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HomeMy WebLinkAboutBuilding Permit #413 - 147 SUTTON HILL ROAD 12/13/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION of"°aT`�� , o Permit NO: / Date Received —13 Date Issued: _0 ��s"�r•v•r°�q°� S�CHUS� IMPORTANT:Applicant must complete all items on this page LOCATION /�z Print PROPERTY OWNER A� Print MAP NO.:---L/)- PARCEL: 512, ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Reside% ' Non- Residential ❑New Building 3,erne family ❑ Addition ❑Two or more'family ❑ Industrial ❑ Alte tion No. of units: epair, replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving relocation ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED ��en 0a E / LAY E-A- S r-( G-L-,-cS dry J rP47�z �A K t�v� Q Identification Please Type or Print Clearly) OWNER: Name: A_f i5_777y Z_ Phone: Address: / Y7 CONTRACTOR Name: Y DA vA i�-Ecus Sa-—Z L.f Phone: 9 2"Y ;I F13 q 47 � Address: /3 ,T' 2 C./ `f' Supervisor's Construction License: -4166'2 C Exp. Date: Home Improvement License: �G / O6 -,k Exp. Date: (N ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.SI2.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ / C)U - �� —FEES Lll5r--- Check No.: / Receipt No.: Page I of 4 - r TYPE OF SEWERAGE DISPOSAL j E] Swimming Pools ElTanning/Massage/Body Art Public Sewer ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. F] Electric Meter location to project i NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 ❑ ❑ I COMMENTS DATE REJECTED DATE APPROVED 'i CONSERVATION ❑ ❑ i COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS 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 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Require Provided I Dimension Number of Stories:Total square feet of floor area, based on Exterior dimensions. i Total land area, sq. ft.: i NOTES and DATA— For department use i Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created IMC.Jan.2006 e 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 i ❑ 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 �I 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 co and roof of re copy p cording must be submitted with the building application i Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 NORTH '9 TONM Of tAndover 41/3 C o L �` dover, Mass..�a ' /zap LA COCHICKEWICK V ADRATED C7 `r E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System � BUILDING INSPECTOR THISCERTIFIES THAT....... . ..�,.��M!l�r..�............ .f��.. .... .............. ............. . ....................... Foundation has permission to erect....................................... uildings on .../Y.96........ h... .,�..... .............. Rough • to be occupied as...� ........r.... �� ....................................................... Chimney . . . . . .. . . .. . . . . . .. provided that the perso ac eg this permit shall in eve sped co orm t e terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Ins ection, 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 NTHS ELECTRICAL INSPECTOR UNLESS CONSTR ONRough .. .............. .. ............ ..................... ........... 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I ' RAYMOND E. DAMPHOOSSE, Be AND SONS R00FMG CO.,, We BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR LIC. #046636 TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING - SIDING - INSULATION r Date .: From: .} r ,r (Name) ��✓ (Addreee) TO: UTWE E IAB3'BIM A. AD SANS IOOFN CO., MC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 1 (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. ! ,� �' Street, City r/ 1 1 ., ,' ') -; U�, r State ( I In accordance with the following specifications: 7 r 7 All of the above work to be done In a good and workman-like manner. All men and equipment Insured. Premises to be left clean upon completion of work. For the total sum of dollars. Entire Sum to be paid Immediately upon completion In accordance with plan as shown below. TOTAL CASH SELLING PRICE . ... . . f. , DOWN PAYMENT IN CASH . . . . .. .. .. .. . DEFERRED BALANCE UPON COMPLETION . .. .. ... . . . . . . . . . . The undersigned agrees to keep property mentioned in this agreement properly Insured against 1033 by fire including the Contractor's interest therein. This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promises or agreements, written or oral except as herein set forth. It Is the Intention of the parties hereto that this contract shall be binding upon their respective heirs,executors, administrators, successors and assigns. Customer agrees to pay a 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 after 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. Said contractor shall not be responsible for damage or delay due to strikes, fires, accidents, or other causes beyond his reasonable control. We, the undersigned, certify that we are the sole owners of the property herein described on which said work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has(have) hereunto set his(their) hand(s) and seal(s) the day and year written above. Accepted By Husband lea�"ftA4% 7 YMOND DAMPHOUSSE,JR.AND SONS Wife RO FING CO.,INC. Mail Addreaa (Signatur title of difioi pt different from above) ✓fte L�ammon�ueeyld o�vtrat�sacY%�i.Jel�a - _ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101862 y Expiration: 6/29/2008 Type: PrivateCorporatidn RAYMOND E.DAMPHOUSSE,JR.&SONS Raymond Damphousse,Jr. 75 Butternut Lane 4?ylethuen,MA 01844 Deputy Administral� "" _Icenss: CONSTRUCTION SUPERVISOR t Number: CS 046636 _ 1 ' �BlrthdtiAa:..t75102M,948 i .. Expp :` t3A�f17, Tr.no: 11748 i Resfrittk�f;tG :-:� RAYMOND E DAMPHO3USSE 75 BUTTERNUT LANE. C- METHUEN, MA 01844' ,' Commissioner t ,Y TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-663X466-A-06) RENEWAL OF (6KUB-663X466-A-05) INSURER: THE TRAVELERS INDEMNITY COMPANY , 1. NCCI CO CODE: 11347 INSURED: PRODUCER: ,:,. RAYMOND DAMPHOUSSE & SONS INTERNET INSURANCE AGCY r« ROOFING CO INC 522 CHICKERING RD 75 BUTTERNUT LANE NORTH ANDOVER MA 01845 ME THUE N MA 01844 a< Insured IS A CORPORATION Other work places and Identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-22-06 to 08-22-07 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA m� m= B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in o— item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Or= Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A o. _ D. This policy includes these endorsements and schedules: o= SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating LL� Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 08-16-06 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: INTERNET INSURANCE AGCY 753XF 000386 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street � r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Dt rvN t-"t4o v C Address:'Sr v r�"T".�,2�t ,•i City/State/Zip: �14AI�5 ^l 111A o t 9-V y Phone#: ��0, Areyou a ployer?Check the appropriate box: Type of project(required): 1. am a employer with c�L, 4. ❑ I am a general contractor and I employees<��u�a d/ _part-time have hired the sub-contractors 6. F]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working far me in any capacity. employees and have workers' co insurance.$ 9. E] Building addition [No workers' comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.U;:m*f repairs or additions myself. [No workers' comp. right of exemption per MGL 12. of repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: (1%3 — G16 ^/-I-0 G Expiration Date: a Job Site Address: 11"i-e— ,2,7 City/State/Zip: /1/fINOD./fit 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb un the p 'ns and penalties of perjury that the information provided above is true and correct. Si ature: �u Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 defined 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-contractor(s)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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia T UESTIONNAIRE 1. a-i-n f 2. Streit Address Ni 3. Hwy.- rnany members are in your household? 4. tvpe, of sewage disposal. system do you have? Cs'�0-c f:eptl- tank and leaching area connection to municipal sewer .her (describe) no* know rc te plans (drawings) for your sewage disposal system on file with the Board of Health? 1 saes El no 0 do not know ow olc': is your sewage disposal system? 0 0-5 years El 6-10 years El 11-20 years over 20 years ❑ do not know our sewage disposal system been rebuilt or repaired? yes D no [N do not know le4; Tproximately how long ago? years. What was done? o�A7 frequently is your sewage disposal system pumped out? ❑ annually every 2-4 years El every 5-10 years El over 10 years El never ave you had any problems with your sewage disposal system? El yes M no hat problems? ❑ repeated pump-outs needed El system clogs, backs up, or drains slowly 0 odors EJ sewage surfaces through ground Yriany of each appliance are connected to your sewage disposal system? garbage disposal machine dishwasher n humidifier drain SUMF;�utnp toilet 3 of/pavement drains shower/bathtub e st,-,to the'brand and type (liq6id or powder) of detergent you use for: -asir rwi ier kl>V'_ you property have a lawn? yes El no zp,-roximately what size? ess Clan 1/4 acre EI/4 acre E 2 acre E34 acre E 1 acre more than 1 acre (Specify) - acres often, do you fertilize your lawn? f al --Iications per year n(s)'of the year state the brand and type (liquid or granular) of lawn fertilizer you use: C ck here if your lawn is maintained by a professional landscape contractor.