HomeMy WebLinkAboutApplication - 1500 FOREST STREET EXT 6/21/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
43
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION �� (-GS I.- rXT ,AIMT�-I
Print
PROPERTY OWNER M A(ZY aAQ-sSo7 ,J AL iL4 kA; 17-1 LJ
Print 100 Year Old Structure yes no
MAP NO: U! PARCEL ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement Assessory Bldg C;NR)Lt2 SHE . ❑ Others:
❑ Demolition ❑ Other
❑ Septic H Well ❑ Floodplain ❑Wetlands` ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: MA fL K �j-n(1-cso of , Phone: 012 �
Address: IS��0
CONTRACTOR Name: P&C i S Ft 2{�_ S %�1ZS.Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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 contracting with unregistered contractors Flo not have access to the guaranty fund
Signature of A ent/Owner / �
" ' Signature of contractor_
..............
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBodyArt ❑ 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'A"DEVELOPMENT ❑ ❑
CO MEN T S
f
CONSERVATION Reviewed on / I Si nature`- l- J11
COMMENTS
I HEALTH Reviewed on 3 Sign ture
V
COMMENTS
v
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 Toiv;> Engineer: Signature:
_ Located 384 Osgood Street
FIRE DEPAIATMtIIL-'NT - Temp Dumpster on site yes no
Located at 124 Mai6 Street
Fire DeOritmet f signature/date
COMMENTS