HomeMy WebLinkAboutMiscellaneous - 20 ICEHOUSE ROAD 4/30/2018%j �
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APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
Building Permit # `6 /0
ADDRESS/LOCATION OF PROPERTY: 20 ice kvuse i"o 4
Map 4a- f C Parcel 3 % Lot Number ()Jj l T' %
SUBDIVISION
DATE REQUESTED FILED/READY FOR NSPECTION
CLOSING DATE ON PROPERTY: ! 1)
ALL WORK AND SIGN -OFFS MUST BE Ct
INSPECTION FEE OF TWENTY DOLLARS
DOES NOT MEET ALL APPLICABLE CODE
SIGNED
ROUTING
1 WITHIN THIS TIME FRAME. A BE-
LL BE CHARGFD IF THE STRUCTURE
N Q N - S V R \S.DI CT 10,A)AI ,
PL*N ING I I _ N I'k C,� 40, 13
DPW - WATER METER 7� 1
SEWER/WATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
jA () rI Q..%,2 rJ`-
Signature
File: OC form revised 2006
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"O PTH qM TOWN OF NORTH ANDOVER
° �7
Certificate of Occupancy $
s�cMusE�� Building/Frame Permit Fee $ _
Foundation Permit Fee $ �•
Other Permit Fee $
TOTAL $ •��
Check #
190165
Building Inspector f„_
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: NO DATE ISSUED: O
SIGNATURE: da,
Building Commissid'her/InEeEqu of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map
Map Number
and Parcel Number:
3')
Parcel Number
NG fir' Jl/I /I
1.3 Zoning Information:
l s FD C 6J1JDO
Zoning District Proposed Use
1.4 Property Dimensions:
30, Zj (_ 7,5
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
ReqWred Provide R red Provided
Re red Provided
N
t
1.7 Water Supply M.GL.C.40. 34) 1.3. Flood Zane Information:
Public X Private ❑ ZOne Outside Flood Zane
, 1.8 Sewerage Disposal System:
mankipal K Oa Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHNUTHORIZED AGENT
'! ":�;r c; "IStriot: `�eS �qo
2.1 Owner o R
Ne, v 4/,LLC _ �2 c� - P� N. ,� -4.
Name (Print) Address for Service
Sig,neqe Telephone
r
2. ner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1Lice sed Construction Supervisor:
aV
Licensed Construction Supervisor:
K)Q
Address
�Vz�� q),f b 2 tt�
nature Telephone
Not Applicable ❑
L/
License Number
Expiration Date
p
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration
Signature Telephone
v
SECTION 4 - WORKERS COMPENSATION (NLG.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 bwldrne permit.
Signed affidavit Attached Yes ...... A No ....... 0
SECTION 5 Description of Proposed Work check aH a ble
New Construction Existing Building 0 Repair(s) 0 Alterations(s) ❑'i Addition ❑
yea
Accessory Bld NIiolitio , ❑ Other ❑ Specify
Brief Description of Proposed Work: .
s F R C") F S
l�N GLA �IZ Z171 -Z C6 : jbro�'ia- Z3570
�rD
RF.rTION 6 - FATIMATRfl (Y1NCTD1TVTrnN r•neTc r� , J
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY•
I . Building
v' 7 Sv '
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing d L
Building Permit fee (a) x (e)
r
4 Mechanical HVAC �,U
5 Fire Protection ev
6 Total 1+2+3+4+5 7-3 % 6 n
Check Number Q e'
.+++�. a ava. ... .. a.a.a� a-av a aav� •+ i lV(\ a v Dr V—%J1VlYLL' l Ell W r=rN .
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• Y�t.tt S as Owner/Authorized Agent of subject property
Hereby authorize 2a' to act on
My Ii; in attr-s relati to ork authorized by this building permit application.3 L
k6 -
e o er L, Date
SYCTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1•--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 1 A
Print
3igna1RM&at3dwner/Agent Date
4W
NO. OF STORIES i SIZE
BASEMENT OR SLAB S
SIZE OF FLOOR TIMBERS 2' 1J 3
SPAN A -A - )
DRAENSIONS OF SILLS Z 2
D20ENSIONS OF POSTS 3 L
DRVIENSIONS OF GIPDERS C.
ly
HEIGHT OF FOUNDATION THICKNESS d
SIZE OF FOOTING �• X Id '
MATERIAL OF CHININEY N
1S BUILDING ON SOLID OR FILLED LAND S L
IS BUEDING CONNECTED TO NATURAL GAS LINE vM-1cr,
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Date .....
.(...........................
NORTH
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that 1 e /.124,WC ...................:......
.......... .......................r: 1 _"
has permission to perform ' v� . y'���-��
wiring in the building of......�f..
at .................
4G��d rJs ....... , North Andover, Mass.
i
Fee. -260.'07. Lic. No. ., /L........... :........ -.. .......
ELECTRICALINSPECOR �
Check # 11
'690$
.-.b._...c,.._^. �e�e ..,_.-... ..... ...e .._�1 ..... f,__.r_�. __. .-mer n. c,_.. .�.. w�.z.. ..�.. ._ .i _. _., r.. ....... ... ....... .......
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MMUHOrV FOR PET
PWORM EU=CU Mn
RARIV
ALL woRK To BE PERFORM IN ACCORDANcB wrrH Tm MASSAcHuSM ELEMIcAL com, 327 cmR 12:00
(PLEASE PRDFT IN M OR'h?E ALLUPMR]AAMION) pa
Town of North Andover. To the Inspector of Wires;
The undersigned applies for a permit to perform the electrical work described below.
Location (street AL Number)
Owner orTenant P
Owners Address. 17-1 'ILam. Vj -ev
Ls this I perinit in conjunction with a budding permit: YesM'--No
Purpose of Buildifts 6--6- > I 6W 1 V+'C—
Aqrol Ro4 ) Ll Lj Fi Z,
utilityAuthorization No.
ExistingService Amps —f Volts OvertmA [:3 Unoer—momw r-1 NO. Of Me"—
,
New'S :zz> 1) Amps ts Overhead- M Undnround No. of Meters
Nwnber of Feeders and Ampecity
Location and NUM Of PfOP05W Electrical Wolk �l
No, Of U01ft oudem
NO. of Hot Tube
I No. Of TmoftTim
KVA
KVA
No. Swimming Pool Above beiaw
Mea RL----,tm Out
W of ODA
Ljoitir- -Bar
'ffy UBIU
No. of Switcb Outleft
No. 0;' Gm Bonma
ALA RIAS
No, of zmm
No. of awqg-. Air e=d. ToW
Tom
1 No. of MOWN aw
No- of Diwafth No. of H44 Total Totat
Dm
Tons
KW
Udiding Devices
No. of Sourift Devices
No, of i; Mi Spwe Am Heaft K -W
ND. 4H WC�
OnAm
L=4
Other
W of Drym Heating Devica KW
Cortnectiorm
W of waw Heatm Nvy Na. Of No. of
31--m
Balk3b
Mo. Hydra mmomm Tube
No. of Mican
Tatid HP
OTHER -
FIV oil
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TOWN OF N)QRT44 ANDOVER
.a
is � ,� . ,..., • �t
PERMIT FOR PLUMBING
i o� ••� J
This certifies that .......:.. - '.. �._ . /�`:.............
has permission to perform .....................
plumbing in the buildings of ``�✓ ..�r�..x� ..`--�r
J '
at........................North ,North Andover, Mass.
Fees 745G.S
? .... Lic. No:: :.............
/ PLk M f�NG INSPECTOR
Check .H /jf
707E
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
Owners Name
Date 913,106
6
Permit # 7& 7l0
Amount '�—Y6 el
Type of Occupancy
New Iff Renovation ❑ Replacement ® Plans Submitted Yes ❑ No
FIXTURES
(Print in type) � j T Check one:
Installing Company Name � Al (/lam �i� I ti S ®Corp.
Address 16c4 Lum„®Partner,
Certificate
Business Telephone 17 �- — C/,1 � i 5-0 c— ® Firm/Co.
Name of Licensed Plumber. /W/t 4cj :; &
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
` Liability insurance policy a Other type of indemnity E3 Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus tate malChapter 142 of the General Laws.
By:
WgnatUre 01 LiCenSeCium er
Type of Plumbing License
Title
City/Town ,M sed 1 u� Master ® Journeyman �]r
APPROVED (OFFICE USE ONLY t=�
TOWN
/D
ate. X.—O
OF NORTH ANDOVER
PERMIT FOR PLUMBING,
This certifies that ..................... ...............
has permission to perform —49 ........................
plumbing in the buildings of .
at. c2q ....
North Andover, Mass.
"M
Fee.,�--.,. o..C�2
Lic. No. ? .............
-1,
U4� 3,WG INSPECTOR
Check ff
7CJ75
NIASSACHUSEI'IS LJIN F NI APPUCATON FOR MENU TO DO GAS FITTING
(Type or print) Date LL� G
NORTH .ANDOVER, MASSACHUSETTS
Building Locations 12 f ??el1wvs{ Permit # Zr76-
� �•
O Amount Owner's Name
New Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or type)
Name
plilmk&v i/
Address A0 Ii P�'LfZfz Li /PSI
Ch c one: Certificate Installing Company
Corp.
Partner.
E]Firm/Co.
-- - •.•.. u ,•v, cui—u) Iu auuve appucatlon are true and aCCUrate to the -
hest of my knowledge and that all plumbing work and installations herrornu(l uncia Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusettS State ode and Ch:"t�4;e��the Gencral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
.'Signature of Licensed PlUmber Or Gas Fitter
Pltimbcr �.W/' f y.)-
13 Gas Fitter License Ium cr
E
VOaster
ourneyman
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SUB -BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. F L O O R
4T II. FLOOR
5TH. FLOOR
6TH. FLOOR:
7TH. FLOOR
8 T H. F L O 2.11
(Print or type)
Name
plilmk&v i/
Address A0 Ii P�'LfZfz Li /PSI
Ch c one: Certificate Installing Company
Corp.
Partner.
E]Firm/Co.
-- - •.•.. u ,•v, cui—u) Iu auuve appucatlon are true and aCCUrate to the -
hest of my knowledge and that all plumbing work and installations herrornu(l uncia Permit Issued for this application will be in
compliance with all pertinent provisions of the MassachusettS State ode and Ch:"t�4;e��the Gencral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
.'Signature of Licensed PlUmber Or Gas Fitter
Pltimbcr �.W/' f y.)-
13 Gas Fitter License Ium cr
E
VOaster
ourneyman
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 i1_ a rr\p�S LLC- PHONE q8~C8T2635
LOCATION: Assessor's Map Number /��C PARCEL 3 f
SUBDIVISION l� I -e< � LOT (S) j g
STREET -L cp, >OUSq Rod ST. NUMBER 2 d
USE ONLY
***
RECO,"ENDATIO,NS OF -TOWN AGENTS:
CO ERVATION ADMINISYRAT
COMMENTS -0 e 4 I uu "c aft:-4fe
_.N/A
TOWN PLANNER
COMMENTS (-h.
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
�- I V R-riCHL ! tt DATE APPROVED
DATE REJECTED
COMMENTS 'aWE.
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
i
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
.. _ DATE
Revised
Revised 9197jm
1
ING REGULATIONS
ION SUPERVISOR
5417
I
Tr. no: 21,033
THOMAS D ZAHO Kulmul 4C*l---" 121CARTERFIELD RD,
iJ-ANDOVER, 'MA 0184'5 Acting
M_
The Commonwealth of Massachusetts
1 1 Department of Industrial Accidents
Office of Investigations
No, 600 Washington Street
Boston, NFA 02111
www.mass.gov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nnlicaIa Infow---��=
Naive (Business/Organization/Individual):
Address
Please Print Le
City/State/Zip: , �j ,�t�,1��/�? 'Phone #: —Z4_? C
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ i am a general contractor and i
2.'6�employees (full and/or part-time).*
I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp, insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.]
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. �S New construction
7. ❑ Remodeling
8. ❑ Demolition
9. EJ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
I .❑ Other
IC
ion DelOW showing their
kers' compensation
' Homeowners who submit this affidavit indicit vut ating theyarea erdoing all work and then hirer outside contractors must submicy it aanew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
i ant an employer that is providing workers' compensation insitrance for my employees. Below is the po
irr forination. licy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DiA for insurance coveran��rification.
i do hereby certify tinder th � aims acrd pe alties if perjury that the information providhove is trite and correct.
Si nature: ?"7
Date: 04
Phone #: /
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
Issuing Authority (circle one):
Permit/License #
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person:
MECcheck Compliance Report
Massachusetts Energy Code
MECcheck Software Version 3.3 Release Ib
Data filename: Untitled
TITLE: The Hampton at Meetinghouse Commons
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 03/24/06
DATE OF PLANS: 09/01/05
PROJECT INFORMATION:
Meetinghouse Commons
North Andover, MA
COMPANY INFORMATION:
Meetinghouse Commons LLC
North Andover, MA
COMPLIANCE: Passes
Maximum UA = 296
Your Home = 271
8.4% Better Than Code
Ceiling 1: Flat Ceiling or Scissor Truss
Wall 1: Wood Frame, 16" o.c.
Window 1: Vinyl Frame, Double Pane with Low -E
Door 1: Solid
Floor 1: All -Wood Joist/Truss, Over Unconditioned Space
Furnace 1: Forced Hot Air, 90 AFUE
Air Conditioner 1: Electric Central Air, 10 SEER
Permit Number
Checked By/Date
Gross Glazing
Area or Cavity Cont. or Door
Perimeter R -Value R -Value U -Factor UA
998 0.0
30.0 31
1467 0.0
13.0 118
198
0.340 67
35
0.340 12
998 0.0
19.0 43
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans,
specifications, and other calculations submitted with the permit application. The proposed building has been designed to
meet the Massachusetts Energy Code requirements in MECcheck Version 3.3 Release lb and to comply with the
mandatory requirements listed in the MECcheck Inspection Checklist.
The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard
Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater
than 125% of the design load as specified in Sections 780CMR 1310 and J4.4.
3 �
Builder/Designer Date
MECcheck Inspection Checklist
Massachusetts Energy Code
MECcheck Software Version 3.3 Release lb
DATE: 03/24/06
TITLE: The Hampton at Meetinghouse Commons
Bldg.
Dept.
Use
[ ]
[ ]
[ l
[ ]
[ ]
;[ ]
[ ]
Ceilings:
1. Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 continuous insulation
Comments:
Above -Grade Walls:
1. Wall 1: Wood Frame, 16" o.c., R-13.0 continuous insulation
Comments:
Windows:
1. Window 1: Vinyl Frame, Double Pane with Low -E, U -factor: 0.340
For windows without labeled U -factors, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
Comments:
Doors:
1. Door 1: Solid, U -factor: 0.340
Comments:
Floors:
1. Floor 1: All -Wood Joist/Truss, Over Unconditioned Space, R-19.0 continuous insulation
Comments:
Heating and Cooling Equipment:
1. Furnace 1: Forced Hot Air, 90 AFUE or higher
Make and Model Number
2. Air Conditioner 1: Electric Central Air, 10 SEER or higher
Make and Model Number
Air Leakage:
Joints, penetrations, and all other such openings in the building envelope that are sources of air
leakage must be sealed.
When installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements:
1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture
and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space.
2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944
L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture
shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled.
Vapor Retarder:
[ ] Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors.
Materials Identification:
[ ] Materials and equipment must be identified so that compliance can be determined.
[ ] Manufacturer manuals for all installed heating and cooling equipment and service water heating
equipment must be provided.
[ ] Insulation R -values, glazing U -factors, and heating equipment efficiency must be clearly marked on
the building plans or specifications.
Duct Insulation:
[ ] Ducts shall be insulated per Table J4.4.7.1.
Duct Construction:
[ ] All accessible joints, seams, and connections of supply and return ductwork located outside
conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed
using mastic and fibrous backing tape installed according to the manufacturer's installation
instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted.
[ ] The HVAC system must provide a means for balancing air and water systems.
Temperature Controls:
[ ] Thermostats are required for each separate HVAC system. A manual or automatic means to
partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided.
Heating and Cooling Equipment Sizing:
[ ] Rated output capacity of the heating/cooling system is not greater than 125% of the design load as
specified in Sections 780CMR 1310 and J4.4.
Circulating Hot Water Systems:
[ ] Insulate circulating hot water pipes to the levels in Table 1.
Swimming Pools:
[ ] All heated swimming pools must have an on/off heater switch and require a cover unless over 20%
of the heating energy is from non-depletable sources. Pool pumps require a time clock.
Heating and Cooling Piping Insulation:
[ ] HVAC piping conveying fluids above 120 °F or chilled fluids below 55 °F must be insulated to the
levels in Table 2.
Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes.
Table 2: Minimum Insulation Thickness for HVAC Pipes.
Fluid Temp. Insulation Thickness in Inches by Pie Sizes
Piping, System Types Range F 2" Runouts l" and Less 1.25" to 2" 2.5" to 4"
Heating Systems
Low Pressure/Temperature
201-250
Insulation Thickness in
Inches by Pipe Sizes
Heated Water
Non-Circulatinp, Runouts
Circulating Mains and Runouts
Temperature ( F)
Up to 1„
Up to 1.25"
1.5" to 2.0" Over 2"
170-180
0.5
1.0
1.5 2.0
140-160
0.5
0.5
1.0 1.5
100-130
0.5
0.5
0.5 1.0
Table 2: Minimum Insulation Thickness for HVAC Pipes.
Fluid Temp. Insulation Thickness in Inches by Pie Sizes
Piping, System Types Range F 2" Runouts l" and Less 1.25" to 2" 2.5" to 4"
Heating Systems
Low Pressure/Temperature
201-250
1.0
1.5
1.5
2.0
Low Temperature
120-200
0.5
1.0
1.0
1.5
Steam Condensate (for feed water)
Any
1.0
1.0
1.5
2.0
Cooling Systems
Chilled Water, Refrigerant,
40-55
0.5
0.5
0.75
1.0
and Brine
Below 40
1.0
1.0
1.5
1.5
NOTES TO FIELD (Building Department Use Only)
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
n
BUILDING PERMIT NUMBER: DAM ISSUED:
3,o gas a 0
SIGNATURE:
Building CommissAer/Inspector of Buildings Date
SECTION I- SITE INFORMATION I
1.1 Property Address:
IT
Aq
✓1.4
1.2 Assessors Map and Parcel Number:
/0y C 3
Map Number Parcel Number
1.3 Zoning Information:
I SFQ C6.PJDCD
Zoning District Proposed Use
Property Dimensions:
-30, Z,
i.a-t Area (sf) Frontage (A)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide E! Provided R�red Provided
,qMred
1.71�y M.GLC.40 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System
P.b�Z� -Private 0 zone Outside Flood Zone MmicipaI I On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSB74AUTHORIZED AGENT 1-111:�J.(,,j ;C; UiStj,iCt:
*r 0
2.1 Owner o R
Me; I t)LSC (4 -�--
Name (Print) 0 Address for Service
Si a Telephone
2'715wrier of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
I -F
Licensed Construction Supervisor:
N\License
Address
2-Zl
Jnature Telephone
Not Applicable 0
Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (XG.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 buildina Dermit.
Signed affidavit Attached Yes ...... A No ....... 0
SECTION S Description of Proposed Work check aH a ble
New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bld 'aii Drolitio • ❑ Other ❑ Specify `'
Brief Description of Proposed Work: T ., ,• y; r . �t:`h_�,
S r- �z r' 'J" JF"
w
ON COLA t 6AK, SV x lz�-' - ZJ77 Z6 ; jr�rsa� v � z357• �
1 b � • °�
S �
SF.CTTON 6 - ESTIMATED CONSTRUCTTON MIZTc
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
% TO "
(a) Building Permit Fee
Multiplier
2 Electrical )
(b) Estimated Total Cost of
Construction
3 Plumbing O L
Building Permit fee (a) x tbl
a`/ t9 �` < <5 0
4 Mechanical HVAC GU
5 Fire Protection ej >
I
6 Total 1+2+3+4+5 7,-3 5 % 6 ti
Check Number Q
am%-JL1V1'% is Vr11y.AHV 1nUM1,A11VP1 1V ISE LUMMMIED WMN v .
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize_ D , L -XPi' to act on
My beh ; in , att res relati w ork authorized by this builduig permit application,Ll
5194Ge o Date /
I SEtTION 7b OWNERIAUTHORIZED AGENT MCLARATION
►, as Owner/Authorized Agent of subject
property
Hbreby hectare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief ) 14
Print arr,N
NO. OF STORIES iSIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS3RD
SPAN M A-� i` )
DINIENSIONS OF SILLS Z Z
DB/IENSIONS OF POSTS 3 2
DIMENSIONS OF GIRDERS C
HEIGHT OF FOUNDATIONR' THICKNESS d75
SIZE OF FOOTING �. X 1.6
MATERIAL OF CHDANEY !�
1S BUILDING ON SOLID OR FILLED LAND S L
IS BUILDING CONNECTED TO NATURAL GAS LINE vii—
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