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HomeMy WebLinkAboutMiscellaneous - Exception (91)I Location No. /-/ 9 o�- Date f'� ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ C, Foundation Permit Fee Other Permit Fee TOTAL 104 Check # 1866' 8 $ 30 '-'� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A�ONE OR TWO FAMILY DWELLING 00 OW BUILDING PERMIT NUMBER: � DATE ISSUED: d� SIGNATURE: _A00 bLAA� Building CommissionerlInwwor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: (7� 1.2 Assessors Map and Parcel Number: Map Number Parcel Number nye 10 woes (Zidyedrt- 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT ' N; 01 i,; ijSti- iCt: ;6_ r;lO 2.1 Owner ofrrdVe— Q, � © C 0 � ' � l Name (Print) Address for Service : () _ �Kr(y Oa Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signa re Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construct on Su rvi or: Licensed nstruction Supervisor: q 9- Tt 9 - " / _ r� �% Address /t _ Signature Telephone Not Applicable ❑ 00/304 C License Number D 0 Expiration Date 3.2 Re' tered Home Improvement Contractor Not Applicable ❑ Company Nam > �/ Registration Number 1 La / 0 5 Address I Expiration Date Signature _ , Telephone SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § 25c(6) I ' 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 as a Ucable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. ❑ 1 Demolition 0 1 Other 0 Specify Brief Description of Proposed Work: �( Vv V) r -f C(� (,L00d C)ud-e, w et'1in,� I SECTION 6 - ESTIMATED CONSTRITC'TTON CORTS I Item Estimated Cost (Dollar) to be Completed b permit applicant { MCIAL USE ONLY 1. Building(a) t 'yvt d MCI ��Id Ih d �V — Building Permit Fee Multiplier 2 Electrical i (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5°d! Q d d Check Number JLIL11v1II /a vwfln CavinVMJmA'r1VN 1V 1SE UUMNLElEll WHEr4 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this Wilding permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ; I IQ U ('d- G Fa v) ,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 el,V ( Print Name of Fed l/ d� Date t;' NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS i s 2 3 KD SPAN DIMENSIONS OF SILLS s DIMENSIONS OF POSTS , DIMENSIONS OF GMDERS 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 Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of /nve0gat/ons Boston, Mass. 02111 Worirers' Co rWnsetibn Insurance AflA* t Please Print Locatl_on: D -J Co U r� City Phone 7 �` r 5 !7 U 5- 71 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ErI a n an employer providing workers' compensation for rry employees working on this job. Comoern name: �\(`C� Y1� Q0 cfc, Insurartoe Co. Pokv 0 Failure to secure coverape as required under Section 25A or MOL 152 can lead to tiro impaillon d ch. l Penalties d.4 -Are LIP to $1,500.00 andlorawyeere'Imprisomcent_as.reel.r_c�xM4mmMnJnb@fa®dASTOP.VAOMORDER.sad.a.Aasd.(21AO.Msdsyapelost_ma 1 understand that a copy of this staternent may be forwarded to the OfAae d Invesdiptle s of the DIA for coverepe verification. I ab hereby asrt/y undsr ft PBkw ark PBjfih s or Perjury that ft Infam don provi W above /a bus and Carso. Print Oftial use only do not write in this area to be completed by city or tam dtider 1t � �?oo-",5^?2uY— City or Town Pamrts ensina ❑ Building Dept []Check X Immedete response In requied ❑ L tGnafnD Boold ❑ Selectmen's Office Contact person: Phone ❑ Health Department ❑ Other 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: 9 / ¢1� (Location of:i'g"'nature ity) �, o�f,Permriit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector s CA 2 rl� � M d z cro LLJ am v It0 c� O N O tj4'-'—c.� CLc c .L o Ea aCF s C. y Aep ocm� is r 1 mCL c mm 0. n O N ,_ 0 3 •� c �� y W pp+ • eo CL Co O 3 ��o w Z c c o H � .0 n teoc c 3 n�i CL p =ID«+t W C .0r1=05 w p F. ell dt t0 c SO Leo Z LAJ 10 �-40DIsCL ID A go M CD 5 esw 00 M KI 0 O v� :v i I cc o •— CIO •D r m m = Ozip% �3 LIM ecv o a � v�Q o c ev EL 0 G3 Cal C Z ts m 0 CL C.3 y O C W 0 ui U) 19 W W W U) a a a u A A 5 c � � ° ;� � a � W � " z •� a°' w a°' w oo cn cn rl� � M d z cro LLJ am v It0 c� O N O tj4'-'—c.� CLc c .L o Ea aCF s C. y Aep ocm� is r 1 mCL c mm 0. n O N ,_ 0 3 •� c �� y W pp+ • eo CL Co O 3 ��o w Z c c o H � .0 n teoc c 3 n�i CL p =ID«+t W C .0r1=05 w p F. ell dt t0 c SO Leo Z LAJ 10 �-40DIsCL ID A go M CD 5 esw 00 M KI 0 O v� :v i I cc o •— CIO •D r m m = Ozip% �3 LIM ecv o a � v�Q o c ev EL 0 G3 Cal C Z ts m 0 CL C.3 y O C W 0 ui U) 19 W W W U)