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,ORTM TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
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ss,•�° • tt� Building/Frame Permit Fee $ (� d
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Foundation Permit Fee $
Other Permit Fee $ %
TOTAL $
Check # .7 /
6796 M114� ..�
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Use
BUILDING PERMIT NUMBER: DATE ISSUED: to A �,
SIGNATURE: " " CCQX,�
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and
Map Number
Parcel Number: I
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
Required Provide Regaired Provided
ReQuired:17 Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
A
ame (Print) Add�r Service :
Signature Telephone
2.2 Owner of Record:
R
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
r_ ;7U- �,i Gh/i d Z
r ensed Construction Supervisor:
Address
7rExpiratioA
nature Telephone
Not Applicable ❑ /^
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License Number
Date
32R red Home Improvement Contractor
Not Applicable 0
40�
Registration Number
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pmpany Name
( ,5?7 f ! 4" �� �/��
Address
/Expiration
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Si nature Telephone
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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 application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Tlterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
ROO? VOC
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by pennit applicant
OFFICIAL USE ONLY
>.
1. Building
00
(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
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
t
Hereby authorize to act on
My behalf, in all matters relative fo work authorized is building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, 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
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TAMERS 1 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
IIEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIlvINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-954
DEBRIS DISPOSAL FORM
In accord ce zth 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 properly
licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project
through the Office of the Building Inspector
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PARAMOUNT
VINYL SIDING & CARPENTRY 7 School Street
MA LIC #056858 Methuen, MA 01844
Reg #108659 s (508) 794-9950
�,,UA; e7 -,j( TI ^1 A & w
PROPOSAL SUBMITTED TO
PHONE
DATE
STREET !r7 �A
(�
JOB NAME
CITY, STATE AND ZIP CODE
JOB LOCATION
ARCHITECT
DATE OF PLANS
i
JOB PHONE
We hereby submit specifications and estima s for: �- t
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Foe- CO!'l?S=(- 6
It shall be the obligation of the contractor to obtain all permits as the owner's agent; owners who secure their own construction -related permits or
deal with unregistered contractors will be excluded from access to the guaranty fund.
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Payment to be made dollars ($�as follows: / �-
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifica- Authorized -
tions involving extra costs will be executed only upon written orders, and will become an Signature - -
extra charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within _ days.
'&r"Vt8tWt Of rJ0;1V.0d —The above prices, specifications DO NOT SIGN THIS CONTRACT IF
and conditions are satisfactory and are hereby accepted. You are authorized THERE ARE ANY BLANK SPACES
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: ' 1 ""'�1`d `-� Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:�� ��) ��T���Z`C —Z—
Location:
City Phone # T ? is �9'i� i� .7 CI
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
City: Phone#
Insurance. Co. Policy #
Company name: ,
Address
City: Phone*
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties. of a rme tipto Vit,:
and/or one years' impftonment_as_wmff_as_ciyjpeoaNiesjo.tb&rano_&a_STQPMAKDRDFRanctaAne-6%(S1Mm)-jaM
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/ do hereby certify under the pains and penalties of perjury that the inrormabw provided above is true and correct.
Signature Date
Print name Pine-#
Official use only do not write in this area to be completed by city or town diiciar
City or Town Eumit/Licensing
Building Dei
]Check I immediate response is required Licensing &
selectman's
Contact person: Phone #. Health Depa,
Other