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HomeMy WebLinkAboutBuilding Permit #348 - 38 GILMAN LANE 10/31/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 04 N°DTN 0 M Permit No:—S�VL Date Received 07+tOCMHMrK•,�1• Date Issued: ���r•o�� 43 SSAC HU`��� IMPORTANT: Applicant must complete all items on this page LOCATION_'. 27 6z",/- NI Print PROPERTY OWNER-D4 U 1\1 E 19 c Print MAP NO.: O PARCEL: /,3 ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Commercial Demolition !❑ Moving(relocation) her A/,5�,v ❑ Others: ❑ Foundation only D CRIPTION OF WORK TO BE PREFORMED d rl 2 xz u ; O"f F L'�-- • —rA F-Lt/ .v+k tk-� G L.F Identification Please Type or Print Clearly) OWNER: Name:_���vG f- � ,.r ti, ec Phone: Address:3� L e-vA l� CONTRACTOR Name: c,N , DA01? v 1 c£- Phone: 9 17 F C"�i 7 ySSr T a� Address: cry i A 11--'- Z.,--t E 1q, r-1 -I 1 4 4 Supervisor's,Construction License: 0 yd'r;3 Exp. Date: Home Improvement License: 2D/9'6 Exp. Date: �- ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT.$12.001) $1000.00 OF THE TOT,4L ESTIMATED BASED ON$125.00 PER S.F. Total Project Cost :$ (p0 U FEE:$ ( �- Check No.: q67d Receipt No.: l / Wage I of 4 Location No. �/ Date MORTM TOWN OF NORTH ANDOVER O',. e y,ti0 ' F w A Certificate of Occupancy $ sACMUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ N" TOTAL $ j Check # (� 177441,9 Building Inspector I TYPE OF SEWERAGE DISPOSAL Swimming Pools 0 Tanning/Massage/Body Art Public Sewer Well Tobacco Sales Food Packaging/Sales LE Permanent Dumpster on Site 7.1 Private(septic tank, etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to thWSuamtped and Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ lans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM i DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ I COMMENTS DATE REJECTED DATE APPROVED EALTH ❑ ❑ COMMENTS FIRE,DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer connection/Sienature& Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Require Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 uf'd Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created 161C.Jan.2006 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 q Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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. Thea applicant must then pp get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPAR'1'NIEN'f:BPF0RNI05 Page 4 of 4 ,tAORTH Town of : Andover No. - - _ F! LAI(E dover, Mass.,/d O G COC MICME WICK �,95 RATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .��i `.......... ..... ......... .... .......................................................... . ..:A......................................... Foundation has permission to ere .................... ................ buildings on .. Rough to be occupied as tIr ... �. OV Mal... .................. Chimney .... ... ..... .. ..... .... ............................................................... provided that the person acceptin is permit shall in every respect 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 S� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TR S TS Rough ............... Service .... Z__ .... ... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy 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. RAYMOND E. DAMPROUSSE, R. AND SONS ROOFING CO., INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTIONLAWRENCE, MA 01842 SUPERVISOR UC. #048636 TEL: (978) 683-4588. HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSU1.Ji1TlON Date 1/ 2 ,r From, ,'� '�^`''9 � � �.T .�"�►/r°"! ,J� ,'� (Name) (Address) TO: UT L U=11= A = SEMS 188Mi Cf., OC., 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. 1 (r r L_r'V/--x t Street, City ' ?/14 0 d e_'2 State � ?�� r f In accordance with the following specifications: c' u.Jt J e_ ,rO ?f, '%"'. 'f 1 j 7 r'.#1.4,— a✓ /.( .:.' / �i< �l-J ,i!= /�}! CJ f�1 rt J t l�''y, ') r/�I r f < .-�i? i =' i �'`' � �,/) r�rS ��7 / C '.���-?"7 .'� '� r•G .,�, F/�, ' _ - ;� ,� r/% y ... ,Z ,�,L- - •. - •'�..,i'/i� t'!� i , "`� f'�"- '' fr✓ rt; �2. , i:_ it � t ��G 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 ......... 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. r 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. Accepted By usband 4AYND DAMPHOUSSE,JR.AND SONS Wife ROOFI ,INC. Mail Addreaa pl Olflarent from above) Ynatu an ills of O i (J l' k.., Board of Building Regulations and Standard HOME IMPROVEMENT CONTRACTOR Registration: 101862 Expiration `'6/29/2008 Type: Private Corporation RAYMONu E.DAMPROUSSE;JR.&SONS � Raymond Damp housse,Jr. - "75 Butternut Lane %,je1huen,MA 01844 Deputy Administrat l icense: CONSTRUCTION SUPERVISOR Number CS 046636 I _ Birthdate �5� 2/y948 - Exptr_es 306/.ETZif2©t 7 Tr.ri 1.1748 i Restnef m - f }, I RAYMOND E''DAMP OT�S`SE { Ii 75 BUTTERNUT LANE ` METHUEN,, MA.01844d .. Commissioner The Commonwealth of Massachusetts artment o Industrial Accidents e 1? f P Office of Investigations 600 Washington Street Boston, MA 02111 wmv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual)\�� � A6P1-ty .lSS Address: 3L2 t r 2N L N City/State/Zip: e1\1 lv?A o t%cd t1 Phone #: t`J 1 Are you an employer? Check the appropriate box: Type of project(required): 1.� am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (91d/or time)-* have hued the sub-contractors 2. El am a sole proprietor or partner- listed on the attached sheet. $ �- ❑ Remodeling ship and have no employees These sub-contractors have & F1Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building addition o workers'comp.insurance 5. ❑ We are a corporation and its [N p- 10.❑ Electrical repairs or additions required.] officers have,exercised their 3. I am a homeowner doing all work �' p right of exemption per MGL 11.0 Plumbing repairs or additions ❑ 52 e. 1 , , and we have no myself. [No workers comp. §14( ) 12. Roof repairs insurance requued.] t employees. (No workers' 13.0 Other comp-insurance required.] ' J *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information: Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- JC uch tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy in Hformation. 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.I ic. #: �-I( -- K 6 z X X166 T�9'o Expiration Date: c Job Site Address: O �s—i L— !� �4 n1 City/State/Zip: Jul O • iQ�� a��✓Lyn 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 coverag�verification. I do he certify under the pains and penalties of perjury that the information provided above is true and correct- Si ature: Date: X5 — 21- 6 C Phone# Oficial 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/ToFva Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other t Contact Person: Phone#: �p TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-663X466-A-06) RENEWAL OF (6KUB-663X465-A-05) INSURER: THE TRAVELERS INDEMNITY COMPANY 1 NCCI CO CODE: t 1347 INSURED: PRODUCER: RAYMOND DAMPHOUSSE SONS INTERNET INSURANCE AGCY ROOFING CO INC 522 CHICKERING RD 75 BUTTERNUT LANE NORTH ANDOVER MA 01645 METHUEN MA 01844 Insured is A CORPORATION Other work places and Identification numbers are shown in the schedule(s) attached. 2. Tne pollcy period is from 06-22-06 to 08-22-07 12:01 A.M. at the Insured's mailing address. 3. A., WORKERS COMPENSATION INSURANCE: Part One of the policy appiies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A D. This policy includes these endorsements and schedules: SEE' LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE - 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY. i DATE OF ISSUE: 08-16-06 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: INTERNET INSURANCE AGCY 753XF i veca�e