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Home My WebLink AboutMiscellaneous - 44 ASH STREET 4/30/2018 / 44 ASH STREET 210/106-D-0038-0000.0 �f I I I Location ' No. _c2 _— Date /f"4,- Th ': TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f � � Check # 18664 , / wilding Inspector TOWN OF NORTH ANDOVER � BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: 2,d S / r SIGNATURE: Building Commissionerll for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: M6p Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage fl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.I_C.40.1-54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 0l ) OCJ ��7 r N e( nnt) Address f i Service Signature Telephone 2.2 Owner of Record: Ns:.ne Print Address for Service: t M Si nAre Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Q xv ✓� r� License N ber I ) v � ) Al u , � xi /�f j N✓r. r✓ Address - �f Expiration Date S re Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 2 YV61 Al •3 r. aA tj c)qj 4E , A,T3a-t- 4 j�RcF;t�+Ca- f Company Name D n Reg ration Number LcJ-:r'�<crly i L ri/ /►'1¢�'�L�t�¢'�/ i'+�r4. Addr qMF Cs Expiration Date Signature Q�7�febbone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) 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.......0 No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ • t"% ' ' Ilk Accessory Bldg. ❑ ` Demolition ❑ Other ❑ Specify BriefI Descrof Proposed Work: r"1 d V6 A I- L T) tZC+o P,M ,4 3%;I L e P.' 30 Y ds�e I2C,C' F s H F M G /V ii tar+i i "9 0'(" �7 0 a "tE 0 t/eq- i C.E-r ) 00 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be " OFFICIAL USE:ONLY Completed by permit applicant , 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection --` 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of 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 SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION r�A," '77A ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief /211 YIM 6 +1J -CE 1 1.1' ;3t-t0 +1 sSc— Q'., Print N e Si atur Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3PM SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRvMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE a ! RAYMOND E. DAMPROUSSE, JR. AND SONS ROOFING CO., INC. 'Z BOX 431 LAWRENCE P.O. , MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR LIC. #046696 TEL: 978 683-4588 (/ HOME IMPROVEMENT REG. #101W ROOFING - smrnG - INSULATION l Date From: �_, �'/ 7-D IV �L s (Nana) (Address) To: BArnD L NAW/RISK JI. = $IBS 18OFMC C1., MC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01942 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. / Cs/ r r 4 Street, r City t) r_, `J ` !�-State accordance with the following specifications: �1/ rf7 /� e? �,• ��` lig `�� /4 r'r ,� /l��7-1 I�A/�� fr/.�! i 2 ✓�'�'Gi�I,�.2 •4frv'c� ::3 Ai �- -a' G —T77 . � ,� ! J/ rr �.% ! (! •�?!� L..'r� !X 1 '/.Z :a rCl � Q �4 L- Z_' Aff ,' lL Gtr rrc. S% nG�tlV`1t_.� 1 V,. iC.7k C1+--4. All of the above work to be done in a good and workman-like manner. +�i UJ f t) -17 �1._ 0� C C All men and equipment Insured. Premises to be left clean upon completion of work. �/) G ` 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 . .. .. ... . . . . . . . . . . _ i 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 (theilrhand(s) and seal(s) the day and year written above. _.---1�;fes /�/C �"�,�'fir`,✓ ��,,s%.�� Accepted By Huftia ^_RAYMOND E.DAM.PHOUSSE,JR.AND SONS Wife ROOFIN13 CO.,INC. Mail Address (II different from above) (Signature and Tiff*of Official) NORTH Town of Andover No. 2. 00 9F C 0 o dower, Mass., �. - � COC NIC ME WICK ORATED PP��y h BOARD OF HEALTH PER I Food/Kitchen i Septic System I BUILDING INSPECTOR T D THIS CERTIFIES THAT ..................... ... .................... ........................................ •'••'•••••••••••'•' Foundation buildin s on ,� ........... Rough has permission to erect......_............................... ..... ...... ....................... ..... ............ tobe occupied as..;,. .1 .......... :............................................................................................................................................ Chimney provided that the person acce ing this 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION �� ,p- (,/��, Rough �....... Service . . .... ......... ....... .... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR f Rough f Display in a Conspicuous Place on the Premises — Do Not Remove Final I 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. The Commonwealth ofMassachusetts Department ofIndustrial Accidents office 01invesfigadons 600 Washington Street, 7hFloor Boston,Mass. 02111 Workers'Com tion Insurance Affida ical Contractors vit:Buflding/Plumbing/Electr V let,&�PRWHeA name: address: city state: Zip: phone# 1 am a homeotyner performing all work myself, Project Type- E]New Construction DRemodel Buil Addition �211 raployees working an this job. 4 ; A;'or below who have the following workers'compensation polices: address* p� 7 7 7 777 i 7 c1tv: -------------- ----P—nolle insurtinee,an. # Failure to secure coverage as required under Section 25A,of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisounient as-erefl,as civil penalties in the form of a STOP WORK ORDER and a fine of MOM a day against me. I understand that a copy of this statement may be forwarded to the Office of Inve.stigations of the DU for coverage verification. I do hereby penVi under thepains andp, In MA perjuq that the informadon provided above is true and correct :> Signature Date Print name ;> Phone official use only do not write in this area to be completed by city or town official city or town: permit/license# -E]Buflding Department .4 OLicensing Board check if immediate response is required OSelectmen's Office E]Health Department contact person: phone#; DOther (mvised SepL 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7th Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 Board of Building Regulations and Standards g g , 4�1_ HOME IMPROVEMENT CONTRACTOR (Y'. V'- Registration: 101862 "z= Expiration: 6/29/2006 Type: Private Corporation RAYMOND E. DAMPHOUSSE,JR.&SONS Raymond Damphousse,Jr. 75 Butternut Lane Methuen,MA 01844 Administrator i A 't "�{JPBfRfG �kr� . _icense: CONSTRUCTION SUPERVISOR Number: CS 046636 Birthdate: 06/02/1948 x Expires: 06/02/2007 Tr.no: 11748 Restricted: 1 G RAYMOND E DAMPHOUSSE JR l 75 BUTTERNUT LANE G METHUEN, MA 01844 Commissioner I !III[ I i The Commonwealth of Massachusetts Department of Industrial Accidents ,,: Office of Investigations 600 Washington Street Boston,MA 02111 \ ItMp / f -J) www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers j Applicant Information Please Print Legibly Name (Business/organization/Individual): S6 1L p"'J t2ba 1 C Address: (?,S 0 y—z t—tc-2 e-q 61 5^Itf' City/State/Zip: �I ri/�v �1� ,g Phone #: 9 7 �.3 Y Z d ' Ar�yoemployer?Check the appropriate box: Type of project(required): mployer with 4. ❑ I at n a general contractor and I 6. New construction employees�(f /or part-time).* have hired the sub-contractors ❑ 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. * E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P h'• 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions ` myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box#I must also till 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 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.!!l ►y`-��•fit—1=J� / �I Policy#or Self-ins. Lic.#:b « IJ G G �x Expiration Date: Job Site Address: LJ L4 'A S H City/State/Zip: J4 I u 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sip,nature: Date: Phone#: Official 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/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 employes. 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 perfonnance 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 cavy 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 confinnation 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 Fax # 617-727-7749 Revised 5-26-OS www.mass.gov/dia