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Location I _ Q© PW Rj No. Date �a NORT1y TOWN OF NORTH ANDOVER 3? � oAL � ; p ' Certificate of Occupancy $ �'�s'••'° Eta' Building/Frame Permit Fee $ �d ACHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 103 a 17373 -9 y Building Inspector e TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING 3 ,u .i4 k 6k2 BUILDING PERMIT NUMBER: ~ . w DATE ISSUED: _ SIGNATURE: VA Building Commissioner/Inspector of Buildings Date SECTION I-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parbel Number \ I 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReApired Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone lnfornution: 1.8 Sewerage Disposal System: n Public ❑ Private 0 Zone Outside Flood Zone 0Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSIIIP/AUTFIORIZED AGENT i i � . 2 O 2.1 Owner of.Record � v r Name n Address for Service Signature Telephone 2.2 Owner of Record: _1 Nkame Print Address for Service: t -it Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name J G �— £f Registration Number Addre /� G _i5_8 8 Exptratton Date Si ature Telephone 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 Description of Proposed Workcheck all applicable) New Construction ❑ 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 OF 'ICIAIaUSEKONI.Y : Completed by permit ap licant 1. Building (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 v 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 !1 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/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I ST2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Cf C - -VE EXEMPT ANDOVER CHIMNEYS DATE 640 South Union Street March 1, 2004 LAWRENCE, MA 01843 NUMBER (978) 683.5139 Larry Kellam y ' ' C 17 Poplar Street North Andover, MA 01845 TERMS: $ 8,300.00 DATE CHARGES AND CREDITS BALANCE BALANCE FORWARD Roof estimate: Strip entire main house roof. Install three feed of water and ice shield on horizontal perimeter and aluminum drip edge on horizons l perimeter too. Apply tar paper on roof surface. Apply IKO asphalt 25 year shingles. Install lead flashing on rear of chimney Remove all debris. Permitj will be secured Andover Chimaays has general liability . and Workers Compensation insurance. Howe Agency in Andover is the insurance ?gent. O d ! TOTAL PRICE $8,300 00 �/ DUPLICATE PAY LAST AMOUNT IN THIS COLUMN N r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 0� Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: i4A--.(An Location: (o V, �_ U,/,., 1� City Phone # I am a homeowner performing all work myself. 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 Ci!y: Phone#: Insurance.Co. L Policy# G Company 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$1,500.00 and/or one years'.imprisonment_as-well_as_civii..penalties in rhefnrm of-a_STOP WORK_ORDER-and..a line of.($1-00.D.0)_a iiay against.me. I understand that a copy of this statement may be forward the Office of Investigations of the DIA for coverage verification. I do hereby . rtify under the pai a d pen ties of erjury, hat the information provided above is true and correct. Signature Date (o C Print name a W C 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 0 Licensing Board F-1 Selectman's Office Contact person: Phone#: F-1 Health Department ❑ Other 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: _e � � � — f2+ (Location of Facility) Signat re f 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 �.10RT1y Town of Andover No. 7m% C% _ LAK dover, Mass.,—/P— ,- COC NIC NEWICK V, A0 TED pP�t-`C BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR #4 AZ THIS CERTIFIES THAT.........XFoundation v p1 has permission to erect.. �1 1. .../............. buildin son ..... .....�...................................................... .. Rough 12 V r O 0 &�"4 ! Chimney tobe occupied as..................... .. ................................... .......................................... . y .... . . .. . . . . ............. .. provided that the person accepting this permit shall in every respect conform to the ms of the application on file in Final this office, and to the provisions of the Codes and By- ws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 4.33 lq PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN .6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S Rough t ......./..11 .................................10A .... ............................ Service BUILDING INSPECTOR 44000 Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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.