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Home My WebLink AboutBuilding Permit #241 - 107 SANDRA LANE 9/21/2011 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: , Date Received Date Issued: Z � ' IMPORTANT: A plicant must complete all items on this page LOCATIONy r-17 z Print PROPERTY OWNERV G '�L /� r<< Unit# Print MAPNO: 41 PARCEL: /y ZONING DISTRICT: Historic District yesno Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑'One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic C®�Well - {(])Floodplain ®tWetlands I®?1WatershediD stncf, D�Wate&S` Bei DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: , 1 r� r�i't-.tet i Phone• Address: 67 eaN 3,z_-n L rl �S -c CONTRACTOR Name:� �/ ��9� t-E s,�, c c Phone: Address: /J� i� ,i i_�i'�r��'- G �g Supervisor's Construction License: L�6 �� C Exp. Date: �3 Home Improvement License: Za/ Y C 2 Exp. Date: _ / Z ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULD/NG PERMIT 92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: 6100 . FEE: Check No.: %o s 70 Receipt No.: NOTE: Persons contracting with unregistered.,Zontractors do not hav ac ss to e gu anty f d Qinnati ranf{Oncant/(linnan..t- Cnnati ira nf.r nntrnc Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED ` PLANNING & DEVELOPMENT ❑ ❑ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i R Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No ' MGL Chapter 166 section 21A—F and G min.$1oo-$100o fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C..And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I, Addition or Decks ❑ Building Permit Application -u Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Flo or/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi XAORT►y Town of CO, _ o , dover, Mass., �DCOCHICHEWICK "QATED 11 BOARD OF HEALTH T D PE Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... 'room*. ............ ....�►.. ......LmwwatL............................................................ Foundation u dation has permission to erect............ buildings on .....1.0': ........ ...... ....O..!........... Rough to be occupied as.................. .. .... Chimney provided that the person accepting thi permit shaltin everyrespect J::Ifllwoorll:�=61i arms of the application on file in Final this office, and to the provisions 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 INNTHS - ELECTRICAL INSPECTOR UNLESS CONS LJ � � ' b r S�' TS L.,� Rough ..... ......................................................................................................... ervtce BUILDING INSPECTOR Final Occupancy Fermit 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, Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 4v osier dh0 f.q T'SCi�,T�`•Q�O X63�°°,aOe,�`Zi��'�„f, X078 4F 0GS of _.�tflCe o C II,;CL;�P2l,/lG urner f,:airs 62 HOME(rWPROVEMf NT CONT a........ Registration: RAC fOf: — ,1018ti2 Exc�rafi.�n '6/2 9/ 0�z Fnc f RAI� . CA'C9FhI0USSE SONS. ` Ray D e- '.'r 1 .. amn,ausse i 7 75'Butternut La*�F1-2 All et{YUen. MA 01844 'U. Is , r f' Inform • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is define d as an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers',compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation.of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,;please call the Department at the number listed below. Self-insured companies should enter their ,self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been'officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: 4110 Co17a.,.-.orme-a1`h of P0'assachnsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston}MA,02111, Tel.#617-727-4900 ext 406 or.1-877-MASSAFE Revised 5-26-05 Fax#61.7,727-7749 Www.mass.Lyov/dia The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street s� Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Lels>ibly Name(Business/organization/Individual): q 2f r�'l�I t'l v �^2„T �O T'1 C' �G i f1"G. �', � ��• L Address: ,v City/State/Zip: �� - `��A r �n,a Phone#: 2f2` ,?_ C F3 4 [atn P�a =mppllotyerr r?Check the appropriate box: wi Type ofproject(required): – 4• ❑ I am a general contractor and I P 11 and/or part-time).* have hired the sub-contractors 6. F1 New construction sole prc�rl or or partner- listed on the attached shgaet. 1 7. ❑Remodeling and have no employees These sub-contractors have 8. ❑Demolition ing for me in any capacity. workers'comp.insurance. orkers comp.insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its red.] ,officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions lf. [No workers' comp. c. 152,§1(4),and wee no cerequired.]t , 12• of repairs employees.[No workers comp,insurance required.] 13.❑Other ,�/� . / t :Any applicant that checks box#1 must also fill out the section below showing their workers' Homeowners who submit this affidavit indicating they are compensation policy information. doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for information. my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#:_ Expiration Date. —/ Z Job Site Address: ,2 �l City/State/Zip:_,,�,_!�)• 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required Wider Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA,for insurance coverage verification. I do Itereb y under t pains an penalties perjury that the information provided above is true and correct. Si nature: Date: Phone#: �� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: RAYMOND E. DAMPHOUSSE, JR. AND SONS ROOFING CO., INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01012 SUPERVISOR LIC. #804M TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862ROOFING - SIDING - INSULATION Date ' From: '3 a — /4 �C � N�� /�/ • f��?his�c.r�{Z (N em.l IA ddra.) To: RATII113 E NAMPO$#= JR. All SINS 11IEINS CO., 11C., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01642 I (we) hereby authorize the Contractor to furnish all materials and labor necessary to Install, construct and place the Improvements described below in-on building located at No. / / ~�'`��.2� Street, i City `�. Ati► n �'� Slate ^.-9 r In accordance with the following spectficalions: We will remove all roof shingles off total roof area,up to two layers. Replace any boards or sheathinga_ tad- ditional cost. A new 8" clear or white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3 f in valleys, strips around skylights, along chimney flashing and sidewall junc- tions. A new base sheet applied.A Iko 30yr Cambridge architechual or standard roof shingle installed. Install new vent pipe boot flashings. Waterproof existing chimney flashing and remove debris. .. .optional Product Roof Over Shingle Ridge VenLt.V� 4! /; ►i E �'�� zy,r.S Existing Roof Soffit Vents All of the above work to be done In a good and workman like manner. All men and equipment Insured, Promisee to be left clean upon completion of work. For the total sum of dolle,rr— Entire Sum to be paid Immediately upon completion In accordance with plan as shown below. !J` TOTAL CASH SELLING PRICE .......... G-0 ° DOWN PAYMENT IN CASH . .. , J DEFERRED BALANCE f UPON COMPLETION ..... .- The undersigned agrees to keep property mentioned In this agreement proper) Insured against loss D fire Including the Y g Y 0 Contractor's Interest therein, This agreement shall become binding only upon the written acceptance hereof by sold Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promisee or agreements, written or oral except as herein set forth, It Is the Intention of the parties hereto(hal this contract shall be binding upon their respective heirs, executors, administrators, successors and assigns. Customer agrees to pay ■ reasonable sum as attorney's fees and Court Costs If placed In hands. of attorney for collection. The owner further agrees that In event of cancellation of this contract atter acceptance by the contractor and before the work Is commenced the OWNER agrees to pay 20% of the total consideration herein named as liquidated damages for breach of contract. Sold contractor shall not be responsible for damage or delay due to strikes, Was, accidents, or other causes beyond his reasonable control. We, the undersigned, certify that we are the sols owners of the properly herein described on which sold work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (thelr) hands) and eeal(e) a day nd year written above. Accepted By "Husband ! RAYMOND E.DAMPMOUSSE,JR.AND SONS Wife C1 ((( CO.,INC. Moll Address 11 dlllu.nt,roma above) Do q ip ur.and TI11.01 hcul) Location l��r No. Date NORTIy TOWN OF NORTH ANDOVER O'tNo , 1%yp O L 9 Certificate of Occupancy $ s�cMus<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # U V 24601 Building Inspector