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HomeMy WebLinkAboutMiscellaneous - 85 CORTLAND DRIVE 4/30/2018' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Zi1pf Iw BUELDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: M E&T, lit L6& t_OMIAA"W (0y--+)ir• j N 1 r 1.2 Assessors Map and Parcel Number: Number Parcel Number -, AMap 1.3 Zoning Information: (-Z 1 S .'�.D Zoning District Proposed Use 1.4 Property Dimensions: 36 . 2 A -<- Lot Area Fronts 1t 1.6 BUILDING SETBACKS ft -I o Front Yard Side Yard Rear Yard EERMred Provide Regpired Provided Re 'red Provided N 1.7 Water Supply M.G.L.C.40. M) LS. Flood Zone Information: 1.8 Sewerap Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal ki�_ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1''T 'i 1c: 'ictriCt: Ye; �.(O 2.1 Owner of Record M L -12-1 ri l(d V.A.XJel;�— Name (Prin Address for Service 7 687 5f-- S' ature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: -11,-G 5 .b 7� 6rZ,t Licensed Construction Supervisor: Address Si re Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature _, Telephone SECTION 4 - WORKERS COMPENSATION (N.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 ..... X No ....... 0 SECTION 5 Description of Proposed Work check a ble New Construction X Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition @V Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: sUwR-00K/bEnk (,N�J&AP I CF.rTInN 6 - IWATIMATFII rnNCTRim TrnN rnVre Item Estimated Cost (Dollar) to be Completed b permit applicant OFFICIAL USE ONLY I. Building t Yar- (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) /'0 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number 77 -- " r7 et,y 4, ----- .. I- ---- Av alVL\ av AM "-11lgri,L' Im" Wr=fJ . OWNERS AGENT OR CONTRACTOP,, APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize o to act on My beh i; in Pmatters relat' work authorized by this building permit application. / l )� Sigi of Owner CTION 7b OWNER/AUTHORIZED AGENT DRri.ARAT16N 1, ' "1W n' Lew' ,as Owner/Authorized Agent of subject propirty Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief f• Name of "�Z)� r - Date NO. OF STORIES / — - SIZE I S 4; BASEMENT OR SLAB FR 6 tJ ) SIZE OF FLOOR TIMBERS 1�Q 2 3 RD SPAN r� DIMENSIONS OF SILLS Dl vIENSIONS OF POSTS D]MENSIONS OF GIRDERS d HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING Z' Saud JPy g" 19 X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND g & d IS BUILDING CONNECTED TO NATURAL GAS LINE -v"r 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 SECTIO APPLICANT �t` M4 G C PHONEq Z63S� LOCATION: Assessors �Map Number Id 4 L-7 L PARCE) SSUBDIVISION'2 �T 4L LOT (S) Z� STREET_ _ �d��'' � a n�-�� ST. NUMBER OFFICIAL USE ONL OF CONSERVATION WA TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS >y 1 A FOOD INSPECTOR -HEALTH DATE APPROVED N d A DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS v� Z -5-o5 DRIVEWAY PERMIT 2 S�Os FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE RevhW Wjm BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 055417 Birthdate: 04/0511960 Expires: 04105/2006 Tr. no: 21033 Restricted: 00 THOMAS D 7ANORUIKO 121 CARTERFIELD RD N ANDOVER, MA 01845 Acting ca mis over ■�■112J1111\V The Commonwealth of Alassachusetts Department of Industrial Accidents £� Office of Investigations 600 Washington Street Boston, AIA 02111 w"'minass.gov/dia Workers' C0D3Pcnsati0n Insurance Afiidarrit: Builders/Contractors/E lectricians/Plulmbers nt Information Name (Business/Organization/individual): Address: )_2 1 ( 6 City/St21e/Zip:_() "41 A4 r? j Please Print Levibl 01 C Phone: 78- { 7-7 `�� 3.5� Are you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and i employees (full and/or part-time).* have hired the sub -contractors ?. ZI am a scle proprietor or partner- listed on the attached sheet 1 ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers* cornp. insurance required.] f These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGI, C, 152, § 1(4), and we have no employees. [No workers' corrrp. insurance required.] Type of project (required): 6. )] New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10_❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12_[] Roof repairs 13.❑ Other -•�-rr••--••• ••• -•-L-n r, I iu aibu II11 Out Me Section Wow showing their workers' compensation Policy inforination: I homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such - !Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' corrin. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. LIC. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-yearimprisourneut, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for imuraneepef�rage verification. I do hereby certify under tpe pains of perjury that the information provided T Oficial use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense # >ove is true and correct- ., A orrect..,fin t -- Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. 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