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Location IG F–,-,IZcTZ —I STr4
No. Date
01 40 4 11
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $ /I�j
.0
,V ACH Foundation Permit Fee $
Other Permit Fee $
sewer connection Fee $
.160 )eWC WrV $
t
,,,,nnection Fee
4 IjG $
,21 TOTAL
410. 1199,
14ndc Met C-0 ,, Building iAb�66ior
Ileac.
Div. Public Works
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Location
Date
2-15�44
No. Q21 -74L -
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
C"
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
17823
4�1 �--Llding inspector
00,
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TOCONSTRUCT REP RENOVATE,OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.:
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: 144/ l (iAA-t r
Building Commissioner/I for of BuildingsDate
SECTION 1- SITE INFORMATION
1.1 Propetty Address:
21e,
1.2 Assessors /Map and Parcel Number:
Map - 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
Regaired Provide R 'redProvided
Re 'red Provided
7
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
" "7'I+c `ti lCt; yes (,Jq
2.1 Owner of Record
r`7/
Name (Punt) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si nOure Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
1/ s
Licensed Construction Supervisor:
�3 _$� Act /e/d'G C' � �/� SO IY,
Address
� ( 0 3 .3�-moi
Signature Telephone
Not Applicable ❑
69
icense Number
3,130)c? ?
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
a
Expiration Date
Sig -nature __ Telephone
00
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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
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No.......❑
SECTION 5 Description of Proposed Work check aH applicablel
Failure to provide this affidavit will result
New Construction ❑ Existing Buildmg?{J Repair(s) /11_�' Alterations(s) ❑ Addition 0
Accessory Bldg. 0 Demolition 0 Other ❑ Specify
Brief Description of Proposed Work: L
PX R �zi ��P/y3/c��i is / �X /S///9S I"' k
�12 *",w / /
SECTION 6 - ESTIMATED CONCTRiTrTInN rncTc
Item Estimated Cost (Dollar) to be
Completed bv vern-dt applicant
OFFICIAL USE ONLY
1. Building
L " .S' vv
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
w 1
U
4 Mechanical HVAC✓'{
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
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
1, ' "'� g S as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are Ln:e and accurate, to the best of my knowledge
and belief
Print Nam
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVIBERS 1' 2 ND 3
SPAN
DIMENSIONS OF SILLS
DINIENSIONS 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
a
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4-1
op
F y 8 pec y e
It FORM U - LOT RELEASE FORM
K 9mat -�- L,L111'16
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 HONE 46e3 -?'gZ
LOCATION: Assessor's Map Number PARCEL 93-
``//SUBDIVISION LOT (S)
XTREET � for s <ST. NUMBER 2/e
******************************OFFICIAL USE ONLY***********************
RECOMMENDATIONS OF TOWN AGENTS:
'ATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
7SEPINSPECTOR7AL
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
Revised 9197 jm
IB7_t>i; a
MORTGAGE INSPECTION PLAN
` UNITED DATA SERVICES INC
95/00881
20 BLANCHARD RD. • BURLINGTON, MA 01803
TEL (617) 272-9100 0 FAX (617) 272-6900
APPLICANT.' RORY J. MARTIN & CHRISTINE E. FRANCHI DEED/CERT: 2718/328
LOCATION: 216 FOREST STREET PLAN REF: #8220
CITY, STATE. NORTH ANDOVER, MA PREPARED: 4/26/95
s
- =_7 - - - .17, - " -
7 !:IIXa
FOREST STREET
y
0 `L"
SCALE: 1 inch = 50 feet
CERTIFIED TO: MORTGAGE FINANCIAL SERVICES
1994 (c) 5-1011 Vanly 301-10
The permanent structures are approximately located on t��p of /pot According to Federal Emergency Management Agency
ground as shown. They either conformed to the setback yit �C maps, the major improvements on this property fall in an
requirements of the local zoning ordinances in effect a �0
the time of construction, or are exempt from violation -V area designated as Zone G
forcemeat nction under M.G.L. Title VII. Chapter 40 Community Panel No: ZSDO%? - Qo0 96
Section 7, and that there are no encroachments of maj
improvements either way ncross property lines except Effective Date: 6 z -y,3
shown and noted hereon. \0 Note: Zoun C in areas of minlnmi flooding leo shading). This
,A#0 su% desigunllon is not based on an elevation certificate.
NOTE: This is not n bmnuinry or Lille insurance survey. This plan was prepared in nccnnlnnro to prorrdurnl and technical standards for Mortgage Loan Insinoctions as
adopted by the Atnssnchusetts Board of Registrnlion of professional engineers and land surveyors, 250 CMIL 6.05. and use for any other purpose is prohibited. This plan is
not to be used for recording, preparing deed descriptions, or construction
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✓lze 1�Joma�¢o?uueu� a� ��aaaac%i%�e--:
=-_ - Board of Building Regulations and Standard
"- HOME IMPROVEMENT CONI RACTOm
Registrabon: 112595
Expiration: 4/9/2005
Type: individual
GARY E. LISS
GARY LISS
13 STONEWALL TER
AMNSO:J; NH 03811 Administra*or
/ze �anvrrmu�iea.�z o�✓�/%�ra�/zuaelld
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 053506
Birthdate:. 03/30/1957
Expires: 03/30!2005 Tr. no; '9713
Restricted: 00
GARY E LISS
13 STONEWALL TERR
( ATKINSON, NH 03811 y `
i-, Administrator
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 of Faci ' )
ignature 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
A
Name
Name:
Location:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
City Phone #
71
I am a homeowner performing all work myself.
71 1 am a sole proprietor and have no one working in any capacity
ETI am an employer providing workers' compensation for my employees working on this job.
lame: Z. /
/3 � ��1t1
D 3 -341;1 - .-/8 .c-"
, 31/�s 6
Company name:
Address
City: Phone *
Insurance Co. Policv #
Falture to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a tine up to $1,500.00
andiorone years' imprisonment.asweU-as_chill.penakiesinThe fmnde..STOP WOiZKDRDER.and..a.fineaf.(SJ00.OD)-aAday.agaimt_rW I
understand that a copy of this stateme t may be forwarded to the office of Investigations of the DIA for coverage verification.
1 do hereby certify under fire pai nilcities perjury that the information provided above is true and correct.
pq�
Signature riatp /l�f�/� t/
Print
Official use only do not write in this area to be completed by city or town official'
# be, -S , 34-: C -/,e s_
City or Town Permitil-icensina
❑ Building Dept
❑Check if immediate response is required [] Licensinf, j Board
❑ Selectman's Office
Contact person: Phone #. ❑ Health Department
❑ Other
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