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HomeMy WebLinkAboutBuilding Permit #530 - 1592 SALEM STREET 3/18/2008 40RT)l BUILDING PERMIT .Of TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION * ,� z ^e Permit NO: �✓ Date Received ��SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page g ��x-�---xy � Ml Ar.,y rr `rnfat . 21 b - 1 lA ANO P RCE _� 3 ING JSMR,10 `r 4tonc. V as#rtcf ©, �*1 e ice. r �^ �'yri � „� 3 ` - ' •- � _� , - Japl �rloplllaes r� ; 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 VIP `,F°` t� 8° rte- 4+ "§ ',ya` €- -- s c ag e ca 'a� ftl eptic= ll� } , Eloo aar1ards' _ Ue�ersled DESCRIPTION OF WORK TO BE PREFORMED: Wov 5 '� �. �TA �� 4/-t �_,!t✓��. t3< —�- ` /2���^teams Identification Please Type or Print Clearly) OWNER: Name: r Phone: Address: � � �t S'� lel r9�r Bfc/t— a. �" CD3R1T0# �atneA .. taone� Address �kY '�"` ' s i � a+ ; S� erarisor Ct3r�strt�c �onLJcer�se lorelnproi�eri�i�tceaase � w . � ,. .Ex ,u 'Date z .� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cos�1t: $ �a � 97-- FEE: $ Check No.: �Y I Receipt No.: a� lel NOTE: Persons contracting with unregistered contractors do not ha access o e gu ran nd i 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 I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS IIS DATE REJECTED DATE APPROVED HEALTH M1 COMMENTS Zdoing 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 Located at 384 Osgood Street FARE EPA TII�I'E'J�ITg fiemP R.- on site yee f fFOK o *v,: "1_+,.WS."g, `�,- , s`•a`r¢rt; t,., ..:-*�. ->. '77 -a t .mak`:4 st ^ -'+ =LOCatedat'12IIa�n Scree#} ` c a * aa: sr •, f:.` .. x Firee a ent � nt� e/date w 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.$100-$1000 fine NOTES and DATA-(For department use ❑ Notified for pickup - Date I Doc.Building Permit Revised 2007 �I �I 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 ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application L3 Certified 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) ❑ Engineering Affidavits for Engineered products NOTE: 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 ❑ 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 ❑ 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 i Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. Date NORTH TOWN OF NORTH ANDOVER t Certificate of Occupancy $ o J # CMUsE<� Building/Frame Permit Fee $ . Foundation Permit Fee $ Other Permit Fee $ TOTAL $ :k Check # �Y ;9 209 ' ''Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass.gov/dia Workers'. Compensation Insurance Affidavit: Euilders/Contractors/Electricans/Plumbers A Iicant Information Please Print Le 'bl Name(Business/Organization/Individual): � v N� �_ Ve*wl rIN 0 V 1 ms's S t`t J ;K Address:_f %C '/R City/State/Zip: © r.�i �l�/ Phone.#: Q/ 9T 6�3y� T Are ayou employer? Check the appropriate box: L am a employer with ' 4. I am a general co Type of project(required). �-�- g contract❑ and I t employed/Qe)* have hired the sub-contractors 6 New construction 2.❑ I am a so netor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g, [:]'Demolition working forme in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9• ❑Building addition , required.] 5. (] We are a corporation and its 10.❑Electrical repairs or additions 3. ,their❑ I am a homeowner doing all work officers have exercised11. PI in repairs or additions myself. [No workers' comp. tight of exemption per MGL 12 oof repairs insurance required.]t c. 152 1(4), ep s § and we v q have no ] employees. [No.workers' 13.[] Other j1g U1 1&vj(:�' comp. insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeov hers who submit this affidavit indicating they are doing all work and th-en hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the narrme of the sub-contractors and state whether or not those entities have employees. If the sub-contractorshave employees,they must provide their workers'comp.policy number. I am,an employer that is providing workers'compensation information insurance for my employees. Below is the policy and job site Insurance Company Name: Z/ ,A Policy#or Self-ins.Lic.#: X U1'3-4 Expiration Date: Job Site Address: City/State/Zip: At �A ;his v£,Z M A 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 Investieations of the DIA for insurance coverage verification. I do hereby rd under the p penalties of perjury that the information provided above is true and c G �O � Si afore: � _ Date: Phone'#: Officuil.use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuinb 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." r 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"ever state or local licensing agency shall withhold the issuance or renewal of a Iicense or permit to,bpera°tera business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage I required." Additionally,MGL chapter 162,§25CO)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 maybe 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 perinit 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 callthe 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 sureto 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.#617-727-4300 ext.406 or 1-877 MASSAFE Fax # 617-727-7749 Revised 1122-06 www.mass-gov/dia NpRT#j Town of And No. S3 z _ == 3 • �F � o� ' LAK o dower, Mass., �. COC HIC ME WICK � ADRATED PC3 `s U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT.........0.... ... ....... .. .` .......................................... .......................... Foundation has permission to erect............... ........................ buildings on.. . . I ...... Rough to be occupied as..... /.. . �. ...................................................................................... Chimney provided that the personi�Z�'tl hg this permit shall in eve sped/ W conform to the terms 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 �d *saw PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU T TS ELECTRICAL INSPECTOR Rough ......... ..........................................::............ ..:.. Service BUILDING INSP' OR . Final Occupancy Permit Required to Omipy 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. THIS IS A QUOTE , NOT A POLICY TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 POLICY NUMBER: (6KUB-663X466-A-07) RENEWAL OF (6KUB-663X466-A-06) INSURED'S NAME AND ADDRESS WORKERS COMPENSATION RAYMOND DAMPHOUSSE & SONS INSURANCE PLAN ROOFING CO INC A/R (WCIP) # MA 75 BUTTERNUT LANE ME THUE N MA 01 844 POLICY PERIOD FROM: 08-22-07 TO 08-22-08 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 22351 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 284 TOTAL ESTIMATED PREMIUM 22686 TAXES AND SURCHARGES 9 DEPOSIT AMOUNT DUE 3622 I i Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: THE TRAVELERS INDEMNITY COMPANY Adjustments of Premiums shall be made ANNUALLY ******************************* Deposit Amount Due: $ 23622 POLICY NUMBER: (6KUB-663X466-A-07) DATE OF ISSUE:06-27-07 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 1 61 PRODUCER: INTERNET INSURANCE AGCY 753XF -- ,nortusect,�l� ding Regutatious and Sl:w+„ Pr:I klr.i d l Use onl tOVEMENT.CONTRACTOR +ti ie:'nrturn to: �r; 101862 it 30ari' dards (":e i'i z .u/2_9/2008 } hist", 3e Private Corporation 3SE;JR.&SON'S oe t - J1ie �anvnwm�aeai.o�✓�aaa«cfaccaella -oard of Building Regutations.and Standards :onstructi4nSupervisor License e: CS Licens 46636 Birtfadate 6/211948 Expiration 612/2009 Tr# 14t24 Restnc�on 1µG,�., RAYMOND E DAMPHOUSSE JR 75 BUTTERNUT LANE - METHUEN,MA,01844 Commissioner,,-. r RAYMOND E. DAWROUSSE, in. AND SONS ROOFING CO., IHC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR LIC. #046636 TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSULATION Date 2 _ 1 7 f' F From: /�rO%/i'r i�1 �� � !/��"''�'? j'i l�� �-1 f/17 a ✓ c'. .� (Name) (Address) TO: 1ATON1 L 1AMOVSK, J1. AND SONS ROOM CO., MC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 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. Ar 7.2 fes`? S7-- Street, City / 17 ✓'/L State in accordance with the following specifications: 4/ r.7 �',r_";" r"� ."i >� � ;r„t' -;�"' ,.,r' r`G -t %./� f '�F� ✓�`J�/-,.Y1.'� �.T/ _ lit, -,/ �-.._ f" r�!?JS /-r ..1Lf7. ri/�-1 r2/��cc .� � ��Ci J 15e r Y r 1 r rf !i r/�.'f��r_��r {'G `i f ((, /1 r� l :> "F't r) ✓ - All of the above work to be done in a good and workman-like manner.' '�� L ft3,2 r� ''� `"`� r.fc��Q 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 . . ... . . ... _ �0 DOWN PAYMENT IN CASH . .. . . . . .. . ... DEFERRED BALANCE �'✓� UPON COMPLETION . .. . . . . . . . . . . . . . . . The undersigned agrees to keep property mentioned in this agreement properly insured against loss 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 '�'� _ e RAYMOND E.DAMPHOUSSE,JR.AND SONS W,4Ia L�7YC.C1'(G/.� —� ROOFING CO.,INC. 1 Mail Address 7 (if different from above) J, / i-ISi9nat6@ an Tit le 1 Oi'ficiillrf�l' � .