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N,q,r.,t]�-A,n.qoy�*,Boa�r,d:�o,,fi-A,, " C�
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roperty Record Card
Location: 27 PETERSON ROAD
Owner Name: PRASHANTH, TARIKERE
PRASHANTH,REKHA
Owner Address: 27 PETERSON ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 0.17 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1590 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 340,600 340,600
Building Value: 185,600 185,600
Land Value: 155,000 155,000
1 F MTarket —Land Value: 155,000
A
IChapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=l 888956&town--NandoverPubAcc 5/17/2012
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,AORTH.
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4. TOWN OF NORTH AND ER
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PERMIT FOR GAS It ALLATION
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This certifies that.G..
has permission for gas installation
.....................
in the buil&ngs of
................
at ............... North Andover, Mass.
Fee--.� ....... L i c. No. ......
Check#
6568
MASSACHUSETTS
or
Newo RenOV21tiOn 0
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR'
STH FLOOR
6TH FLOOR
7TH FLOOR
-Instaiiing conwany
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Name,ofl.lcensedPlurnber.ard2s; Fitter eV
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APPLICATION FOR PERMIT TO DO GASFITTING
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Check -one: Certificate
0 corporation
Partnership
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INSURANCE COVERAGE:
I have a. cuit . entpblllty Insurance policy or its'subs-tantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 0
if you have checked yes. please indicate the type of coverage by checking the appropriate box-
Other.type f Indemnity 1:) Bond 0
A liability Insurance Policy
OWNEWSINSURNACEWAIVElt I.am aware that the licensee does not have the Insurance coverage required by Chapter
142 of the Iliass. General Laws,, and that my sigitlature on thi� permita Ication waives this requirement
or
Check one:
Owner 0 Agent 0
I hereby certify that all of the details and Information [.��have subrrdtted (or entered) In above application are true and accurate to the best of
my knovA edge and that 211 Plumbing work and Installations performed Und uLe,,d for this applicatio 11 be in complia ce vAtti
10�9:e M -I -f -hl I
-C ode and C hapte er T'
all perti nent provisions of the Massachusetts S tate Gas- r 142 of ne
Type d -f License:
sirthture of Licensed P- Fitter
By Plumber lWffber or Gas Fi
ID
FTitle '.;&4�tte r
Qityfrown'- Veastier License Number qC3 0-3
APPROVED (OFFICE USE'014L-Y1 D.JoUr ' neyman
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TOWN OF NORTH ANDOVER
WPM& PERMIT FOR GAS INSTALLATION
This certifies thAt
................. ......
has permission for gas installation ...............
in the buildings of .................
North Andover, Mass.
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Lic. .........
Fee --,k5.
Check #
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Business Telephone
Name'of Licensed Plumber- or Gas Fitter
INSURANCE COVERAGE: 142.
I have a,currentfiabilitY Insurance policy or its sgbstantial equlv2lent� which meets the requirements of MGL Ct
Yes No 0
if you have Checked yes, please indicate the typem of coverage by checking the appropriate box.
A liability IMUranCS 130IIcY other type of Indemnity 0 Bond 0
OWNEWSINSURNACIEWAIVER: 121M aware that the licensee does not have the Insurance coverage mquired by Chapter
142 of the Mass� General L2ws, and that my signature on th s permitapblication Walves this requirement
Check one
qvwneot)G&i� OvMer..El- Agent. 0
i hereby certify that 211 . -,0 - F t hS - tiet alis" 2 -fid Information 1 -have subrrdtted for -entered) In 2bove.applicatio and,appyrate,to the best of
n'2re tru.
th
my knovAedge and thAtblipluffib fil; work and histallati6ns performed. under the.per, s uedfort.his P . 1JC2ti0 1.1 be in complia Ce vA
- ' ; - - - I - - I . . I - C
-of the Ma�'Sachusetts StateCas code and chapter U12 of 'Me tid- I
ail pertinentprovlslon.s�
A Am; �A-1'
4AX70
Type of License: iA ' 9 1 V L.-1611
By [] Plumber re of L1 ftte-i
Title 0 G, tte- r9. -S
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, (;ityrTown License Number '?'�5 03
'�PPKOVED (OFFICE USF, 0140) I)Jourreyman
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Location
No. 62 5� Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
uildin ector
10959 111111974: &25.00C QT
Div. Public Works
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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 +-h- 1% �-4
_k1k, %_ . cany or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phone Lsos
LOCATION: Assessor's Map Number Parcel
Subdivision Q Lot (s)
Street IV St. Number
************************Official Use Only************************
R7E�co DATIONS OF TOr AG S:
Co'ngei��ation Aftin 119-trator
Comments
Date Approved
Date Rejected
A
% Town Planner Date Approved
Date Rejected
Comments
Food Inspector -Health Date Approved
Date Rejected
Date Approved
septic Inspector -Health Date Rejected
Comments
-Public works sewer/water connections
driveway permit
Fire Department
Received by Building Inspector
Date
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EST -481.1.5i
A91PISION
MA YS A9
� IrERN, EN
PLAN a
NOR
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ARAWN FOR APA
TO 3E)Vcl iN,3W3-qVNVH N33d9d3A3 STOBV9980S L66T/pl/�O
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J02.
�EPARTHENT OF PUBLIC SAFETY
48TRU TION SUPERVISOR
'Expires Bi rthdate
PAR VIENNEAU
)19 PEARL ST
READI G MA 01867
51
office Use Only
he Lfamummutalth tif :9ass#u5rtt5 Permit No. 7z-
4
Ilepartintut of public *afztV Occupancy & Fee Checked 17
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 0eave blank) 4
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date / - /- 9(�
Q* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described
Location (Street &Number) (—So
Owner or Tenant /� 1, ff
Owner's Address / D :� 10 CIA I r 7- r-'� 9-1 .) tk t1-1 AJ(
!s -!iis permit in conjunction with a building cermit: Ye s No L— (Check Appropriate Box)
Plumose of Suiiding I -J a I,. <A, 1-D §.3 Utility Authorization No. 76
Vc:+s
=xis -zing Service — Amt. s Overnead Unagrnd No. of Meters
New Service 7-6'n Amps "Z-0 Z'1`6.voits Cvernead Undgmd L��-/ No. of Meters
Number of Feeders and Ampacity
Lccaticr. and Nature of ProPosed E!eC*r!cai Wlcrirc A -IQ C6 &:�g KC K,%
-No. of Lignting Outlets No. of Hot -��-cs i No. of -.ransformers
Atove— 'n-
KVA
No. of Lighting Fixtures Swimming Pool grr.c. — zric.
i Generators
1 No. of Emergency Lighting
No. of F;eceotac!e Cutlets No. of Oil Eurners Battery Units
No. -at Switcn Out!es
No. of Gas Surners
FIRE ALARMS No. of Zones
No. of Cetection anc
Initiat ng --evices
I
7o!ai
No. of Air Canc.
No. at Ranges :Cris
Heat -czai
No. Oisoosals No.zf -.ons
of
Pumas
No. of Sounding Devices
No. of Self Containec
No. of Dishwashers
ScaceiArea Heatinc
Oetec*,;o niSounding Devices
Munic:oai Other
Local . :
Connecl.:On
No. of Dryers H.eating Devices
No. of Nc.
Low Voltage
No. at Water Heaters KW
I S;cns Sa!�as:s
Wiring
No.- Hycro Massage -iubs
No. of motors 7otai �-iP
OTHER:
lNSURANCE CCVERAC----':: Pursuant to the recuirements at Massacr-,L;seas ;erieral I-aws 1
1 have a current Liaoiiity Insurance Polic, ' , inc:ucinc; Ccrr-c!erec Ccera::cns Ccverage or *Its suoslantiai ecuivatent. Y ;� NO Z 2 1
have sucrititted valid -proof of same to the Cfics- YES J NO :: if -,ou lave cneCKea YES. please inoicate zMe type bt covera e y
checking the aDcrooriate Dox.
INSURANCE 7 BONO = OTHER :: iPlease S--ec:'?-,,
(Excitation Oatei
Estimateci Value of E!ec*rical WOrK S
WorK to Start //-- I -2!L —
Sigrieto �.ncer Penalties of perlun
F: R.1.11 14 A Ni E
insoec-.:cn Date ;;acL;es*ec: Rcugn LAJ((( C--((- Finai
UC. NO.
'-!C. NO.-
<:� I:;- - t- R
Bus. -,ei. No.
ACdress Z 24-k -/-/A Alt. 741. No.
C*.Vr,'E;;*S iNSURANCE WAIVER: I am aware that !Ile L-;censee aces not Mave the insurance acverage or its suostantial ecuivaient as re-
cuirea ny Massacnusetts General Laws. anc 'hat rny signature an -.nis zefmit application waives riis requirement. Owner Aaent
'P!ease c!%ecx onel
(Signature of Owner or Agent)
7eiecrione No. _ PERMIT FEE S
X -i5;65
n
'$ - Date ..... //`..7d ........ V..
TO
567
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............. g—v-'e -- ----------------------------
has permission to perform ...... .. .... ...... ........................
wiring in t�he buildlin ........ 1. . . ..... ...................
at ......... ................................... ;�- W North Andover, Mass.
ZD ...... .....
Fee.OA! ........ Lic. No. ZO .. 7 7/� . ....... *i�i;�� R*'[C* A**L* *1* N -S' P**E' C*'T* 0** R**...
—V
O&DIA�n1ja e 175- 50 PAID
WHITE: Appiicant CANARY: Building Dept. PINK: Treasurer
r�
. . . . . . . . . . . . .
ob,f n c, A ............ ....................
Iw
Date. . 44/w....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
W.
has permission for gas installation
in the buildings o,
........ V.2
a ........ - . ....... ....... I North Andover, Mass.
Fe Lic. No. .. ..........................
GASINSPECTOR
Check #
WOW
4678
MASSACHUSEM. UNIFORM APPLICATION FOff PM:tMff TO DO GASFITTING
Mass. Date 2Q Permit
Bu1d1kV1AcdIon,",;17 6rk J, Owner's Namea �4/1,�OtC
of 0ccuI�_z4LA__
New [3 Renovation. Replacemer*Q( Plans Submitted. Yeso No tj
Installing Company
Address 4 A- A
(Ze
Business Telechone —rA i - n S�A - QA q t,�
Name of Ucensed Plumber or Gas Fltter�
Check -one:-, Certificatef
13 Corporatim-
13 Partnership
P Firm/Co.
INSURANCE COVEFLAC-E:
I have a cuffe.4IIab1lltY'irWJanCC'P0IiCY Or Its gub$bnW CqUIValeft-WhiCh-Meft the requirements d..MGLCh,. 142.,
Yes )( No 13
If you houre -cheelead-M&;ftmJndicata*wtylwcovemge -by checking the -app—a)prlde box
A IWARY Insurance:Poile-Y X Ouw�b",CtWemnity.[I. Bond 13
OWNEROS INSURANCE WAWER: I am aware that the licenseedoes -not hry - the Insizance -coverage required -by
Chapter 142 of the Mass. General I.Awa. and -thd.my signatiwe on Vft -permit application waives this requirement
Check one:
Signature ot owner-ar-oww3 4mr OwnwO Agent El
I hereby certity that all of the details and infarrnation I have 3ubff&W (or antereW in above I application we true and accurate to.the bed of my
knowlWge and that all plumbing WWk arid insWiatim perfWm9d UrKW #0 Permit for this VVIM be in complium with d
Pertinent Provmons of the Massachusetts State Gas Code and Chapter 142 of the General
Tj Off Wmense:
�r
Plumber SignaluWaf LicensUpNumber or Gas Fift
Tale or
M er
I aster Ucense Number Q(.0.
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
'�SA US
This certifies tha ...... ...... ....... ...
L
has permission to erform ........................... ..
plumbing in t4-Uuildings of ......
at ........... North Andover, Mass.
. ............. ................
Fee Lic. N o./�). )6 PLUMBING INSPECTOR
"'Check ff
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
It "ralt or Type)
(Print or
Mas& Date dow
Permit t
SuRdina I oca ion Owner's Name- L��z 13
%:S- 12-- Type of Occupancy
New In RerxxatW [3 Fleplacemerit 1!�_ Plans Subrnitted: Yes No
A
Business Teephone
Nanle of Licensed Plumber ';
Check one:
0 Corporation
13 Partnership
DWAIRMICE COVEPAM
I have a current liability policy or ft substantial equivalent which meft
YWX No the requirenwaft of MQL Ch. 142 -
If you have chefted YM Plem indicate the type coverage by checking the appropnate b03L
A liability irm"arlm policy -g Other type of indemnity c Bond C-1
OVMEFrS INWRANCE WAnMk I am aware that the licensee don not have the insurance coverage required
bYCNWW 142 otihe Mass. Gerwal Ums, Old that rW signatureon this pwra-applk, Nm waiVINStftmquirwrient.
Check ow
SWW= of Owner or Owners Agent Owner Agent C3
I hmadw fWWWW "wat .11 -4 � -
--sum a'k'QmFw= (Grente"in al)cwea
j;;j- , pph
the bW of rny Wowiedg& VWall =- -=-�_7t
Pkm*ft wcx and installabons
be in cartgol iance vft all Pertinent prow0mm of Ve Mumftawns this applicam us
s t� - of the GeneW Law&
SW="0fLWenSW0i_ff�
Type of Ucense: master X. Journeyman
ucense Nun*er - /-2"/ CIO
mom
MENEM
M
Business Teephone
Nanle of Licensed Plumber ';
Check one:
0 Corporation
13 Partnership
DWAIRMICE COVEPAM
I have a current liability policy or ft substantial equivalent which meft
YWX No the requirenwaft of MQL Ch. 142 -
If you have chefted YM Plem indicate the type coverage by checking the appropnate b03L
A liability irm"arlm policy -g Other type of indemnity c Bond C-1
OVMEFrS INWRANCE WAnMk I am aware that the licensee don not have the insurance coverage required
bYCNWW 142 otihe Mass. Gerwal Ums, Old that rW signatureon this pwra-applk, Nm waiVINStftmquirwrient.
Check ow
SWW= of Owner or Owners Agent Owner Agent C3
I hmadw fWWWW "wat .11 -4 � -
--sum a'k'QmFw= (Grente"in al)cwea
j;;j- , pph
the bW of rny Wowiedg& VWall =- -=-�_7t
Pkm*ft wcx and installabons
be in cartgol iance vft all Pertinent prow0mm of Ve Mumftawns this applicam us
s t� - of the GeneW Law&
SW="0fLWenSW0i_ff�
Type of Ucense: master X. Journeyman
ucense Nun*er - /-2"/ CIO
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Locatio n
No. :1.4- Date
ThWN OPNORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ az
V$ CHU
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
0/jOer Connection Fee
�07A
$
TOTAL
$
Building Inspector
,40/18/%
12,17 66i.00
PAID
10355
Div. Public Works
oodil
—.00f.j
Location
Date
9/nAo-
TOWN OF NORTH ANDOVER
S
Wpm
Cettificate of Occupancy
$
Building/Frame Permit Fee
$
csmu
Foundation Permit Fee
Other Permit Fee
$
Sewer Connection Fee
Water Connection Fee
TOTAL
n L Building
1% M:M 150. 00
Inspector
PAID
10,
Div. Public Works
Location',2-7
No. D aft e
TOTAL
9-145
(;10
Div u lic Works
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
4 S
CHUS
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
9-145
(;10
Div u lic Works
__ _ ___________rn'
.` � -_
�
^ `/ -��
` ` ~.`
PRILHIT NO.
APPLICATION,' FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE I
L6T N
UB DI'l LO- NO
2 RECORD OF OWNERSHIP jDATE
BO K PAGE
LOCATION,
PURPOSE OF BUILDING
Its
OWNER'S INIMME
. P - - 1 -1 s:)
NO. OF STORIES SIZE
OWNER'S ADDRESS �� > )A ko &E
A)
BASEMENT OR SLAB
ARCHITECT'S NAME 771
SIZE OF FLOOR TIMBERS IST,,NX/p 2ND ;oXj4o 3RD
BUILDER'S NAmr_---/-,� Al, " - b
SPAN I
ix — 1- . - -_
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS .f! / - -
DISTANCE FROM STREET
,:lz
POSTS ;�o4 , ,
DISTANCE FROM LOT LINES SIDES REAR
'. . 4
GIRDERS e;�llla
AREA OF LOT qCrr-rt) FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITIOWI
MATER:AL OF.CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE-
ye�S;
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE, V4p
- A
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVE D BY BUILDING INSPECTOR
bATE FILED_
SIGNATURE OF OWNER OR A(JTHORIZED
3 PROPERTY INFORMATION
LAND COST
ES'r. BLDG.COST
EST. BLDG. COST PEd SQ. -FJW_AL&_— a->
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
NUILDINGANSP&CY.01111
-OWNER TEL. 7% 7q
CONTR. TEL. #
CONTR. LIC. #
H.I.c.l# . lo:�919
B U I L&I.N G' R E C 0 It D
OCCUPANCY
12
SINGLE FAMIt SiORIES.'' JU— ,T -H CT Im ONS -60 LOT'Afi DIST)kNit-lit FROM
Y. IS SECTION MUST SHOW EXA 9NSI'
MULTI. FAMILY -OF,,EiU -�Wl`tk -1§
�S AND EXACT DIMENSIONS ILDINGS) PRORCHF GA
APARTMENTS ES..ETC. SUPERIMPOSED THJS,REPLAdkS PLOT'F:rLAN-.'�
CONSTRUCTION -
L
FOUNDATION
2 8' INTER16i FINISH tN
CONCRETE 2
CONCRETE BL'K. PINE 12 -
BRICK OR STONE HARDW 0 %
PIERS PLASTER
DRY WALL
I UNFIN.
3 BASEMENT
AREA FULL -LIN. B-M-T-jAREA
1/1 1/2 1/1 FIN.' ATTIC AREA
NO 8 MJ FIRE kACES.,
HEAD ROOM MODERN KIICHEN
4 W�LLS 9., FLOORS
DROP SIDING Cb N CRETE
WOOD SHINGLES EARTH
ASPHALT SIDIN HARDxNl*D
ASBESTOS SIDING -�-O-MIACN
STUCCO ON FRAME
STONE ON MASONRY
'WIRING
STONE ON FRAME
SUPERIOR _j -22 RH
ADEQUATE OgN E
ROOF
10 PLUMBING
GABLE I I HIP
GAMBRELI_A MANSARD
2 L ---
F AT SHED
BATH 13 FIX61
TOILET RM. (2 IX.)
WATER CLOSET
rl
AqPi4AtT
L -4r
LAVATORY.
6 FRAMING HEATING
WOOD JOIST- PIPELESS FURNAC
FORCEDHOT AIR tFURN.
TIMBER EMS. & COLS, STEAM
STEEL BMS. & CQLS�j S:7- HOT W -T -R OR VAPOR
WOOD RAFTERS AIR CONDITIONING
RADIANT H'T'G
Ut4fi,14EATERS
7 NO. OF ROOMS L
01
uW T 2nd I ELECTRIC
3rd I NO HEATING
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41�
Growth Management Bylaw Exemption Statement. ---
Town of North Andover Building Department
This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the
Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary'information
as requested below.
Name of pplicant on Building Permit (below) Address of Property for Permit (below)
7JyV',AS
Map and Parcel : Purpose rpplication (check below)
Phc?e(N��e� of Applicant: V,
D -K 4, -7 _i Single Family Two Family
I the undersigned applicant for the above pro perty attest that the attached building permit for which this
form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth
Management Bylaw. I also understand providing this form does not absolve me or any party to this permit
from the requirements of obtaining other permits required prior to the issuance of the Building Permit.
Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building
Department and is only officially accepted when the Building Permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling
existence as of the effective date of this by-law, provided that no additional residential unit is created.
The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
Bylaw.
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
conditions of 8.7.6.c are met andior represents Dwelling units for senior residents, where occupancy of the units is
restricted to senior persons through a properly executed and recorded deed restriction running with the land. For
purposes of this Section "senior" shall mean persons over the age of 55.
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently
designated as open space and/or farmland. The land to be preserved shall be protected from development by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an
adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the
parcel.
This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and
commissions have been reteived and the project is in compliance with those permits), and the Development Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
Development until such time.as the Development Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS.
By signing below I attest to the accuracy of the information provided and that the attached building permit
allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or
inaccurate information, or the checking off of an above item which does not comply, whether done to my
knowledge or not, nds for fefusal by the Building Department to issue a Building Permit.
AJXA J,,
Signattire of Owner or Authodie nt who sighedPe Attach d Building Permit @afe t
This form must be attached to In Building Permit upon application for such permit.
FORM U - IA)T 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 local or state law,
regulations orrequirements.
****************Applicant fills out this section*****************
APPLICANT: .0 6A
A&CO—, Phone
LOCATION: Assessor's Map Number C>_ o Parcel
Subdivision Lot (s) -6
Street St. Number
************************Official Use Only************************
REC9MM];NDATIONS/6FTOWN AGENTS:
�J -
Date Approved
vat lori/Affii-in i strator Date Rejected __ 1z 'I/
Comments
— 5LQ
town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved q I I n t C? 1,
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections _'7,7,TL-,d
- driveway permit _(_TL10
Fire Department
Received by Building Inspector
Date,
i
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