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No. 1— Date .-6--09
NORTH
TOWN OF NORTH ANDOVER
i •
°k
Certificate Occupancy '
* : ,
of $
s�cMus
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Check # (�
2 2 5
-
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: •
IMPORTANT: Applicant must complete all items on this page.
LOCATI
� ® A
Print
MAP NO:PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Vllaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
'A8
ESGRIPTHON OF WORK TO BE PERFORMED:
t-� -1Y"e- A�c e J VK �
Please Type or Print Clearly)
OWNER: Name: \--)A\,\-*
Address:,) q k
CONTRACTOR Name: Phone:
Address:
N
Supervisor's Construction License: Exp, Date:
Home Improvement Licen
ARCHITECT/ENGINEER Phone:
J�0
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.000 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 7 7 % . I V FEE: $
Check No.: S' Receipt No.:
NOTE: Persons contracting w' unre ' tered co tractors do not have access to the guaranty fund
ign�ature of Agent/Owner Signature of contractor
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
a Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
Dimension
Number. of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — For department use)
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL1
4
�
Public Sewer
Taririing/Massage/Body Art
Swimming Poole
Well
Tobacco Sales
Food Packaging/Sales i
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM "
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMEKTS
C
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Sianature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 3840A6& 6& `St�'Qet
FIRE DEPARtMENT = Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, IUA-02111
www.massgov/dia
Workers' Compensation Insurance Mridavit: Builders/Contractors/Electricians/Plumbers
Naive (Business/Organization/Individual) -<—� A L�
Address: '�D� ( t 4r-\�
City/State/Zip: 1`!, YV\A Phone #: 7E68 3 d 3 C
Are you an employer? Check the appropriate bog:
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3* I am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
* :.:y applicant that checks box 91 must also .11 out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
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 up 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 coverage verification.
of perjury that the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability.Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. . The affidavit should
be retained to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Eine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
Tel. # 617-7274900 ext 4.06 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
www.mass.gov/dia
Gerald A. Brown
Inspector of Buildings
Please print
DATE: MD —
JOB LOCATION:
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Number
HOMEOWNER 0 Aviv
Name
PRESENT MAILING ADDRESS
Telephone (978) 688-9545
Fax (978)688-9542
3tr&t Address Map/Lot
Home Phone
S,
'F 7E-6 53 -3/G F
Work Phone
�0, X','3k4 - NA- Q (fts_
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and req�ents and thpt�he/she will comply with said procedures and
requirements. �
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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Location ��
No. }� Date Z4 So
f
Check # 6 1), S-
19� 50
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
r
Building Inspector
apTN ,�
o
F
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M9SSACHUS�
peunit ND
d•
I
lan P'nd
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i
1
�00 from the Board of
Deeds. One copy and
J
ANDOVER
Ov ORTH MIN AT10N
TOwIoN FOR PLAN EXA
ApPLICA 21(e G
pate Received:
Date Issue l'roR
LOCATION O� v t,
PROPERTY PARCEL:—
MAp NO.'S
ND USE OF BUILDING
TYPE OF [MPROVEMENT
TYPE
0 Tlew Building
p,ddition
tion
all items on
this
must
y`I
print ZONING D1STR[CT:
�C D15TRICT
WST0w
PROPOSED USE
Residential
oneorlm re family
po
o of un
Assessory its: Bldg
I tera
epair, replacement
❑ er
Demolition
Oth
0 Moving (relocation) TO BF, PREFORMED
p
❑Foundation onl F WORK�� vers TION O �u b�
DEgCRI
Y)
Identification
R: Nam
Address:--V-�
CONTRACTOR Name.
YES �
No R ntial
❑ [ndustrial
0 Commercial
please Type
print Clearly)
or
Q�J <
0 Other
Exp Date:
Address: Exp Date.
Sup
ervisor's Construction License:
ent License: Name: Phone ��
Improvem
g 6 V3
ral
HomeS.F.
EER Reg. No' ON $125.00 PER
ARCIIITECTIENC' COST BASE
THE TOTAL ESTIMAFEE:�--�
Address: PERMIT: $10
00 PER $1000.00 OF x10 OO–
LE:gULDING Receipt No.
Prof :
FEE SCNEDUect Cost
.r=
T-----------
TYPE OF -
Public SEWARGE DISPOSAL
Suver
Wel] Lj
Private (septic tan 0
k, etc.
No
E' Persons �o
ntroetin
Signature Of Age
Tanning/Massa
ge/BodY Art
Tobacco Sales El
Permanent Dumpster ❑
on Site 0
Iswimming
Fr
Plans nt/ Uwner r" ""'' d
be •
Submitted ❑
f . j� ab0\ee
t"I
C(
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Seo\3e`\\ed
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Decision: ti s C�,edl �°
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ecision: e $e
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on yes V° C 11a1 \I� oCC`eemaatOe
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Building Permit A o �0
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by.\,
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41
41 n
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9SSACNU`��.(
Permit NO:
Date Issued: 6
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received: 2-61 G
IMPORTANT: Applicant must complete all items on this page
LOCATION 0C 9 1 I1, DY ->)'( -k `\ _ 5 � - -
Print
PROPERTY OWNER'PrV q) 1(/) -
Print
MAP NO.: PARCEL:
TVPF AND ITV%F OF RiTII.DING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ AIteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
epair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED )4 e,014r lk�,Gt-1r d
2 mov, "n
Identification Please Type or Print Clearly)
OWNER: Name: \ r)A- \`U P/ -A Phone: /'7 9 6 O3 -J -33 -do �
Address: `I 12,0� Q `yy
CONTRACTOR Name:
Address:
Supervisor's Construction License:
CSU ,(\
Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. N
FEE SCHEDULE: BOLDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ O&Q0 7 x10.00=FEE:$ Q �—
Check No.: 62; L--/ Receipt No.:
Page I of 4
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Rooting, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic
Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
New Construction. (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of
Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and
proof of recording must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Page 4 of 4
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required
Provided Required Provides Required
Provided
DIMENSION
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
NOTES and DATA — For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT43PFORM05
Created JMC. Jan.2006
TYPE OF SEWARGE DISPOSAL
Tanning/Massage/Body Art Elg
Swimming Pools El
Public Sewer
Well
Tobacco Sales ❑
Food Packaging/Sales 11❑
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unre istered o' tractors o not have access to the guaranty fund
i
Signature of Agent/Owner ! Signature of Contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
z
Zoning Board of Appeals: Variance, Petition N
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Water & Sewer connection signature & date
DATE REJECTED
❑ ❑
❑ Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJ> CTED
11
Comments
Comments
Temp Dumpster on site yes_no Fire Department signature/date
Building Permit Approved and Issued by:
Page 2 of 4
Fl -
DATE APPROVED
The Commonwealth of Massachusetts ,.
> Department of Fire Services
Office of the State. Fire Marshal
P. O. Boz 1025 State Road, Stow, MA 01775
PERMIT Date �.4 C _ r«
North Andover. Permit No Dig Safe Plumber
( Cityof Town) (If Applicable)
In accordance. with the provisions of M.GG.L1. 4 8 C�hhapter_];Q.aas provided in section --5-7 7 (MR 34 start Date
This Penait is granted to:
Full name ofperson, Firm or Corporation'
Permission to locate dumpster for construction/ renovation/ demolition of building.
Comrnentg:. dumpster must be 25' from structure if unable to place with required
Restrictions: c1earance/ dumpster must be -covered with plywood or tarp end of work _day
at y %i�''f fi1 c� /
( Give location by street and no., oi,descrr-be in such manner as to pr ied adequate identification of location )
FeePaids 50.00 J w Fire Chief
This Permit will expire 31 y G ( Signature of offical granting pen -nit ) Offical granting permit ( Title )
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t+oRT#j TOWN OF NORTH ANDOVER
1
0 OFFICE OF
BUILDING DEPARTMENT
°! 400 Osgood Street
� 1
RJ,q°-0wre° �p*,�qy North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:— 0?
dG
JOB LOCATION:-) � i A KJ A -
Number I ' Street Address Map/Lot
HOMEOWNERy U 10 M • Q i-'�
Name Home Phone Work Phone
PRESENT MAILING ADDRESS eP L/ � 1.4:;� S�
N
PMwrC1C_
Am,
6 ( ?__�
City Town
State
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures an7requir ents and6the/she will comply with said procedures and
requirements.� �_1 /f
APPROVAL OF BUILDING OFFICIAL \ �--
Revised 10.2005
Fonn Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-
9535
Zocationr,-�
��
Datei�
I
TOWN OF NORTH ANDOVER
r
Q
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
A;46 G
jiv- Building Inspector
Div. Public Works
Location `�41 PP&'m Sr
lNo. Date
i
TOWN OF NORTH ANDOVER
Certificate of an, $
BuildinglFram Perm Fee $
Foundatio Per it Fe $
Otnmi-Fee $
Si er C nne tion Fee $
Wat `rr.�
`OTAL
�1
9382
on Fee $
6) $ - (0�7 -
Building Inspector
Div. Public Works
PERAfff NO. 59
!
i
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP 4-40. !_
(y
LOT NO. ? 4
2 RECORD OF OWNERSHIP (DATE
BOOK PAGE
ZONE
I SUB DIV. LOT NO.
i
LOCATION /Z q I /! iqv'.+��
IL�
u*'�[1
PURPOSE OF BUILDING Anil
�v('�'
OWNER'S NAME
. �R
i�/1
NO. OF STORIES SIZE
OWNER'S ADDRESS
4 t A �'�'[.1
f7� 71 d3T
BASEMENT OR SLAB
ARCHITECT'S NAME
-
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME `
SPAN ---
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES �Z%j REAR
�J
20�
GIRDERS
FRONTAGE
AREA OF LOT 5 �6�
/C
iJ /
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 CODE
IS BUILDING CONNECTED TO TOWN WATER yC5
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER / `S
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE t FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS t - t2
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE IL
S N
11 TURF OF 6WNEK OR AUTHORIZED AGENT
F E E %7.N I "'e-
00 -
PERMIT GRANTED
l
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST V Oov
EST. BLDG. COST PER SQ• FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
MUILDING INSPECTOII
OWNER TEL. #
CONTR. TEL. #
CONTR. LIC. #
H.I.C. #
q3TI-
BUILDING RECORD
1 OCCUPANCY 12 1
SINGLE FAMILYS-- It
MULTI. FAMILY �- OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR
B
PINE
P
PLASTER
DRY WALL
UNFIN.
FINISH
1
2 I3
_
_
CONCRETE
CONCRETE BL K.
BRICK OR STONE
PIERS
_
3 BASEMENT
AREA FULL
FIN. 8 M AREA
'/. 1/1 '/.
FIN. ATTIC AREA
_
N_O 8 M
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
4 WALLS
I 9 FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
8
1
2
�_
3
_
_
CONCRETE
EARTH
HARDV'D
COMMON
VERT. SIDING
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR _
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I� POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
1 IP
BATH (3 FIX.)
GAMBRELMANSARD
A
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
to 13rd
ELECTRIC
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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TOWN of NORTH ANDOVER
.•n- IIO • cu=.I qLve t•@- .•
ta_.• z =r .• • .• ✓.1■ •
Type of Work:
Address of Work of y Aby 1 c_4b,-,,
Owner Name: PA ` 1YA V 10 C
Date of Permit Application:
D-6 Est. Cost aoa
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
-Job under $1,000
Building not owner -occupied
pulling
permit
Other
Notice is hereby given that:
• • • • ti• • • • r ►� r it y• H
r
•- .111
r:
Signed taxies putties of perjury:
I hereby apply for a = the agen the owner
:lo 9s
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the
owner of the above property:
Date Owner Name
Town of North AndoverHORTN
Qt «ao ,ti0
OFFICE OF 3? �`` Qc
COMMUNITY DEVELOPMENT AND SERVICES ° .
146 Main Street
o •ra`4�J
KENNETH R- MAHONY North Andover, Massachusetts 01845 .933 US
Director (508) 688-9533
Please print. %
DATE �/ 0?Q
JOB LOCATION
"HOMEOWNTER"
HO%1EOWNER LICENSE E:LE�fPTION
f -
Number 1 street address Section of town
a>3�v �D VoC. 6%3� 3(. a C 19 33/
Name Home phone Work phone
PRESENT MAILING ADDRESS a � I � of lI r) s4-'
City/'Town
State
I k'L[S
Zip code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Sec-
tion 109.1.1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which heishe resides or intends to reside, on which
there is, or is intended to be, a one to six family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-vear period shall not be considered a homeowner . Such "homeowner" shall submit to
the Building Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersijned "homeowner" assumes responsibility for compliance with the State Building
Code and other applicable codes, bv-la«vs, rules and regulations.
The undersigned "homeowner" certifies that he -'she understands the Town of iVo. Andover
Building Department minimum inspec-,on rocedures and requirements and that he/she will
comply with said procedures and requ4nts. ---7
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICL�L
Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0, Construction Control.
BOARD OF .APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parriao D. Robert Niaetia Michael Howard Sandia Starr Kathleen Bradley Colwell
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