HomeMy WebLinkAboutApplication - 83 OLYMPIC LANE 10/4/2011 TOXIN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION PS )'C 4--6A yl c
Print
PROPERTY OWNER �i�?1 U I} Unit#
Print
MAP NO: PARCEL:ZONING DISTRICT: °� Historic District yes np`
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building XOne family
Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
0 Septic D Well ❑Floodplain 11 Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
/K t,.r
(Identification Please Type or Print Clearly)
OWNER: Name: C N' ,s , vi- C�C)I I'fN ` Phone. , ;§'
Address: X3 0 6mo c- La r'-a Al r 1�AOo1_� h`co 01 �� /
CONTRACTOR Name: r /��1 i th'(`i�- Phone: 6�� �6 :.2Q),_A 0
Address: qa /.,;n, (c
�lri l�s° c
Supervisors Construction License: 2 "/0 :56- Exp. Date: L11 c► 3
Home Improvement License: 3 6 Exp. Date: O
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 S.F.
Total Project Cost: $ 0 �,�//: &)00, o, FEE: $ _
Check No.: Receipt No.:
NOTE: erso��s contf rating with un1 egiste�ed contractors do not have access tot gu�c anty fund
(Sign f Owner - Signafiure of.contractor: Gcc�
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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
CONSERVATION Reviewed on Signature
COMMENTS
JHEALTH Reviewed on / l% Signature
14 A411"
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
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS