HomeMy WebLinkAboutMiscellaneous - 85 PUTNAM ROAD 4/30/2018A
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Date... 2. //-. d/:.........
......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . ..............................................................
has permission to perform .............................. I ............
wiring in the buil ' ding of ....................................................
at ... ........ . North Andover, Mass.
F6- ....... Lic.
ELECTRICAL INSPi&
Check #
6 9
Official Use only
Commonwealth Of Massachusetts
Permit No.
Department of Fire Services
Occupancy and Fee Checked
t, t BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TY E ALL INFORMATION) Date: 6
City or Town of:�; Jrh —�� To the Inspector of Wires:
By this application the undersigned gives notice his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant,
Owner's Address',
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service OU Amps Volts
Telephone No.61) J—n p IC/�
Yes ❑ No J�,_ (Check Appropriate Box)
Utility Authorization No.
Overhead..E Undgrd ❑
No. of Meters
New Service )-� Amps / / 2 Volts Overhea+?T-- Undgrd ❑ No. of Meters
Number of Feeders and Ampacity l '9- C�,,
Location and Nature of Proposed Electrical Work: '%�
Completion of the fnllowino tahle mnv ho wnivoll h., tho 1v v —t— 1 wi,
No. of Recessed Luminaires
No. of Ceil: (Paddle) Fans
TransSusp. Total
Trsformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above EJIn- ❑
rnd. rnd.
o. o mergency ig ing
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
I Number
Tons
KW
...
No. oSelf-Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. o Water KW
Heaters
No. of-- No. o
Si ns Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommun�cat�ons Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (0d 00 (When required by municipal policy.)
Work to Start: �? QG Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and pen It' of perjury, that the information on this application is true and complete.
FIRM NAME: ; C LIC. NO.:
Licensee: e Signature LIC. NO.:3? ?'O
(Ifapplicable, ent"exempt" i the license number line.) Bus. Tel. No.• 6'/ x,5-9 3
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; -if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent co
Signature Telephone No. PERMIT FEE. $�j —
-C-1
Location �--'
No. t%�� DateI�
TOWN OF NORTH ANDOVER
3 •
s ; . Certificate of Occupancy $
CBuilding/Frame Permit Fee $
S�NUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ —�.L—
Check # �-o L/
184'18 , 2,
—Building 14 ector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT BEPAa RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
s ,! 5•'
BUILDING PERMIT NUMBER: —/ DATE ISSUED:
AL AP
Aj
SIGNATURE: . .
Bui din Commissioner for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Propert"ddresp
. (/Jl
1.2 Assessors Map and Parcel Number:
0 O O3
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Fronts R
1.6 BUILDING SETBACKS (ft
Front Yard Side Yard
Rear Yard
Required Provide Required —+ Provided
Rec pired Provided
11
1.7 Water Supply M.G.L.C.40. 54) 1.3. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
Public ❑ Private 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
le istrict: Y� !
2.1 Owner of Record
t
M AD�l� �l1GG�2 _ 64'T✓���i
flame Tint) Address for Service
7 �/--3
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.ItLicensed Construction Su or:
i
Not Applicable ❑
Licensed Construction Su ryor:
License Number
Add
7WzA6Wz44 7 73
Expiratio Dat
Signature Telephone
3.2 Registered Home II�mppro((v''ement Contractor
Not Applicable ❑
Company game
J3K Y
/
Registration Number
Ad ess
w (�
Expiration D e
nature Telephone
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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 .......0 No ....... 0
SECTION 5 Descrition of Proposed Workheck aR applicable)---l—
(c
New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. ❑ Demolition 0 Other ❑ Specify
Brief Description of Proposed Work: ..poll
I SECTION 6 - ESTTMATF.D CnNCTRTT'TTnN rn4ZTQ
Item
Estimated Cost (Dollar) to be
Cleted b _permit applicant
OffICIAL USE ONLY
1. Building
„1
rs csaea (�
a_
Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
--�^
3 Plumbing
Building Permit fee (a) x tb)
— f
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
cFrTTnV 7. nwrrvID ATTIrKirnnirl
• TT`M .
Check Number
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r
i
L as Owner/Authorized Agent of subject property
r
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
- - -'"—V% as Owner/Authorized Agenl of subject
property IV
Hereby declare that the statements and information on the foregoing application are Lrue and accurate, to the best of my knowledge
and belief
�
Print Nafnel
Signature of Owner/A Wt
NO. OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TIIyIBERS
SPAN
DM ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATUlZAL
LINE
Dat 7��'`o dS
SIZE
2'
THICKNESS
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GS # 022680
HIC# 103358
Proposal Sgbmitted To: & Al '
ropomil =
A. J. Walsh & Sons
55 Pleasant Street
North Andover, MA 01845
# of pages
Job Name t1 I Job #
Job
978-688-6737
or
1-866-AJWALSH
G � Datexb f�6/ Date of Plans
Phone # . _ i� -7 /i_ . / G "].– 7ax # Architect
We hereby submit specifications/and estimates for. ...... _.......... _ .
W
propose hereby to furnish material and labor — complete in accordance with the
with payments to be made as ollows:
el.sOcifications for the sum of:
Dollars
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon wdtten order, and will become an extra charge over and submitted
above the estimate. All agreements contingent upon strikes, accidents, or delays
beyond our control. Note — this proposal may be withdrawn by us if not accepted within days.
Zcceptance of Pr
The above prices, specifications and conditions are satisfactory and are 4 jgnature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
0;; NC3819 MADE IN USA
Workers'
The Commonwealth of Massachusetts
Department oflndustrial Accidents
office oflnitestigaffons
600 Washington Street, 7'h Floor
Boston, Mass. 02111
sation Insurance Affidavit: Buildin2/Plumbin2/Electrical Contractors
1 am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel
I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
I am an employer providing workers' compensation for my employees working on this job.
" 1 am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comnanv name:
address:
city:
p one
insorance.co.
.ti... r+�. ar�.0+nar Y i, Policy #
Aitacliaddiho alis eetat} a essa , idte , a ENIV rs rr,tr4r i a " G�
.... �. ...�.....f.�.��.M..�... i......C!tt'n ....c._�.'t...jfY•.4�-lil��..-01�KY.�+�...��t��'�.... Yi�I�liL�i�T.��S1C�.e11'Yiiititl�.kl7.1.L�n•K,�i
Failure to secure coverage as required under Section 25A of 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 verification.
7 do hereby cer un r the 'ns and penal ' of perjury that the information provided above is true and correct.
Signature J Date
py d�
Print name /�/ T7Ll c //l� � (� Phone #
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
❑Licensing Board
❑ check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone #; ❑Other
(revised Sept. 2003)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
.the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
'- � ,'� '�a�4 .",�; ft'"� -b ` r?•Yof� c_ " �*' �t }v3�tr' a�...,� i •• �.m��t�;;:s��r�n�j%:.:��:4,;'3 .�k �, 4a�, 5�'Trrj �; i`d :.'� .+"��.`a
i� c},.ta'�� � 7�!' .F�v"1t, 3 ml. "k"-r5r 3 �5'���!((4 r� Y'�'k'�"' y� *�� �t�v "�- • 1 ,+M 5 �.(s i. �y; '� r�
;5 �,,ri�'r. i � �..-•.� � y `v'. i�� �� r. � .?! �.:#;ia1�'d�7�,; L`�.,�,i, '9F` s- a�t' 'Pi'''�,'s!4,k.�i�.4�°'��� �"t `"� � `t. b. ' �r i.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address -and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if
you are required to obtain a workers' compensation policy, please call the Department at the member listed below.
!-� jr rt , . !.4,; ,,,,t��**a �`� �,e k"' ar �^4 r;UhYr- .v 1 r q;a r�4 r .t+, d� '{9 l r r ^f•+c, n�W�-. T.agi••.�#t c • yy,.. '•
t .! ?'4 rfi tl' th>k., s "i h'hja ,�� �'l afu.,r, ,� tI�. tt ra c . t�,• �1s€i� T
tUr�'9.'. Irli��F v��.. .'G.x�S»A. sl.l�'#�4H',�'�.�J�•sure"+•Gd�`Y`�vh�{'i+tFB.'.•�'�'P r: 'r Y�. �t�3dr:.t� ��n�Ltd.�i�,7�'�.r��ri�'-i� .. Skrm.�,ti.��ar.�:,!'.'y�+k�_, - ,S§�:
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the.event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
5 ,
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The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents .
Office of investigations
600 Washington Street,7t' Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
N
9
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 i
(L
n of Facility)
Sign ture of Per it Applicant
7 4
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
13
E
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
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
Fire Department Sign off
Dumpster Permit
(Location of Facility
Signator of Permit App cant
Date
Date.....�—.�...1 ��.
of ` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .....................
has permission for gas installationin the the buildings of ... .�:?:°1-.c-..........�............. .
e'%0
at s ::'`.-s- G-�..-.�-!'� ... . . , North Andover, Mass.
Lic. No'j t,?',//. mac:.: ..�'
GAS INSPECTOR
Check # /L"/ti/�
ASSACHC-SETTS UNUMNI APPUCATON FOR PERiNIlT TO DO GAS F rnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Locations Sig` Permit #
Amount O
Owner's Name
k c- t �� n
New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or type)�j Check one: Certificate Installing Company
Name 41AA, 4:�'U st gz
Corp.
Address 5
Partner.
�nnnP>t u� IIS {�A(A c�z��t.r
Business Telephone f„/ 7- 7 Z! — 5 s 70 Firm/Co.
:Mame of Licensed Plumber or Gas Fitter /�j,�y � f' s
INSURANCE COVERAGE 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.
Liability insurance policy Other type of indemnityBond13
1 1:1
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
as oral L at my signature on this permit application waives this requirement.
Check one:
Signature of Owner or wnc;r's Agent Owner �� Agent 13
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 nry knowledge and that all plumbing work and installations uncler Permit Issued for this application will he in
compliance with all pertinent provisions cif the NlassachuSCUS• State Gas Co de and Chapter 142 of the General Laws.
By:
Title
Citv;Town
\PPROVED (OFFICE USE G.NL,
Signature of Licensed Plumber Or Gas Fitter
tJ Plumber 3Zq.?Lj
Gas Fitter License rum Lr
Master
Journeyman
3c?
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SUB-BASE��I ENT
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BASEM ENT
t
1ST. FLOOR
_
2ND. FLOOR
s
3RD. F L O O R
�---
- -`
4T II . F L O O R
5TH. FLOOR
6TH. FLOOR
7 T H. F L O O R
1
8TH. FLOOR
(Print or type)�j Check one: Certificate Installing Company
Name 41AA, 4:�'U st gz
Corp.
Address 5
Partner.
�nnnP>t u� IIS {�A(A c�z��t.r
Business Telephone f„/ 7- 7 Z! — 5 s 70 Firm/Co.
:Mame of Licensed Plumber or Gas Fitter /�j,�y � f' s
INSURANCE COVERAGE 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.
Liability insurance policy Other type of indemnityBond13
1 1:1
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
as oral L at my signature on this permit application waives this requirement.
Check one:
Signature of Owner or wnc;r's Agent Owner �� Agent 13
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 nry knowledge and that all plumbing work and installations uncler Permit Issued for this application will he in
compliance with all pertinent provisions cif the NlassachuSCUS• State Gas Co de and Chapter 142 of the General Laws.
By:
Title
Citv;Town
\PPROVED (OFFICE USE G.NL,
Signature of Licensed Plumber Or Gas Fitter
tJ Plumber 3Zq.?Lj
Gas Fitter License rum Lr
Master
Journeyman
3c?
�'
Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that (; .. .....................
has permission to perform -1. -........ .
plumbing in the buildings of-./ ...................
at .x5^.--•---� ......... North Andover, Mass.
Fehr ..
Li c. No?�4`5,( r ' ,��......... .
C. PLUMB�G INSPECTOR
Check # / Ul � roSll.�'�/ 1/
71 U6
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date �'0'Q6
Building Location ,� U7? jac � & Owners Name 22�e,�z Permit #-72-6�
Amount
Type of Occupancy
New ❑ Renovation 0 Replacement .Ca Plans Submitted Yes No
FIXTURES
..(Print or type)
Installing Company Name /-,"Cfee h
Address
S607Crt-i%IC i-71' Oz V5",
Business Telephone G ? _ / — 6--r117 O
Check one:
Corp. _
Partner.
Firm/Co.
Name of Licensed Plumber: /—,a`K _ _
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity 11 Bond
Certificate
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
t surance
ignature Owner ET� 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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Ce and Chapter 142 of the General Laws.
By:�1 �gnature - 42251 um er �.Aj►v
Type of Plumbing License
Title
City/Town icense Numoer Master ❑ Journeyman El
APPROVED (OFFICE USE ONLY
W-11-1717j1NMMMMMMMMMMMMMMM
..........
is -�.-.�..®'A-.---.-N--....M
..(Print or type)
Installing Company Name /-,"Cfee h
Address
S607Crt-i%IC i-71' Oz V5",
Business Telephone G ? _ / — 6--r117 O
Check one:
Corp. _
Partner.
Firm/Co.
Name of Licensed Plumber: /—,a`K _ _
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 11 Other type of indemnity 11 Bond
Certificate
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
t surance
ignature Owner ET� 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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Ce and Chapter 142 of the General Laws.
By:�1 �gnature - 42251 um er �.Aj►v
Type of Plumbing License
Title
City/Town icense Numoer Master ❑ Journeyman El
APPROVED (OFFICE USE ONLY
Location po- Pt'l
No. Date
NaRTM
TOWN OF NORTH ANDOVER
%
Certificate of Occupancy
$
as " x
-Building/Frame
Permit Fee
$
�ss�c►+u,E<
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee $
TOTAL $
;ij
Building Inspector
n � A
Div. Public Works
PERMIT NO.
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP M40.
I LOT NO.
2 RECORD OF OWNERSHIP iDATE
BOOK 'PAGE
R
ZONE
SUB DIV. LOT NO.
LOCATION
PURPOSE OF BUILDING
OWNER'S NAME `
NO. OF STORIES SIZE
OWNER'S ADDRESS C� ra /1
BASEMENT OR SLAB
ARCHITECT'S NAME
BUILDER'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
SPAN
DISTANCE TO NEARE T BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES — SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION _
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
&2-,Z96
//ATURE /�i7t I o W/ U/�f 1,7k- /R 1ED - -N AGENT /i T
FEE
PERMIT GRANTED
-2 19
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 9 Q
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
SUILDING INSPECTOR
OWNER TEL. 11 Lf
CONTR. TEL. #
CONTR. LIC. # 423 q.0 qq
H.I.C. # � 3 l 7� 6 7
BUILDING RECORD
1 OCCUPANCY 12 kr�-- -.
SINGLE FAMILY
STORIES
MULTI. FAMILY
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
PINE
d
1
2 13
CONCRETE BL'K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
_
UNFIN.
3 BASEMENT
AREA FULL
y. 1/2 1/
NO BMT
HEAD ROOM
4 WALLS
FIN. BMT* AREA _
FIN. ATTIC AREA _
FIRE PLACES _
MODERN KITCHEN
I 9 FLOORS
CLAPBOARDS
B
1
2
3
_
DROP SIDING
CONCRETE
WOOD SHINGLES
EARTH
ASPHALT SIDING
SIDING
HARDW'D
COM/,nCN
COMIAASBESTOS
VERT. SIDING
_
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. 8 fIOOR
_
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR (J POOR
ADEQUATE 1 NONE
5 ROOF
10 PLUMBING
GABLEHIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR 8 GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. 8 COLS.
STEAM
STEEL BMS. 8 COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
ELECTRIC
I NO HEATING
B'M'T 2nd _
to 13rd
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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