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HomeMy WebLinkAboutMiscellaneous - 132 STEVENS STREET 4/30/2018 (2) 132 STEVENS STREET i� �' 210/036.0-0013-0000.0 i Town of forth Andover f MORTN , Office of the Zoning.Board of Appeals Community Development and Services Division 27 Charles Street North Andover,Massachusetts 01845 CHU D. Robert Nicetta Telephone(978)688-9541 Building Commissioner Fax(978)688-9542 Any appeal shall be filed Notice of Decision within(20)days after the Year 2003 date of filing of this notice in the office of the Town Clerk. Property at: 132 Stevens Street NAME: John J.&Charlotte R Ronayne HEARING DATE:December 9,2003 ADDRESS: 132 Stevens Street PETITION: 2003-043 North Andover,MA 01845 TYPING DATE: 12/11/03 The North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday,December 9, 2003 at 7:30 PM upon the application of John J. &Charlotte R.Ronayne,132 Stevens Street,North Andover,MA,requesting a Variance from Section 7,Paragraph 7.3 of the Zoning Bylaw and Table 2 for the rear setback in order to add a proposed attached garage. The said premise affected is property with frontage on the East side of Stevens Street within the R-2 zoning district. Published in the Eagle Tribune on November 24&December 1,2003. The following members were present: John M.Pallone,Ellen P.McIntyre,Joseph D.LaGrasse,Joe E. Smith,and Richard J.Byers. William J. Sullivan chaired but did not vote. Upon a motion by Joseph D.LaGrasse and 2nd by Richard J.Byers,the Board voted to GRANT a Variance from Section 7,Paragraph 7.3 and Table 2 of the Zoning Bylaw for relief of 15' from the rear setback in order to add a proposed attached garage per Plan of Land in North Andover,MA drawn for John& Charlotte Ronayne,date 9/24/03 [by]Dante E.Bartolomeo,P.L.S.# 15309,H&'B Survey Service,219 Salem Street,Andover,MA 01810 and Plans for Ronayne Residence,"122"Stevens Street,North Andover,MA,date: 10/22/03, [7 pages].on the following condition: 1. The existing detached garage will be razed and removed. Voting in favor: John M.Pallone, Ellen P.McIntyre,Joseph D. LaGrasse,Joe E.Smith,and Richard J.Byers. The Board finds that the applicant has satisfied the provisions of Section 10,paragraph 10.4 of the Zoning Bylaw and that the granting of this Variance for an attached garage in the rear that can be reached by the existing driveway will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Y Pagel of 2 - r'dr 7 - s a' 53 7 - 5 Board of Appeals 978 688-9541 Bi rl rig 9 8 688-954 Con ery trop 97R-6RR 9_.0 Health 9 R 688 9540 Planning 978 68R 9.35 V. R Town of North Andover f NORTH Office of the Zoning Board of Appeals o Community Development and Services Division 27 Charles Street ` .• -- `,r North Andover,Massachusetts 01845 "Ss„CHU D. Robert Nicetta Telephone(978)688-9541 Building Commissioner Fax(978)688-9542 Furthermore,if the rights authorized by the Variance are not exercised within one(1)year of the date of the grant,it shall lapse,and may be re-established only after notice,and a new hearing. Furthermore,if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two(2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice,and a new hearing. Town of North Andover Board of Appeals, r' William I Su Ivan,Chairman Decision 2003-043 M36P13. I Page 2 of 2 Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535 .1131 y FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT ��✓. /''1,,,,ti��ti ' Jy��• (l,wg-to-A PHONE 6O J�S3-3'_ LOCATION: Assessor's Map Number 03 PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER *********************** *************OFFICIAL USE REC MENDATIONS 9 FTOWN AGENTS: CO SERVATION ADMIN17kATOR DATE APPROVED ,U DATE REJECTED COMMENTS L FJS 0L,1V 4Af ;> ,-,00/ aU&2u�! TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED S I I CTO EALTH DATE APPROVED DATE REJECTED COMMENTS .S CJ Lt_j- G ir­ PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Town of North Andover f ,,ORT{ Office of the Zoning Board of Appeals �a °A Community Development and Services Division x 27 Charles Street *• - North Andover, Massachusetts 01845 AZ—Hu - 4 . D. Robert Nicetta Telephone(978)688-9541 . Building Conimissibner Fax(978)688-9542 Any appeal shall be filed Notice of Decision within(20)days after the Year 2003 date of filing of this notice in the office of the Town Clerk. Property at: 1.32 Stevens Street NAME: John J. &Charlotte R- Ronayne HEARING DATE: December 9,2003 ADDRESS: 132 Stevens Street PETITION: 2003-043 North Andover, MA 01845 TYPING DATE: 12/11/03 'flee North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday,December 9, 2003 at 7:30 PM upon the application of John J. &Charlotte R.Ronayne, 132 Stevens Street,North Andover,MA,requesting a Variance from Section 7,Paragraph 7.3 of the Zoning Bylaw and Table 2 for the rear setback in order to add a proposed attached garage. The said premise affected is property with frontage on the East side of Stevens Street within the R-2 zoning district. Published in the Eagle Tribune on November 24&December 1,2003. The following members were present: John M. Pallone,Ellen P.McIntyre,Joseph D. LaGrasse,Joe E. Smith,and Richard J.Byers. William J. Sullivan chaired but did not vote. Upon a motion by Joseph D.LaGrasse and 2nd by Richard J.Byers,the Board voted to GRANT a Variance from Section 7,Paragraph 7.3 and Table 2 of the Zoning Bylaw for relief of 15' from the rear setback in order to add a proposed attached garage per Plan of Land in North Andover,MA drawn for John& Charlotte Ronayne,date 9/24/03 [by]Dante E. Bartolomeo,P.L.S.# 15309,H&B Survey Service,219 Salem Street,Andover,MA 01810 and Plans for Ronayne Residence,"122"Stevens Street,North Andover,MA,date: 10/22/03, [7 pages].on the following condition: 1. The existing detached garage will be razed and removed. Voting in favor: John M.Pallone, Ellen P.McIntyre,Joseph D. LaGrasse,Joe E.Smith,and Richard J.Byers. The Board finds that the applicant has satisfied the provisions of Section 10,paragraph 10.4 of the Zoning Bylaw and that the granting of this Variance for an attached garage in the rear that can be reached by the existing driveway will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. r Pagel of 2 Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 t-lealth 978-688-9540 Plamning 978-688-9535 5 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facili y) Signature of rm' Applicant 3 ) v Dat NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector p The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name f/ Please Print Name: � CJ - Location: l 3 Z S1- S •.* City �� >Q G��`t� Phone # I am a homeowner performing all work myself. F-1 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: VJy Phone -r33 r Insurance Co. Policy# /". C_ yarn L� l Com name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,5W.00 and/or one years'imprisonment-as weti_as_civil.penaltiesinbefmncfa..STOP WORK.ORDER,and_a.fine.of.(.S100.00)-aday againstme. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification, I do herebyertify un a pains penaltie of perjury that the information provided above a true and correct. Signature. i nature 1 9 Date Print name . .: Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other _ µaerH Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 "�1s""''°0E'ay. SwCHt15 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION Ma /lot Number Street Address P "HOMEOWNER Work Phone Name Home Phone � PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"home6wners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner'certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Town of North Andover NORTH Office of the Zoning Board of Appeals Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 9Ss�c►+usE� D. Robert Nicetta Telephone(978)688-9541 Building Commissioner Fax(978)688-9542 Furthermore,if the rights authorized by the Variance are not exercised within one(1)year of the date of the grant, it shall lapse,and may be re-established only after notice,and a new hearing. Furthermore,if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two(2) year period from the date on which the Special Permit was granted unless substantial use or crostrt ction I ccc«inenced, it shall lapse and may be re-established only after notice,and a new hearing. Town of North Andover Board ofAppeals, i' W William I Su ivan, Chairman Decision 2003-043 M36P13. Page 2 of 2 I Board of Appeals 978-688-9541 Building 978-688-9545 Conservation918-699-9530 Flealth 978-688-9540 Planning 978-688-9535 i DOMENIC J. SCALISE ATTORNEY AT LAW 89 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 TELEPHONE (978) 682-4153 FAX (978) 794-2088 - January 26, 2004 Mr. &Mrs. John J. Ronayne 132 Stevens Street North Andover, MA 01845 RE: Application for Variance from Zoning Board of Appeals Property: 132 Stevens Street,North Andover, MA Dear John and Charlotte: Concerning the above captioned matter, this letter will confirm that we appeared before the North Andover Zoning Board of Appeals on December 9, 2003 regarding your request for a rear setback variance in order to add a proposed attached garage. The Board allowed the variance and issued a Decision which was filed with the Town Clerk. After the required twenty(20) day appeal period, I recorded an attested copy of the Decision and the signed mylar plan with the North Essex Registry of Deeds. I have submitted copies of the recorded documents to the North Andover Building/Zoning Department. This concludes the permitting process. You may not contact the Building Department for your building permit. I am enclosing herewith a copy of the Zoning Board Decision, as well as the Registry of Deeds recording receipt. I am also enclosing my bill for legal services. Please contact me if you have any questions. Thanking you for having considered me for this service and hoping that everything is satisfactory, I remain Very truly yours, Domenic Scalise DJS/cm Enclosures -'-- DOMENIC J. SCALISE ATTORNEY AT LAW •• ' ., 89 MAIN STREET NORTH ANDOVER, MASSACHUSETTS 01845 TELEPHONE (978) 682-4153 FAX (978) 794-2088 January 21, 2004 Town of North Andover Zoning Board of Appeals 27 Charles Street North Andover, MA 01845 RE: Jolui J. and Charlotte R. Ronayne 132 Stevens Street North Andover, MA 01845 Dear Sir/Madam: Concerning the above captioned applicant, I am enclosing herewith: L An attested copy of the Decision (Petition 2003-043) regarding the Stevens Street project which was recorded at the North Essex Registry of Deeds on January 9; 2004 as Instrument No. 1092; 2. An attested copy of the Plan of Land in North Andover, Mass. drawn for John and _ -- Charlotte Ronayne approved by the Zoning Board on December 9, 2003 and recorded in the North Essex Registry of Deeds on January 9, 2004 as Plan No. 14664 (Instrument No. 1091); and 3. COPY of document recording receipt from the North Essex Registry of Deeds. Very truly yours, ZI Domenic, . Scalise DJS/cm Enclosures cc: Mr. & Mrs. John Ronayne s. lc� L t.ci a�.(Lct /(-tom Towin<of lor�h'° ndov er Off><ce of the : NORTH g Btaa>�tof A ;ps M�R1j • ��Op< eolnrlmuni#y.�eve�o�>r�.�1�t 2fi Chanes Skteet �. North Andover,Ivl�ssacitusetES �n6Hus�`' D Robert Nkata Telephonic(97f1).68&9541 B ildog Co rmnussjoner.: Fax This i.s tti certify that twenty('01 t" elapsed from date of def.isirni, IT5 have t . without filing.of an appeal AnY appeal shall be filed. 1Votice=ofDedsionDate` With in 20 da after the..,.. oyce a Shaw J A Br d ( ys Year 20.03 : Town Clerk date of.filtng.of this> totice.: in the:gffiCe of the I'or?vn Clerk Pfoptertygt 132 SEevens Sheet NAME :Johtr J ,&Ghartotte llt�ogle�rne • " 1t AkRINi 1 AI Dece fiber ADDRESS 1, 2 Steyens;�stt RET11( Northflndov... alE$45 - ZtfQM43 T'YP1N (J:DAT'E..:12/l - ne North Andover Wgrd ofA;ppeals held a public heAring atxts regular mee ttg arrTuesday,Decetnber 9; . 2003 M73, PM upon theapplicatton afdolttt`.1icblaxtoEte R.soma Andover, g SteVOW Street,North . MA,requestiit a Uartancn 1ott►Seetton 7,',PeragtUplt 7 3:oftlie:.7pIIluggylg�►antfi TabTe.2 for: the rest setback itt ea dei Ea add n proposed attainted garage The said premise a8�cted is o frontage;op the East std&bf Stevetts.Sheet witl to d;ie_:1>�2 zaaing disttx`ct..Published in the r burse on Noeinber Z Decetn�er.1,2003: . The followutg members ereOresent:.:John.-M..'Pjolone,ElYe i-P McIhtyr-e Joseph D L» sse,Joe E: . ; mtth,and Rach'ard J Byers' tlha n J:Sullivan chaired. t+did.ftot vote :. 1Jport a motion by Joseph D LaGrange aid 2°d RtcAard J H �3' Yeti,the-Boai~d.yotel to GRANT a Yartanee fi om Section?,Paragraph 7 3 and Table 2 of fheonuig Bylaw forIief of..t5'8}�m.:the.rear setback to order to ad PFW�Pseit;attarhed garage;:pet P]6 of Ladd m Ati�dnver drawn far� Eharlotte Ronayite,date;9 /43. . Iaut�lL. att 8t. { '� I5309�I . Survey.3ervtce,219 Salem Street,Ai dove ; 018 0 and P lana for.Roua)MeRegM ence. 122"S' `5.treet,North,' Atxdover;MA,date 10/22/03,�7•yg$ss on the b 16W. m" Qondi' . e�sisEln ;detadiecl garage w111 be teand pved: Yotmg In favor >Joltn IVJ Pallone, Ellen P h�Iclntryre,JaQepti DLL k.at!C�rasserlae l;,snuthy aid R1ltartt J $yew �1ie Board finds that the appltr t,bds sattsfidd the Prov scans of ecktob 10 ar Bylaalnctltatttis �.p agraph,l(l4 oftheZoptng . gra png�f th,s V�rtar►ee eor an atrac�e�garage m tl re$,r.that M tea.4ed by the existu][g drivewa}+>wnllatotadvets�ly aactt&eeagl�bvtliood orderegat $otar.tHethtett anpvrpose of.tlie: Ziinutgy�aw. Page.1 of 2 ' Copy , r"1 $oard of Appenls978 688-954)i Building 978 688-9545 Conservation 97R 68R-9530 t3ealth 978 688 9540 Planning 978 88-9535 „ Town of North Andover 01F?T11 Office of the Zoning Board of Appeals F� '' `�'~°p Community Development and Services Division ; 27 Charles.Street " -- �`w' North Andover, Massachusetts 01845 'Ss„ 58� D. Robert Nicetta Telephone(978) 688-9541 Building Commissioner Fax(978)688-9542 Furthermore, if the rights authorized by the Variance are not exercised within one(1)year of the date of the grant, it shall lapse,and may be re-established only after notice,and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two(2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice,and a new hearing. Town of North Andover Board ofAppeals, i' ii ^f William J. Su livan, Chairman Decision 2003-043 M36P13. Page 2 of 2 Board of Appeals 978.688-9541 Building 978-688.9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535 I I ( . , _7 / Essex North County Registry of Deeds 381 Common 5treet Lawrence, Massachusetts 01840 01%09/04 I! SCALIS:E It 14 Rec. TvE c. ;i 5:s;„;!t; DOC„ 109:1 C„ P. :_'ti„:ti:: �t� R„ iia 00 Copies 31.tb;) It 15 Rec., Type CERT .i;„00 DOC. 10941”, i .oo 5.00 Total 1`i3„tit) 16 Paur�ient Check 1,13„0';1 THANK OU! Thomas J„ Burke Reiiisteir, of Deeds s zoo/ No. 11rr-- T Date d p NORTH TOWN OF NORTH ANDOVER 00 p BUILDING DEPARTMENT �9ADAATiD i.)* � .. �SSecHuBuilding/Frame'Permit Fee : $ Foundation Permit'Fee $ Other Permit Fee $ 7a ZBA 174 OF r10R7H, TOWN OF NORTH ANDOVER O T RECEIPT CHUs�t This certifies that llWt :..t........ .t...........`�...l.6(�.......................... has paid. ..S[/..!.0r?.....4-G�.:.........7T...0` .�. .......................... for...� 5.....vA....... ..Tr..... ........................... Received Z................................................... Department..... WHITE: Applicant CANARY:Department� PINK:Treasurer i R TFi Town o Andover 0 No. ly ` ' r dover, Mass., 9 8 T 0 _= LAKE 1 T COCMICMEWICK ADRATED PPS` �5 �SSAC HO FOR EXCAVATION AN o FOUNDATION THIS CERTIFIES THAT ..... N.. .. ..... ........................ 111 ................................... has permission to excavate and pour foundation at ..... .3. 4 ) r' ! • tib S .......... .................................................................... for the purpose of.., ypy o J bull at* r. w.,� A, �.......!!!�..�4.6�rr ....... ..... ....... ....,................... The person accepting this permit must return to the office of the Building Inspector a certified plot plan show %� X14 rA of building thereon before Foundation will be inspected. i 6A Dee * 0006- 643 �4 -y- 03 VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS The holder of this Foundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS assurance that a permit for entire building structure will be granted. BLDG. PERMIT FEE o< L ... . ............................... . ................................. DUE SEE REVERSE SIDE BUILDING INSPECTOR �.1ORTH Town of :�._ over No. 1 o�� d0 LA ower Mass. 8 �'© Y COCMICHEWICK V ADRATE D O`?�,`�5 .S BOARD OF HEALTH PERM IT T Food/Kitchen Septic System BUILDING INSPECTOR 9;.A40 ... ..�i�THIS CERTIFIES THAT..... .... 1 . ........ Q�.ov.lq.�, ..�i�.................... Foundation • , has permission to erect.!�.�.,�-ap.............. buildings on ....., ..• .....4S.*1tW.V.#V.4......4.. — .... Rough to be occupied as..q?..0 "t-.a �/ g�o�� �� A��w I ' • �'�M'jW� Chimney . . . . .. . . . .. . . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in I Z Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. G/! 2 4SA . a�o3�Oy3 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. —of-403 Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI N S ART ELECTRICAL INSPECTOR Rough ..... ................ ..... Service .. .. .. .. .,.. . ..................... BUILDING INSPECTOR Final Occupancy Permit Required to Ocatpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough al No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location �,. No. Date 14ORT1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ • O� •w�iw.n4 • s' Nus<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r. TOTAL $ l e n ` Check # r X7628 _ - Buildingg lnspgCtpF` TOWN.OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED. X SIGNATURE: Building CommlSdoner/InSpeetor of Buildings Date SECTION 1-SITE INFORMATION I 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 03 001 -3 Map Number Parcel Number 1.3 Zoning hiformation: 1.4 Property Dimensions: lel Zoning District Proposed Use Lot Areas Frotua e ft `�' 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided p l.7 Water Simply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private 0 Zone Outside Flood Zone Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1 fistal ic bisti ict Yts M X2.1 Owner jm`of Record Name(Print) Address for Service S' ature V Telephone 2.2 Owner of Record: J u\� Name Print Address for Service: Si re Telephone �= S CTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Su rvi r: Q53 b l `) License Number ��"` 1Sv A— ,�..� 's� Iry � t��,. aan Address Expiration Date r Sig ture Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name M Registration Number ddress z SA Expiration Date /1 Signature Telephone {�/ •� T 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 Pioposed Work(check au applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be UFFICIALT7SE()NLy` g ' Coni leted b ermit a licant �y ,4 1. Building (a) Building Permit Fee k,U , 6 v v Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)X (b) 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> J 12�.+•-� ✓. A S.A.—_–'k as Owner/Authorized Agent of subject property \ Hereby authorize `<g"'-z /11-k to act on M e alf 1-n–aA matters relative to work authorized is building permit application. ��- S' e of Owner Date S TI tON 7b OWNER/AUTHORIZED AGENT DECLARATION 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 j and belief ri e Sil ure of Owner/AJ 11 gill Date NO. OF STORIES k ( SIZE D BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 ST – 2 RD 3 RD SPAN l DIIv1ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS `` h.; HEIGHT OF FOUNDATION ` THICKNESS SIZE OF FOOTING 4 X t MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND y u✓> IS BUILDING CONNECTED TO NATURAL GAS LINE