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Home My WebLink AboutMiscellaneous - 15 WALNUT AVENUE 4/30/2018Location /`J No. d �?�� Date i NORTH TOWN OF NORTH ANDOVER o f p • ; ; Certificate of Occupancy $ Is b'••so Building/Frame Permit Fee $ ,ss�Ic Musa Foundation Permit Fee $ Other Permit Fee $ .+v TOTAL $ Check # 1141 16013 r Building Inspector d -,-el 76 .. -s - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: C2DATE ISSUED: 16,5) CR SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: i� 33 U odzF Map Number Parcel Number 1.3 Zoning Information 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 Required Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) — 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service sk- 67� ? Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: _ Ll 4of!Wk9�Y 77 Licensed Const&ction Su rvisor: Address gnature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone M rn X Z 0 v rn Q W 0 Qct I � 1 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 .......0 No ....... ❑ SECTION 5 Descripfiq"a of Proposed Work check all applicable) New Construction Existing Building R" Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: , 4DOIA1 oN /) F C.A / a X IK .91�� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant_ " OFFIC1AL VSE,0NLY 1. Building �U (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) O �- 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, �1CA4 X 01 1'144e4 7-,te-;,) as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1,�i¢ As Owne CuthoDnzedAnt of subject property— Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief '/ 4W9 r7 Print Nam zl 2— Sigdture of Owmer en Date RNIEW 1111 1111il —W NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r; o J I HEREBY CERTIFY TO THE TITLE INSL'ROR AND 1'II1 :3A1J.Y ffLjT ?'SIE DIrEL%ING IS LOCATED ON i'I21s i)if: S I-01 T.W rNry T1L4: Ij Do CONFORM 1Ni Fll TIP "a 0. ZONING REGf1ATIONS ,r((iheFROM REK t S' d I.t�T LINES. I F,r p-RFR C.E:RTII'P TIMI MIS LVEI,LiM0 IS NOT IN Tll, FRDV& L FLOOD HAZARD AREA AS Sm" pn" CIN YO :-r i,� i fi Y ��1INEi :. , , 9 - L+d t�a" s-Ijyi1k`i'.ifi R. C.. ,S. A;T a' r ii: %°h i .rc;7ia c, k7a Ti_r E, R;.r,'` _ 0R.f)S• �>I ntpnn lr eccm rieut�stf�l9a91n�sagg�relans+e�wrn®arsa�aa�mm�ra�......�.��.. L'I0.i WN FOR i 66 PAARii STl>'U'll, f ANDOVER AfASSACIIU�'A'7'7S 011110 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_/} � 4 �/C a4_ 2 &ej PHONE !�'7F-�S8-SG 71 LOCATION: Assessor's Map Numbero)/a 033,0 -44 ZJ PARCEL 06a9 SUBDIVISION LOT (S) / STREET Ll- (� 1 ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** REO MMENDATIONS ,F e t//CONSERVATION ADMI T COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH TOWN AGENTS: SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT I RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm it , .t Ll �J# J, r � j �_ �� 1e -�an�rrianurea�i o�✓�iaaoac�ivaelld i BOARD OF BUILDING REGULATIONS x License: CONSTRUCTION SUPERVISOR Number'C$ 081804 Birthdate: 05/20/1951 } , Expires: U5l20l2006 Tr. no: 81804 Restricted GARY J LOPRESTI } 60 WEBSTER ST rz.* MALDEN, MA 02148 Administrator I I 14'-p° x C0 r., CD m C m C/) 0 m v rA C � d y n 10 0 CD n Z co) CL �• O CL _• y > CO o � CD o v CD O CL c CU CD CCD O CD w w 23 C O C/)CD• d D CCA CD i I rrn cn n O z cn0 z cn d C C O ?� 01 = �' N, O Q H EL - .CD .O CO) Z H Dao m Cf �lo H --i oma. -* m " T � a a m CD �OOy p ti O = m y m D O y. CO! c 'Z o N a C O �-► * 44,m O N C O m GO MCL O d y�k y C. ? ' Q a a C4 CO to .. �m y m mw CO3 CD lrCD Li 0 0 CD o Ilko CD CD N cs wt a'g . CM _ C o O z H w G yGO) phi G �- G QT rd ro 0 w ]" C a tz b O Off. x �i rA omi 0 0 c l) No 1766 Date....... ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... :::................ t.......... .......................... has permission to perform.............. ................................................... ........................................... wiring in the building of ...... ; .......... i17 .7. at ................ ............................. . North Andover, Mass. Fee -:..t.5.......'...... Lic. I .. ......... ...................................................... ELECTRICAL INSPECTOR 08/04/99 11.30 M-00 WHITE: Applicant CANARY: BuildPAID ing Dept. PINK: Treasurer =(J9 V0NWEALTHOFMASSAGR=7N Office Use only DEPARTMENT OFPUBLIC&= (� 1= Permit No. ^�? BO* OFFNEPREVEM ONREGUL4TIONS527CNR 12:00 Occupancy & Fees Checked 3t5 r APPLrICATI PERFORM ELECTRICAL WORK ALL WORK TOB ASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRLN7IN INK OR MAT%TNFn=!W1 RMATIO Town of North :Andover MAP The undersigned applies for a permit to perform the electrical work described beloPARCEL _C4___ Location (Street & Number) /6 W oj/� u l \5 Owne, or Tenant /"1%�J. VA1 V U10 Owner's Address XQ 1 I&M�� LlWL/IJ(, I _S/ Is this permit in conjunction with a building permit: Yes = No (Check Appropriate Box) the Inspector of Wires: Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Underground a No. of Meters Ne%v Service .Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work . or 7—ii5-rALG14T o7 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No of Lighting Fixtures Swimming Pool Above Below Generators KVA Q(round ¢round No. of Receptacle Outlets No. of0d Burners No. of Emergency Lighting Battery Units No OI Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No of Dishwasners Space Area Heating KW No. of Self Contained ----1 Detection/Sounding Devices Locala Municipal Connections r"'� Other `'o of Dryers Heating Devices KW No of Wafer Heaters KW' No. of No. of Signs Bailasls No HvCro ,`laW2e Tubs No. of Motors Total HP i OTHER 4-sx3rce Co>a e Ras M b the r>a?u r=s ct-VLissx� Gaiaal Laws .._.�,/ I Ise a arrm L miv Pch y nidng Co riple � Coy rai e cr its ailstaqrl e4r akTx YES �[E] NO I have ay cx Lmed valid pr fofsarne sa the Owe YES U NO r-1If;cu have chezie YES, please irdca� dre type cf by chef: � the Z=bac RA,\:CE BOND O OT I -E R a ftese Specify) Siz� X'±rm Ptd ofpe: jw FIRM NAME cSa 64t/AIU Air -111n,417- V AL,t?r�o2i1 Estes Valted.l Wait S Frtal L=-seNa ;ASST -b L 1i�Cr D• S�/r 1-14/V since r� .� ;sUf,�tt/T�-� Limsetvo �Z S C B(sm-sTeLNo QZl &*z 6 V7 AIL TeL Na OWNER'SD\a"RANCEWAVER;Ianawareth� d-eLr_ersct rxttrovether<suarr� ct ai l cast zdby G��a�L��s acxi dna my si�aaseat dris perms � the r�x>>rar�erx. (Please ch�--k one) Owner Agent Telephone No. PER:MT i FEE S r • PERMIT NO 31rC. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP NO. LOT NO. I 2 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE SUB DIV. LOT NO. LOCATION �3 !i ._ a•� PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES SIZE i® OWNER'S ADDRESS c BASEMENT OR SLAB ARCHITECT'S NAME BUILDER'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD SPAN DISTANCE TO NEARE BUILD G r DIMENSIONS OF SILLS DISTANCE FROM STREET /1/G L'�/JClpl� t[ POSTS DISTANCE FROM LOT LINES — SIDES f` /I REAR IV, AREA OF LOT FRONTAGE " " GIRDERS HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEA.R G IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BEyFILED /AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE/OF OWNER OR AUTHORIZED AGENT F E E PERMIT GRANTED 19 3 PROPERTY INFORMATION LAND COST tf EST. BLDG. COST e7' EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY FM ALARM: BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN !P" FCS' � BUILDING INSPECTOR 'NV-ld 101d S30b'1d3H SIH1 '43SOdW1213df1S '013 's3` vH -V0 'S3H:)HOd H11M 'S9N1a11f18 d0 SN0ISN3WI4 10tJX3 4NV S3N11 101 W02ld 30NV.LS1❑ ONV lO1JOSNOISN3WI0 10`dX3 MOHS1Sf1W N01103S SIHl Z L AONvdf1000 L (1110:)311 VNiaiins EJNIIV3H ON — I P'£I +51 P"L LWA D18ID913 110 SWOON dO SV0 SS3IV3H lINn `JE,H 1NVIOVd JNINOIIIONOJ SIV SOdVA SO S.I.M IOH WV31S 'Nbnd SIV lOH MD80:1 3JVNdn1 SS313dld _ _ _ S831dVd OOOM 'S10J '8 'SW9 1331S 'SIOJ 18 'SW9 2139W11 1">IOf DOOM DNIMH L L II ONIWVad 9 OOVO 3111 dOOld 3111 S3Sn1X11 NS360W 0NIdO0d llOb _ S3MOHS 11VIS 13AVdO '8 SVl _ JN19Wnld ON 31V1S NNIS N3HDlIN S30NIHS DOOM A60IVAV1 S310NIHS I1VHdSV 13SO1� d31VM 63HS 1Vld [IT3d9WV0 ('X13 LI 'WS 131101 Od VSNVW 'X13 £I HIV9 dIH 319VJ JN19Wf11d OL d008LNON 5 �I 3dOMcIns dOOd JNISIM 3WVSd NO 3NOIS AdNOSVW NO 3NOIS 'Nl9 S36ND dO 'JNOJ —� _ £ z SOO13'S l 9 'Sd1S 3111V 3111 'HdSV 3WVd3 NO NDIS9 ASNOSVW NO NDIS9 3WVSd NO O55n1S ASNOSVW NO 555nIS ONIOIS 'AM N'—D WOJ ONIOIS SO1S39SV 0.M(MVH ONIOIS 1lVHdSV H1dV3 S319NIHS DOOM 313d�N0� d0 SOdVOUVNIGIS ID S>fOOld 6 511VM b W008 OV3H 1.W.9 ON '/e t/t %i lln3 V38V N3HDlIN NS360W S3JVld 3dI3 V3dV DMV 'Nld V3dV .I.W.B 'N13 1N3W3SV9 £ — £� — l — 1 — _ 2 NIdNn i 11VIA ASO 6313Vld Sd31d O.M(JdVH 3NOIS SO )IDIH 3NId 'N.19 313d)NOJ 3138JNOD HSMId 110IMNI 9 N011VONnod Z NouDnN1SN00 SIN3WAVdV _I S3DIddO AIIWVd 'IIInW S31d0!S AlIWV3 DONIS Z L AONvdf1000 L (1110:)311 VNiaiins Location 45— 40111 07` AU C - No. 333 Date '7/0-)d(?? (?? N�RTh TOWN OF NORTH ANDOVER 3?0�,,`•D •,�0 A Certificate of Occupancy $ }° Building/Frame Permit Fee $ a� Foundation Permit Fee $ ,SSAGHUs Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ✓ "� Building Inspector 10/15/99 13.55 25.00 PA?n Div. Public Works N C � r Z zts e � Lv ,n C C s 4J � z � CA iJ 2 Zoo G -o - U I c '� C I C G• �' v z z <n E u 0 0 r Z Lv ,n C C s 4J � CA Zoo r Z C s CA Zoo U U c '� C I C G• �' v z z M 0 GI L.I C � C �I55 CIO C3- ~ a LJ � � F F c C U c - U = C U y C C4 N O Q � � O a, � z v j V /1 r.r w _ C F G.1 C � in a U G Z C7 — on r = V7 U. c U O L o, c �c., c Z C C C y o O O U G i..w rCr' ts O L U L d � c � t C(� C v M — — " f z ^ VI G 'n _ _ uU z z u z c c 0 GI L.I C � C �I55 �0 C3- ~ a LJ � � F F c C U c - U = f C/) m C/) 0 m U y CA Cl) 'v C � 10 O CD z C4 Cc) O �� r 0 d _• y O � 0 CD av CD O cr CD CD O CD °D C• CD Cl. v CA •O to CD F v y O 1 z O O a a O CD O CD 0 I O z 0 CD O to O a to IID Co2t O N C 0 a N y m c?�� m = �• V! O Q co) dOSm1 y »o O m Cl) yn CL co) � m H CL m d O C/) N � ® m 8 O N m c.5. O z<_IOU Go CD J a N CL.. -•:A 0??� �/►� O m N am 3 cc CO) � Z O N d d C CCD �C3 m N m m N CD A ;� co w 00� CD 0: 0m Cn�O co) : .� OCD: t o, m n i. CA 1 O pr o f Di � °= aq : y w � ::r7 c p'. � "�% b w ) rD oGc a' CC;:b CL aj CA It n 9 o. hn z W W W . y 0 O C ri Re 9� IeCtc ,. FORM U -LOT RELEASE FORM �B4f C -'a, 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/ G/+,19,eb PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET 1,5— t1,J,4 L,uU% (Si SPC 'T ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** RECgMMENDATIONS,.,OF TOWN AGENTS: CdWS1 COMM RVATION ADMINI RATOR DATE APPROVED DATE REJECTED TOWN PLANNER COMME FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm 0 J " I HEREBY CERTIFY TO TWE TITLE INSUROIi AND TO IM' 11411K 1IL4T TUE MULLING IS LOCATED ON "HE LOT AS SIIOWN AND T'llAT IT DOES CONFORM INI7 1 rf..!�:'r�w� OF . ,,a,. o •c iz ZONING REGULATIONS i,'EQ(R1)l.NG SETBACKS FROM ST'REET'S & LOT LINES.' 1 ,FURTHER CERTIFY T'IMIT MIS DWELLING IS NOT j,OC1Affj.D IN TlI FED.&' L FLOOD HAZARD AREA AS Si7O FIAT LIN 1s'liR _ C .titITY PANEL o0 03 c ' c PLOT PLAN Ar DRA WM FOR n P=URPOSES - NOT FOR DETER111M.A TOIL 130U1�11AI:Y lh'FORe(ATIOiV RR AIEIIlAcK ENGINEERING S'EIM)'CES it;t� i'ROhi F.k'IST N"C .RFiF'OROS, 66 PAMW STREET' /"y? , I ANDOVER, MASSA C-HUSE TTS 011110 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/Insmaor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1/1 x A //;)0 a" 1.3 Zoning hrf rormation: Zoning DiAiid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record _Rclox,6 �a�� lr /S G✓celNu,� �� / �•� ��.� � Name (Print) �/� Address for Service c�Jb� " `�' 9,? c- - Z 5�� — Sign tune 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 0 - 3 /7 y1 gnatur Telephone Not Applicable ❑ License Number S = Z o— 2_00C.% Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M Z O 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 Descrido f Proposed Work check all applicable New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: dale.) /Zk Y %J €enc A 77-Aes« 6 7-V leg,4 A a� 1,A4e_if J, /fhP) V' Ng Ar— SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant <fFk'ICIA�: USE 0AY 1. Building� v w 4 (a) Building Permit Fee 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 1, Et e:#A+/- b � u 414 / J as Owner/Authorized Agent of subject property Hereby authorize y J 6-yx" r7 to act on My behalf, it11 matt s relative to work Whorized by this building permit application. �c( C' Signature of Owner Date 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 Signature of Owner/Agent Date SEE - NO. OF STORIES SIZE ` BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OP FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE -1r 1°oa�aman�uesrr a'✓�t'aasar�ivae�ld BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR r - Number: CS 081804 Birthdate: 05/20/1951 Expires: 05/2012008 Tr. no: 81804 Restricted: 00 GARY J LOPRESTI 60 WEBSTER ST MALDEN. MA 02148 Administrator Ii • I J�- L -� - is F "-7 S k a.,r c— Y, s j CRY /" am a homeowner performing all work myself. 01 am a.sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my ernplayees working on this job. '�Q,dmraany name: Address *� G✓ f �S r t f �t' S Ci>sic: jet /� Phone # ? f 7 Y,1 �Gl1`t7�E'11f-name: Address city,. Phone �' FallUtO tv SOCU a caveroge as r Ldmd under Section 25A or MGt_ 1,52 can team latheNNEINN and/or one ars' 1i1 on of ohninatpen .ofaling up to $1:500.00 ye imprisonment as Well as dvd penalties in the form ora STOP WORK and a fine of (3100:00) a day against me. t understand that a copy of this statement may be forwarded to the Of & of !nom of the [Jill for coverage verifippon. / do hefty certify under the pains and peneitles of perjury && the kft oration p►ovided above: is tare ani/correct Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' Q Building Dept QCheck if immediate response is required Building Dept Q L inng Board Q C Selectman's office Contact person: Phone # Q Health Department Q Qfher W 63ORKaiAN S COMPENSATION 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: 4s/,?aU, Z - (Location of Facility) zAn�� Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector �i 16 J w 16 J