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HomeMy WebLinkAboutMiscellaneous - Exception (515)Location �3 J No. '7 V Date M20-0 NORTH TOWN OF NORTH ANDOVER I t } % Certificate of Occupancy $ cNusE< Building/Frame Permit Fee $ (/ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 10 r :r I Check# 1 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING - . � . � � �_ �� . � " a�v«"►a'fox Uff'lHc><a1Usc4t?Iri ���; �},. � � , � � �, _ BUILDING PERMIT NUMBER:DATE ISSUED: � / 6 (a SIGNATURE: Buildin Commissioner/InsFxctor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: n / 1,fap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Diroposed Use Lot Area Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone lnfotmation 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 Rec rd / C - S`=—l/U D- !,) , /IO% S77 Name (Print) �� , Address for Service NO, figDo VFX Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone NSFC.'TinN i _ CnlVQTVy1TVTTnnr Q rovrnvs 3.1 Licensed Construction Supervisor: .s Not Applicable ❑ Licensed Construction Supervisor: r License Number Address Signature Telephone Expiration Date 3..2 Registered Home Improvement Contractor Not Applicable ❑ PAV'P CASr-Me-100 r= R6;, 04, C�mpany Name Ai �1 �" Su� TIF -Z�� Registration Number�J ` ss � Expiration Date Signature Telephone �1 M 01 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 25c(61 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 0 Other 0 Specify Brief Description of Proposed Work: V AN yZ- CS D I r�'f- :r-RIN SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant = xOFFICIALUSE°ONLY 1. Building �� 0 C) (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X tbl %%� C d �f 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 1, 124 V I J s 7-k [ co /V 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 D v' Prir e Signature of Owner/A ent Date —T— NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRvIBERS 1 2 ND3FM SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS ' HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CI RvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Board of Building Regulations -and Standards s HOME IMPROVEMENT CONTRACTOR Registration:, 104569 Expiration "7L14/2D06 - Type Private Corporation DAVID CASTRICONE ROOFING 'SIDING & David Castricone j 7 Hillside Road�� Boxford, MA 01921 Administrator I p a�Icm my 2 So y S mama m p n 3 m Z m .. c m y W c H -4 ~' � C a o' T O ? m =0 0 y m m �« 0 4.0 POO d mac: y CO) O oyixrp a0 � e a�� ;� QV ►d = w CD 0 -0 IJ i E > o ago �' 2 C7 `<CD � y C C/)m m 1 iii ? O b 0. —• yn a m \ / y 0 MO z n= R g C o p* = a �'� _ CD CL y o m crCD "` O o\CC3 r. a ?` m CDCD —• O y 3 ~ 0.v CA ,� Z t0• CDD o m f � 0 O a, CO)10 to ca 0 CD z 0;121 CD COL -a CD c o mac_ Cp R� o .fir ro w � b �' CA b rro" b -Op t77 � O IL � x a O H n � gIL O IL x a O Name The Commonwealth of Massachusetts Department of Industrial Accidents OMCS of Invesdgadons Boston, Mass. 02111 Wormers' Compensation Insurance Atftdavit Please Print I am a sole proprietor and have no one working in any capacity I am an employer provi workers' corapensation for my employees working on this job. ULL«. k[6,. -,-- _( i' a. j ComRM name: Address Cox.Phone #' Faikme to seane coverage n required under Section 25A or MGL 152 can lead to the imposition d criminal penaitles d.a fine up to $1,500.00 ancilor one years' imprisonrrreat.as rmati_as_cbdl.penaWMJn he flow dA STOP -VVDRK ORDER.and.a.flne ot.(,i1G0.t� dad Lip to .ore I understand that a copy d this statement may be {orwarded to the Office of Investigations of the DIA for coverepe verification. I db hereby Print Perjury that the Information provided above is true and correct. Official use only do not write in this area to be completed by city or town official' City or Town P si #_f LL'ILS tl-3I/`- 0 ❑Check df, Immediate response Is ❑ Building Dept p requ�t•ed ❑ Licensing Board ❑ Selectman's Office Contact person: Phone # ❑ Health Department ❑ Other Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........................................... has permission for gas installation ............................ in the buildings of .......................................... at .. ......................... ......... North Andover, Mass. Fee......... Lic. No........... GASINSPECTOR check # I I MASSACHUSETTS UNIFORMAPPUCATON (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations New'/' Renovation ❑ POWU TO DO GAS FITTING Date Plans Submitted ❑ Permit # _ / 0 Amount $ � U S - 6> (Print or type)�� /,[ .G Y Check one: Certificate Installing Company Name G Li Co Address A © J ` e {� �o ❑ Partner. 1usiness Telp one _� .-78 —63 1 - � � � �j' �Firm/Co. Name. of Licensed Plumber or Gas Fitter � �N jell C� INSURANCE COVERAGE Check o I have a current liability Insurance po y or it's substantial equivalent. Yes No ❑ ' If you have checked yes, please ' icate the type coverage by checking the appropriate box. ❑ Liability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that.my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and mtormatnon i nave sunrmrrea kor emereu) in auuvc appnk;auvu aic uuc a„u atuuiaLc Lu u,c 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 S?7 Gas Codel. and Chap 142 the -6 ral Laws. VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter License um er ®Master C3Journeyman I MARE 3§0 0 A FLO 6TH. FLOOR (Print or type)�� /,[ .G Y Check one: Certificate Installing Company Name G Li Co Address A © J ` e {� �o ❑ Partner. 1usiness Telp one _� .-78 —63 1 - � � � �j' �Firm/Co. Name. of Licensed Plumber or Gas Fitter � �N jell C� INSURANCE COVERAGE Check o I have a current liability Insurance po y or it's substantial equivalent. Yes No ❑ ' If you have checked yes, please ' icate the type coverage by checking the appropriate box. ❑ Liability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that.my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and mtormatnon i nave sunrmrrea kor emereu) in auuvc appnk;auvu aic uuc a„u atuuiaLc Lu u,c 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 S?7 Gas Codel. and Chap 142 the -6 ral Laws. VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter License um er ®Master C3Journeyman