HomeMy WebLinkAboutBuilding Permit #Exception - 10 LACY STREET 5/1/2018 ,Y
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TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION o',,�.• ,,'��
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Permit NO: Date Received A
Date Issued: 'y��°'�*�•�'' �'
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IMPORTANT:Applicant must complete all items on this page
LOCATION,
Print-,
PROPERTY OWNER
Print
MAP NO.: r L> PARCEL: A9 7 3 ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
0 New Building 0 One family
0 Addition 0 Two or more'family ❑ Industrial
❑ Alteration No.of units:
❑ Repair, replacement ❑Assessory Bldg ❑Commercial
❑ Demolition
❑ Moving relocation 0 Other ❑ Others:
❑ Foundation only
DE CRIPYO OF WO TO BE PREFORMED
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Identification Please Type or Print Clearly)
OWNER: Name:
Phone:
Address:
CONTRACTOR Name:t5�_ ,rO Phone ,f. 0—
Address:
Supervisor's Construction License:i�fJ 0 %17 Exp. Date:
Home Improvement License: C 70` p
! Exp. Date: C S 7
! ARCHITECT/ENGINEER 11-'1 ,e/ Name: Phone:
73 elgd o
Address: 7
�/ 3�t �/, �0"45Reg. No.
FEE SCHEDULE:BOLDING P RMI_T.•SIZOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ONS125.00 PER SF.
Total Project Cost :$ 5 D 06DFEE:$
Check No.:
Receipt No.:
Pop W4 4
TYPE OF SEWERAGE DISPOSAL
❑ Tanning/Massage/Body Art ❑ Swimming Pools p
.Public Sewer ( i
.Well F1Tobacco Sales ❑ Food Packaging/Sales ❑
Permanent Dumpster on Site ❑
Private(septic tank,etc.
Electric Meter location to
project
NOTE: Persons contrac;Plaansived7E]
contractors do not have access to thMaranloy
nd
Signature of Agent/OwnerSignature of contracto
Plans Submitted � Certified Plot Plan
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
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COMMENTS
REJECTED DATE APPROVED
CONSERVATION
COMMENT
DATE REJEC D DAPROVED
HEALTH
T
l
COMMENT S'
CAA R R . Rn\
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-
FIRE DEPARTMENT - Temp Dumpster on site yes ��
no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals: Variance,Petition No:
Zoning Decision/receipt submitted yes
Planning
Board Decision:
Comments
Conservation Decision: .. d
Comments
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Water& Sewer Connection/Si nature& Dat
Driv wa Permit
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