATION ® _ a � �q�oR � Permit Not#: �/� Date Received 7 QDRgrED PPPy�f7 gSSaC14 US Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 267 BK610M �5 /Qd DM print PROPERTY OWNER Mj - �`yC.o _ Print 100 Year Structure yes o MAP 0 7 PARCEL: ZONING DISTRICT: Historic District yes n Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ;K One family Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic; 1/Uell' ❑ Floodplain ❑Wetlaniis f ❑ Watershed Dstnct DESCRIPTION OF WORK TO BE PERFORMED: 0 tificatio Plea Type pr Print Cl arly o , OWNER: Name: 1�l ` Pho �. Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 1 1V V 456 C Phone: Address: �� Reg. No.but FEE SCHEDULE:BDI G PEWMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $� � �d FEE: $ 0 Check No.: 7 Receipt No.: % J NOTE: Persons contracting wit egistered contractors do not have access to the guaranty fund NORTh Town of Andover ® C,, h Ver, Mass, / COC MIC NE WICK A' 7� RATEiD PP S V BOARD OF HEALTH Food/Kitchen PF.; RMIT T L D Septic System THIS CERTIFIES THAT / .. .,.. BUILDING INSPECTOR ' S� Foundation has permission to erect.......................... buildings on ..... ...7... .... �::�Y:. ............................. Rough � to be occupied as .............v...�`G.�� d.�? 2.... .........2...... ............................................. Chimney provided that the person accepting this permit shall in every respect conf6rm 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 I MONTHS ELECTRICAL INSPECTOR UNLESS C SR CTIOTS Rough Service ............. ' ' ... -- p. ....... ;. ...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of_1k assachusetis Department of IndlustrialAceldents 1 Congress Street,Suite 100 Boston,MA 021�201 7 www.mass.gov/dia We kers'Compensation insurance Affidavit:BuaXdexs/Contxactoxs/ElectxzcianslPXumbexs. TO BE FILED WITH THE PER WING AUTH07.2ITY. Please Print I,e ibl A licant information 7M Name(Business/Organization/tn(duivi *01, � � AJftAddxess: City/State/Zip: Are you an employer?Check tfie appropriate box: Type o£project(lteC(uiled): 1.❑I am a employerwith employees(fall and/or part time)" 7. New construction 2. I am'a sole proprietor or partnership and have no employees working forme in 8. Remodelhig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q lam a homeowner doing all work myself[No workers'comp.nisurance required.]t 10 Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. l will `�C 11.[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. -12:n Plumbing repairs-or additions 5.❑I am a general contractor and I haye hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and haveworkers'comp.insurance t 14.❑Other 6.❑We are a corporation and ifs of-ftrs have exercised their right of exemption per MGI,c. 152,§i(4),and we have nq efn' a s.[No workers'comp.insurance required.] kAny applicantthat checks box#1 must also fill outthe their workers'compensation policy information. i Homeowners who suliriiiti this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. tConfractozs Haat check this box mus$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.' d am an employer that is pi ovidirzg workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins,Lia#: . fob Site Address: City/Sfate/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00 Failure to secure coverage as requixed 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 ver'if'ication. I do hereby cel y der thepains andpen lire ofperjary that the information provided above is true nd correct. Si nature- Date: Phone#: 7'7 Official use only. Do notwritein this area,to be completed by city or town Official City-or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Ifealth 2.Building Department 3.City/Town Clerk. 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t%ORrti TOWN OF NORTH ANDOVER Of Teo ia�ti �a ¢��, �•..s oG OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 .9s RATao pp�,tRy North Andover,Massachusetts 01845 SACHUS� Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print J DATE: c � JOB LOCATION: N ! Aor 41k CX_ ... ; Num er Street Address r q Map/Lo, _ 41-1 HOMEOWNER �C)M6C"/ / ! Name Home Phone Work Phone PRESENT MAILING ADDRESSeAf e Pdel� o 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 hue 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/shestands the Town of North dover Building Department minimum inspection procedures and requirements rfd that he/she will comply Nit said procedures and requirements. 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