HomeMy WebLinkAboutBuilding Permit #529 - 535 PLEASANT STREET 3/18/2008Permit 140: 15-� 1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 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 Sep# c`e11F1sdlaiad �tershed Disir�o Iter/S;anrer DESCRIPTION OF WORK TO BE PPREFORMED: Q P'-� U j`�l�i� e'2-_ e'r" j(20'G T i r✓ .I- Gc1 ff i riZ ��'+ £ �3�2f1 n1� 1�/�c� 2o-/ S/ N1 A it 1 C ig LC.. —S %!i Identification Please Type or Print Clearly) OWNER: Name: /6- L/ 7 Phone: "a -r " 1yr� "CO TRS+ TOR I lam vitsc 1 g g= one 4 4Supervisr r Constr coon .icer�se. � W �. '. � 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: $ (1 ° 6" FEE: $ Check No.: 9 `% Receipt No.: NOTE: Persons contracting with unregistered contractors do not hav access the guar my fi 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 Li 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 DEPARTMENT:BPFORM07 Revised 2.2007 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL . e S rax�a " a^ kS e �" L e . k {�yz �. � �, ✓^:�' x.+ '��[x3 " �r a,e, � -� .src' x .�':� i YLoctedat12-4a biret� ti 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Zoning Decision/receipt submitted yes Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street �FI2EDEPARTM�i' 1`empr�s#er ©itere� roY . e S rax�a " a^ kS e �" L e . k {�yz �. � �, ✓^:�' x.+ '��[x3 " �r a,e, � -� .src' x .�':� i YLoctedat12-4a biret� ti a t�MCA 0--4 { Freepar eat gr _. fk MIMETT\/vrv}�1 „W 6.• "r»-Y.:i!i;y '. .yin. A* 4"�rcL"` 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 NU I t5 and UA I A - (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location 1-.5/ z No. :!5;1 Date TOWN OF NORTH ANDOVER L A a Certificate of Occupancy $ Building/Frame. Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # W 43 20998-- f "-" uilding Inspector 1-2 RAYMOND E. DAMPDOUSSE, JR. AND SONS ROOFING CO., INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR LIC. #046836 TEL: ( 978) 683-4588 177 HOME IMPROVEMENT REG. #101862 ROOFING - SIDING - nvsu ATION From: Date (Name) (Address) TO: UTMON E. DA1QSIUM JR. ANO SONS BOOMS CO., at., 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 �f�� Improvements described below In -on building located at No. � Street, City %. O[�z ,2 State in accordance with the following specifications: /rte / t�'r` L- ✓%�'* % or (/e r=�G S^ bi,' �v / ;e �/ 4 --1 01 1�6 �C-� G�/r9�"<2 ���.<•��3,2 Aai,c %r1 ZL At +34ttLAG ��{� .jt�%r/GG! <_v,LG- i r��/Jr�rr�`.5 All of the above work to be done In a good and workmanlike manner.:/_//jam/G All men and equipment Insured. Premises to be left clean upon completion of work. For the total sum of dollars.�7 v Entire Sum to be paid immediately upon completion In accordance with plan as shown below. TOTAL CASH SELLING PRICE .......... III 1 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) hand(s) and seal(s) the day and year written above. Accepted By Husband RAYMOND E. DAMPHOUSSE, JR. AND SONS e OOFIN CO., INC. (signature Ville of official) Mail Address (it different from &bore) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations T d 600 Washington Street .Boston, RTA 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): ,4`/ m a N ;) �yr-11 H G cJl f i il_ S e +� f r'Za� F�"• t G e. �t Q, Address:. 1 3 v't- t¢ 214 u"'- r r City/State/Zip: /-17 4j C , Are you a plover? Check the appri 1. am a employer with �2_ ° employee d/�T 2. ❑ I am a so a prieto�or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] , 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone.#: I? q a 6 t./.; r F to box: I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.$ ' 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' comp. insurance required.] Type of project (required).., 6. ❑ New construction 7. ❑ Remodeling . 8. Demolition 9. Building. addition , 10.❑ Electrical repairs or additions 11 -[1 Plumbing repairs or additions 12. oof repairs,���/ 13. [1 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-contractorshave 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: Policy # or Self -ins. Lic. #:' (. ; - ® Expiration Date: Job Site Address:- City/State/Zip: 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 I do hereby area, City or Town: of perjury that the information provided above is true and correct Date: or town official 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." r 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 "ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,bpera"te�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(g) 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 maybe 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 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 Qf Industrial Accidents Office of Investipt ons 600 Washington Street Boston, MA 02.111 Tel. # 617-727-4904 ext 4.0,6 or 1-877-MASSAFE ` Revised 11�22-06 Fax # 617-727-7749 r www.mass-govldia CA m X m m m N m C2. y C � 10 O CD azco CL 'o. r C CL W y a� � O d o v CD CD o CLQ CD CD o CD C CD va �. CD O y CD S v y O 10 Z CD O CD O CD I cn C) O z cn O �• N O Q H ap�m -0y »® N m 1 me�aC-) m Z ?y Co O, ._« Mb O !A -. TI .. tea-= 0 m 4 O H O y O =' O m n2 7 N m O Z�•n O N C2 W O m C �y7% �c oat?� mCD N1 CD C= C O a CD 0 N O N • N CCL COEL CL- N CCD IE N N N 0 m m 01 N o� r OCD. ca Z N ,y r •O O ft); CDp: a3 T co) d 0 =r : 'o d ate• nd o �. o ~" p MA Cn C7 CC 0 Q9 D CD Ix °� Jd oda GOD -X °= ( Ci7 X17 W or- c� It X17 p? n 'id oCa O r w tz pt r� c �^• C O x rD by o M W v . omi 0 0 c 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/Electricans/P lumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,A`/ m e N ;�., i{y�-1 i (_ I G zJ1 ► t� 12 , S a 1 rZc� e Address:. 1 3.21i u- Lr City/State/Zip :'J,r',>� Are ayou a ployer? Check the apprt 1. am a employer with employee d/ 2.0 I am a so e prietotor partner- ship and have no employees working for me in any capacity. [No workers' comp, insurance required.] , 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone.#:_ riate box: 4. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet 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' comp. insurance reauired_1 Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. Building. addition , 10.0Electrical repairs or additions 11.0 Plumbing repairs or additions 12. oof repairsX���i/ 13.0 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 indicatiro 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-contractorshave employees, they must provide their workers' comp; policy number. I am. an employer that is providing workers' compensation insurance for my employees. information. Below is the policy .and job site �—, Insurance Company Name: Policy # or Self -ins. Lic. G + L_9`may Expiration Date: —, — O Job Site Address: _!�3 s City/State/Zip: /9 4,74-VIF4, 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 Tnveatioatinne of f},o TIT A 4- I I do hereby pains -an enaldes of perjury that the information provided above is true and correct Date: c' use only. Do not write in this area, tb City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: or town official. Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: 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-07 ) RENEWAL OF (6KUB-663X466-A-06) POLICY PERIOD FROM: 08-22-07 TO 08-22-08 WORKERS COMPENSATION INSURANCE PLAN A/R (WCIP) # TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ PREMIUM DISCOUNT 0900-20 EXPENSE CONSTANT TOTAL ESTIMATED PREMIUM TAXES AND SURCHARGES DEPOSIT AMOUNT DUE 22351 NONE 284 22686 9 3622 „,... Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: THE TRAVELERS INDEMNITY COMPANY MA Adjustments of Premiums shall be made ANNUALLY ******************************* Deposit Amount Due: $ 23622 ****************************** POLICY NUMBER: (6KUB-663X466-A-07 ) DATE OF ISSUE: 06-27-07 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: INTERNET INSURANCE AGCY 753XF ding Regulations and Sw�utiu .dUl Use only 20VEMENT CONTRACTOR ' ! �e''nrturn to: - �r 101862 [` i 3069dards � 3n 6/29/2008 Ti .- )e Private Corporation 3SE' JR. & SON1S Dctip�� a l�:iini J�ee 1°r7mmrnzwea�.a�✓G�aaaac<uc -oard of Building Regulations and Standards 3onstruction Supervisor License License;,CS 46636 Birthdate 6/2/1948 iExpiraton 6/2/2."009 Tr# 14`24 I _ ttes#nciion 1G.} RAYMOND E DAMPHOUSSE JR 75 BUTTERNUT LANE METHUEN, MA 01844 Commissioner.