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HomeMy WebLinkAboutBuilding Permit #836-13 - 104 AUTRAN AVENUE 6/4/2013 Q*,OORTH 'V�90 6 AH BUILDING PERMIT oT 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 14k I I IOgAy..0. Date Issued:A 141 1:� AcHU IMPORTANT:Applicant must complete all items on this page J LOCATION f _!fl ".0 O W, I�N r PRO t UP E c S MARN G DIST alk, PARC AV- Gz�-r s no yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential F1 New Building 0 One family Ll Addition 0 Two or more family [I Industrial 11 Alteration No. of units: D Commercial �epair, replacement El Assessory Bldg 0 Others: 11 Demolition [I Other V, ❑ 6 !�t lu lahc1i" 'el I F1 tiershedb i IS 61 io e F-, OF Ice-, t�,A(to_ a(c V6 -jl OF ROO, P o)C e , fv Newt V0\Jf M5 L,) -fakXL- MP_ 5 L Identification Please Type or Print Clearly) OWNER- Name: A�C-Re� WP�L­1(2—� DPhone: 0. Address: 0l0 U-((2 Phon, CONTRACTOR WOE"' 1,1111 A ddre AA �si Pl,�Iffl WW� 6 78 t0".ense,: 9P t4"' b Iss AIY� ery sor s Construldio' V 'b" 14 .......... =Home Im'proyem enttbi c- ense h , a,e* 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- $ —FEE: $—. Check No.: 14 at Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatun�,ofAg_e­n't/0,w- ner ure of contractof TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page 0 `PR®PERTtY OWNaR _ _ Pnnf ' 100 Year�Old tructure y}es nod 1, Y �MAPNO? _ P-ARCEL _ Z®NING ®ITRICTa __SHisto�ic Distract es) _ moi Macfine�Sh''op)Vil agog_ 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 q1Sepf j [wWell f'" ,. ®1Floodplaln) Y ®rUVetlands `Y �i Watershedj®str ct ~� . .�❑iWater/S,ewert .�__ -.._-. .. - _ :a __ .. _.. __ .. .. _. I� DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address � S Nameno �CONTRACTj.a ORF' _ f " SuPAW sofjsConstruction>rLicense .___ _ . Home)Imp�roveme_nLicense:; Er 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: $ FEE: $ Check No.: Receipt No.: INOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund t 'Signature of Agent/Owner Signature:of contractor..... 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location N4 W , 2 ' No. Date • • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ ; Building/Frame Permit Fee $ � Foundation Permit Fee $_ Other Permit Fee $ a Ari: TOTAL $ Check#71G4 26474 Building Inspector J Plans Submitted ❑ Plans Waived"El Certified Plot Plan ❑ Stamped Plans ❑ TYPE OFFSEWERAGEDISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . _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 ❑ El COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/recei t submitted Decision/receipt yes—.- Planning es --Planning Board Decision: Comments 1 Conservation Decision: Comments Water & Sewer Connection/SjDriveway Permit DPW Town ]Engineer: Signature: Located 384 Osgood Street — 7Fire E DEPAR7�Ii.WT - Temp Dumpster on site yes no ted at'124 Main:Street I ®eparmett sriatoe/elate COMMENTS I I 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 filo DANGER ZONE LITERATURE: lies No i MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine i NOTES and DATA—(For department use i I I B Notified for pickup - Date oc.Building Permit Revised 2010 r— nuilding Department 'rine following is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofirig, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L: Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products 10TE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building pp Permit Application Q Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o 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 OTE: 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 app.al 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 2012 NORTH Town of t E : ., ndover No. ver, Mass, coc Mlc Nl WICK ��• AERATED S U BOARD OF HEALTH PER j Food/Kitchen LD Septic System T T THIS CERTIFIES THAT ,,..,,.,,,.. BUILDING INSPECTOR CPa % . ............ .......... ............... .... ........... ... .... ............... 1 .. A� Foundation has permission to erect .......................... buildin son .... ....:�.. ................. .......� Rough tobe occupied as ......+�1'i��. .�.�..... .... �....... . .......................................................................... Chimney h h erson acce tin this permit shall in eve respect conform to the terms of thea application provided that the p p g p every p pp Final on file in 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 0NTHS ELECTRICAL INSPECTOR UNLESS CONSTRU T Rough Service ............ .. ............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name(Business/Organization/Individual): `7 /y —v— Address: L( City/State/Zi ©T2#: 500, 5a-�) -( / I e you an employer?Check the appropriate box: Type of project(required): 1 tM am a �employer with_ 4. ❑ I am a general contractor and I * have lured the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. Y P tY• 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I 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' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. n Insurance Company Name:, (AI v� 2 Policy#or Self-ins.Lie.#: -30 W(_� > �� Expiration Date: a t Job Site Address: ��-1 �-�'`"► " City/State/Zip: N 4114D01t7L vhf 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. Ido hereby certto and t�pns penalties ofperjury that the information provided above is true and correct. Si atur Date: `s' Phone#: U 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 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-contractors)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 fox,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 of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,govfdza I i .aco CERTIFICATE OF LIABILITY INSURANCE DATE (MMDDry 06/04/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: .... ........ NORTH ANDOVER INSURANCE AGENCY INC. PHONE 978) 686-2266 FAx AGENCY, IAC No Ext) ( (ACG No) (978) 686-6410 _... ..... ... ........ ....... ........_ _......... .......... ......................._... ADDRESS:M.J. FOSTER INSURANCE SERVICES ADDREss: Jroberts@nafins.com PRODUCER_-______ _____ __......------------- ...__.___..___-_-______ 163 MAIN STREET CUSTOMER ID #JOHN BUCKNER NORTH ANDOVER MA 01845-2508 5-2508 INSURER($)AFFORDING COVERAGE MAIC# ....... ... ......... ..... ... ........ ......... ......... ..... _....... ......... INSURED INSURER A MERCHANTS _INSURANCE_ _GROUP ........ ,2.3329 _.... JOHN BUCKNER INSURER B .GUARD INSURANCE ............ .-............_..._...................... ................................................. DBA SHORELINE CONSTRUCTION INSURER C 84 MAGNOLIA AVE INSURER o INSURER E GLOUCESTER MA 01930-5110 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I•!$R ......... .. ...................... ..._.... __- 'WOOL SUOR ... POLICY EFF POLICY....UP _.. .._........ LTR -TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM'DD.,YYYY1 (MM'DDYYYY) LIMITS A ;GENERAL LIABILITY 'BOP2063453 01/25/2013 0 1/25/20 14 ,IF-E(.,1- !,{ 1,D00,000 v, I X '-rI•aLlr r r_h i I ILII EI CT tl e fi. 500,000 u7CL IF _tt .aC CCE Av:,i ),I__n; C 15,000 1,000,000 _._ ........ . -.vF I F.,,TF 2,000,000 ......................................................... -'-IJ a F -T. Lit 1- EP ._....._._.._ }: 2,0 00,000.F4i ................._ ............................................................... L1000 A AUTOMOBILE LIABILITY HCA7015674 01/25/2013 1/25/2014 f_r,pgE=ED IN'�LE LN,11T AId'Y, r 1,000,000 ................ ---...... ........ . ._.. i ........................................................... IN U. i.I X (:I'.UL ... ,.£.... ..... .... ...... .... - ..�r,C T X .., v C:a:Ji,,c.E i Ai-IT A XUMBRELLA uae X •„_;_I.. ';CUP9144555 !01/25/2013 1/25/2014 ;,-;T .,:..Fh,.Ef�-;F "£ 1,1000,000 .... ...._ .......____ .......... EXCESS LIAR ........... . E -•TE F 1,000,000 ........ ............. ................................................................. � - ETEr)ToN !WORKERS COMPENSATION 7oWC332450 02/04/2013 )2/04/2014 B !AND EMPLOYERS' LIABILITY -_ Y1 N: - _ r IT III 'ifFl FP.•1Ct1RF F. J. .(' N f A l_ C 'i 'IL r ....... f 500.,000 {Mandatory In NH) / ! / ! ;ul ..........................t 500 000 .L 500 000 A BOPPR ZOPI063453 01/25/2013 1/25/2014 25,000 DESCRIPTION OF OPERATIONS ! LOCATIONS VEHICLES (Attach ACORD 101. Additional Remarks Schedule. 4 more space is required) CERTIFICATE HOLDER CANCELLATION ( ) - (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1600 OSGOOD :ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- �� s ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025r;q ,) The ACORD name and logo are registered marks of ACORD SHORELINE CONSTRUCTION 84 MAGNOLIA AVENUE GLOUCESTER, MA 01930 978 525 3700 shoriinejbayahoo.com Home Improvement Contract John Buckner,dba,Shoreline Construction, Massachusetts Registration Number: CS 79530 ; EPA Safe Lead Certification No. R-I-18499-10-10189 agrees to do the following work for the Homeowner Alfred Paaaalardo 104-106 Autran Ave North Andover MA Name Address Phone Number Scope of Work: 1. STRIP EXISTING SHINGLE ROOF TO DECKING,INSPECT DECKING AND APPLY THE FOLLOWING: -- 6 FT. GRACE ICE AND WATERSHIELD TO BOTTOM EDGE OF ROOF 3 FT. TO VALLEYS AND CHIMNEY. -- 30 LB. FELT PAPER TO ENTIRE ROOF. -- NEW VENT PIPE BOOTS. -- 30 YR.ARCH ITECHSHINGLES(37SQ.)WITH ALUMINUM DRIPEDGE TO ALL EDGES OF ROOF. 2. CUT OUT CHIMNEY AND INSTALL NEW COPPER STEP FLASHINGS AND NEW LEND FLASHINGS. 3. INSTALL 2 NEW SKYLIGHTS TO MATCH EXISTING. 4. CLEAN AND HAUL AWAY ALL DEBRIS. Required Permits - The following building permits are required. This will be obtained by the contractor as the homeowner's agent: Building permit: Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL Chapter 142A. Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise: ,lune 1, 2013 Date when contractor will begin contracted work. June 15 2013—Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of 14,700.00 Payments will be made according to the following schedule: $_1,000.00 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ 13.700.00 upon completion of the contract.(Law forbids demanding full payment until contract is completed to both party's satisfaction) NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor?No Yes fall terms of the warranty must be attached to the contract Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance?Check to see that your contractor is properly insured. • Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. Was your house built before 1978? By Signing this contract..the Homeowner acknowledges receipt of the following EPA form: Renovate Right: Important Lead Hazard Information for Families; Child Care Providers and Schools. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract in List be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contractor. aAW,- VJPL4A A UA Homeown is Signature s Sign ure Date Date it Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitrati as oxide In Massachusetts General Laws apter 2A. Homeo per's ig ature Contra or's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A)may not be waived in any way,even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. _ I • . e Additional Information If you have general questions or need additional infonnation about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of"A Consumer Guide to the Home Improvement Contractor Law," contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301, Boston, MA 02108 (617) 727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617) 727-8400 AND/OR Better Business Bureau (508)652-4800 (508) 755-2548 (413) 734-3114 i This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A), but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"a Massachusetts consumer guide to home improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools Office�io, Oume' f airf�itsines�s xegutah License or registration valid for individul use only I HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 134582 Type: Office of Consumer Affairs and Business Regulation ' 10 Park Plaza—Suite 5170 i ; Expiration: t.]2/12/2013 DBA Boston,MA 02116 J BUCKNER;CARPENTRY_ ;i- JOHN BUCKNER ' 84 MAGNOLIA AVE-Y` GLOUCESTER, MA Undersecretary Not valid without signature e- __ I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor l License: CS-079530 JOHN F BUCKNER 84 MAGNOLIA AVVE GLOUCESTER 1qA 0193 cJw Jy � „ iso Expiration Commissioner 08/25/2014 J, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: l o t I o i ofao uoS City NOLlt� 800(),/(JL AAA_ Phone _5os N%-fW9 am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for may employees working on this job. > Company name: ��1N VC^`t�- 4 l A- Address -1 � City: (Loy6«f� ' °_ 1 L/t I Phone#- Insurance Co. "'`� Policy# J0 LA) 1 �V Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. /do herb certify under the ain a d a r u that the information Y Y p����� p 1 rY o atron provided above is true and correct. Signature %//L Date C9 3 Print name �)'0 HN &CMrl� Phone# Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department 171Other FORM WORKMAN'S COMPENSATION