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HomeMy WebLinkAboutMiscellaneous - 1120 Great Pond Road r I ?W (� ea 4- P,/Y\j )2c4. BUILDING FILE i 7 . � Qrf � 4 Location Date © Na y \ TOWN OF NORTH ANDOVER . ^\ Certificate of Occupancy $ ./ Building/Frame Permit Fee $ 610 § CH § Foundation Permit Fee $ §} - A . Other Permit Fe $ \/ � . .. TOTAL $ \\ . Check * \ } 592 \ Building Inspector ^ ) Q o TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT HtM_& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED. Ac)lo (,r� a SIGNATURE: 4 -'i Building Cominissionerff or of Buildings Date 0 SECTION 1--SITE INFORMATION ® 1.1 Property Address: 1.2 Assessors Map and Parcel Number: , ifzo c�Qe� � < 0� Map Number Parcel Number 1.3 Zoning Information: 1.4 Properly Dimensions: v Zoning District Proposed Use Lot Area Fronts 11 1.6 BUILDING SETBACKS R Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply UG.L.C.4e. 34) 1.3. blood Zone Infmmrtion: 1.E Sewerage Disposal System: > ❑ Private ❑ Zone Onside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ aaaaaf PublicSECTION 2-PROPERTY OWNERSEIP/AUTHORIZEDAGENT lt, .jISt(ICt: 2.1 Owner of Record Name(Print) Address for Service: e Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 1 is 7 Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ raj Licensed Construction Supervisor: C J r JLicense Number ( U Kin Address > /2 �3/ d Expiration Date xP gi' narum— Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name _ Registration Number Address NOW Expiration Date z Signature Telephone G) SECTION 4-WORKERS COMPENSATION(XG.L C 152 25e(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 unit. Signed affidavit Attached Yes.......❑ No.......0 SECTION S Description of Proposed Work check ad applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) 0 Tdditi on ❑ Accessory Bldg. 0 'Demolition 0 Other ❑ Specify' Brief Description of Proposed Work: 'SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFItIICIAL USE ONLY Completed by permit a licant 1. Building g®o (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x tbl 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 as Owner/Authorized Agent of subject property r Hereby authorize to act on My behalf,in all matters relative to work authorized by this builduig permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject 'ra 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 Si tune of Owner/Agent Date NO. OF STOREES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 RD SPAN DM ENSIONS OF SILLS DIMENSIONS OF POSTS DUVIENSIONS OF G.MDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE �" BOARD OF,BU NBA eGd�AON- \\ \\> . ° \ \ \ \ ? ® . . \I �\ \ ] i \ dK,gc n■ CONSTRUCTION RR�P�vm0�\ � | /\ \\Nmb \ 08955 a � > ]■rthdit 04123ti 964 - \ \ \ # 1 7666Tn: 8175 } »{ Rsri 0od. .. �� gRATEND WC kUW © � . /\ 104 fHORTON S\\ ,/ \ ^`LAIMENCE,MA y / ©A wn ftat\\ \} \ �C- m-&a FORM U - LOT RELEASE FORM <Ek O INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTIO APPLICANT PHONE LOCATION: Assessors Map Number PARCEL SUBDIVISION— LOT STREET G d"�e.-�� - �cr,� ST. NUMBER 11,12B OFFICIAL USE ONL REqP*—E—N-0jAT1PW OF TOO AGENTS! COHSE ATION ADMINIS RAT R DATE APPROVED DATE REJECTED COMMENTS . S W QQ� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS v� FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO DATE___ R@vb@d 9IY'1Im W The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 - Workers'Compensation Insurance Afdavit Name Please Print Name: Location: Cltv Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address City Phone# Insurance Co. Policv# Comoarty name: Address City: Phone# Insurance Co. Poli # ra - cv Pasture to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,5170.00 and/or one years'imprisonment_as weU-as_civil..penaltiesintheformda_STOP WORK_ORDER..and..a fine of.(.$100.00)-aitay against.rr�, I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the ir►fonnation provided above is true and correct Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensin ❑ Building Dept ❑Check Y immediate response Is required J] Licensing Board ❑ Selectman's OfficeContact person: Ph one o #. ❑ Health Department Ei 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: (Location of Facility) Signature of P rmit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector May 26 05 02:17p Brooks Facilities Dept 19787256295 p.2 I � I log If t May 26 05 02:17p Brooks Facilities Dept 19787256295 p.1 i 1 1 1H� pN IN z 1 \ �y 1 .ny L' i./ *tea/.•' •N- 1p \` / "� �� /,ter � � � 'O�'' , .. � • i oil 01i-1 s• � I� ` JAAjAA ♦ IM� 11 9 •�' t / s OIL `:. :cam----�`i�A.•`"'�`_ ,revs �� CI �\. � •� ui \ n "� � ����-'�/� / t rte, l' x k z•`t { ; pBr- w+s'•—� Ott{�' \ � �t�` �C rhe`'}'•�. ,�� > 4,,Sr �-�s.,1 YilE.J4 }' w: o • T8 ` lit,,�t� ..� � ♦ r\`\l � �u�ZY'��rY,S i t r_v., y I J yyR �r r _ . ,p { ° sA -„`GENE AL :�ON also to Sl .10 OL \\�`,, \\ \\ / �(fir � � � `� 1 i t /�� 1 I i � I/ II /� ,l I • \ \ \ I \ \\ . '- � III , � / d ��/ � / � ( 4 I -I I \ i i' •' � 1 I NO�TM Town of Andover 0 -!-- .-j 0 Al • 8 m i L A E over, Mass., COC MIC HE WICK AO'4ATEO `s BOARD OF HEALTH PERMIT .. T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......34*#4 S..c ti.o t.................................................................... oun tion has permission to erect... �..�►./ ............ buildings on 1.1.41 ...!. ...'...... ®�.�............. Rough to be occupied as. O P�..p.... .�'.� V. .........�' x r O r' "b`y y ) r 1 Ar Chimney ........ ................................................................................�.......... .. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspeoflon, Alteration and Construction of Buildings in the Town of North Andover. ,� � i PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARSA ,Rough� .. .. .. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT t Until Inspected and Approved by the Building Inspector. Bumer Street No. SEE REVERSE SIDE Smoke Det.