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210/045.G-0037-0001.0
Location yo- � ^
No. Date
NORTp TOWN OF NORTH ANDOVER
4 F w
+ s
+ � ; , Certificate of Occupancy $
�' b''•'
scMus E<� Building/Frame Permit Fee $
�S �►
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ L
Check #
17121
l� Building 6 spector
4
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DAT EE ISSUED:
�J
Alot'i
SIGNATURE:
Building Commissioner/I for of Buildings Date U 7 -70
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parol Number:
MAr, n A ver _ -7
Map number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District li osed Use Lot Area(sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 Water Supply M.GL.C.40. 54) I.S. Flood Zone Information: I.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site DisposA System 0 M4
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
J o -k tl'A 19 pA, �� y a Al A4-fiT
Name(Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Address for Service:
Name Print z
M
Signature Telephone 00
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
7
C) G 7
Licensed Co"ruction Supervisor: S 5��
License nse Number
t
3 arV / �,
7
Cl Expiration Date
to Telephone �� xp
3.2 Registered Home Improvement Contractor Not Applicable 0
air ,-v4d
Company I a
Registration Nu er
rum
AddressOEM
.-:2 �' �� Expiration ate
i atu Telephone
F
SECTION 4-WORKERS COMPENSATION(NLG.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.......0 No.......0
SECTION 5 Description of Proposed Work check all a livable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory.Bldg. ❑ Demolition ❑ Other ❑ Specify. ti
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be & z !", (ygCCSE{ X r u
Completed b permit a �
applicant
s� "` ,fig' 'ST k,„z, i2�1 All
Y%.m xar
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of Q
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 BUILDING PERMIT
I, as Owner/Authorized Agent of subject property t
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
I, ,as Owner/Authorized Agent of subject
prop rty
Hereby d are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
e b
Print N
Si atur Own A ent Dat
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T ,4BERS 1 2ND 3kD
SPAN
DIN ENSIONS OF SILLS
DMIENSIONS OF POSTS
DEVIENSIONS 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
9
l EOARD&BUILDING REGULATIONS
: y
License CONSTRUCTION SUPERVISOR
r` Number� S 035W
4
• Birthdate 12/15119(41
Y d Expires 12/1512005 Tr.06: 11958
- - —
+t...-.ears !
� .
\ Restricted y A0_,
RAYMOND V BER'UBE'
-N ANDOVER,`,MA 61 W Administrator
� � .
✓1ze iJanvmdiuUea o� aajaccrr '
13oa d of Building R%t!p o4s qpd Stanq#pi,4
HOME IM.ROVEI'dIENT CONTRACTOR
Registraot _1,05523. :r
Rx >rat�sn "
,t p _.a 7%171205 i
Type Iridlridual
ri �ymonri t3ersibe' .`
111C{C:.,in Rd'
e
'N'E�r+�ov.r W+,109845 `
d ;
_saw=-
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:
r
W o a V/,*<, i
(Location of Facilit
V�%nature of Permit Applicant
Ll s4 4-1-
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
NORTH
Town of "JI ." 6 Andover
No.
--rQL7
clover, Mass., 3 •/����y
CO�CHI C HEWICK
O�S RATED 0
U BOARD OF HEALTH
Food/Kitchen
in
ER T U Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.......... . ......................... ..q04. ..1................... .......................................................................0^....... Foundation
has permission to erect........................................ buildings on ......Y ........ Rough
tobe occupied a%.A.7,., ...........................................................I............................................................................... Chimney
a7
I
provided that the person acc ing this permit shall in every respect conform to the terms of the application on file in Final
, ns
this office, and to the provisi ns of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover.
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPMES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
............... ........ .....................................
.0.... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.