HomeMy WebLinkAboutMiscellaneous - 258 Salem StreetLocation`
No.* l Date !,
k. NORT1y TOWN OF NORTH ANDOVER
- OL
Certificate of Occupancy $
s�cMust`A Building/Frame Permit Fee $ ///"
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
1358
Building Inspe6or
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
3..,....,. ..r ,ryt'z^ ->• r is , a , .:. . � .�.,., x,� ._.... ,aF. :s � ,,;R4* �
BUILDING PERMIT NUMBER: ® DATE ISSUED: o / ® 00
SIGNATURE: �" " 0
Building Commissioner/I for of Buildings Date
SECTION i- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Par&I gumber
/f lal-f/ Alaolvc� AA
If
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
2s1.0zLl
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. F1 Zone Information:
Public N"' Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System lily
SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT
2.1 Owner of Record
jb
- M:(Kr, S A TER 1 A L►= VLJ 1F --
Name (Print) Address for Service
vVinj %9- ,2-379
S gnature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature 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
SECTION 4 - WORKERS COMPENSATION (XG.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 all a licable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. Demolition ❑ Other . ❑ Specify 00 [,u L K
Brief Description of Proposed Work:
G�
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to beOFFICIAL
Completed by permit applicant
USE ONLY
1. • BuildingO
Z17I
(a) Building Permit Fee
Multiplier
o
'
2 Electrical
(b) Estimated Total Cost of
Construction
/ �7 QQO
3 Plumbin
Building Permit fee (a). X (b)
s
4 Mechanical (HVAC)//0
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, ,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
AIM
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T NIBERS 1 2. 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUU DING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
ft
FORM U - LOT RELEASE FORM
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 SECTION***********************
APPLICANT Mork PHONE W Y-29 76
LOCATION: Assessor's Map Number �PARCEL
SUBDIVISION LOT (S)
STREET �� ST. NUMBER as�
**************OFFICIAL USE ONLY*********************��
DDAATIIOO 4SSOO-Fy TOWN AGENTS: LF &X00 a, r- C/�7fV6[
-)1,-3
j �
ATION Al
COMMENTS
TOWN PLANNER
COMMENTS
FOOD I
I INISTRATOR DATE APPROVED 'L W 6
DATE REJECTED
VQ
H10
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
/Atlr�
&K
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS C
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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