HomeMy WebLinkAboutMiscellaneous - 432 WINTHROP AVENUE 4/30/2018Location �`3� �/ ������ /G
No. /- /3Date 49
TOWN
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 3
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #� z
14081
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO�CONSTRUCT REPAIR, RENO OR DEMOLISH A ONE OR TWO FAMILY DWELLING
aVAT
tow
i90 a
BUILDING PERMIT NUMBER:DATE ISSUED:
SIGNATURE:
Building Commissionef/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
/r
1.3 Zoning Information:
Zonin 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
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record a V V , �"r�� -i
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
p
Name Print Address for Service:
a
Signature Tel hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
CS C�6r\
Licensed Construction Superviso
Signature Telephone
Not Applicable ❑
GS
License Number
6 r v O
� , ;-6
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
z
M
90
r
M
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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 check au applicable)
New Construction ❑
Existing Building ❑
Repair(s)
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work: (�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL,USE ONLY
1. BuildingD
a v
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (N)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
pile)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING 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
I, �'e,, S1 --e �. 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
Print Name
ignat o wner/A ent
NO. OF STORIES
Date
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS I
2ND 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Location: �)- "i X--, o�k wt
City /U D S �k m J-;�- Phone
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
MI am an employer providing workers' compensation for my employees working on this job.
Comoanv name: z'� � `�'– +,\^
Address
City: "�, ^'" Phone** 1Y Yr liC
0--
Company name:
Address
X
City: Phone *
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 well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) 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 ver cation.
I do herby certify
S
Print name
penalties of perjury that the information provided above is true and correct
Date
Official use only do not write in this area to be completed by city or town official'
E] Check if immediate response !s required Building Dept
Contact person: Phone A
FORM WORKMAN'S COMPENSATION
# `r�`�~4�z � �
❑ '
Building Dept
❑
Licensing Board
❑
Selectman's Office
❑
Health Department
❑
Other
Town of North Andover o4 NORTH �41
O
Building Department o
27 Charles Street
North Andover, Massachusetts O1845
(978) 688-9545 Fax (978) 688-9542
4o�.o
rP .��
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, A 50a.
The debris will be disposed of in /at:
Facility location
Signature of Applicant
/ 1, 00
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
ju
ly crl� a�. i IrYS,4t1:CfttJt f(J � '.. i
I d� OEPARTNENT OF PUBLIC SAFETY
11 I CONSTRUCTION SUPERVISOR LICENSE
Nusber: Expires: Birthdate:
t CS 069055,1 1108/26/1000 00/26/1968
"-Restricted.To00
SEAR P. SZEKElY
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