HomeMy WebLinkAboutMiscellaneous - 57 Hickory Hill (2) Hickory Hill, 57 `
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Location �5-
No. O Date
AORTol TOWN OF NORTH ANDOVER
F • Lp
+ ; ; Certificate of Occupancy $
��as�c►,uSE Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
1�
Building In for
• TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: � DATE ISSUED•
SIGNATURE:
Buildln Commissioner for of Buildings Date l Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: k6s
� sac..— d `
Lo
Zoning District Proposed Use Lot Wea s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Regaired Provided R red Provided
1.7 Water S M.G.L.C.40. 54) 1.5. Flood Zone Information: ewerage Disposal System: n
Public Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn
2.1 Owner
[of���/�R//ecco�rd
Record
/e O
Name(P t) Address for Service
Si ture Telephone
2.2 Owner of Record:
Name Print Address for Se Z
�� rn
Sign26rz Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Constructi Supervtsor: D��3
� L! � License Number
Address ����
.-'
! ��`• ` �a>� Expiration Date icic
Sign ure Telephone r
M<
3 Regi ed Home Improvement Contractor Not Applicable ❑ v
Company Name eArewwr�
rn
-7v�
Registration Numbe r
ress
Add10,
�j Expiration Date <
Si re
Telephone
SECTION 4-WORKERS COMPENSATION(NLG.L. C 152 § 25c(6) r
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 rmit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Evs m'�Buildin2 Build' ❑ Repair(s) ❑ Alterations(s) '❑ ,: Addition ❑
Accessory Bldg. ❑ Demolition ❑ ' Other Specify �llif/.� Gds.
k
Brief Description of Proposed WorIk
\
r.,s
SECTION 6-ESTIMATED CONSTRUCTION COSTS
v + , Item Estimated Cost(Dollar)to be
OMICIA USE ONLY
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing - Building Permit fee(a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION O BE COMPLETED WHEN
If OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/A orized Agent of subject property
s
Hereby avL to act on
My beh f al n s relative to werk authorized by this building permit applicati
inure of Owner Date
TION 7b OWNER/AUTHORIZED AGENT DECLARATION - �-
as O er/Authonzed A t of sghject
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 Nain
- 10 . 3-�
Sijnatiof O r Agent Date
NO. OF STORIES SIZE 1
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST2 ND 3RD
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
FORM — U — LOT RELEASE FORM
z
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.
I.................................................................sora as
APPLICAN �`�% PHONE��D �I��
ASSESSORS MAP NUMBER6)jO K/ LOT NUMBER ODBS`�
SUBDIVISION LOT NUMBER
STREET STREET NUMBER ��
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS
sommomme
'C kLk,r, o•- �� DATE APPROVED 1
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS 17 ��! 1 ���r i Wj(!!!s
DATE APPROVED
TOWN PLANNER
DATE REJECTED
CONMENTS
DATE APPROVED
FOOD INSPECTOR-HEALTH DATE REJECTED
DATE APPROVED O
SEPTIC IN9PECTOP,-HEALTH
DATE REJECTED
COMMENTS
PUBLIC WORKS—SEWER 1 WATER CONNECTIONS
DRIVEWAYPERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
'71,��
Oct 02 00 04: 34p Field Force User ENTER YOUR NUMBER p. 2
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.a,,,,,'���oa��-N_a., �„� �.����1 H Stf33NOWAN3
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Aff1davit
Please Print
Name: J,,ry �S / gz�OZ2_V
Location: 0 7
Ci ��15b I Phone
am a homeowner performing aff work myself.
01 am a sole proprietor and have no one working in any capacity
11am an employer providing workers' compensation for my emp ees working on this job.
Company name:
Address /
2Y. Le Ste' Phone*:
Insurance Co. C. Policv
Company name:
Address
City: Phone#
Insurance Co. Policv#
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 fine 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.
I do herby certify under tand enalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone#L �U
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 Office
Contact person._ Phone A- ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION
Board of Building Regulations and Standards License or registration valid for individul use onl
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
' Registration: 105485
One Ashburton Place Rm 1301
Expiration: 07/17/2002 Boston,Ma.02108
Type: Supplement Card
SOUTH SHORE GUNITE POOL&
ROBERT FISKE
7 Progress Ave. ,
Chelmsford,MA 01824 Administrator t d w' hoot signature
BOARD OF BUILDING REGULATIONS ,
License: CONSTRUCTION SUPERVISOR
Number. CS 076339
Birthdate: 07/07/1946
Expires:07/07/2003 Tr.no: 76339
Restricted To: 00
ROBERT J FISKE
4 LONGWOOD DRIVE
ANDOVER, MA 01810 Administrator
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NORTH
Tolm . of RAndover
1- LA E o dower Mass.
COCHICHEW111 V
7,ps RATED 5
1 BOARD OF HEALTH
PE IT Food/Kitchen
Septic System
RR
BUILDING INSPECTOR
THIS CERTIFIES THAT
..... i Foundation
has permission to erec . . ........... buildings on ................... Rough
t0 be Occupied as. Chimney
provided that the Pers accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the ovisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST 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 BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner r
Street No.
SEE REVERSE SIDE Smoke Det.