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HomeMy WebLinkAboutBuilding Permit #61 - 33 MOUNT VERNON STREET 7/20/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: !Z Date Received Date Issued: -7 -2,bL-01 IMPORTANT: Applicant must complete all items on this page LOCATION 3U.' Print' PROPERTY OW NER 1 �P/ Print MAP NO: PARCEL: 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. Others: Repair eplacemen_ Assessory Bldg Demoli ion Other SeptiC Well Floodplain Wetlands Watershed District Water/Sewer ur-0L*Kir i IVN Ur VVUKK I U t5h PKEFURMED' ; C", r 14 .r7 -A lr!� a i -4C -P -,s Identification ease Type or Print Clearly) OWNER: Name: Phone: Address: .3 s N�� (/ e f� .�-/ �� /_fa .a r c t 6a i2. -f-S a res CONTRACTOR Name: s c C Phone: 7, is Address:'.. / Supervisor's Construction License: Exp. Date: Home Improvemen# License: Exp, Date: ti ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 4 FEE: $ Check No.: Receipt No.: a D3 S NOTE: Persons coWrqcd# w' registered contractors do not have aeFRrivqhe/�ranty fund Siqnature of Plans Submitted IPlans 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 r 4 'oning 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: LOcatea s64 VS ooa Street FIRE DEPARTMENT'Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature%late 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-$1-000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2009 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 Li 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) o 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: Building Permit Revised 2008 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: We Commercial. Repair eplacement �+ Assessory Bldg Others: r— Demolition OtherVe5 GzJ"1,&,v Septic Well Floodplain Wetlands Watershed District Water/Sewer C DESCRIPTION OF WORK TO BE PREFORMED•( lif–, CG/-;-) C ( - --4JAL.L d �% '2 � � � � � �, l' �' %� , /T it' (� � S' �"f�/7 �i- �--� U -G t "��-' fi-S Q �ici •�--- Identification rLease Type or Print Clearly) OWNER: Name: �.A L'�,�s Q v2G Phone: Address: �3' ,3 s �i'i r/ �`� �- �� ;�a ✓2 rte/ -t-• CONTRACTOR Name: 20 G .,s rt C Phone: % 0/-F2- z1 Address; U "1 1r '' y j. Supervisor's Construction License: .> Exp. Date: Home Improvement License: o % Exp. Date;_ / o 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: FEE: $ Check No.: Receipt No.: �% NOTE: Persons contra w�f"u3 egistered contractors do not have a ,\thgguganty fund of Agent/Owner 7i Signature of contractor- �- �� Location AhZ- 1,41A�0;57 No. Date 2'Z. t0MT#t TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# 9— M5� Y 222%,,15 Building Inspector N m x m C m y m y v m C CO) CD CO) Z E O wa r - W C. a� o p CL c =� CD O 3: 1= co CD H CD O _0 y d O CO) O COD Ma CDO rF CD 3 C� CO) 0 O rF CD O CD I cn V / n O z cn C 0 C .C. - d dy O m y y m !09 Cl) C6 d m = SES CA to a, =rm o .. ? m n _lorrC y c o m O • m a a y O < d Z O mr aCA a c CD ? O m y 1 O O CO d y CL M �C 11 O y y a y 'O aCD o� . w. o � ®a r tea: m ^. ?. m: � m a� ® y d� O_ Ii O d d O.� C-3: a C O ' fel a m Bo fD n 2 za- OGQ co 0 E. o pip Cl7 HH M z o 9 a' M W �? w n � 7d G o C pr•,� b n (`YD o O �' o I� 07d omi 0 RAYMOND E. DAMPR00SSE, JR. AND SONS HOOFING CO., INC. BOX 131 LAWRENCE P.O.' MA. CONSTRUCTION LAWRENCE, MA 01812 SUPERVISOR LIC. #8046636 TEL: (978) 683-4588 HOME IMPROVEMENT ' REG. #101862 ROOFING — SIDING — INSULATION Dale From. r,, l- v r _ IN.m.I IAddru.) To: IATrID E IAN7111iilt, A A4 MIS 111FaC CO., INC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 "w" I (we) hereby authorize the Contractor to furnish all materials and labor necessary to Install, construct and place the Improvements descrlbed below In -on building located at No. ..... �- - ` " `�- f � ` Street, City . a s;;" r :J `_,� _ Slate `` 1 r ,� r > In accordance with the following specl(Icatlons: We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathingat_ ad- ditional cost. A new 8" clear or white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junc- tions. A new base sheet applied. A Iko 30yr Cambridge architechual or standard roof shingle installed. Install new vent pipe boot flashings. Waterproof existing chimney flashing and remove debris. /i 11 f- S.. .-: r'- ! L. C) S ...<- I ^f K.1 ♦ ::. E r. t V.. 1 .....e., % �( Roof Shingle Ridge Vent f Existing Roof / ; A6� '7 P i. _Soffit Vents J : ~ ` f' u.r .,' -<,: c_> v - ,4 ; ;z ;0 3 CH All of IM above work to be done In a Good and workman -like manner, All men and equipment Insured.-Promlaea to be loll clean upon completion of work. C_ J��Z% i't For the total sum of dollars. fc-1- ` Entire Sum to be paid Immediately upon completion In accordance with plan as shown below. TOTAL CASH SELLING PRICE ..... , , . DOWN PAYMENT IN CASH , .. .... , . , DEFERRED BALANCE UPON COMPLETION ..... F -D 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 sold Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promisee 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 10 pay ■ reasonable sum as attorney's tees 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 h rein named as liquidated damages for breach of contract. Said contractor shall not be responsible for damage or delay us to strikes, (free, accidents, or other causes beyond his reasonable control. We, the undersigned, certify that we are the sole owners of th property herein described on which sold work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has lhave) hereunto t his (their) handle) and @sells) the day and year written above. Accepted By Husband ;YMOND,,E*,DAMPHO,CUS.3E , JR. AND SONS Wife ROOM O., INC. Mail Address III d11t.iM1 Iron .Dore u r Olhcnq � r Q x Lu .,.,(.) I/ ti cV c _G ..' . N w U IT C o Q .Q F F. N1LL, U O a " v N Uj Z (o06 Z" W0 LU O w i juj- >- m Go _Ja G ce ai �f c m M z co 2WVr Q F Za g J am' ' Qru Q x Lu .,.,(.) "T. _G L U H e w Z- a " v ami II Z" W0 LU O w .: O y >- m w _Ja G ce ai p .f U c m M O co 2WVr Q x Lu .,.,(.) "T. aZV- L U H e w Z- m ami II Z" W0 LU O w J y >- m ir ir ^ Z TRAVELERS 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 The Commonwealth of Massachitsetts Department of Industrial Accidents Office of Investigations 600 Washington Street _ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � �/ .L' - ,> �.�� }-40vJ t 0 -r S U K S �clo t`E G C 4 ��♦ Address: L- rt /State/Zip: N.A 01%Q'-1 Phone #: q Are you a ployer? Check the appropriate box: 1. am a employer with -�' 4. ❑ I am a general contractor and I employees - 11 a rTg -ii )•* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' insurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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. Contractors 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: l ; �e�1 t1 _� L `� •� -i` Policy # or Self -ins. Lic. #: b 13 ^ O 6 k G Expiration Date: F— ,2 a 0 q Job Site Address: / S C�� n� t —E(z City/State/Zip: iq Kt 0 o,,from 1✓(�4 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 hereff cer c ander >Ne pair and penaltiesoperjury that the information provided above is true and correct. Signature: % Date: Phone Official 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: