HomeMy WebLinkAboutBuilding Permit #288 - 22 MAPLE AVENUE 10/18/2005 r- TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A,ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER. � B � DATE ISSUED:
SIGNATURE:
Building Commissioner/lEyector of Buildings Date
SECTION 1-SITE INFORMATION z
1.1 Property
/Address:
1.2 Assessors M�d Parcel umber: �o
.0^ D�
Map Number Parcel Number
��. � >`1.7 a ✓�2
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided R aired Provided
1.7 Water Supply M.G.L.C.Q.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print* Address for Service:
z
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
?',,A,,4 rll 6M r7 AI" o Js 1 E �/
Licensed Construction Supervisor: ��/ ��� G
�f, ,-� U�&2 N 11� M /�t7K v-El4 Licen a Number
/ - 1-�
Address
—3 7—r, Expiration Date mmmmma�
g a Telephone
3.2 Registered Home Improvement Contractor Not Applicable 0
ZlYvlu
IV,:)
Company Name J D /
tom—E2 Registration Number
1 tJ_1 C Ill K��I^� �
Address
° G z
q-7 4S Expiration Date
Si natu Telephone
f
SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......
SECTION 5 Description of Proposed Work check ail applicable)
New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations( Addition 0
fi
Accessory Bldg. 0 Demo ttion" ❑ Other 0 Specify
Brief Description of Proposed Work:
2ca F
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be {1
Completed by permit a licant
1. Building (a) Building Permit Fee
rCf p
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(al x(b)
4 Mechanical HVAC
5 Fire Protection '
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I> A���'►7 a Al.1 I —T� as Owner/Authorized Agent of subject property
v
Hereby authorize to act on
My behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
r9'Y1't i I dU ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge _r
and belief -�
Print Na
G2•G
Si ature of O er/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1sT 2 3
PD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
RAYMOND E. DAMPNOUSSE, JR. AND SONS
ROOFING CO., INC.
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 _ co,`1
From:
(Name) (Address)
To: 1ATKID L BAWNIUM n. ANL! SONS 1I0EOIC CO., INC., 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. 9 C�''�'-'�4, Street,
/
City -/ ^J•,;) d State 122 `q P in accordance with the following specifications:
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V+ ri`r 1 r = icrr� �� d' 'R-`J !•ai'f,> �.�'�� r; .
All of the above work to be done in a good and workmanlike 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 . ... . . . ... t S
DOWN PAYMENT IN CASH . . . . . . . . . . . . .
DEFERRED BALANCE �Jzn, c�rf
UPON COMPLETION . . . . . . . . . . . . . . . . . . t
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.
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnuestigations
-- 600 Washington Street, 7`h Floor
Boston,Mass. 02111
4, Workers'Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors
1Pulticant:lnforrrlatiob. . .s.?._ .; .� 'Iease Pit.,,.. :leeibly� W •' :, '
name:
address:
City state: zip: phone#
work site location(full address):
❑ I am a sole pr
er pe and ing all work myself. Project Type. ❑New Construction❑Remodel
I m a homeowner erfo
❑ p� g' any capacity. ❑Building Addition
m an employer providing workers compensation
have no one working m
for my employees working on this fob
company'name: KV M H"'d v#Sr "1
pl address:
city'. /'9 +G-r"y W Al plione# `
insurance cow pohcy# L '
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices
comnariy.name'.' 5.
;address.
city'
phone# J
I`
insurance ro..
pohcy
rcompany_name
.address.
city' phone*:
insurance co. policy'# _
_ a
�Aftachadditiopall'sheetifaechssary �
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
Ido hereby certify under the pains and pen Ities ofperjury that the information provided above is true and correct.
Signature Date / d�
1100,
Print name "I M d rri H to 1UXS E Phone# � 0 F'
official use only do not write in this area to be completed by city or town official
x
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
Lcontaer"on
: phone#; []Other
.2003)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",an employee is defined as every person in the service of another under any
contract of hire or express implied,oral or written.
P P
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 employer,representatives of a deceased er or the receiver
P P Y
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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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,7th Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
4
��.,e ✓1ze �orrurrao�rir.��eall� o��7�`icJJac�ivanita
` Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101862
Expiration: 6/29/2006
Type: Private Corporation
i
RAYMOND E.DAMPHOUSSE,JR.&SONS
Raymond Damphousse,Jr.
75 Butternut Lane � ,� .
Methuen,MA 01844 Administrator t
r
, �. _icense: CONSTRUCTION SUPERVISOR
Number: CS 046636 P
,Birthdate: 06/02/1948
Expires:06/02/N07 Tr. no: 11748
Restricted: 1G '
RAYMOND E DAMPHOUSSE JR
75 BUTTERNUT LANE.
METHUEN, MA 01844,
Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
; Boston, MA 02111
'y! www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): "( t`k
Address: ( o-r— L., til
City/State/Zip: M-z-L R j` ,.t ryx A Phone #: CIL T% (-. -63 LAS r$
Are you employer?Check the appropriate box: Type of project(required):
1.Qa employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees ul d/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. * Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
• officers have exercised their 10.❑ Electrical repairs or additions
required.] o
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 P I u!i!n!Ob4trepairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12. oof repairs
insurance required.] t employees. [No workers' 131-1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also till 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.
*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 my employees. Below is the policy and job site
information.
Insurance Company Name:`
Policy#or Self-ins. Lic. #:_6 K o iS "�•OSExpiration Date: 2 '..2_2'--0
v� Gi IF lis
Job Site Address: o�v� /'�� G-E J�i City/State/Zip: AJ o x4 1H 0(n 64- V,1 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 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 DIA for insurance coverage verification.
Ido liereh cer ' and ns and penalties of perjury that the information provided above is true and correct.
Si nature: Date: 61e q0
1 F`
Phone#: 9 a 2
Official use only. Do not write in this area,to be completed by city or town official.
I
City or Town: Permit/License# f
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
t
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 tilled 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 burn 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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Location '"'
No. a Date
�oRTM TOWN OF NORTH ANDOVER
..y,pf�•. n ,x'1,6
� s
` Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # _.
18683
G "--86ilding Inspe
r