HomeMy WebLinkAboutMiscellaneous - 299 MAIN STREET 4/30/2018N
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No. Date e'F', Z ;�002—
Check #
15 8 U 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
$ P6 ffv
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Z��jlding lnspectorz�
TOWN OF NORTH ANDOVER
. BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1*14'r 5
jMk_,ff 1211111$ M
BUII,DIT DATE ISSUED:
SIGNATURE:
BuilEng Commissioner/Inspector of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
0 L/ Z-11�013 ?
Map Number Parcel Number
1.3 Zoning Information:
Zoning DiAtict Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BUIELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
lic 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWR�RSEEIP/AUTHORIZED AGENT
2.1 Owner of Record
.,4 Gq 0C C/'
/44ame (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 0
Licen se Number
Expiration Date
3.2 Registered Home Improvement Contractor
—V, � Z, czer-o7
Not Applicable 0
dompany Name
Registration Number
Expiration D;te
Address
/7 -76
Signature Telephone
00
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0
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I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 4 25c(6) I
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 ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Ferations(s) 0
7,tion 0
Accessory Bldg. 0
Demolition 11
Other 0 Specify
Brief Description of Proposed Work-
�- We,
-,SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
C�mpleted by permit applicant
ONLY
1. Building �60
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) 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 BUMD11% PERM[IT
as Owne uthorized Agent of 'ect property
Hereby authorize o act on
My behalf, in all matters relative to work authorized by this building permit application.
Si�iiature of Owner Date
-SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION
1, 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 er ent Date
NO. OF STORIES SIZE
-BASEMENT OR SLAB
SIZE OF FLOOR TUVIBERS I ST 2 ND 3 RD
SPAN
DINIENSIONS OF SILLS
DINENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TFI]CKNFSS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLD) OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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HOME IM�ROVEME", Is and StQndards
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ROBERT .1ndl , v
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CHELMSFORD,',MA 0 , 8, t
Adminiii,,,tor
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL 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 IVIGL
c 11, S 150 A. I
The debris will be disposed of in:
Irld (Olqln �w el- (er-a dCe lAk- �q A
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(Location of Facility)
1r4
Signature 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
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