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Home My WebLink About36 REPLACEMENT WINDOWS IJIL IN PE IT o� CS LHO �g TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 001A Permit No#: Date Received _ ss�cH0��5 Date Issued: IM]PORTANT: Applicant must complete all items ora this page LOCATION S- dt,,s i P n1y-e✓ m✓-7 o fobs ri nt PROPERTY OWNER R^ Print 100 Year Structure yes n MAP 6Z PARCELOO ZONING DISTRICT: Historic District yes o Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition O/Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other F❑lSeptic�, Q Well ❑ Floodplain ❑Wet(�nds � ❑ Watershed Dtstnct DESCRIPTION OF WORK To BE PERFORMED: w ✓�� Identification- Please Type or Print Clearly OWNER: Name: G Phone: �1 �' Z®�®-W Address: ® �� S S ✓� Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date. Home Improvement License: Exp. Date=. ARCHITECT/ENGINEER Phone: Address: Reg. No,.� FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED€}N$125.00 PER S.F. Total Project Cost: $ 10�DOD FEE: $ (2-t � l Check No.: Receipt No Z. NOTE: Persons cont acting with unregistered contractors do not have access to,the guaranty fund - 77, 7', - - - i ®ff4TH AndoverTown of0 ? ,. ® •�% y0 I.- 11mul4�'114Mass, Ills_• A ver, Will COCMIC QwICK 7 0 RATED I` 47 BOARD OF HEALT Food/Kitchen PERMIT T LD Septic System • BUILDING INSPECTOR THISCERTIFIES THAT ................................I......... ...... ........... ' ....................................... Foundation .... buildings on ... has permission to erect .. .......� .. .. ... ... . ...5V.`' a Rough to be occupied as .... A ............?. . �..... ................................. 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR TARTSUNLESS CONSTRUCTION Rough Service ..... . . . .. . ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BuildinRough Display a Conspicuous Place on the Premises — Do Not Remove Final r all TBeDone FIRE DEPARTMENT No Lathing Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER OFFICE OF a � BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDINO PERMIT APPLICA'T'ION Please 12ri DATE: (� JOB LOCATION: _s Number Street Address Map/Lot HOMEOWNER :- G 0)--g- 3 Nam me Phone Work Phone PRESENT MAILING ADDRESS jS 3 rJ_,z,-.s S)-Yl� City Town State Zip Code The curTent 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 sLipervisor. 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 strictures 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 110.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. HOMEOWNERS SIGNATURE w APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-95=41 CONSERVATION 688-9530 HEALTH 688-9540 PLAI\tNR\iG 683-9535 The Commonwealth ofMassochusetts Department ofXndustrialAceidents X Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gohldia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE PILED WITH THE PERM[TT1NG AUTHORCTy. Applicant Information nn Please Print Legibly Name(Business/Organization&dividual): Address: 3 5` V Q ✓ S City/Mate/Zip: N . A ndeoyQ/ m A- x`45 Phone#: Are you an employer?Checktfte appropriate box: Type of project()Vequited): 1.❑I am a employer with employees(full and/or part time).* 'T, ❑New construction 2. 1 am a sole proprietor or partnership and have no employees working for me in 8. F]Remodeling any capacity.[No workers'comp.insurance required.] 3_,�I am a homeowner doing all work myself.[No workers'comp.insurance required.]i 9. E!Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions propiietors with no employees. • 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ f 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and ifs of. . have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box W1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit:#his affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. fContractors 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. Ifthe subcontractors have employees,they must provide their workers'comp.policy number. T arra an employer that 1spiov1d1hg worf s'compensation insurance for 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 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 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 DTA for insurance coverage verification. X do hereby certify under the pains andpenatties ofperjzuy that the information provided above is true and correct. Signature: —Ly 6tc Date: 5 I 1 I 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: