HomeMy WebLinkAboutBuilding Permit #649 - 215 FOREST STREET 5/28/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: (a Date Received
Date Issued:
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I IMPORTANT: Applicant MUSt complete all items on this pace I
LOCATIONS-6�(
Print
PROPERTY OWNER H, -r -Ce- &�
Jc!, ( -q '7 4 Print
MAP NO: PARCEL ZONING DISTRICT: Historic District yesn
0
Machine Shop Villaae ves Kno
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
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer ,
I
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address: Q/
L/
CONTRACTOR Name: ?-oo r* c, co Phone: VJ--F �7-
Address:-�/ t, I
Supervisor's Construction License: 04ZQ"'C -3C_IExp. Date:
o
Home Improvement License: Exp. Date: -
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 Cost: $ el -N 0 FEE: $
Check No.: S-�� Receipt No.: oaod )
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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Signature ofAgent/Owner Signature of contractor
LocationAr I—w17,e:47— ST—
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Ss. Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check# Iti !:;r
22U6j
Building Inspector
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
. COMMENTS
H EAL7 H
3
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed on - Siqnature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Sewer Connection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signature:
t_ocatea su4 us ooa Street
FERE 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 ori 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
Doc.Building Permit Revised 2008
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
❑ 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
Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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RAYMOND E. DAMP80QSSE, JR. AND SONS
ROOFING CO., INC.
SOX 431 LAWRENCE P.O.
MA. CONSTRUCTION LAWRENCE, MA 01841
SUPERVISOR LIC. *046696 TEL:(978) 683-4588
HOME IMPROVEMENT
REG. #101862 ROOFING — SIDING — INSULATION
From:
Date
(Nanta) IAden.i)
To: RAir8101 E 1AN7111M A. All UNS 111M9 CO., INC., SOX 121 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01012
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.
City
State
Street,
In accordance with the following specifications:
ditional cost. A new 8" clear or white aluminum drip edge applied on all edges. Approx. _6fl-of ice and wate.
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 32 r Cambridge architechual or standard roof shingle installed. Install
new vent pipe boot flashings. Waterproof existing chimney as >_ng and remove debris.
Optional Products f _f>,-, K=. Roof Over ?
Shingle Ridge Vent , ; . x f 1 Existing Roof
All of the above work to be done In a good and workman -like manna. Cr
All men and equipment Insured. Promises 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 .... , . , ... i� �: `a -1
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 lees and Court Costs It 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 contrac(.
Said contractor shall not be responsible for damage or delay due to strikes, fires, accidents, or other causes beyond his
reasonable control.
We, the undaslgned, certify that we are the sole owners o1 the properly herein described on which sold work of repalre are
to be performed.
IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (their) hand(s) and sesl(e) the day and year written above.
Accepted By/` u�--i{usb d
t
1
RAYMOND E. DAMPHOUSSE, JR. AND SONS
ROQFINO CO., INC,
W f
(SlQnalura araC Ulla $1 OII,GaII
Wife
Mall Address
(If 01416011 from above)
TRAVELERSJW
INSURED'S NAME AND ADDRESS
RAYMOND DAMPHOUSSE & SONS
ROOFING CO INC
75 BUTTERNUT LANE
ME THUE N MA 01 844
THIS IS:A QUOTE, NOT A POLICY
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
QUOTE PROFILE — VERSION 01
POLICY NUMBER: (6KUB-663X466-A-08)
RENEWAL OF (6KUB-663X466-A-07)
WORKERS COMPENSATION
INSURANCE PLAN
A/R (WCIP) # MA
POLICY PERIOD FROM: 08-22-08 TO 08-22-09
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $
PREMIUM DISCOUNT
0900-20 EXPENSE CONSTANT
TERRORISM
TOTAL ESTIMATED PREMIUM
TAXES AND SURCHARGES
DEPOSIT AMOUNT DUE
17008
NONE
318
56
17382
935
18317
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: $ 18317 ***************************
POLICY NUMBER: (6KUB-663X466-A-08)
DATE OF ISSUE: 06-27-08 WC ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: INTERNET INSURANCE AGCY 753XF
..l` sa
1
ii «6e
The Commoynrnealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 NrashhTton Street
Boston, MA 02111
c ' www nwss.gov1&a .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectriciaas/Plumbers
iicant Inform2tinn
NaMe (Business/Orpwiration/Individual):
•r'SOr`( J %o r n r, C
Address:�,j C -, C ' r
7�
_kone
Are you an employer? Cheelt.the appropriate box: --
I. ❑ I aro a em to er with 4. Type of praject (required):
P Y [] I am $. general contractor and I
employees (fun and/or part-time).* have hired the sub -contractors 6. Q New construction .
2. ❑ I am a.sole proprietor or partner. listed on the attached sheet. 2 7• Q Remodeling
ship and have no employees' These sub -contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance.
�Tio workers comp, insurance 5. 9. Q Building addition
p ❑ We are a corporation and its
required] officers have exercised their 10•❑ Electrical repairs or additions
3. Q I ani a homeowner doing all work right of exemption per MGL 11.7 Plumb -
myself [No•workers' comp, r-152, § 1(4), and we have no
12.
insurance required.] t .employees. [NO workers'nParrs
COMP. insurance rewired..) Eur/ j� c;
`Any eppiiearrt filet checks boy' $ I must also fi[! out the section below showing their workers' compensation policy information
t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indiceiios such
$Corrtracton that check this box musta7ached sn additiaaa) short showing. the name of the sub -contractors and their worimrs' cern „ '
r Fc•tis mfnrtnatioa.
! ar• an er-floyer teat is prorrding workers' rnmpensaden insurance for cry employees: Below is the policy mad job site
it formatiom ;
Insurance Company Name: 1-;:,/ 10" Z !'
Policy # or Self -ins. Lic. #:/e
Expiration Date:
Job Site Address:
r
,2LCity/Staie/Zip: N. Ti1�7a vc
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date}.
Failure to secure coverage as required tinder 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 anti 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.
! do her .%Y under p nd penalties of perjury that the information provided above is true and cotes
Si tree: r'
Date: G
Phone #:
Of,)°kill use Only. Do trot write in this area, to be completed by ci y or town otr
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector
6. Other S. Plumbing Inspector
Contact Person: Phone #:
O
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