HomeMy WebLinkAboutMiscellaneous - 32 SOUTH CROSS ROAD 4/30/2018 (4) ..
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Location 3 a So Cr o S S Pc�
No. Date -3-of - D-)
NORTq TOWN OF NORTH ANDOVER
9
49
� Certificate of Occupancy $
CMUSE<�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ S
Check #
16243
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH
A1�ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: _. DATE ISSUED.
C
SIGNATURE: icic
Building Commissioner/I for of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: j� 1.2 Assessors Map and Parcel Number:
2— S t �.l 1 t✓� �a ( )3 !b 0 07`7
Map Number arg cel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning DisUict Proposed Use Lot Area s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Re aired Provided
1s 3 b Tb v
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: n
Public Private ❑ Zone Outside Flood Zone Municipal ❑ On Site Disposal System
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn
2.1 Owner of Record
l is
�fame(Print) Address for Service:
ignature Telephone
2.2 Owner of Record:
O
Name Print Address for Service:
Z
M
Signature Tele hone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supel rv~iso P 61 3 t S j O
License Number
Add res
S 3 Expiration Date icic
Signature Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name It 0 m
Registration Number r
ress
SA L1 Expiration Date Z
xp
I Sin a Telephone �1�
I
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 rmit.
Signed affidavit Attached Yes.... No.......0
SECTION 5 Description of Prfiposed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ [Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
J
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL'USE ONLY
Com leted by permit applicant
1. Building (a) Building Permit Fee
b
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 PlumbinE Building Permit fee(a)X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 p L LI) Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
H reby authonz ("� to act on
y be matters relative to work authorized by this wilding permit application.
Si nature o Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I,_15 ,`� 6�L� 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
\-,N ,) �in12A
Si ature of Owner/A ent Date
Fr
NO. OF STORIES l �LZ SIZE
BASEMENT OR SLAB G r.! U 3
S17E OF FLOOR TIMBERS 2ND
7-
SPAN IZ
DINIENSIONS OF SILLS
DMIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
_f[EIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING '` X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
u The Commonwealth of Massachusetts
= Department of Industrial Accidents
F Office of investigations
Boston, Mass. 02111
c�O+M Sy9�, Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone # �S Z�� �, 3 J
0 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 m`y employees/working on this job.
` Company name: �ii, •J 6 1.64
Address
City: Phone#: 31\—
Insurance.
3\`Insurance.Co. Policv# M Uy,,t
Company name:
Address
City: Phone#
Insurance Co. Policv#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00
and/or one years'imprisonment_as_vtielLas_civil penaltiesjn-tbelarm-f-a-STOPYV9RK ORDFRand afme_of..($1D0-00)artay.againstme. 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
y
!doh y certify er—S►a per' s and nalties of perjury that the information provided above is true and correct.
Signat Date 3 v
Print name Phone.# -6t -533
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
_ 9 p
Check Y immediate response is required Licensing Board
p Selectman's Office
Contact person: Phone#. Health Department
Ei Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with 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 a properly licensed solid waste disposal facility as defined by MGL
c11, S150A..
The debris will be disposed of in:
(Location of Facil ty)
Signature of Pe i Applicant
3 -LL I
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
0" .
Of
ED .f / over
No. a cl
3-a � Iva
3
T O A_- LA ` X11 dower, Mass.,
COCIiIC CX
DRATED p? 5
S H E
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT....... e1N..�.l� Q.
Foundation
has permission to erect....... 4
....�KY . wldmgs on ..a.lk. Q ...C %.S......�g. ... Rough
to be occupied as.....`�!... .... ...��. wgR.,..up . . . ..`�.. �� a W Chimney
. . .. . . .. ........... . .
provided that the person accepting this permit shall in every respect conform to the erms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Insp ction, Alteration and Construction of
Buildings in the Town of North Andover. 3 g 1 /X100 � PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Fina`
UNLESS CONSTRICTION ST TS ELECTRICAL INSPECTOR
Rough
........................................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove. Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
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