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HomeMy WebLinkAboutMiscellaneous - 1 FOREST STREET 4/30/2018" t Location No. Date I 140"Th 0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 616�� r —, Building Inspector 1.1 Property Address: /„ C Fc, 1"` c--,s'i 5`t 1.2 Assessors Map and Parcel Number: /0 49.11 00b Map Number Parcel Number y,�y 1} SGS a V r v✓1 Gl 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Let Area Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided C, � c06 Pt. .5d 7 1.7 Water Supply M.G.L.C.40. § 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record ( cx Ori c' L d 1` c S 1 Name (Print) Address for Service: U -b 7 �- Gd's 4 A� o Signature V Telephone 2.2 Owner of Record: Name Print Address for Service: Si ,nature Telephone SF%CTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Pw (a w©ted �v�o�v��S Licensed Construction Su sor: License Number C. k lC.-.-� Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone OU M X 3 z O z M 90 O "n e r M r r MEMNzz V) SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work (check an annlicable New Construction ❑ I Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition 0 Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: W o o CP S Al (2;"d I SECTION 6 - ESTIMATED CONSTRITCTIoN ro-TS I Item Estimated Cost (Dollar) to be Completed bpermit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction f y 3 Plumbing Building Permit fee (a) x (b) _ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ;5M-11V1N /8 V WNEK AU 1riUK1LA1lUN TU 11E CUMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work au* rized by this building permit application. Si tore of 0caner Date Q SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/, NO. 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