HomeMy WebLinkAboutApplication - 280 GRAY STREET 11/5/2004 .FORM U - LOT RELEASE 'FORM
INSTRUCTIONS.: This form is used to verify that all necessary approvals/permits from
Boards and'Departments having jurisdiction have been obtained. This does not relieve
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APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT Litchfield Company, Inca PHONE 781-270-6859
LOCATION: Assessor's Map Number 107D PARCEL 10
SUBDIVISION LOT(S) 1
STREET Gray Street ST. NUMBERAW 260
USE
N A OFT GENTS:
ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS . " lY l! �'ticKy V
,/'TOWN PLANNER DATE APPROVED.-.
DATE.REJECTED
COMMENTS
FOOD 1 PEqTOR-HEALTH DATE APPROVED
1 DATE REJECTED
SPECT. -HEALTH DATE APPROVED / S"
DATE REJECTED
COMMENT � r-�
v► /c.W
/2S Cr �t C? ✓`° Ls '- .� i cam ✓ �s ! r l a
PUBLIC WORKS -SEWER/WATER CONNECTIONS //-
DRIVEWAY PERMIT
FIRE DEPARTMENT �sI l"z�✓w1�S'. rPa�tl /� ,�� :J^� �s /i,/ �- l�� t��. Y
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
SECTION 4-WORKERS COMPENSATION
(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial,of the issuance of the building unit.
Signed affidavit Attached Yes.......❑ No.......
SECTION 5 Description of Proposed Work check aII applicable)
New Construction M( Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
New Construction — Single Family Home
4 Bdrm, 2 1/2 Bath, Colonial
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be
Completed by t applicant OEM=
1. Building (a) Building Permit Fee
50,000 Multiplier
2 Electrical (b) Estimated Total Cost of
13,000 Conshuction
3 Plumbin 13,000 Building Permit fee(a)x(b)
4 Mechanical HVAC 1__0_Q0
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Gary J. Litchfield as OwnerX2U0R3aW0@kVbf subjectproperty
Hereby aufhoriz to act on
My behalf,in a e o ed by this building permit application.
Signature of Own r Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, Paul Litchfield asXXMWAuthorized Agent ofsubject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Paul Litchfield/
Print N
4'L
Si a r9W er A ent Date
-NO.OF STORIES SIZE M
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST 2 NV 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING ' X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
TOWN OF NORTH- ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building CommissionerflpEeEtor of Buildings Date
SECTION 1-SITE INFORMATION 0
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Lot 1 Gray Street
107D 10
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R7 Si ngl e—Fami l w Tromp 41560 1 Sol
Zoning District Prol Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS 11
Front Yard Side Yard Rear Yard
Required Provide Required Provided red Provided
40 30 30,
1.7 Water Supply NMI—CA0. rm
34) 1.5. Flood Zone Information: 1.E Sewerage Disposal system:
Public i Private ❑ Zone Outside Flood Zone $) Municipal 0 Ou Site Disposal System$)
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT c • 0 m
2.1 Owner of Record
Litchfi 1 na. 1 26 Ray Avenue Burlington, MA 01801
Name(Print) Address.for Service:
781-270-6859
Signature Telephone
2.2 Owner of Record:
;Name Print Address for Service:
0
m
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: O
96 Riay Ave. 'lirli-ingi-inn. MA 01801 License Number Mfl
Addles
/ 781-270-6859 Expiration Date
*nature Telephone r
s
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name rn
Registration Number
Address
n>_
Si nature Tele hone Expiration Date