HomeMy WebLinkAboutMiscellaneous - 4 Belmont Streeti
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N o. 114 Date C�- 1�?- 01
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
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Building/Frame Permit Fee $
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Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 0
Check #
16 7 /24 V( A (U-�-
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
:-.� s y r � 3 ea Y ; �a � ^���,$� rF .� Sr �.;.a u � F �} }Y .� iec��,F � � h r a,�� ii�•s^ ��.,� �
BUILDING PERMIT NUMBER: ' Q l r DATE ISSUED:
SIGNATURE:
Building Commissierner/laWtor of Buildings Date
ar,%.iivir i- �i1 r� uvrvxmAi>Vly
1.1 Property Address:
9)�UMAIT 5-77
1.2 Assessors Map and Parcel Number:
L F)
Map Number Parcel Number
A S O 8,,x11 A. g 0 O 9 F-�
/
1.3 Zoning Information Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING 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:
Public ❑ Private 0 Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
C 14,4 i-" F- FAP #
NamePrint
C )
— B U/ -t' /VT -377,
Address for Service
Na, A A) 0o E'ER wt
Signature
Telephone
2.2 Owner of Record:
5
a
Name Print
t
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2«Registered Home Improvement Contractor
Ph 117 C,+STR) CpdF-
R -fie
Not Applicable ❑
��
Company Name
f
Registration Number
s
Expiration DateG
Signature
Telephone
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SECTION 4 - WORKERS COMPENSATION (M_G_L C 152 S 2AW61
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 ....... 0
SECTION 5 Description of Proposed Work check a licahle
New Construction 0
Existing Building
Repair(s) 0
Alterations(s) ❑
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
V 0 YL SlD M16-
-SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Co leted by permit applicant
OFFICIAI.kIISE
Q,y
1. Building
4 d a
(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
Q
Check Number 1
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
11 126 V M CA S TX I C. 0 ALE 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
S CZ E
-"
Prin Nt J C_�
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2ND 3RD
SPAN
DIN ENSIONS 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
i i f
APPLICANT INFORMATION
`he Commonwezdth of Wassachuse=
Department ofIndustr zd gccidents
Office of Investigations
600 Washington Street
Ooston, 9M 02111
Workers' Compensation Insurance Affidavit
pp�--'� //�� Please PRINT Legibly
Name: f -t> ti/�% EA&
Location:k-:)n� L 146 Al /_d�
City: Ab. A V 1✓ Q OF Il Telephone #: _ 4�g.$--
0 I am a homeowner performing all work myself,
I am sole proprietor and have no one working in my capacity
❑
lam an employer providing workers' compensation for my employees working on this job
Company Name: J-) H V I L) U. hl,5 I l � I r, /) A)E le h /7 F/A) t'�- d—
Address:!3 J K n LA 7%%_D' X11 S t,
City: 611 P—Tzi %�Ii L?fl V F— k h_ Telephone #: Jy'
0
Insurance Company: A10-yAL. 57ayu AkLiAJVC 4I Policy #: 1)?/ X ?7 '_4 D
I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
workers'. compensation policies:
Company Name:
Address:
City: Telephone M
Insurance Company:
Company Name:
• Address:
Policy #:
..,City:. Telephone #:
Insurance Company: Policy #:
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby 1 under 'Ii pains at,4f penalties of perjury that the information above is true and correct.
Signature: Date: _ L/ lln o
Print Name: D - CAS %A L f --,Q A� E Phone # Q-3
Official Use ONLY - Do not write in this area
Pity or Town: Permit/ ❑ Building DepartmentLicense #: o Licensing Board
C) Selectmen's Office
0 Check if Immediate response is required ❑ Health Department
0 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
Numberis that the debris resulting from this work shall be disposed of in properly
licensed solid waste disposal.facility as defined by MGL Chapter 111, S 150 A.
The debris will be disposed of in:
�- S C, 6SA-FM ✓ill-�
(Location of Facility)
Signature of Permit Applicant
9
0-3
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project
through the Office of the Building Inspector
10
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