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HomeMy WebLinkAboutBuilding Permit #573 - 365 MASSACHUSETTS AVENUE 4/30/2009 It NORT1t BUILDING PERMIT Oq TOWN OF NORTH ANDOVER o - -*' '° °0 APPLICATION FOR PLAN EXAMINATION ^C ee # Permit N0: 3 Date Received �y"°R,T.o SSACHUS� Date Issued: IMPORT T• Ap is t must complete all items on this page LOCATION b — '+t'9 I"1 & `��1 .t� f)oy LZ � 9G� Print PROPERTY OWNER �JZ L'� Print MAP NO: PARCEL: ZONING DISTRICT: Historic Districty n Machine Shop Village y s 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: S/ end y J ci 0�= SIS% ty Crt� Identification Please Type or Print Clearly) OWNER: Name: x—,e-e4K L-y Phone: Address: J /-*7� S 'JrR v� >`I `� - �> o ✓ CONTRACTOR Name:_S©r-.t ;�aL F , <-tG Co c-t C- Phone: cl 7 ' Address: )°3 t 2-N ��/ /''►ee rt A Supervisor's Construction License: &C 3 Exp. Date: Home Improvement License: a` �7 6 - Exp. Date: C-7 iy 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: $ 1p a� FEE: $ Check No.: Receipt No.: NOTE: Persons contract' ith unregistered contractors do not have a7 o th uaranty fund Signature of Agent/Owner Signature of contractor 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 .s 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 DEPARTMENTMFORM07 Revised 2.2008 Location Aw ��---- .S7 Date No. / �oRTh TOWN OF NORTH ANDOVER �?o°,•`•O •• •yon 0 s � ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 Building Inspector RAYMOND E. DAMPHOOSSE, R. AND SONS ROOFING COs, INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE. MA 01842 SUPERVISOR LIC. #04M TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSULATION > -✓� / - Date �� tj Cj From: r r /l �r f 4 % l-7 5 /^"7,tet C 5 f l /tJ r. ==� ,I ;l,! l (Nam.) (Address) To: OATNIR L OAWNINK, J!. ANO SONS ROOFING CO., INC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 011142 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. -� 4 S P)n s 1 "q ;)% Street, City ' T., ), %? State /'� + in accordance with the following specifications: C_ i— .S !-� ;'t'J f ! j r rr i:j�'_1 L 1 n ~ ' =' ; /'^� r / F',.>^ -►' f,�.J,-i + r `� �' �-.r r'r a ,3 .�.>�r-Jr ,'-"=? ? 1 L ,',c_ �-J (.�/=� l.Lr= "/ t ,=-) /s1rr�1 /� �� f •� l !-/-'- i , ,tet � "; ,<� 1,'r'kJ Z ��^^1 J / I"'�/'r-1�.- -•i /<, l � t- / S .'` ,' i) � f �� {�.% 1 i.t/r-� i `- ? / �. .7 n � li � / r,- All of the above work to be done In a good and workman-like manner. 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 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 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)/ha�nd(s) andel seal(s) the day and year written above. Accepted By Husband RAYMOND E.DAMPHOUSSE,JR.AND SONS Wife ROOFING CO.,INC. Mail Address v-.-.�- (1l different from above) (Sienatura and Title o,Ot iaq VkORTH Town of , � _ 4 over O No. %S7 3 C% dower, Mass., D D O _ LAKE 1. co MIC ME WICK V 7�S RATED O'Pa� �� BOARD OF HEALTH PERMIT T Food/Kitchen Septic System .. ................................................................................ BUILDING INSPECTOR THIS CERTIFIES THAT.......... .. ... ............... .�'......... Foundation vt has permission to erect........................................ ildings on ...................... ..... .... ....*00saw........ Rough to be occupied as.......Sgi�i......T.......... .... ..�Q.. ..... Chimp y eprovided that the person acce this permit shall in every re ct 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSU STARTS Rough Service PECTOR Final Occupancy Permit Required to Occltpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved .by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts kj ! Department of Industrial Accidents Office of Investigations 600 TTfashin-jon Street tl lt� 1 Boston, MA 02111 www_mass gov/dia . Workers' Compensation Insurance Affidavit-. Builders/Contractors/Electricians/plumbers Aoolicant Information Please Print LeQibiy Name(Business/orgmization/individual).'� A-I Address: i3 ► ti-t,J 17 1_IN City/State/Zip: LI .Y-+�A, CA �q y Phone Arse you employer?Check the appropriate box: I. am a emplo 4. ❑ am a general I e contractor and I Type of project(required): � (� employees 11 and/or part-time * have Dred the sub-contractors 6• New construction 2.0 I am.asole p a`l`ter- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capacity, workers' comp.insurance. [No workers'comp.insurance 5. 9• Building addition p ❑ We are a corporation and its required.) officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No-workers'comp, c, 152, §1(4),and we have no 12, Ro e required.] ❑ repairs insurance �N ] .employees. [No workers' �r comp. insurance required.] 13 er Y�iIN' I 'Any applicant that checks boZ#I must also fiat out the section below showing their workers'compensation policy information, t homeowners who submit this effiddavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box_must rtteolted an additiaas]sheat showing.Che name of the sub-eontraotors and their worker`'oemp.poli-;irfvmmdon. I am an employer that isprotridutg:workers'compensation insurance for my employees: Below is the policy and job site . information. Insurance Company Name: y L 51t- 1 .. Policy#or Self-ins.Lic. 1<V 3 LZ U G p U Expiration Date: Job Site Address: �� !'�'`1!I ,q City/State/Zip: A/o ry 15 p, r►i�{ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dzte) 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 D1A for insurance coverage verification. I do hereby nde the pains nd penalties perjury that the information provided above is true and correct Signature: f / Date: Phone#: 3? Official use only. Do not write in&&area to be completed by city or town'ffciofficial 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#: 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 locai 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)acid 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 requiredto cant'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 nurnber.listed below. ;elf-insured companies should enter their self-insurance license number on the'appropriate line. City or Town Officiais 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 pernit(license number which will be used as a reference number. in addition,an applicant that must submit multiple permitilicense 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. When 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#617-727-7749 www.mass.gov/dia f' Board of Building Regulations and Standards '' HOME IMPROVEMENT CONTRACTOR a Registration': 101862 TO 267825 ..€ Expiration:,' 6!2912010 +i Type; Private Corporation ,f r2AWOND E DWPHOUSSE JR &SONS Raymond Damphousse,dr• i„ 75 Butternut Lane pdn,;nistrator Methuen,MA 01844 x ��myyianu �t� d Standards ��e [n ulations an oard of Building ervisor Licen$e ,onstruction Sup License' CS 46636 to6 Blfthda.. 1211g48 7r# 14024 EX 3iratiOI ' 61212009 1G Restriction E DAMPNOt)SSE R5 OTERNUT to 4� Commission 513 1t1EN.MA o1B 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 01 844 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: $ 1 831 7 ****************************** 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