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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION /�G�GI �� G�OGI 7
Print
PROPERTY OWNER Unit#
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes 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 0 Wetlands ❑ 'Watershed District
q Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
(Identification Please Type or Print Clearly) '
OWNER: Name: O Phone:
Address:
CONTRACTOR Name: ���1''�� �Q �'/J� Phone: , 2 ���,•G
Address:
Supervisor's Construction License: 7�'��2 Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$$12.00 PER$9000.00 OF THE TOTAL ESTIMATED/coST BASED ON$125.00 PER S.F.
Total Project Cost: $ �1 , (�� �„ Z6 FEE: $�, '`�
Check No.: 012
Receipt No.:oP-(/37:31 C/
NOTE: Persons contracting with unregiste ed contractors do not have access to the guaran and
`Signature_of Agent/Owner : Signature of contractor ; �G�
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
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o 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
o Certified Proposed Plot Plan
o 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: Doc.Building Permit Revised 2008mi
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
i
-----------------
-----------
i
❑ Notified for pickup - Date
�I
Doc:.Building Permit Revised 2011 June/mi
guaran
�_.._. •_:.�:rvl ICI ." .-. - .-
S,ignature of.contractor: -
J
Plans Waived ❑ Certified plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑
GE DISPOSAL in Pools
TYPE OF SEWERA ❑ swimming
ElTanninglMassageBodY ArtEl �
Public Sewer Food Packaging/Sales
❑ Tobacco Sales ❑
Well
❑ Permanent Dumpster on site
Private(septic tank,etc.
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF , U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
Si nature
CONSERVATION Reviewed on
COMMENTS
Si nature
HEALTH
Reviewed on
I
COMMENTS
Zoning Decision/receipt submitted yes
Zoning Board of Appeals:Variance, Petition No:
NComments
Planning Board Decision:
In Comments
the Conservation Decision: Drivewa Permit
mu Water & Sewer Connection/Sicinature&Date
DPW Town Engineer: Signature:
Located 384 Osgood Street
no
FIRE DEPARTMENT -Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS - - - - - - - - - -- -- - -- - - - -- -- ---
Location
No. _ /�'' Date
Na^T� TOWN OF NORTH ANDOVER
3? � • OL
F p t
• s ; . Certificate of Occupancy $
�7s''•e''t�'
Building/Frame/Frame Permit Fee $ `'�J_
s�CMusa 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Z_.--
2 �� � i4
Building Inspector
IAORTH
Town of ? Andover .,
O
_ o , over, Mass.tmLAK
,
COCHICHE W ICK
�70
RATED P'Pa„���
7 V BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
• • BUILDING INSPECTOR
THIS CERTIFIES THAT..... 0 �� � �. . ��11.�. d�
i...... .. . .. ..... ..... N .................. Foundation
i
has permission to erect.... ........ buildings on .........I.I��. .. 1N .... Rough
... ...
40 be occupied as �respect
� .dl/....Ir
...... /4.j.•� ney
provided that the personAceouptin ,
k..
permit s*'Ii conform to the terms of he application file in Final
this office, and to the provisions 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 CONSTRUCTIO ST Rough
Service
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.
-�omt.»ianu�eal���.�.aQod��aelta �
Office of Consumer Affairs&B smess Regulafion
tdO11A fM�12OVEIIAENT
co
Registration: 116404
Expiration 012 DBA.
ST P,&SON C ( I
IVELL MA 61'86'�
I
Jul 11 2011 9:51AM BROOKS SCHOOLFacibbes 9787256295 page 2
PROPOS:
STAMP! SCS N. ONSTRO
O'TIOl
37 Ru nford-
(0 x:937j' 155
June 1,2011
Submitted to:
Ery,M
�
All
N:.•,�,N�,q r.w J n ' ra L..� �.� ° ",�.a 4 t?1� '� �" t u :Y> '
e hereby Propose to furnish materials and labor necessary for the completion of
1. Frame 58'X P over with soffit vents and.rubber.
2. Install 116 feet of gutters and down pipes.
3. Remove four dormers off roof and two ridge vents and plywood in holes.
4. Remove and install 6 square of siding on walls.
5. Remove existing roof and replace rotted boards as needed.
6. Install Hicks vented drip edge.
7. Install 100 percent ice and water shield on roof.
8. Install new step flashing on all walls.
9. Install 30 year architect shingles.
10. Cut in ridge vent and install cobra ridge vent.
11.Removal of all debris.
WE PROPOSE hereby to fiunish material and labor,complete in accordance with above
specifications.For the sum of$26,220.00 Twenty Sig Thousand Two Hundred and Twenty Dollars
00/100
a ent to be made as follows: Please make checkga
able to: AnthonyR Stam
Start
Completed
26,220.00 Total:
Contractor's registration#116404
All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according t
specifications submitted,per standard practices. Any alteration or deviation from above specifications involving extra costs will
e executed only upon written orders and will became an extra charge over and above the estimate.
CCEPTANCE OF PROPOSAL: p ,specifications and conditions are satistatwy and are hereby accepted
You are authorized to do the work as specified.
�.
SIGNATURE:
DATE
CONTRACTORS SIGNATURE:
DATE
Jul 11 2011 9:51 AM BROOKS SCHOOLFacilities 9787256295 page 3
•PRMS L f
STAMP' & SUET C()1I FRIUCTION
:37tutnfOd; t>lteet
. -U . tkl 0,1852
75 :937=- $5.
une 14,2011
ubmitted to:
0.
We hereby propose to furnish materials and labor necessary for the completion of-
1.
£1. Remove existing sheet rock on outside wall and insulate as per discussion. (l 9t and 2"d
floors)
2. Install new R1 insulation in walls.
3, Install new sheet rock.
4. Tape and mud all sheet rock seams and inside corners.
5. Prime and paint walls color to match existing walls.
6. Removal of all debris.
E PROPOSE hereby to furnish material and labor,complete in accordance with above specifications.
For the sum of$9,300.00 Nine Thousand Three Hundred Dollars&00/100.
Payment to be made as follows: Please make check payable to: Anthony R. Stamp
Start
Completed
9,300.00 Total
Contractor's registration#116404
All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according t
pecifications submitted,per standard practices. Any alteration or deviation from above specifications involving extra costs will
e executed only upon written orders and will become an extra charge over and above the estimate.
ACCEPTANCE OF PROPOSAL: The above prices,specifications and conditions are satisfactory and are hereby accepted.
You are authorized to do the worm as specified.
IGNATURE: L! L
ATE
ONTRACTORS SIGNATURE:,
DATE
Mu%%aciawws- Mpartm nt Eel'Public Safet}
Board 4 Bitiklin_Remdations and Standards
Construction Supervisor License Farre to possess a current edition of the
Massachusdb State BMldiag Code
License: CS 79M is cause for revocation of this license.
PRICE PETERSEN Befgerta WWW.Mass.CovMPS
61 FARM POND RD
DRAG T,MA 01826
Expiration: 8118!3012
t bnxni.�i+.ner Frg: 31511
J1l< �fnarrrtorruccrtt/r!/^lfr;;rr�/rn r/t; License or registration valid for iadividni use only
OMet of Consumer Affairs&Busidess Regulation before the expiration date. H found return to:
1M
E pROVMNT CONTRACTOR Office of Consumer Affairs and Business Regulation
btratlon: 133364 Type:
ration: 6/11/2013 Ltd Liability Cotpor 10 Park Plaza-Suite 5170
Boston,MA 02116
Commercial Contrwas8li od LIC.
PRICE PETERSEN
61 FARM POND RD
DRACUT,MA 01826 undersecretary Not valid without signature
"
VDAC
CNA
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS59UB-4193P65-4-11 )
RENEWAL OF (GS59UB-4193P65-4:-10)
INSURER: CONTINENTAL CASUALTY COMPANY
1.
NCCI CO CODE: 80381
INSURED: PRODUCER:
- - -wSTAMP, ANTHONY-DBA - .- BYE TTE INS-AGCY INC
STAMP & SON CONSTRUCTION 853 MAIN STREET
37 RUMFORD STREET TEWKSBURY MA 01876
LOWELL MA .01852
Insured is AN INDIVIDUAL
Other work places and Identification numbers are shown in the schedule(s) attached.
2. The policy period is from 04-16-11 to 04-16-12 12:01 A.M. at the Insured's mailing address..
3. A. WORKERS COMPENSATION.INSURANCE:_ Part One of the policy applies to the Workers
Compensation Law of the state(s),Ilsted here:
MA
m�
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:
o Bodily Injury by Accident: $. 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
o_
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:
o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0
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: 03-08-11 WC ST ASSIGN: MA
OFFICE: CNA 04J
PRODUCER: BYETTE INS AGCY INC , 25GSF
002507
r NORFOLK& DEDHAM MUTUAL FIRE INSURANCE COMPANY
SPECIAL BUSINESSOWNERS POLICY
RENEWAL DECLARATIONS
Policy# R0639424A
Named ANTHONY STAMP Agent BYETTE INS. AGENCY, INC.
Insured 37 RUMFORD STREET
LOWELL MA 01852 Phone (978)851-6678
Agent# 20434
FORM OF BUSINESS:
Policy Period: 1 YEAR from 07/14/11 to 07/14/12
This declarations page together with the policy jacket, the policy form and any endorsements, completes this policy.
Coverage begins at 12:01 A.M. Standard Time at the covered residence premises.
,,,x.
Basic Annual Endorsements State Taxes Total Annual Additional Return
Premium P or Fees Premium -.Premium .-
$1,699 $201 $1,900
'11.7 „.-.�r; ": t n .<,�rar `rvvQ•.4," .`' ;a -"'X't ,r` .t� ' 1 k s -.;x
` ✓,`.
Building/Location 1 37 RUMFORD STREET LOWELL MA 01852
Address if Different
Mortgagee Information
Business Description CONTRACTOR-CARPENTER-RESIDENTIAL/L
" , .. ._� ., . .. . „._ rte, x.,. ., •�. v. -...
Premium
POLICY DEDUCTIBLE $250
OPT.COV./EXT.BLDG GLASS DEDUCTIBLE $500
BUILDING (COV A) Limit
ACV OPTION (Yes I No) NO
AUTOMATIC INCREASE (%) 8% Included
BUSINESS PERSONAL PROPERTY Limit $10,000 Included
.t '`"` ;a , zk. £ > ,"T'"' x E r, � '�Cx-,� +,y , S �'::b5 „ A'{ Y.S o-z>•. '` '�..0
Premium
OUTDOOR SIGNS Limit
EMPLOYEE DISHONESTY Limit
MONEY&SECURITIES Limit
ACCOUNTS RECEIVABLES Limit
VALUABLE PAPERS Limit
FORGERY&ALTERATION Limit
TOTAL PREMIUM PER BUILDING $1,900
EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF
INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH DA OF THE
BUSINESS LIABILITY COVERAGE FROM ,
LIABILITY&MEDICAL EXPENSES
OCCURENCE $1,000,000 Included
GENERAL AGGREGATE $2,000,000 Included
PRODUCTS COMPLETED OPERATIONS AGGREGATE $2,000,000 Included
MEDICAL EXPENSES $5,000 Included
DAMAGE TO PREMISES RENTED TO YOU $100,000 Included
v
Premium
SEE ATTACHED PAGE
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BOP-1 f DIRECT BILL NON EFT 10 AGENT COPY
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