HomeMy WebLinkAboutApplication - 61 WHITE BIRCH LANE 6/14/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
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Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION / ��! i fG r r,L+
One �•G9��odC��°
_ Print
PROPERTY OWNER j �'�o per- Unit#
Print
MAP N0: PARCEL: ZONING DISTRICT: Historic District yes na
Machine Shop Village yes
100 year-old structure yes (ff
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑New Building &One family
El Addition ❑Two or more family Q Industrial
RIAlteration No. of units: ❑ Commercial
0 Repair, replacement ❑Assessory Bldg [I Others:
❑Demolition ❑ Other
eptic 30Vij�ll� ,�IFiloodplaiuh ®Wetlands �= �'WatershedtDistnct
0 Water/_Sewer
DESCRIPTION OF WORK TO BE PER Nd��� fa � �c
` V2 e- 7`Gr ini Pd j.41 S7rrwe� e S'7`2 ivtelzN v�r��
)-X(v fs �/y ,Dl� irts7�iL/rd - -� /�" °` kycc w z!/�' 2 f- iY ' ®� k,Al,
(Identification Please Type or Print Clearly)
OWNER: Name: I ®d C /6,g®� Phone: q 7� °�d 7.�®
Address: 6/ GcJ y�e •3%�-o a a e /�� �v @v-
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:- C S Q0 3 r 13 Exp. Date: ` -7-.2-DrY
Home Improvement License: L Cis' q q 3 Exp. Date: - /7- 4-0I Y
7' M A IP T he
ARCHITECT/ENGINEER �e 2 vl n e 14 11�.� Phone: ' `�75- Ll 9-4 ° aLA 6 3
Address: 1�_ A I f red S1"- L4 15_2)0 066 ,,,,W12• Reg. No. y s'
- 01161
FEE SCHEDULE:BULD/NG PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $_ o 0 o , FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of:Agent/.Owner '� .. ; �. . . Signature_ofcontractoF-.;'::-'___7:_'___
:
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans R-
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑' Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc, permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
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CONSERVATION Reviewed on Si
anature
COMMENTS
HEALTH Reviewed o n �G �C 1 �Si nature
COMMENTS
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Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/sic
nature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Durnpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS ; I