HomeMy WebLinkAboutBuilding Permit #864-11 - 44 SAWYER ROAD 6/17/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit IVO: 76 LI"/1
Date Issued: %/ /'71 //
Date Received
IMPORTANT: Applicant must complete all items on this pate
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PROPERTY OWNER f! L�� `� ��g t.�.J' Y
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MAP NO: PARCEL: 'BONING 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
❑ Alter
No. of units:
❑ Commercial
q�Rdpair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
Septic 0 well,
❑ Floodplain 11 Wetlands
❑ Watershed, District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
J'3 ,-A e_ A f f 4 73e) -(A. ZZ -r ( }� y►'1.`a `� r .7 G. .tet R G ( (1/ry L.,
(Identification Please Type or Print Clearly)
OWNER: Name ("1 Phone:
Address: Z-1 q -'9_;04LAI°65�- S
`73 ktt S cv e+►1
CONTRACTOR Name: Phone: q 7S ' F ? (/ sl y—
Address:
Supervisor's Construction License: WLI)^ 3 � Exp. Date:
6.
Home Improvement License: ,/O �* '.-2, Exp. Date: K — 1 �2,
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: $%�0 FEE: $
Check No.: /'Z� ��%` Receipt No.: o Z-7-411
NOTE: Persons contracting with unregistered contractors do not have access to the aranty fund
S gnaturj�of Agent/OWner,_Signature - f confractop . _
d
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 e U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENT
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed o
Sianature
r,
F
` Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board'Decision: Comments
Conservation Decision: Co
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
i
Doc:.Building Permit Revised 2008mi
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 G.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: Doc.Building Permit Revised 2008mi
Location 4161 r -
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Mus Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # /0 4/ 12-
2 4 6 �0 . 4(
Building Inspector
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The Commonwealth of Massachusetts
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
Name
Address:
tti6rYIndividual): f�� �� r= �1"�l?�{clC1 t"i ' j�-t S cnNi
. r•�
City/State/Zip:. 4 eS C>/ y Phone #: 13 7
employer? Check the appropriate box:
Are ?arn
a e
4. ❑ I am a general contractor and I
emplo ees (full and/art-time).*
c
-. ❑ I am a sole �-
have hired the sub -contractors
listed
prop or or er-
on the attached shget. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
*An «1:- aL_ _1 --
COMP. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ P1 ing repairs or additions
12. oof repairs
13. ❑ Other.XeW /? an, 'e*=
r� - �• �••��� n1 111 L asu qui out me section below showing their workers' compensation policy information.
I Homeowners who s
cto
ubmit this affidavit indicating they are doing all work and then hire outside contrars 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 their workers' comp. policy information.
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. Lie. #: Gfffdi� ti 66� . j�� � 1 _ / e) Expiration Date:`
Job Site Address:_ W . SSI (�J�j �? s�� City/State/Zip:,o�/ �yj./ j�,���, ✓..�,,q sr
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
pains
penalties jperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Per #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
A 1--;7,- i /
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 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 number listed 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 burn 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
TRAVELERS) WORKERS COMPENSATION
AND
MPLOYERS LIABILITY, POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6KUB-663X466-A-10 )
RENEWAL OF (6KUB-663X466-A-09)
INSURER: THE TRAVELERS INDEMNITY COMPANY
NCCI CO CODE: 11347
1.
INSURED: PRODUCER:
RAYMOND DAMPHOUSSE & SONS PERRY INSURANCE AGENCY
ROOFING CO INC 522 CHICKERING RD
75 BUTTERNUT LANE NORTH ANDOVER MA 01845
METHUEN MA 01 844-1 91 2
Insured is A CORPORATION -�-�
Other work places an ' e:t0NIN
n numbers are showl'riQthe schedule(s) attached.
2.- The policy period ' from 10 to 08-22-11 12:01 M. at the insured's mailing address.
3. A. WORKERS COMPE SURANCE: Part One of the policy applies 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
e
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 .
DATE OF ISSUE: 08-30-10 LA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: PERRY INSURANCE AGENCY
753XF
ST ASSIGN: MA
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• INlassachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
'One- and Two- Family Dwellings
License: CS 46636
RAYMOND E DAMPHOUSSE J
75BUTTERNUT.LANE
METHUEN, MA 01844
--�- �� Expiration: 6/2/2013
('onimissioner Tr#: 16791
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HOME IMPROVEMIENT'CONTRACTOR
Registr�aboi": ,,f1018f2
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Raymond Damorlo s }
75 Butternut Lane
Methuen, MA 01844 Undessecretar .'.
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