HomeMy WebLinkAboutBuilding Permit #734 - 36 MOUNT VERNON STREET 6/25/2009BUILDING PERMIT
TOWN OF -NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date
IMPORTANT: Applicant must complete all items ori this naize
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TYPE OF IMPROVEMENT
PROPOSED USE
a
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
DESC7RIPTION OF WORK TO BE PREFORMED:
r i r --r ,c rs �, F 4 H I cwt G Lf s PI.P�� L L 3 O Y tZ ;7 K b
Identification Please Type or Print Clearly)
OWNER: Name:/7As2+�1��+ ��'�«; r-4_1 "—I otjtc rcff rZw- G-4 r,1 Phone: 4
Address:"'-� /'moi tf �� rr ear c s t. roc +� a ✓c �1:.
CONTRACTOR Name0 � � S �'';z't lb "OPhone: q7 Y Ci -7
Address:
Supervisor's Construction License: Exp. Date: "Z"'1a 1k.
Home Improvement License: //0 % _ Exp Date:e<-_ 9
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST B SED ON $125.00 PER S.F.
Total Project Cost: $ ��C3 � ° "� FEE: $
Check No. Receipt No.: C_)_�;L I '-(p
NOTE: Pers ns contracting with unregistered contractors do not hav access to a guaranty fund
Plans Submitted Plans Waived ICertified 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 i Reviewed on Signature
r
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 signatureldate
COM
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 2 1 A -F and G min.$100-$1000 fine
NU.I t5 and UA I A — (i -or 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
o.. 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 3� n
No. -? 3 Date
NORT1y TOWN OF NORTH AKYOVER
F 9
+ Certificate of Occupancy $
�' s'•^ tt� Building/Frame Permit Fee $
ncMus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # J�, `
22'156
Building Inspector
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TRAVELERS
INSURED'S NAME AND ADDRESS
RAYMOND DAMPHOUSSE & SONS
ROOFING CO INC
75 BUTTERNUT LANE
METHUEN MA 01844
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) #
POLICY PERIOD FROM: 08-22-08 TO 08722-09
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
r 935
18317
Employer's Liability BI Limit: $ 100000 Each Accident
500000 Policy Limit
100000 Each Employee
MA
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
kf
The Commonwealth of Massachusetts
Department ofindustrial Accidents
Office of Investigations .
600 Alashington Street
Boston, MA 02111
c www Mass.gOVI& .
Workers' Compensation insurance Affidavit: guilders/Contractors/Electricians/Plumbers
ninfirst" T}I�ATAsaf:nw
Natrle (Business/orpniza6on/Individual): \
Address:
r": 10 s �7 .y.rFiP �fi� ,;?--L/ Phone ZY t�
Type of prefect (regniretl):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. Q Building addition
10.Q Electrical repairs or additions
11.0 Plumb i airs or additions
12. oof repairs
13.0 Other /�/ 5cf t2•e-y 1
*Any applicant that checks bot: # 1 must atso fill out the section below showing their workets' oompensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors moist submit a new affidavit indicaiiag such
$C0nMwtoni that check this box roust aft -bed an additional sheat showing. the nsmc of dr. sub -contractors
and.Eiezir worker -a' n car, i -vii
r rol i informadon.
I w:. an empioyer that is providing workers'' coinperisatwn insurance or
infornnadon. f m1' employees: Below is the poiizy and job site .
Insurance Company Name:�y�'2�►
Policy # or Self -ins. Lie. #:: 0 i3
Expiraiiop Date: a r Cj
Job Site Address -2 ; -, rc lj�� r r� S
City/State2ip: :>. u .>�
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/ 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.
Are ou oyerY Cireek.the appropriate box:
1
• am a emplo er with �
4. ❑ I am a genera[ contractor and I
employ fun d/o - ' e).*
2. �] I am
have hired the sub-cotttr•actots
.a.so rietor or partner-
listed on the attached sheat. �
ship and have no employees'
These sub -contractors have
working forme in any capacity,
[No workers' comp. insurance .
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. Q I am a homeowner doing
officers have exercised their
right
all work
of exemption per MGL
myself (T!o•w.orkers' comp.
c, t52, § 1(4),'snd we have no
insurance recN�d-1 .t
.employees. [No workers'
•
comp. insurance required_]
I do
the pains
Pte+ of perjrcry that the information provided above is true and corned
Official use only. Do not write in this area, m be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Piuntbing Inspector
6. Other
Contact Person• Phone #-
Information a nd Intstructions
Massachusetts General Laws chapter 152 requires all emp Ioyers 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." i
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
of the'fomgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver ortrmtee of an individual, partnership, associatiorn 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 6cdnsing agency shall withhold the issuance or
renewal of license or permit to operate a business or to construct buildings in the commonwealth for ally
applicant who has not produced acceptable evidence -of compliance with the insurance'coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the pmibrinunce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the cordracting authority."
Applicants
Please fill out the workers'compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es): and phone number(s) along with their certificates) 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' cornpensateon insurance. If an LLC or LLP doeshave
employees, a policy is required. Be advised that this affidavit may be submitted to the Departnimit of Industrial
Accidents for confirnation 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, northe 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 DeImu tznent at the number iisted below, Self-insured companies should enter their
self insurance•lieense number on tiie'appropriate line.
City or Town Officials
Pie= be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for yoiz 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 appikant
that must submit multiple permit/iicmm applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicarrt should write "all locations in (city or
town)." A copy of -the affidavit that has been officiaily stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for futarre permits or licenses. A new affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not miated to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said pars n 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.
Revised 5-26-05
The Commonwealth of Massachusetts
Department of Industrial Asci dents
Office of Emvestibations
600 Washington Street
Boston, MA 02111
TeL # 6I7-727-49Ofl ext 406 or 1-8.77-MASSAFE
Fax # 617-727-7744
www.mass.gov/dia
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RAYMOND E. DAMPHOUSSE, JR.
ROOFING CO., INC.
BOX 131 LAWRENCE P.O.
AND SO""
MA. CONSTRUCTION LAWRENCE, MA 01842
SUPERVISOR LIC. #130486.'96 TEL: (978) 683-4588
HOME IMPROVEMENT
REG. #101862 ROOFING — SIDING — INSULIIrm
From:/2����L�,
INernq
Date _
=Ab - a
IAddrgsl
To: RATr1U E NA17111M n. A4 1113 1I1FDIC Co., 11C., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01042
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. � ?V . (/� _Q ?"I
! / Street,
City /`f UG!L Stale h� �' C' In accordance with the following specifications:
We will remove all roof shingles off total roof area up to two layers Replace any boards or sheathing at 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 11ashings. Waterproof existing chimney flashing and remove debris.
Optional Products Roof Over
Shingle Ridge Vent_ZL: 5 C, v. Existing Roof
Soffit Vents
I C>c-
All of the above work to be done In a good and workman -like manner. /1�� i � 73
All men and equipment Insured. Promisee to be left clean upon completion of work. ///
For the total sum of
dollars.
Entire Sum lobe paid Immediately upon complel Ion In accordance with plan as shown below,
TOTAL CASH SELLING PRICE . , ...... j4
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 sal 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 II 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, Was, accidents, or other causes beyond his
reasonable control.
We, the undersigned, cerllfy that we are the Sola owners of the properly 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
RAYMOND E. MPHOUSSE, JR. AND SONS �1�
ROOFI CO., INC.
Mall Address
of IhGal
(if different from above)