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HomeMy WebLinkAboutMiscellaneous - 169 BOXFORD STREET 4/30/2018 (3) c 0 q0,, ©" \ S. � � Location No. 1=01vV Date NORTH TOWN OF NORTH ANDOVER « • + i PEW Certificate of Occupancy $ 'ss�►CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ 1 TOTAL $ a Check # 15114 / Building Inspector TOWN OF NORTH ANDOVER E BUILDING DEPARTMENT PPLICATION.TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING PON UELDING PERMIT NUMBER. DATE ISSUED: :GNATURE: /Vt Building CommissionerApn3er6tor of Buildings Date 3CTION i-SITE INFORMATION 1.1 Property Address: 1.2. Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ning District Proposed Use Lot Area Frontage ft i BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ,Required Provided ReqiIired Provided v Water Supply M.Cz C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: dic ❑ Private Zone Outside Flood Zone Municipal 0 On Site Disposal System :CTION 2-PROFIERTY OWNERSEIIP/AUTHORIZED AGENT Owner of Record m nt) Address for Service ori _ S 3-3< nature Telephone / Owner of Record: \� \ r I are ® Print /� � Address for Service: }� ! ✓`wV Vim..— 1®Y mature Telephone CTION 3-CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ j .used Construction Supervisor: 3 License Number ress O Ti lv (1 U2 ! 1 Expiration Date ature i j tegistered Home Improvement tractor Not Applicable ❑ pany Name Registration Number I 'ess Expiration Date 111 rture ele hone � w 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.......0 SECTION 5 Descrition of Proposed Work(check all a Ucable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: ID IL---� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by,permit applicant `,„ 1. Building U (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost ofP� BuildO �-- Construction V 3 Plumbin ing Permit fee.ta3 x tb) 4 Mechanical HVAC ! 5 Fire Protection 6 Total 1+2+3+4+5 l/Z) Check Number SECTION 7a OWNER AUTHORIZATIO1 TO BE COMPLETED WHEN OW RS AGENT OR CONTRACTOR PLIES FOR BUILDING PERNIIT I, L L as Owner/Authorized Agent of subject property ereby au nze ` �,. to act on be ,in a 1-ma rs relafiLc,to orized b uilding permit application. Sin re of Owner Date SECTION 7b OWNER/AUT90RIZED AGENT DECLARATION ,as Owner/Authorized Agent of subject property Hereby declare that the statements and in he foregoing application are true.and accurate,to the best of my knowledge an belief 1 L/ vw Print _ SiAl v � ature veer A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS -,k- 1s1 2ND 3RD SPAN DINIENSIONS OF SILLS <—� D11v4ENSIONS OF POSTS 7– DRAENSIONS OF GIRDERS �N HEIGHT OF FOUNDATION t THICKNESS SIZE OF FOOTING MATERIAL OF CHDANEY -� IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE f J ' 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 f acility) Signature of P mit plicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector !1V111 Fi The Commonwealth of Massachusetts Department of Industrial Accidents {- I Office of Investigations _.,`. Boston, Mass. 02911 Workers'Compensation Insurance Affidavit rook Please Print Name: ..., Location: City Nv Phone -6 —S-33'5- 1 am a homeowner performing all work myself. Lig FI am a sole proprietor and have no one working in any capacity 'I I am an employer providing workers' compensation for my employees working on this job. a Company name: Address City: Phone#: Insurance Co. Policy# Company name: Address City'. Phone#: Insurance Co. Policy# Failure to secure cov nn r Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 R fine 1 against me. I one ears'im risivil penalties in the form of a STOP WORK ORDER and a ne of $ 00.00 a da and/or Y PP ( ) Y 9 underst hat a cop y be forward to the Office of Investigations of the DIA for coverage verification. I do herby ce nder ties of pe ury th t the informati rovided above is true and correct. Signature Date W\ \2b G �� Print name � � Phone# Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION NORTFt ® ofE over 0 dlej --7 P71' os Adover, Mass.COC %S RATED H 4 BOARD OF HEALTH PERMIT T D � Food/Kitchen Septic System � BUILDING INSPECTOR THISCERTIFIES THAT...... ..v�� ,>'�c U r........... .................. .... .......... ........................................................�..................... Foundation has permission to erect... 'e. ....a.�............. buildings on........6..1„...... ol ............ .......... Rough to be occupied as !~ S� ll�..........'. N........ .� ti Chimney . . . . . . . . .... . . . . . .. . . . . .. . . .. . .......................................... provided that the person accepting this permit shall in every respect,conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws rela ing to the Inspectio ; Alteration and Construction of Buildings in the Town of North Andover. /tj a tv 6 a�—� ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough C .................. Service ......... .. ... "/kBUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises Do Not Remove Final 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.