HomeMy WebLinkAboutBuilding Permit #815 - 11 DANA STREET 6/20/2006 Of NORTH 11,
TOWN OF NORTH ANDOVER
`•o' . ,>°'•� APPLICATION FOR PLAN EXAMINATION
� 9O+�r.° er`g9
954 CHUSE�
Permit NO: f Date Received: �F /
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION l/ C;
nt
PROPERTY OWNER �wu-
Print
MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑New Building One family
❑ Addition ❑Two or more family ❑Industrial
Alteration No. of units:
❑Repair, replacement ❑Assessory Bldg ❑ Commercial
❑Demolition
❑Moving(relocation) ❑ Other ❑ Others:
❑Foundation only
DESCRiIPTION OF WORK TO BE PREFORMED
Identification /Please Type or Print Clearly) a
OWNER: Name: F,-A-k-- 4 A< oe,�a__,Qa Phone:
Address: t ( o0gn-4 � ( / .."()
CONTRACTOR Name: ?o g � ��`-�S�C�` t Phone:4;d.?- �7 70
Address: CrS,(. 0,94c% S 24-.)
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost S Snloo, U-) x10.00=FEE:$
Check No.: � Receipt No.:
Page l of 4
Location / �l�h1.1 --
No. / Date
NORTN TOWN OF NORTH ANDOVER
9
. i
Certificate of Occupancy $
• o��+,mss:.. ,' s � ��
;,SSA�MUSEt� Building/Frame Permit Fee $ (k
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # �Yf
�' 9 Building Inspector
TYPE OF SEWARGE DISPOSAL Swimming Pools ❑
❑ Tanning/Massage/Body Art ❑
Public Sewer
Tobacco Sales ❑ Food Packaging/Sales ❑
Well ❑
Permanent Dumpster on Site ❑
Private(septic tank,etc. ❑ Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of A ent/Owne
gn r g �,�-� Signature
Contractor
o actor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING& DEVELOPMENT ❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC.Jan.2006
Zoning Board of Appeals:Variance,Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Building Setback (ft.) C
Front Yard Side Yard °
Rear Yard n
Required Provided Required Provides Required—I Provided s
e
vation Decision: Comments r
Water& Sewer connection signature&date
Temp Dumpster on site yes—no x Fire Department signature/date
Building Permit Approved and Issued by:
Page 2 of 4
DIMENSION
Number of Stories: Total square feet of floor area,based on Exterior dimensions.
Total land area,sq. ft.:
NOTES and DATA—(For department use)
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Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:DPFORM05
Created JMC.Jan.2006
J
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
❑ 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
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan
And Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
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
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
And Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Page 4 of 4
{
NORTH
Town of : 4Andover
�INo. • i. - �I+.
dover, Mass.,
11�A COC MICH-WICK
i 7 ORATED P'P�
E BOARD OF HEALTH
I
PERMIT T D
Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..........' �!!�. / ...................�.!'~��..................................................................................... Foundation
has permission to erect........................................ buildings on..//...... 4.0I..4...... 524 ............................. Rough
to be occupied as... *r !!!R f...,T� � .... �i�i1.�!A. . ..�. ... �......��.... Chimney
6
provided that the person accepting this permit shall in every respect conform to the terms of the applicatIbn 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 hermit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU TARTS
Rough
.. .. .. .. .. .. ..... .. ............................. .
Service
BUIL ECTOR
Final
Occupancy PeTm.it 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
1 Street No.
SEE REVERSE SIDE smoke Det.
i
The Commonwealth of,Vlassaehusetts
Department of Industrial:lccidents
Office of Investigations
VIN ; �' 600 Washington Street
Boston, AU 02111
Mt
www.mass.gov/din
Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Name l�
ne (l;usiness;(h•ganiialii,nllndividuul): °r��4'-E � �-(.� Sllyc.
I
,address:
City;StaterZip-4 � t✓ `U Phone #• 60 3 -7 7 0 — Vu 3
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E] New construction
employees(full and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. ' 7• ® Remodeling
ship and have no employees These sub-contractors have 3. ❑ Demolition
working for me in any capacity. workers' comp, insurance. y, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑ Other __
Ury applicant that checks box 41 must also till out the section below showing their workers'compensation policy information.
y llomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached un additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am an employer drat is providing workers'compensation insurance for my emphryees. Below is the policy and job site
in%ormalion.
Insurance Company Name:---- _ _----- —__-- --- ---
Policy 't or Self-ins. Lic. `!!: --__ — _ Expiration Date:__________
Job
ate:—____— __—
Job Site Address:, City:State/Zip: _ — —
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of`vlGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 tine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
1 rhe hereby certify under ns and penalties of perjury that the iglimmation provided above is true and correct.
tii;_n:thtre: _ Hate: ���V 04 _--
l'Iu,nr _moo 3
ffllicial use only. Do nw write in this area, to bei cnrnpleted h),ei(y or too wi of ficial.
City or Tnwn: :Pa:rmtt/License#_
Issuing,authority(circle one):
I. Board of Health 2. Building Department 3.City/To%n Clerk 4. Electrical inspector S. f lumbing Inspector
6.Other
C+)ntact Person: Phone#:
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- Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
�E= Registration: 113566
Expiration: 6/28/2007
Type: Individual
ROGER C.DUSSAULT
ROGER DUSSAULT
86 OAKCREST LN
GILMANTON, NH 03237 Deputy Administrator
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' .__ .. .<.x.ss sw .� ,. {k r..n a« gf;��:*�-wx.:a�_iz�,.. Y , §$�'.,su.�,k.T..:,a,.[u.�a A>.t��.•,A .« ,R.r:l' F.[$re 6
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BOARD OF BUILDING REGULATIONS
k License: CONSTRUCTION SUPERVISOR
Number: CS 046532
i
Birthdate: 08/10/1960
Expires: 08/10/2007 Tr.no: 27241 ,
Restricted: 00 i
ROGER C DUSSAULT
86 OAKCREST LN C
GILMANTON, NH 03237
Commissioner
Roger Dussault
General Contractor
86 Oakcrest Ln.
Gilmanton NH. 03237
603-267-1786
603-7704035 Mobile
June 19, 2006
Frank&Heather Rowe
11 Dana St
No. Andover Ma. 01845
978-687-2228
Contract
Project address: Same as above.
Remove existing basement stairway in kitchen
Remove existing kitchen wall (non-supporting)
Frame existing basement hole and install new plywood underlayment.
Cut hole in bedroom floor to relocate new basement hole.
Build new wall on right side
Install new blueboard and plaster.
Install existing basement door
Relocate existing bedroom door
The total for materials for the above stated work is$4200.00
Repair cracks in existing kitchen ceiling.
The total for materials and labor for the above stated work is$600.00
Remove wall between dining room and living room, leaving 9" returns on right and left side..(non-
supporting wall)
Repair and plaster ceiling where patched.
The total for the above stated work is$1000.00
Remove existing decking on right side entrance porch and replace with new Trex decking. (Gray
in color)
The total for the above stated work is$900.00
No painting or priming is included in this contract
Anything not stated is not included.
The total of all work as stated is$6700.00
Payments are to be made as follows: one third upon acceptance,one third when
framed.Balance upon completion.
Work to be started on or about 6/21/06.Work to be completed by 8/1/06
Roger Dussault
Authorized Signatur
Date�C.f l7c---
