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TOWN OF NORTH ANDOVER -
APPLICATION FOR PLAN EXAMINATION
Permit NO:
-753- //
Issued: ; ?? /
IMPORTANT:
Date Received
must complete all items on this
LOCATIONS
Print
PROPERTY OWNER f� iib J 1 LLA
Print
MAP NOa�— PARCEL ONING DISTRICT Maistoric District yes ( nq)
chine hop Village yes n
TYPE OF IMPROVEMENT
PROPOSED USE
Non- Residential
Residential
J�One family
❑ Two or more family
El Industrial
'New Building
ElAddition
No. of units:
❑ Commercial
0 Alteration
❑ Others:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
0'_, Septic Well
❑ Other
❑Floodlain p Wetlands
p -
❑ Watershe'D
Water'/S ewer .:
_. _ .. -
_ - _
O WORK TO BE P ORMED:
n,pol 'pTPTTON
or Print Clearly)
OWNER: N
CONTRACTOR
Il
-
Address: ' "
Ex
Supervisor's Construction License: �� P- Date:
Home Improvement License:�(���7 Exp. Date:
ARCHITECT/ENGINEER t Phone:
Address:
FEE SCHEDULE. BULDING PERMIT. $12.00
$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ w FEE:
Check No.: v2 y Receipt No.:y/��
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fu`
-_-- Si nature of_contractor -�
.��anature:of Adent/Owner�
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
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ 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
❑ 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
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
fiat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
lust be submitted with the building application
Doe: Doc.Building Permit Revised 2008mi
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 I
NOTES and DATA — For department use
® Notified for pickup - Date
Doc:.Building Permit Revised 2008
Plans Submittedy- Plans Waived ❑ Certified Plot Plan ?� Stamped Plans iQ(
TYPE OF SEWERAGE DISPOSAL,
Public Sewer kr Tanuing/MassageBody Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION Reviewed
nr,,- D q, b
DATE APPROVED
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Com
,Conservation Decision:
i
Nater & Sewer Connection/Sic
DPW Town Engineer: Signature:
Comments
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumfdter on site yes no
Located at 124 Main Street n /�
Fire Department signature/date -cel-• .SL�
COMMENTS
r
Location
No. Date 2 �'
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ / o d —
Other Permit Fee $
TOTAL $
Check #2 0:2
24i�1 /Z.
/ Building Inspector
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