HomeMy WebLinkAboutMiscellaneous - 39 STAGE COACH ROAD 4/30/2018v4ORTH
Date ...... / ............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
"I- �HU"'
This certifies that .............
has permission for gas installation ..........................
in the buildings of .0—)G
.....................................
at North Andover, Mass,
Fee-�'�! f ..... Lic. No ....... G�� I=SEC OR
Check # ")J'g'=v g
5549
a
I
,.rJ -/- 4&
Date. . ............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
CHUS
This certifies that .......................... ........
.................................
has permission to perform 4eiZ�,'
plumbing in the,buildings of ..........................
at
...... North Andover, Mass.
Fe� ...... Lic. No9? ........ .
............
PLUI�481,NG INSPECTOR
Check
6949
Yi
Location
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
C 14U
Foundation Permit Fee $
Other Permit Fee $
TOTAL, $
Check #
15477 d—widing Inspe&
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBE� b DATE ISSUED:
C
SIGNATURE -
Building Commissioner for of Buildin s Date - - �g ?✓
SECTION I- SITE INFORMATION
1.1 Property Ad ess:
1.2 Assessors Map and Parcel Number:
Map Number Parce umber
1.3 ing Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide R 'red Provided
ReTured Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System ❑
STICTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
�f N H �-A rr- A 'ccs 1-9 e. H
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3. If Construction Supervisor:
Not Applicable ❑
LLicensed
Licensed Construction Supervisor:
/
License Number
�`7 .� 3 � '� -� J � ,�� � -t-t .JAN..
Ad ss
-�YF
Expiration Date
Stgna Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
��Llyt�'►� �� �ifim^�,�r 1 PE 3 YL-( s o YJ C v
Co ny Name
Registration Number
U' i� �C �-� �sP' L f-f1�. Z T 4 v Z M
Add?u
FLF
Expiration Date
1—
Si nater Telephone
z
M
90
O
onM
rM
G)
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... No ....... ❑
SECTION 5 Description of Proposed Work check all a licable
New Construction ❑
Existing Building
Repair(s) ❑
Alterations(s) ❑
Addition 0
Accessory Bldg. ❑
Demolition ❑
Other ❑' pecify N iCt J ..Xoo',,E 'A
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed b permit a licant�.
3� OFFiCIAI<;
USEONLY
qw .,..:
1. Building
S p z
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
Building Permit fee (e) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER ALLULORLZAIJON TO BE COMPLETED WHEN
OWNERS AGENT 0NTRACTOWXPPLIES FOR BUILDING PERMIT
1> as Owner/ uthorized Agent subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
-Signature of Owner Date
SECTIO 7b OWNER/AUTIMRIZED AGENT DECLARATION
I> as Owner/A�izedAsubject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
O K 0 V _f 1
Print
Signature caner/Aent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 117- 2ND 3
SPAN
DIMENSIONS OF SELLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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✓lie �o�rvnamuredll! o�✓tac�uaeCla:; r
BOARD BUIL
;OF DING REGULATIONS
400** CONSTRUCTION SUPERV.,ISOR'
Number CS 0466:36
Birthdate ;06/02/194$
Exp res 06/02/2003 Tr. no: 10578 {,
RAYMOND E DANIPHOUSSE JR j
i"
75 BUTTERNUT LANE, /A
METHUEN; A 01:844 I
Adini istrat0r
r
T1.
HOME IMPROVEMENT CONTRACTOR
Registration: 101862
Expiration: 06/29/2002
Type: Private Corporatio
RAYMOND E. DAMPHOUSSE, JR.
Raymond Daaphousse, Jr.
G� o 7!� WButternut lane
ADMINISTRATOR Methuen NA 01844
From: �� r (q,_ P -) r , r .. a !s L_� L_ ta.
qp ®�y�p� �o y�p� �p AM
* CO., MC.,
r 10. �i WIS L Di0ali'BOISM A AS (Mill 16CF99 COMYy BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01:II,1112
i (we) hereby authorize the Contractor to furnish all materials and labor necessary to Instal:, construct and place the
improvements described below in • on building located at No. 3 q S T R c— < q r t Street,
City �' R -A �h o v f- A- State 1M A c s In accordance with the following specifications:
5 S-7-,' ''> /ALL l'HrMGC4-5f 1:7 /
_A REA - RE?LAc.E .a N_`/_!, /3�c)}naaar �1-r /cclS/�o en
. , i L T— 1 ! !'r'4 / T_ i 1 _ {� C� 44/ U f ( lH 4 _r L / f;.. ✓ P�'�t 6 i t tj ✓,n L (�
? 6f:, (3'��; * �> _ 1_rs r r G A t_ L F A G F f A -4PS- Y -T" 1,-
!Ron
cSRon E ..S ft %H LF L,, < --5 T (4 -c N 13 1E i h r ! C_(_4
M; n G1 � S r�..:� Ga_:y � 0-1G C..
i ilf�J6 L4_ +'t �: i 61•1 S A- A Iourt Q C ec Yt.._i G N i � c✓� -p- �{�'� 2a c -i
i1 �ag: "t.r t4; 0-F a
t \ 0 ✓E A fir i7 ,/3 1 S-OCj.
All of the above work to be done in a good and workman like manner. KI6 w 2111 t = c.r E r.e 'r t
All men and equipment Insured. Premises to be left clean upon completion of work.
For the total sum of S t 'Y- �-} O u s A N ',*,. !E ; c yr= H%-# m,-3 -,Le F, ,^.4 dollars.
Entire Sum to be paid irnmedlately upon completion In accordance with plan as shown below,
X i G'�, >1TOTAL CASH SELLING PRICE .......... S �. �
DOWN PAYMENT IN CASH .............
DEFERRED BALANCE
UPON COMPLETION ....... ....... .
The undersigned agrees to keep property mentioned in this agreement properly insured against lose by firs 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, promisee 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
he+rs, 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 turther agrees that in event of cancellation of this contracl after acceptance by the contractor and before the work is
commenced the OWNER agrees to pay 2011A 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 othev 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
thhis
� (their) hands) and seats) the day and year written above.
p Y
Acce ted 8 Husband -
RAYMOND E. DAR+RPIiOUSSE, ER. AND SONS Wife
ROOFING CO., INC.
G a e+t?•
(SiQnatore a tl Tine qt hNCraI,
Mtail Address rs-ys1 e AS aAn.,e
(if diffirent from above)
S i 6 -xi /1-9 ?,/,-7 Sz5� nr ,'�' .3,-4c,, tL 7'—'0 /`i°
A_r
Tii.nN14J
f
North Andover Building Department
Tel: 978-688_954
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of irl a properly licensed solid- waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
_ice
(Location of Facility)
Sig ure of Perm' Applicant
Date
NOTE: Demolition permit from ti?e Town of North Andover must be obtained for
this project through the Office of the Building Inspector
INSURER: THE TRAVELERS INDEMNITY COMPANY
1.
INSURED:
RAYMOND DAMPHOUSE & SONS
ROOFING CO INC
73 BUTTERNUT LANA:
METHUEN NA 01844
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00.00 01 ( A)
POLICY NUMBER: 0SKUB-663X466-A-01 }
RENEWAL OF (GKU8-663X466-A-00)
NCCI CO CODE: 11347
PRODUCER:
INTERNET INSURANCE AGCY
522 CHICKERING RD
NORTH ANDOVER MA 01$45
Insured Is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 08-22-01 to 08-22-02 12:01 A.M. at the Insured's mailing addresss.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Pan 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: Pert Three of the policy applies to the states. if any, listed here:
SEE ENDORSEMENT WC 20 03 06
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
Plane. All required Information is subject to vetiflcation and change.by audit to be made ANNUALLY .
DATE OF ISSUE: 08-21-01 ML
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: INTERNET INSURANCE AGCY
oog®6a
753XF
ST ASSIGN: MA