HomeMy WebLinkAboutMiscellaneous - 38 S CrossFORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT19� F"�� ��[���{,\ &-,Y— PHONE (4?qL ANq
ASSESSORS MAP NUMBER LOT NUMBER 17 "
SUBDI UMBER
STREET...�... o ss .....S ........ STREET NUMBER ....... .... .
OFFICIAL USE ONLY c?D /V 3z
�RECOMWNDATIONS OF TOWN AGENTS
DATE APPROVED
CONSERVATION ADMINISTRATOR
A � DATEREJECTED
COMMENTS �_)p,P,dS � C�_*U r�b� CSS' �'�\lh
DATE APPROVED
DATE REJECTED
DATE APPROVED
FOOD INSPECTOR - TH DATE REJECTED
DATE APPROVED 4-5
S C spEgMR -HiALTH
DATE REJECTED
COMMENTS /411 Z� � 1 ! L+ `y�.-.,:� IZ:)
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PUBLIC WORKS — SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
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COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
=This Sectioe. for Oiii cia! Use Oily
BUELDING PERMIT NUMBER:
DATE ISSUED:
SIGNATURE:
Building Commissioner/IEMtor of Buildings Date
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SECTION I- SITE INFORMATION
1.1 Property .address:
1.2 Assessors Map and Parcel -Number:
3.9
Map Number Parcel Number
1.3 Zoning Information:/
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (d)
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Re red Provided
1.7 Water Supply M.G.L.C.40. 5 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zane Outside Flood Zone 0. Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
p�2..11/��0,,�wJ�nee/�rr oof iRieeccord 'j(�� /�y� �� j� �\ � A0 (///���•Jf/1 Q � ,1/ C - y�/� ay�.�/� � 1� � �7 � yM�
Lea gA- 1 tl \ �C IAA 1 l`I lam. _ �"" 1 e -A .J e ( Oxors s A- (A. � a \ ` i liab Vu'CA � I 1'
Name (Print) Address For Service : ,i, is , S
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ignature Telephone
2. e etG�_
Name Print Address for Service:
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Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
i
t
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (M.G.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 .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
-2 CC;>3 -e-- ion 1
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
b�
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
`/JJ
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
U as Owner/Authorized Agent of subject property
Herebv authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature ot'O\A,,iler Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, 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
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDABERS 1 2ND 3RD
SPAN
DI [ENSIGNS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
1-9 IGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHBV NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE