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Jol s6ugool diiis snonwluo0 AemhoN tixZ IIn3 snonu!luo0 :SON11003 •leu!3 'uo!lelnsul '9weJ3 'uoliepuno3 '6u!loo3 ' uolleneox3 (wnwiu!lN) :SN01103dSNl suog0adsu! ou Jo•'OiO MOO) iWROd 0N`d 'SS3800b''SN38Wf1N 101 llb' 1SOd M0138 SW311 01 0311WIl lON -18I1NO3HO/S310N Wallfl8 lHd3N30 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUII,DING PERMIT NUMBER: DATE ISSUED: OZ d.� SIGNATURE: zo 41 Building CommissioKer/Inspector of Buildings Date SECTION I- SITE INFORMATION LI Property Address: 1.2 Assessors Map and Parcel Number: u a Map Number Parcel Number k \ 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zane Information: Public ❑ Private 0 Zone a F1 Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZ A NT /2.1 Owner of Record A N oll] Name (Print) ' Address for Service Signature Telephon 2.2 Owner of Record: S 1,, Na Ptint s dress for Service: Si na elephone SECTION 3 - CONSTRUCTION SERVICES 3.I Licensed Construction Supervisor: Licensed Construction Supervisor: Address • Signature elephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 0 clVrTTnN a _ WnRKF.RS rnMPFNSATT0N (M_G.L. C 152 S 25461 Workers Compensation hrsurance 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) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. JII; Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ✓ <;�' x a' ��o �t�, s 9. 1i, \4 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b permit applicant °�v� ' OFFICIAL i1: ONLY _' r , �_ +s t , 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (,) X (b) r+ C—xJ 4 Mechanical HVAC t 5 Fire Protection 6 Total 1+2+3+4+5 S©, bD Uhed Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED HEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDPERMIT Aas Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in I m tters ati ve tAQ work authorized by this building permit appli n. J 1� b— b Signature of OwT1eN DAe SECTION 7b OWNER/AUTHORRIZED AGENT DECLARATION I __L,as OAvner/Authorized Agent of subject property r �" 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 Owne /A ent NO. OF STORIES t ate SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 RD 2 �' 3 SPAN DU\, ENSIONS OF SILLS DIMENSIONS OF POSTS DtDvENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVWEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval /permits from Boards and Departments having jurisdiction have been obtained. This. does not relieve the applicant and or landowner from compliance with any applicable requirements. .......n............... mass ................■.■■.......0 ....................■ APPLICANT � e P C ��Pt *J r.� c� PHONE Q? S� — (.%-11Z q S '�3 ASSESSORS MAP NUMBER C5� LOTNUMBER SUBDIVISION LOT NUMBER STREET `�Jpb DSTREET NUMBER .. Soong." 0.0082.60 ............ a 0 a . a 0 a . 0 a a 0 a 0 D a 8 a 0 a 0 S ..... S ... S ... S 0 . 0 . 0 0 . ■ ■ OFFICIAL USE ONLY. ............................................................................ COMMENDATIONS OF TOWN AGENTS .. .a offmannoor ■......................o..................c.�............... DATE APPROVED J I Yi D CO VATION ADMINISTRATOR G / Q DATE REJECTED �natlrFt�irR 7L— �\ ��6l�l�(�N TOWN PLANNER COMIviLN TS DATE APPROVED DATE REJECTED DATE APPROVED FOOD INSPECTOR -HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON v1ENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNIENT DATE REJECTED COMrYENTS RECEIVED BY BUILDING INSPECTOR DATE • Y D. Robert Nicetta Building Commissioner (978) 688-9545 - X978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE 3 1 JOB LOCATION 3cZ ©©O Number "HOMEOWNER �E e PRESENT MAILING ADDRESS tl�, ury i own Street Address (0%-Q1— Home o%-Q1 — Q S Home Phone V\ State Map / lot tJ N OKE C('? 16, 20 - aa-: Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owneracts as supervisor. (State Building Code Section 108.3.5.1} DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner_ The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATUR'E---�M A C APPROVAL OF BUILDING OFFIC 4 N JwzRmBr cIffiff" To r" FRU Imsulgoil "DTO PLOT PLAN. IiZ a&XK rMV rffi,8VXWM0 IS LOCATED ON CA rlff116r, AS SHOW AND THAT IT DOES CONFORM BONING RHOULATIONS JOAAP WG° SXV 8ACX3 FROM SrPAXTS a LOT LINES." Piwoza. osimir THAT THIS DWRWMG IS NOT LWAFWB.X WR PR4DRJM FLOOD RAXARD AREA AN DRAWN FOR smom ON F8 lTY P"rL 4� -------------- UKI _ZVI STEP L.S. DATE lo/ X PURPOSES NOT FOR LA BOUNDARY D ON, BOUNDARY INFORMATION MERRIMACK ENGINEERING `SERVICES "TARN FROM EXISTING WORDS, 66 PARK STRER T zsyB ANDOVER, MASSA CHU'sErys., JwzRmBr cIffiff" To r" FRU Imsulgoil "DTO PLOT PLAN. IiZ a&XK rMV rffi,8VXWM0 IS LOCATED ON CA rlff116r, AS SHOW AND THAT IT DOES CONFORM BONING RHOULATIONS JOAAP WG° SXV 8ACX3 FROM SrPAXTS a LOT LINES." Piwoza. osimir THAT THIS DWRWMG IS NOT LWAFWB.X WR PR4DRJM FLOOD RAXARD AREA AN DRAWN FOR smom ON F8 lTY P"rL 4� _ZVI STEP L.S. DATE lo/ X PURPOSES NOT FOR LA BOUNDARY D ON, BOUNDARY INFORMATION MERRIMACK ENGINEERING `SERVICES "TARN FROM EXISTING WORDS, 66 PARK STRER T zsyB ANDOVER, MASSA CHU'sErys., O F=4 a h m o C 2V) Q O v o z p p v C G � �O�. W a p G a O wow �W w a W p u 5G C O U zA p G w v j z cn v cn O GD O z O O O i O tZ GD CL H G CD o, c CD .c m Ln W 0 W Cl) LU W ryw w o CO o c :o� c y o � Cco G) nc CL 1 m c • O L'� o co • CL ' N E 2 0 : ; cm CO C Q ca CL � C L N cm CD N N 0 �m 'm o N m cc m 0 �.+r"v 0'! o' c c c A' C N Q L o m C? C12 � z ' c o n cm c H = m o N m o N m W Cy. t C ~ m N cm Z O n W"o o� y me ` y '- O Z C n � m O GD O z O O O i O tZ GD CL H G CD o, c CD .c m Ln W 0 W Cl) LU W ryw w io -,I/ -/. /P—L 6 Date. .—. /. �J .......... . TM of HOR o� TOWN OF NORTH ANDOVER �,o s PERMIT FOR GAS INSTALLATION 9e SACMUSE��� 1 This certifies that ..!�.;/ s-F� �� r �. �.......... . has permission for gas installation . />.. ..................... in the buildings of <. f," ............................. at ..3.?.. /0v Ir - ........:i ,North Andover, Mass. Fee. 3 .... Lie. No.2 7`.! :....\.. �!. �. ..: �.,--� ...... . GAS INSPECTOR Check # i ; I �� 4434 <C\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 3 0 (Print or Type) A). AN,UDV E dZ Mass. Date % 8 063 Permit # ,3 Building Location 7( 00-0 A Owner's Name Sri,pN E 1J S MA N N O N AN JOvc- uh Type of Occupancy k S) 06OT) aL (n X) New ❑ Renovation ❑ Replacement(K Plans Submitted: Yespw---Noo ❑ UTILITY C 4s T Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .687-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corke Check one: HCl Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1 A A 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�ate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. Type of License: Plumber Signature of Licensed Plumber or Gas Title Gasfiitter Master License Number City/Town Journeyman APPRONEp 0 FIC SE ONLY Now ME�� �st��■ ���� O_Ni■■.■..■��WENKWNENNNEE ONE NEI MEN 0 NKrffiff "MONEENNEERMSO NO an� WAINUNd .. • ■NNENNONNOMEN MEO ttil��tt�sl 01 .....■.-�.. �.� MAKE .. • .■■..■■...IN.■■■..■........ . . • .....■■...■EE■■■■■...S.OUR Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .687-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corke Check one: HCl Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1 A A 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�ate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. Type of License: Plumber Signature of Licensed Plumber or Gas Title Gasfiitter Master License Number City/Town Journeyman APPRONEp 0 FIC SE ONLY 0 U to 4 N _Z N N W Q 0 O (r CL 15 0 z• H H U. N �A p Z O O o _.....w ........ _ _ _ N O w t U � 6a Lt. 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