HomeMy WebLinkAboutApplication - 115 LACONIA CIRCLE 12/12/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:_ Date Received
Date Issued:
IMPC9RTANT:Applicant must complete all items on this page
LOCATION / ry :w_ r �f ..., A
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PROPERTY OWNER C �'`b( 4 r _Unit
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MAP NO: PARCEL: ZONING DISTRICT: Historic District Tyesno
Machine Shop Village 1.00 year-old structure
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑ , Iteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
ter h'
❑ Septic ❑1Well: oodplam o s ed�D
❑iFl Wetlands, Wa is ct
❑'Water/Sewer` ,, ,
DESCRIPTION OF W RIB TO BE PE//{RFORMED.
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(Identification Please Type or Print Clef ly) �
OWNER: Name: Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.,BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER SF.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors(to not have access to the guaranty,ftind
Si nature o:F_Agent/,OWner. Signature of contractor 1
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tann nglMassage/Body Art o ❑ 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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on �� - I.... Si nature
COMMENTS
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
�„ FIRF DEPARTMENT -Temp Dumpster on site yes no
���ocate at i 24 Main Street
❑�❑%/ ;`
� ��❑�,, �,L!e ,artm.ent signature/date
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