HomeMy WebLinkAboutMiscellaneous - 895 SALEM STREET 4/30/2018 (2)N
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Location�`�
No.Date
�oRT�
TOWN OF NORTH ANDOVER
A
Certificate Occupancy
+ 1
of
$
sACIN
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
17720
24
Building In6gctor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE,A�ONE OR TWO FAMILY DWELLING
��O''R`` ''DEMOLISH
' .. _ •'� 3 -f � �.47C�%fEVp'tlf Vltl\.f7aC�� •. r. ,. - .
BUE DING PERMIT NUMBER: �`�
DATE ISSUED: /0 '4
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address: ('
1.2Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Distrid Proposed Use
1.4 Property Dimensions:
Lot Areas Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
Re red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Address for Service
IZ�' Le, 6� -7 9 '0
-
igna a Telephone
.2 Owner of Record:
Name Print Address for Service:
Si nature 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
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature — Telephone
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SECTION 4 - WORKERS COMPENSATION (KG.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 ....... ❑
SECTION 5 Description of Proposed Work check ao a cable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY '
I . Building
(a) Building Permit Fee
Multi lier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
�20
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
— d'7j�
Check Number
JE1L11U14 /2VWAJrKAU1riUK1LA11UN lUlfEUUMI'LEIEDWHEN
OWNERS AGENT OR^CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ✓ J ' C D"�� �✓ _ G �� as Owner/Authorized Agent of subject property
Hereby authorize to act on
!yNf,,i!�;Ill,matter;y�lative towork authorized by this building permit application.
Si re o Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, ,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
of Owner/.
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 3 k
SPAN (f
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DRAENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
19
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:
(Location of Facility)(V-7F -( 73" Y-1 S' 3
Signature of Per it Applicant
Z - / �( - -
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work:�C.J .li�/rr� r D� ��1G Est. Cost 2-�'' — 3°
Address of Work 93 S7—
Owner Name:�l-lL"7✓ �/,�✓ ��-
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Pemit No.
Job under $1,000 Date
Building not owner -occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND UNER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date
Au� �- R
Owner N me
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