HomeMy WebLinkAboutMiscellaneous - 390 JOHNSON STREET 4/30/20180
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Date ... /0-
......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
) . . .............................................. .
This certifies that ..... ..............................
has permission to perform ...
wiring in the building of ....
........................................................................
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............ ............. 11 ......... ................ . North Andover, Mass.
...........
Fee..7 ............ Lic. Nof-i��.7�j ......... .......
ELEcrRICAL INSPE
Check#
5 5 100 J"
Date ... �;�. —A?, . A . 6 .
.......... .. .. .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... ................. .... ........................................................ ..
has permission to perform
...................
wiring in the building of .... ..................................................
at
............... . .............................. �..! ...... ..... . North Andover, Mass.
q —, :***** ... ** ;,u
i Fee. / ...... . ....... Lic. Noc,23
...........
C** M- A**L* P*E*
Check#
5595
IRE (;UN 1MUIV WLAL1 H UIQ IMINMCHUNE116 Office Use only
DFPARTMFVTOFPUBUCSAFM Permit No.
BOARDOFFIREPREVFV170N�0 5l7CMRl2.lb o�
Occupancy & Fees Checked
APPLICATTONFOR PERMIT TO PERF RMELE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHU TS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ' �' Or
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work scri d below.
Location (Street & Number) aD 5
Owner or Tenant iy! S
Owner's Address
Is this permit in conjunction with a building permit: Yes [�No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service AmpsVolts Overhead a Underground M No. of Meters
New Service Amps/..- /� UVolts Overhead � Underground � No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
o. of Lighting Fixtures
/ rL
Swimming Pool Above
Below
Generators
KVA
round
ground
No. of Emergency Lighting Battery Units
No. of Receptacle Outlets 20
No. of Oil Burners
No. of Switch Outlets
/
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
��•
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
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NSURANCE BOND OMIMR
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OWNER'SINSURANCEWAIVER;IamawarethattheLimedoes nothavetheinstaamamWoritssubstar>dalegtrivalentasrec}medbyMassadusetlsCmeralLaws
anditnTyagnahaeondmpmrrita kahcnwai�mdisragt>uerrlat
(Please check one) Owner M Agent
Telephone No. PERMIT FEE $
Signature ot Uwner or Agent
Location -3 9V -T,-,o A &a &A-, rz�
No.
Date I0 ALO
"I D
TOWN OF NORTH, ANDOVER
0
Yp
Certificate of Occupancy $
CHU
Building/Frame Permit Fee $ C2 C'.;
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
77 u 3
Building Inspector
<4
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT RERAK RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
WELDING PERMIT NUMBER: r�2 DATE ISSUED: 10
1g zC
SIGNATURE:
Building Commissioner[12Tector of Buildings Date
CL`!'T7AaJ 1 CiTR iaJCAn 1t � Tin�i
1.1 Propert�Addr:
1.2 Assessors Map and Parcel
Map Number
Number:
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area
Fronto ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Req*ltd Provide
ReqWred Provided
Required
Provided
1
1.7 Water Supply M.G.1-C.40. 34)
Public ❑ Private 0
1.5. Flood Zone Information:1.8
Zone Outside Flood Zone ❑
Municipal
ewerage Dulposal System:
On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
- -
6.r Vwaur 01 MCC=
S-
Name (Print)
I. I) f ��
.19,&
Address for Service:
2.2 Owner of Record:
Name Print Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Aoolicable
Licensed Construction Supervisor:
License Number
Address
%.
Signature Telephone �(/ Expiration Date
3.t Registered Home Improvement Contractor Not Applicable �r
Company Name
Address
Registration Number
Expiration Date
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 permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work cher a me
New Construction ❑ 1 Existing Building V I Repair(s) 0 Alterations(s) 0 Addition
Accessory Bldg. ❑
Demolition
❑ 1 Other ❑ Specify
Brief Description of Proposed Work:
Au DoNeyi f',5 n C n/=Rr
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed bpermit applicant
OFFICIAL USE ONLY
1. Building(a)
Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
3
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 BUILDING PERMIT
0 n _ /?
Hereby authorize
My behalf, in all
SECTION 7b OW
as Owner/Authorized Agent of subject property
to act on
%e k authorized by this building permit application.
:4 — &2 'y/07 10 <<
Date
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
of
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDaERS 1 2 ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*******'***************
APPLICANT A lCha f
LOCATION: Assessor's Map Number -38—
SUBDIVISION
38
SUBDIVISION
STREET �c� A 4,' Sd�
PHONE �08_9) S__6 0 e C,
a :Po4/ le -141-/
PARCEL Z,3
LOT (S)
ST. NUMBER C3
USE ONLY
COh§ERVATI(W XdMINISTRATOR DATE APPROVED /0 •'tJ 'Qt
DATE REJECTED
COMMENTS Inds b) &(n a '
TOWN PLANN . DATE APPROVED
\11t Afi�R �� DATE REJECTED
COMMENTS eec'CL-Giu- t 1 14
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 Jim
^' ENGINEERING ASSOCIATES, INC.��ti
MORTGAGE OF PLOT PLAN Y CIVIL ENCINEERS - LAND SURVEYORS �wm 0.101 ,eR
390 JOHNSON STREET
NORTH ANDOVER, MASSACHUSETTS
SCALE: I"=50' / DATE: JULY 8, 2002
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I HEREBY CER77FY TO THE 777LE INSUROR AND Til THE MORTGAGEE THAT THE DWELLING
IS LOCATED ON 7HE LOT AS SHOWN AND THAT IT DOES CONFORM WITH 7HE TOWN OF
NORTH ANDOVER ZONING REGULA77ONS REGARDING SETBACKS FROM THE S7REET ONES
AND LOT LINES
_�t►0R
!� RICHARD
/ FURTHER CERI7FY 1NAT THE OWELUlS NOT LOCAlEO /N A FEDERAL
fZ 000 HAZARD AREA AS SHOWN ON FLOOD INSURANCE RA TE' MAP DA 7F0
CUOCANG
N0.2�1
✓UNE2, 199J
�� �►
'
FILE.- 6929
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: Est. Cost
Address of Work 3 c'�O .l A/y.S'012-.1
Owner Name: /G /�.,�i . S'
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s)
Work excluded by law
Job under $1,000
Building not owner -occupied
-Owner pulling own permit
Other (specify)
Notice is hereby given that:
For office Use Only
Pemit No.
Date
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
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:
\,' . LL IDo .O
(Location of Facility)
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
/-/v -'P5-
Date .. .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
N4� )'t 14
This certifies that CAR
....... ....
.....................
has permission to perform . t1. ........
plumbing in the buildin s of . ...................
at .... ........ ;r�. 'or" Andover, Mass.
F e e L i c. N o.
Z
j
Check # PLUMBI'N*G IeS IR!��
63'10
4�
45
MASSACHUSETTS UNIFORM PLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
%�/ Date
Building Location V d /W Sed ,� ner ame A / Permit #
Amount
Type of Occupancy
New Renovation Replacement 1:1 Plans Submitted Yes No ❑
FIXTURES
(Print or type)
Installing Company Name
Address /..y
Check one: Certificate
❑ Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate th type of insurance coverage by c king the appropriate box:
Liability insurance policy Other type of indemnity 11 Bond
IN(
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I haves mitted (or a ered) in ahev
best of my knowledge and that all plumbing work and insta ions perfo ed under t
compliance with all pertinent provisions of the Mass�eh �et�s State �' Co Ch
ity/Town
APPROVED (OFFICE USE ONLY
Ty e of PlumbingLicense
—
icensee lNumDer Master
pplica ' n are true and accurate to the
sue ' application will be in
142 of the General Laws.
Journeyman ❑
I-lq-05,r
Date ... ................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... A C. C4.
has permission for gas installation
............ ....
in the buildings of ..............................
0 L k) t— at—,
...................... I North Andover, Mass.
at
Fee. Y�,... Lic. No.. -3 0 .......
-1. Z 1A
GASINSPECT09
Check#
5 0 0 4.
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUS TTS
Building Locations ,t � •' `
XlZl I``�' "'Oew �Ar—Q Owner's Name
FOR PERMI'i'TODO GAS FfYMG
Date
New 10 Renovation ❑ Replacement ❑ Plans Submitted 0
Permit #
Amount $
(Print or type) d
Name
Address
e1
Name of Licensed Plumber or Gas Fitter
C
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
® Firm/Co.
INSURANCE COVERAGE U Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Li;ibility insurance policy 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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations pe ed unde ermit Iss - 4or this ap ation will be in
compliance with all pertinent provisions of the Massachusetts Stat as Code hapter of the Ge aws.
By:
Title
City/Town
A
APPROVED (OFFICE USE ONLY)
Signature of
®
Plumber
®
Gas Fitter
Master
❑
Journeyman
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SUB -BA SEM ENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
STH. FLOOR
6TH. FLOOR
7TH. FLOOR
STH. FLOOR
(Print or type) d
Name
Address
e1
Name of Licensed Plumber or Gas Fitter
C
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
® Firm/Co.
INSURANCE COVERAGE U Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Li;ibility insurance policy 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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations pe ed unde ermit Iss - 4or this ap ation will be in
compliance with all pertinent provisions of the Massachusetts Stat as Code hapter of the Ge aws.
By:
Title
City/Town
A
APPROVED (OFFICE USE ONLY)
sedPlumber Or Gas Fitter
License Number
Signature of
®
Plumber
®
Gas Fitter
Master
❑
Journeyman
sedPlumber Or Gas Fitter
License Number
APP 3 0 P904
MEMORANDUM/REQUEST FOR WAIVER IT
To: Heidi Griffin, Director
Town of Andover
Division of Community Development and Services
From: Michael A. Demers
Subject: Request for Waiver of Watershed Protection District Special Permit
Property: 390 Johnson Street, North Andover
Date: September 30, 2004
I am respectfully requesting a waiver for the requirement of a special permit for
the purposes of interior construction within a pre-existing structure within the
Watershed Protection District.
The proposed construction will not expand the existing footprint of the existing
structure, is already on town sewer, and will not disturb existing topography.
The proposed construction will change the exterior of the building by the addition
of 3 dormers; additional interior work will be upgraded to accommodate a private
office, recreation room and bath.
Respectfully,
Michael A. Demers
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..,...,............... Permit No. L
B0ARD0FFMPREVEW0NREGUT4770NS527G1212W 0�
Occupancy & Fees Checked
APPLICATTONFOR PERIVIlTTO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
t.EASE PRINT IN INK OR TYPE ALL INFORMATION) Date ' �" Or
own of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
S
To the Inspector of Wires:
L
Is this permit in conjunction with a building permit: Yes 0No (Check Appro"
priate Box) a
Purpose of Building Utility Authorization No. �—
Existing Service AmpsVolts Overhead a Underground No. of Meters
New Service <=,2CAmp!V X 1 � b Volts Overhead M Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
of Lighting Outlets No. of Hot Tubs No. of Transformers Total
KVA
ghting Fixtures / Swimming Pool Above Below Generators KVA
round ound
ceptacle Outlets Q No. of Oil Burners No. of Emergency Lighting Battery Units
itch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
ges
No. of Air Cond. Total
Tons
No. of Detection and
sposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding'Devices
ishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
_
Othe
ers
Heating Devices KW
Connections
ater Heaters KW
No. of No. of
Signs
Bailasis
dro Massage Tubs
No. of Motors
Total HP
CDvwdge. RnsmoDdlew4imialsdfNi%mduseftGeiedLaws
rtLktkkn==R)kygri&gCaq)i&OLmb=CoNaWcrtsmbsb'MqmimI YES NO
Vttlidptoafofsatrtelodt 0 i= YES [ ff)cuhawdedWdYES,pleaseudc*ftt'peofoo =Vby
rsw
u . 12 >Q011 p � ) EViradmDweEstr *dVaireefDac�dcalWedr $
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OWNER'SINSURANCEWAIVER;IamawaedlatdleHoarsedoesmthavedlekmraneamn?critsa*star&givW tasre#WbyMassdumGa>aWLaws
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.:se check one) Owner a Agent c�
Telephone No. PERMIT FEE $
signature of Owner or gen
027
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MEMORANDUM/REQUEST FOR WAIVER
To: Heidi Griffin, Director
Town of Andover
Division of Community Development and Services
From: Michael A. Demers
Subject: IRequest for Waiver of Watershed Protection District Special Permit
Property: 390 Johnson Street, North Andover
Date: September 30, 2004
I am respectfully requesting a waiver for the requirement of a special permit for
the purposes of interior construction within a pre-existing structure within the
Watershed Protection District.
The proposed construction will not expand the existing footprint of the existing
structure, .is already on town sewer, and will not disturb existing topography.
The proposed construction will change the exterior of the building by the addition
of 3 dormers; additional interior work will be upgraded to accommodate a private
office, recreation room and bath.
Respectfully,
Michael A. Demers
z �
r
loclol 0 COl'm ! ' Kap"' "'mNLtv%1 %&-am
ENOINEENINO ASSOCIATES. INE: (a"lz
MORTGAGE, OF PLOT PLAN ECIVIL EN,INEEN, - LAND ,YNtE10N7 �,w*4 �100 mm >a
390 JOHNSON S TREE T
NORTH ANDOVER, MA S SA CHUSE T T S
SCALE: 1 "=50' / DATE: JULY 8, 2002
A$$
xv-
\P
/ HEREBY CERRFY TO THE 777LE INSUROR AND M 7HE MORTGAGEE THAT 7HE DWELLING
IS LOCATED ON THE L 0 T AS SHOWN AND THAT /T DOES CGNFORM W17H THE TOWN OF
NORM ANDOVER ZONING REGULA BONS REGARD/NG SEMACKS FROM INE 57REET UNES
AND LOT LINES
/ FURTHER CER77FY THAT THE DWELLING /S NOT LOCA 7ED IN A FEDERAL
FLOOD HAZARD AREA AS SHOWN ON fZDOD INSURANCE RA 7E" MAP DA 7.0
JUNE2, 199J
IP.(fn d)
RICHARD
E.
CUOt'A
NO.220
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FORM U - LOT RELEASE FORM
3 :Dor-m e v,5 C.>
Ve x -t s! k Vs a ' 1"n +-
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 or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT SCA oI , mm `e r--5
LOCATION: Assessor's Map Number.
SUBDIVISION dC(V&O� STREET�V
•
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN NPLANNJ� �� DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
PHONE �'/ �_ 6 d? e Cl
Ro'/ I -Ciel l
PARCEL Z-3
LOT (S)
ST. NUMBER
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
1.1 Property
SG
1.2 Assessors Map and Parcel
Map Number
Number.
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
2.1 Owner of Record
1.4 Property Dimensions:
Lot Area
Fronto ft
1.6 BUU DING SETBACKS ft
Front Yard
Side Yard
26
Rear Yard
Required Provide
ReqWred Provided
Regaimd
Provided
2.2 Owner of Record:
1.7 water Supply M.G.LC.40. § 34)
Public 0 Private 0
1.5. Flood Zone Infomsdion:
Zone Outside Flood Zone 0
1.8
Mmicipd
a cnV Disposal System:
On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSIfIIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
Address for Service
26
"gigdature Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor.
Not Applicable
Licensed Construction Supervisor:
License Number
_
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable Ir
Company Name
Registration Number
Address
E*ration Date
Signature Tekphone
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: \()Est. Cost
Address of Work 3 20 rl f�ia��SGitJ 5✓ /�/_1,di •
Owner Name:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law
Job under $1,000
Building not owner -occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
Pemit No.
Date
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND UNER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date