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Home My WebLink AboutBuilding Permit #573 - 29 ROSEDALE AVENUE 4/30/2009 r10 BUILDING PERMIT Ot rARTM o t TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION « i r Permit NO: _ Date Received °°""' A 'pAO V 7 RATeD �SSACH�1`�� Date Issued: '� IMPORTANT: ( Applicant must complete all items on this page LOCATION 7C (—/-f t�1 d J f✓t_ Print PROPERTY OWNER_.,D I`Zt 0 N /- ,a)N Ci--- Print MAP NO: PARCEL: I l ZONING DISTRICT: Historic District yes no ( Machine Shop Village yes no 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 DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) e OWNER: Name: ,�C';�t�N �/1 G- Phone: Address: O2 �� m � ��L-5:' tc--)v f CONTRACTOR Name`/ OO r% f G- T)* C- Phone: ,-7 6 Address: %3 m V`- 1-,-k i+u E14 Supervisor's Construction License: L16 6 3 G Exp. Date: Home Improvement Licensed ` " Exp. Date: ` 9,0t u 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: $ � D FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ccess the :Vrantj fund Signature of Agent/Owner Signature of contract 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE 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 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 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location / No. Date 05 NaRTM TOWN .OF NORTH ANDOVER Oi' � e :o,q•C 41 ' Certificate of Occupancy $ Building/Frame Permit Fee $ !L Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 5.,-- � �, / Building Inspector �ORT#q 0 0 t .. over 0 No. *S?v dover, Mass., ' 0 �All �. COCMICMEWICK 7d ADRATE D P'P�` �� S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR 00 THIS CERTIFIES THAT........ �..��..........!!1..........1 ......................................................................................... Foundation has permission to erect........................................ buildings on ...........471....... �a�i.��...�� Rough to be occupied as...... . �' .... . . .... ...... . .. .....VMW Chimney provided that the person accepting this permit shall in evespect 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 I 400, PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place o'n the Premises — Do Not Remove Final No Lathing or D' ! wall To Be Done FIRE DEPARTMENT Until Inspected and Approve&by�the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. RAYMOND E. DAMPHOUSSE, JR. AND SONS ROOFING CO., IHC. ik BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 ut/ C) G S SUPERVISOR LIC. #046636 TEL: (978) 683-4588 HOME IMPROVEMENT C� '7. REG. #101862 ROOFING — SIDING — INSULATION Date From:,/ (Name) (Address) TO: BATMID L NAMOVSK, n. AD SONS ROOM CO., MC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 1 (we) hereby authorize the Contractor to furnish all materials a labor necessary to install, construct and place the Improvements described below in-on building located at No. Street, /City r, / ! !t J ' ��' State ' �" t r in accordance with the following specifications: f_�� .r, >7 ' !. J. �'Z f.J • r, .% � x� � �. '/-, J r J '�/, �fg f+r. �" ��,. /1 Z. .:i! , r/ 1 r i 't - r ) F r t' I ^r'll / t. rrr' [✓r �� 7, Co. , r All of the above work to be done in a good and workmanlike manner. ( si/I r' 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 . ... . . . .. ': DOWN PAYMENT IN CASH . .. . .. .. .. . .. o /G C`r< DEFERRED BALANCE UPON COMPLETION . . . .. . . . . . . . . . . . . . _ G S C-7a The undersigned agrees to keep property mentioned in this agreement properly Insured against Ioss,76 ,fife including the Contractor's interest therein. ,. This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance V r 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 seals) the day and year written above. Accepted By Husband RAYMOND E. DAMPHOUSSE,JR.AND SONS Wife ROOFING CO.,INC. Mail Address -`f (If different from above) 61�. ( ipnstu a and Title of Official) The Commonwealth of Massachusetts k- 1 Department of Industrial Accidents • Office of Investigations 600 N�ashington Street Boston, M4 02111 j www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizafion/Individui l} -/ U ��'—�L• Ad&ess: �I( ?c2 City/,State/Zip: 12 Zig t'k hone Are you an employer?Chec e appropriate box: Type of project(required): a employer with 4, ❑ 1 am a general contractor and I employees an or part-time .* have hired the sub-contractors 6. ❑New construction 2.❑ I am.asole er_ listed an the attached sheet x �• ❑Remo ship and have no employees These sub-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9, ❑ Building addition 10.❑Electrical required.) officers have exercised their repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself. [No•workers'comp. c, 152, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs comp. insurance req ired.] *Any applicant that checks bock I must also fUl out the section below showing their workers'6ompensatic6 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 shit showing the name of the sub-contractors and their workets'comp. Foa1ici tnfornration. I an an employer that is pmvidtng:workers'compensation insurance for my employees, Below is the policy informaa�td job site tion. Insurance Company Name: ' .a//EC4—,&I Policy#or Self-ins.Lie.#:��yi3 —(� f;3 x ��{—o Expiration Date Job Site Site Address cX, > &'IE�3A LE l'i City/State/Zip: N • r-q",�bL ' /c MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d9t4 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 her c under t e pains nd penalties of perjury that the information provided above is true and correct Si tore: r Date: Phone#: 6 ,� L ficial use only. Do not write in this area,to be completed by city or town.official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. 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 ormore 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 numberlisted 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. #617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia A, THIS IS A QUOTE , NOT A POLICY TRAVELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 POLICY NUMBER: (6KUB-663X466-A-08) -RENEWAL OF (6KUB-663X466-A-07) 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 01844 POLICY PERIOD FROM: 08-22-08 TO 08-22-09 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 17008 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 318 TERRORISM 56 TOTAL ESTIMATED PREMIUM 17382 TAXES AND SURCHARGES 935 DEPOSIT AMOUNT DUE 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 �e i�arrvrn°'recuea,�C�•�`� o'c�uaetla . Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101862 Tr# 267825 ' Expirati0n -612912010 Corporation oration + Type; Private P i RAYMOND E.DAMPHOUSSE JR;&SONS Raymond Damphousse,Jr. , 75 Butternut Lane Administrator Methuen,MA 01844 tom, �he 22 .tions and Standards oard of Building Reg isor License ;onstruction SU GS 46636 License, CS ate: 61211948 Tr# 14024 Bi�hd. EXplration: 61212009 Restriction 1G DPW JR.�,�-' OND E DAM RA LANE BUTTERNUT Commissioner METHUEN,MA 01844 r