HomeMy WebLinkAboutMiscellaneous - 140 VEST WAY 4/30/2018Location NO ulel�� W /
No. J Date C ) U3
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TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 30
Foundation Permit Fee $
Other Permit Fee $
t
TOTAL $ 30
1
A Check # 3 y 2
Building Inspector
/11
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1 -SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number 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
Recti fired Provide Required Provided
R rtd Provided
° 1.5. Flood Zone Information:
1.7 Water Supply M.G. 40. 54�`
Public ❑ Private ' r Zone Outside Flood Zone ❑
1.8 Sewerage 1 System:
erag Dispose ys
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
.1 O r of Record
O
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si natutt6 Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
s
Not Applicable
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
4
Not Applicable
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
T
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X
ic
Z
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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 all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
Ard-4 4-99
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
00
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total"(1+2+3+4+5)
Check Number o Z
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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
Print Name
Signature of 0e/A ent Date
=411411W il 111=111 1.
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIN ENSIONS OF POSTS
DiMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHININEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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