HomeMy WebLinkAboutMiscellaneous - 10 LYMAN ROAD 4/30/2018N
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Location./,/"
No. Date X-0
jORTh -1 TOWN OF NORTH ANDOVER
0.
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
14 4 C 7
Buildi ng InCppttor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: 1#94.f
Building Commissioner/19awor of Buildings Date 'L • . vex
SECTION 1- SITE INFORMATION
`1.1 Property Address:
V ik
1.2 Assessors Map and Parcel Number:
Map 1,1u. Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
RecIttired Provided
1
1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information:
Public ❑ Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2. of Record
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Name ( rin) Address for Service: I
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES .
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
•��
Expiration Date
3.2 Registered Home Improvement Contractor
C) e- t VIA
Not Applicable ❑
Co any ame
Registration Number
Address (n 1
Si nature Telephone
Expiration Date
SECTION 4 - WORKERS COMPENSATION (MG.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 all applicable)
New Construction ❑
Existing Building ❑
Repair(s)
❑
Alterations(s) %
Addition ❑
Accessory Bldg. ❑
Demolition t ❑
Other ❑ Specify A OL
., iA - '
Brief Description of Proposed Work:,
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (@)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, 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
� 11,
Print Name
�i at of Owner/A ent
Date
NO. OF STORIES
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST2
ND3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CHRANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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The Conlnionivealth of Massachusetts
Departnfent of Industrial Accidents
Mce offtestlyaUvns
600 TYashington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
❑ I am a homeowner performing'all work
M I aril a talo nrnnr;nf .r -A t....._ –_ _--_
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❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
Co pony mime
Failure to secure coverage as required under Section 25A of MCL 152 can lend to the Imposition of criminal penalties of a fine up to 31,500.00 and/or
one years' Imprisonment as well as civil penalties in the form of s STOP WORK ORDER and a fine or 5100.00 a day against me. I understand that a
copy or this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cerri7jy�u/n'der the pains a penalties ojperfury that the information provided above is true an�d7 cor. ecr.`
Signature` Q'et pl ((2 Date
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Print name Phone q
official use only do not write In this area to be completed by city or town official
city or town: permit/license N -Building Department
[] check if immediate response is required []Licensing Board
❑Selectmen's Office
(]lleaith Department
contact person phone #; _ -Other
('cubed 7/95 PIA)
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Mario Castricone, Prop.
Tel, 682.4266
CASTRICONE ROOFING & SIDING CO.
31 Court St, No. Andover, Mass. 01845
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