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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LDCATI ON` s , `
x Pnnt
PROPERTY OWNER '4Nr �" fir» ` •tN
z , M
100 Year Old Structure yes , no
MAP NO '0,V PARCEL ZONING DISTRIC°T -F Historic Distract yes no ;
achine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
ew Building ><One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Se' tic ' El Well d Floodplain El Wetlands E! Watershed District
ate Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please'Type r Print Clearly)
OWNER: Name: 'fL'A Phone:
Address: >. &'Y-- 1,797 cj��'��.
CONTRACTOR ,Name: /11 Phone:'C?d��';� .GJ
Addres's' la.
� • !fi #tNP �i 3
Supervisor's Construction License rs Exp Date
Home Improvement License: _ Exp: Date:
ARCHITECT/ENGINEER Phone: a?f� �/3J - 9-Sr5 9
Address: :..5 YO -��� n�'i r%� t�• v,��3 1�d "� Reg. No. 30 W7
FEE SCHEDULE;BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
3'" �
Total Project Cost: $ , e FEE: $ I _
Check No.: ' Receipt No.: _
NOTE: Persons contracting wit/i unregistered ontractors do not have access to the guaranty fund
Signature of Agent/Owner signature of contractor.
Plans Submitted L+ Plans Waived ❑ Certified Plot Plan Stamped Plans L '
Plans Submitted Plans-Waived-0 Certified Plot Plan Z Stamped Plans
TYPE-OY SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑. . Swimming Pools ❑
Well .Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc.. FL111- :Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U.FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT 7 Y
COMMENTS A ly�5 7-0 13A0.
-CONSERVATION Reviewed on Signature
COMMENTS f
4
HEALTH Reviewed on Si nature
COMMENTS
-
L Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
�Y
r
Planning Board Decision: Comments
Conservation Decision: C ments
y mater Sewer Connection/Si nat A ate A Driveway Permit �✓
VA
DPWTor; Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTML - Temp Dum er on site yes no
Located-at 124 Mair, Street
Frye Depaftmentsignature(date-.
fl ,,�MENTS