HomeMy WebLinkAboutMiscellaneous - Exception (76)o+ Location—
No.
ocation No. 2��5 ., Date
TOWN OF NORTH ANDOVER
v',f♦40 ,• 'h
' '• °0.
3?
I-.; %
`
Certificate Occupancy
$
of
�� J'�••°' E<�'
�cMus
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
{
rel
TOTAL
$
Check #
17788
Building lnspe
" TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
! hv,. , ., ,. ,.. „' •k5.. 5 .., � �' x ... ��'£' .`: ,.. ... � � 2`r T "'k T. v: � t .:`fie$ 1 4::.
BUILDING PERMIT NUMBER: ` DATE ISSUED:
dl
SIGNATURE- Aawf
Building Commissioner/Inspector of Buildin Date
SECTION 1- SITE INFORMATION
1.1 Property Address: /
/�
/ �s L./cI 1 1� 5
1.2 Assessors Map
i01-(
Map Number
and Parcel Number:
cit o�
Parcel Number
1.3 Zoning Information:
Zoning Dia6c-t Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
R red Provide R 'redProvided
Required Provided
1 ;PWater Supply M.G.LC.40. 1.5. Flood Zone Information:
c ❑ Private ❑ P Zone Outside Flood Zone ❑
PubUFCTION
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
R()h /-C-110 ("(-G �f U( �?-s--
Name (Print) Address for Service :
Signature Telephone
2.2 Owner of Record:
Name -Print Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
DO � 6�'
Licensed Construction Supervisor:
rC) r
/ ct.0 P02 l c �l�
Address
Signature Telephone
Not Applicable ❑
0 � Q
License Number
5�
Expiration Date
3.2 Registered Home Improvement Contractor
7�dvK 1� S V ✓� d G 2
Not Applicable ❑
C P
Company Name
/ d SAl 'r L/ / �
1� C (
Registration Number
O <`
J
Address Z� 6
Expiration Date
Signature Tele hone
ou
M
z
O
SECTION 4 - WORKERS COMPENSATION (M.G.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 .......❑ No ....... ❑
SECTION 5 Description of Proposed Work checkapplicable)
New Construction ❑
Existing Building 0'
Repair(s) ❑
Alterations(s) 0
Addition 0
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify,
Brief Description of Proposed Work:
�-L n
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
Q,y
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 d v
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 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
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T OERS iST 2 ND 3RD
SPAN
DMIENSIONS OF SILLS
DIMENSIONS OF POSTS
DIlVIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CBEVNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Ilm
w
o
H
W
a
w
a
E
a
aa
a
W
a
ca
r
wcn
w
lz
c
•
6
z
0
LULL
e
I:Lm
c 0
o �
ID
c
H
O cc
C. C
cc A
O C
r o
o �
Ea
D yo
V
:
:CD
d
CA
E5
:oma
a :.
h lC
m
�.m3
c J
C C �
o� 32C
�4,
Eo
a
cmi 7vim, o
ca a Z
is :oao
m 0 c
= o ia=o
F'• S v, C:
ON
«+
.y
CLS
W C
W E V��.a
h a •� oa
= W ce
H z wnwm
E
h
Z
h
cc
cmc
m
0
cm
c
c
s
t
0
Z
O
g
0
f
R'
U
O
0
��
2
O
O
O
as •
CD
Z d
O H
D =
ICDO cm
O�
hO O
g mm
CD
CLte_
� � L
�a
rmQ
CD
C
c Z ts
CL
O C
CL
C_
C
C403
ul
W
0
W
U)
ropogat Page of
Free Estimates 105 Haverhill Street
Fully Insured Methuen, MA 01844
THOMPSON'S ROOFING �yra� oaI I3oo
Shingles — Slate — Rubber Roof
Single Ply — Copper Work
PROPOSAL SUBMITTED TO
PHONE
DATE
5-24-04
STREET
JOB NAME
CITY, STATE AND ZIP CODE
JOB LOCATION
North Andover MA 01845
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
F. _..�.�_ .'.'O"",. ��.. ,..�_-^.n nn h,,..i� -�nr�
Renail all loose plywood and if any need replacement it will cost
$50.00 a sheet
Install aluminum drip edge around roof line
Apply ice and water shield 6 ft.up all along edge and in valleys
Apply 151b. felt paper on rest of roof area
Reshingle with a 30 eyar Archtiect shingle
Install new flanges around soil pipe
(Waterproof chimney flashing
ICut in a ridge vent
Remove all work related debris
30 year warranty on material
5 year gaurantee on labor
construction lic. #060112
improvement #128612
C,
We PrOP05C hereby to furnish material and labor —complete in accordance with above specifications, for the sum of:
Thirteen thousand eight hundred dollars ($ 13,800.00
Payment to be made as follows:
$4,800.00 down balance upon completion
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner
Authoriz
according to standard practices. Any alteration or deviation from above specifications involving
Z2
extra costs will be executed only upon written orders, and will become an extra charge over and Si natu
above the estimate. All agreements contingent upon strikes, accidents or delays beyond our
control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully Note: This proposal may be
...........JL.. ..�
OW.I Uy UJ II IIVI gVVUp't V Wllllll
Acceptance Of j9ropozal — The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized to do the
work as specified. Paymentwill be made as outlined above. Signature
:�':)
Date of Acceptance: U C � Signature
days.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Location: �1 S D, /,P 5 -
0 1 am d homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
aI am an employer providing workers' compensation for my employees working on this job.
Comoany name: �fz�.�-r n a ►�- S' d >
Address n -
V),, —2
Z -C
Cowany name:
Address
City: Phone *
ctwC 7 01111 Lt a I z.v o y
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 Ymil_as_coiil.penalties in ]he form nfeSTQP WORK ORDER.ead..a fine of.($100.OD)-a ift.against.me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby certify under �e pains and penalties of perjury that the information provided above is true and correct.
Signature�ir J •� ; ��-i Date__L
Print name I ITJ- t7 rn ct Sy i l P.hone # 6`� f 3 Ste~
Official use only do not write in this area to be completed by city or town official'
City or Town PermitfUcensing
❑ Building Dept
[]Check if immediate response Is required ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone #. ❑ Health Department
❑ Other
Id
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
c 11, S 150 A.
The debris will be disposed of in:
Z L�5w�l(
9/,
(Location of Facility)
Signature of Permit Applicant
%/ - �- — y L-1,
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
A