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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number /tea Date Z`
THIS CERTIFIES
THE BUILDING LOCATED ON `%
1�,4oariz �S
MAY BE OCCUPIED AS l/ r C `f S P,4 CC- ,� IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO
ADDRESS 1411' c/o 'S 7` -
Building Inspector
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number C�? 70,
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 4 �5
Date 9-
MAYBE OCCUPIED AS ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE .AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO
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Buildi�Inspector
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Location 4A5 /`„"`P"`'
No, A ,;L Date
Check # &/ 0 Sj
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
15648 Building1�inspec��
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: V" �l
Z. AML•
SIGNATURE: V WI `��
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION I A
1.1 Property Addr s:
1.2 Assessors Map and Parcel Number:
62
' I / Sn,Q
J
^ Map Number
Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Re red Provide
Required Provided
RecIaired
Provided
1.7 Water Supply M.G.L.C.40. 54)
1.5. Flood Zone Information:
1.8
Sewerage Disposal System:
Public ❑ Private ❑ Zone
Outside Flood Zone 0
Municipal
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 O ner o Record
y-
VNamqKF' rint) Address for Service
llp---
tgnVure V Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Li ensed Construction Supervisor: Not Applicable ❑
a L) Ll 0 V-) e0 L-) La
tcensed Constructio pervisor: _
q 1 S License Number
Address Cy �/ C�i�� �
l y ^'` 1 Expiration Date (f
Signature Telephone
1.2legistered Home Im o ent Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 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 .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alteration s(s
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Propose Work:
l
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit a licant,
CIAI. USE ONLY`
1. Building
(a) Building Permit Fee
Multiplier_
K
(o S
2 Electrical
(?
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (b)
�26
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
n'U
Check Number
SECTION 7a OWNER AUTHORIZATIOr4 TO BE COMPLETED WHEN
.OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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, 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
Signature of Owner/Agent Date
NUNN
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TEVIBERS 1ST2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
T� �ancnwn+aealfl n���•��crds�rc#u�dP,fis
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 059666
Birthdate: 03/25/1952
- Expires: 03/25/2002 Tr. no: 18267
Restricted To: 00
CLAUDE 3 BEAUDOIN
19 WESTMINSTER LN
MERRIMACK, NH 03054 Administrator
J
me:
191
City PI
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name. - ► \ ��
Insurance Co. Policy # �(/ C. 1 0
Company name:
Address
City: Phone #:
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or 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 rine 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.
t do herby certify under he pains and penalties of penury that the information provided above is true and correct.
Signature c Date
Print name It U k -C- c v vO y
Phone # �"�
Official use only do not write in this area to be completed by city or town official ❑ Building Dept
❑check if immediate response is required Building Dept ❑ Licensing Board
Selectman's off ce
Contact r.x?rson Phos — HA i
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