HomeMy WebLinkAboutApplication - 140 MARIAN DRIVE 12/10/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION �� /f�.rJ
Print
PROPERTY OWNER �if7T, �•�E.yO
Print" 100 Year Old Structure yes ;
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes n
Machine Shop Village; yes ' no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 1�t'6ne family
❑Addition ❑Two or more family ❑ Industrial
aeration ,No. of units: ❑ Commercial
impair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
e'Septic ❑Well ❑Floodplain etlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO RE PERFORMED:
,ETE/Z/®Aof PW,6 716e A-- 41 A) 14 s 70 AC .e2e_--ewr-A ,I( 16250
Identification Please Type or Print Clearly)
OWNER: Name: 1105f-�iZklee ,Ga Phone: � •3�.�-��s�
Address: �`l® Amx A/tlE r
CONTRACTOR Name: 14ee FDic'S etc Phone: 97y?b?_43z4(0
Address: 15;7ee7- �• /.vG.r�iF oi���
Supervisor's Construction License: Exp. Date: ,z3 A01
Home Improvement License: /S316_57 Exp. Date: f� W/ /
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contractin with unregistered contractors do not have access to he ua my fund
Signature of Agent/Owner Signature of contractor
. . nom_ ,�. . I rn „ . - r . r� —, r-1
Plans Suumitted Plans Waived ❑ Certified Plot Plan "tamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank, etc, Pr Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - IJ FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
ONSERVATION Reviewed on Signature
COMMENTS
a
HEALTH Reviewed on Si nature
COMMENTS
h�
r
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
]DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire ®epaa meri signature/date
.COMMENTS