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Home My WebLink AboutBuilding Permit #834 - 114 VEST WAY 5/1/2018 TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit NO: `7 Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION lle2r 04i/ Print PROPERTY OWNER Print MAP NO:/-0-41PARCEL:�ZONING DISTRICT: Historic District yes o Machine Shop Village 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 p Septic ❑Well ❑Floodplain 0 Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION O WORK TO BE PERFORMED: Cv# Ae�A&,r- (Identification Please Type or Print Clearly) 0WNER: Name: G rs v Phone: ?/9 Address: // T 6AJ / CONTRACTOR Name: &e L .IA'C A641 Phone: Address: I OLV�- W0001F Q-�D 5A2z K '�(A 03 p� Supervisor's Construction License: s `1 7 SSU Exp. Date: '�3 Home Improvement License: 1 Exp. Date: I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BAS ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: q0 Receipt No.: 3 �-- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund SignatureofAgent/®wnerr _.. _ _:___-t_ Signature of contractor . Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: 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 ❑ Notified for pickup - Date E Doc:.Building Permit Revised 2008mi 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 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy 0'f 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 Ideon► 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: Doc.Building Permit Revised 2008mi Location&T/ No. Date la �ORTh TOWN OF NORTH ANDOVER • ; Certificate of Occupancy $ Cs<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # qv 24 ` ,:) 2 xl-� Building Inspector �y ��ze -U�omunw�ruuecr�� o��acsz�.t�`a f Office of Consumer Affairs&Business RegWatiu.r HOME IMPROVEMENT CONTRACTOR Registration':'-140997 Expiration:..----12/17/2011 Tr# 29:1368 i• Typef Individual PMC HOME CONTRACTORS PETER CIARALDI+ 9 OLDE WOODE 1Rb. - SALEM, NH 03079. _- Undersecretary Massachusetts- Department of Public Safety Board of Buildin- Rel-ulations and Standards Construction Supervisor License License: CS 97650 - I PETER CIARALDI 9 OLDE WOODE RD SALEM, NH 03079 I Expiration: 7/3/2013 ('ununisiuncr Tr#: 17860 ti Professional Building Services by PMC Date Estimate# Due Date 9 Olde Woode Road Salem, NH 03079 ;v7 nse#: CS97650 5/11/2011 1959 5/11/2011 " Phone# (603) 898-2977 F r> ,1,. ,� ^� j Name/Address: Michael & Heather Ursu Fax# (603) 890-3931 114 Vest Way E-Mail pete@professionalbuildingservices.com ,_ � , North Andover, MA 01845 Web Site rofessionalbuildin services.com �d/ G`SERV►CEsj Description Qty Cost Total Install James Hardie house wrap across rear wall Install 3' ice and water barrier across rear wall Install additional layer of flashing between pavers and wall Re-install 1 slider and 1 rear door. Install 1 x8 PVC freezeboard across rear wall Re-install pavers Masonry: Add 2 courses of 4" blocks, waterproof and seal. r�° 1 2,750.00 2,750.00 Do all additional bracing R19 insulation ' '�` k • 278 2.01299 559.61 Upgrade to r-20 closed cellpray foam add $500 �--- _. Trash disposal & Clean up''•,. �N' 1 280.00 280.00 No work shall begin prior to contract being signed by both parties.Warranty period is 1 year on workmanship defects A 2J- . and material is manufacturers warranties. Payment schedule is: 50%is required to begin work,35%once 75%of Total $7,429.61 work has been completed,15%upon completion. Payments made to Professional Building Services by PMC.All C changes,additions,deletions to scope of work MUST be submitted through a chan<.zc order and agreed/signed by both Customer: parties. Customer agrees to pay(up or down)where allowance was allocated.Conc.truction dumpster is for the sole use of contractor. We will not be held responsible for any driveway, lawn or any other damage by dumpster placement or equipment.All money owed will be charged 1.5%monthly(18%annually)until payment in full has been received. Contractor: Work scheduled to begin on and be completed by Page 2 Date: N t ��imate# Due Date _____j PMC L��O�� 5/11/2011 Services by 'sional Building 5/11/2011 1959 foode Road ? „nse#: CS97650 Name I Address: Michael & Heather Ursu ..a 03079 `') 114 Vest Way . none# (603) 898-2977 North Andover, MA 01845 Fax# (603) 890-3931 , rofessionalbuildingservices.com Q G SERVICES E-mail pete alp Y Total Web Site rof ,ssionalbuildin services.com Qty Cost Description Scope: Repair rear wall sill and wall damage. Add 8" of masonry blocks 1 3,840.00 3,840.00 Remove 39' of exterior sheathing to expose wall and dispose Remove 1 course of pavers to expose sill Remove existing insulation and dispose n of doors until they are removed and inspected. Remove 1 slider and 1 rear door-will re-install after wall repairs. ** Please note* Contractor does not know conditio to re-use those doors. Contractor will make all attempts Build temporary bracing to support wall Install sill insulation Install sill pan across entire concrete sill Install 2 - 2 x 6 pressure treated sill plates As to NOT remove existing drywall on electrical side, sister d 2x4 studs to existing 2x6 studs and attach across the 39 wall. No ** Jack stud and King stud removal may need to change casing of doors to wider trim **TSD in field during construction Install 1/2" plywood for exterior sheathing across 39' wall ear on workmanship defects Total No work shall begin prior to contract being signed by both parties.Warranty period is 1 yon 75%of and material is manuracturerowarranties. PamenPavmedntsemade t prole 'ioat Building Serv3ces�by PMS bAboth Customer: work has been completed,15/o upon completion. changes.additions.deletions to scopeoffworkMUST be allowance was ed hallocat a Construction ddumpste s for the sole parties.Customer agrees to pay( p charged 1.5%monthly(18°/<)annually f until payment in frill has been received. Contractor: use oPcontractor.We will not be held responsible for any driveway.fawn or any other damage by dumpster placement or equipment.All money ocl.d willbe to begin on and be completed by____._.— pate: Page 1 Professional Building Services by PMC [Pato M ate Date Estimate# Due Date 9 Olde Woode Road Salem, NH 03079 M nse#: CS97650 5/18/2011 1964 5/17/2011 + Phone# (603) 898-29771 �.. r, _ Name/Address: Michael & Heather Ursu Fax# (603) 890-3931 _ 114 Vest Way E-Mail Pete@professionalbuildingservices.com North Andover, MA 01845 Web Site professional build in services.com V, ' SERVICES Description Qty Cost Total Product: Smooth-Star Entry Door , Unit Size 31.625 x 81.125 1 636.16 636.16 Dimensions: Call Width = 26, Call Height = 68 Therma-Tru Door Options: Hinge Right, Out-Swing, Slab Height Cut Down Size = 78 Therma-Tru Frame Options: Primed, 6 9/16", Mill Fixed Outswing Sill Therma-Tru Hardware & Prep: Bore Lockset & Deadbolt Therma-Tru Door Grille: Molded Non-Removable Grille Glass: Clear, Standard Therma-Tru Door Style: 5262 TT Performance Ratings: Impact Rated Glass = No Wrapping -Therma-Tru Exterior Options: No Casing Trash - Can throw in existing dumpster if there is room 0 0.00 0.00 Pan and sealants 1 175.00 175.00 Interior Trim 2 1/2" primed 1 65.00 65.00 Install Labor to remove and install new door 1 800.00 800.00 Plumbing Allowance to move heat: Estimated 1 450.00 450.00 ***2 trips must be made - 1 to disconnect to install door, second trip to reconnect No work shall begin prior to contract being signed by both parties.Warranty period ].; I year on workmanship defects and material is manufacturers warranties. Payment schedule is: 50%is required it) begin work,35%once 75%of Total $2,126.16 work has been completed.15%upon completion. Payments made to Professional Building Services by PMC.All changes.additions,deletions to scope of work MUST be submitted through a chaneorder and agreed/signed by both Customer: = parties. Customer agrees to pay(up or down)where allowance was allocated.Con;iruction dumpster is for the sole use of contractor. We will not be held responsible for any driveway, lawn or any other damage by dumpster placement `s/��%V or equipment.All money owed will be charged 1.5%monthly(18%annually) until payment in full has been received. Contractor: Work scheduled to begin on and be completed by Date: _LI Building Services by PMC �� 0 �' Date Estimate# Due Date Road 179 nse#: CS97650 5/13/2011 1962 5/13/2011 �9 iO3) 898-2977 rii � �..,��, Name/Address: Michael & Heather Ursu 803) 890-3931 _ 114 Vest Way a ' e�professionalbuildingservices.com North Andover, MA 01845 cfessionalbuildin services.com 6 %: G�SERVICES Description Qty Cost Total TOTAL coverage - Hardie shingle in Cobblestone 31 1,350.00 41,850.00 Strip All siding down to exterior plywood sheathing All disposal included Install Hardie wrap around entire dwelling Install Hardie painted fibercement siding to manufacturers specifications. Hardie wrap included. Hardie soffit included Hardie wide corner boards included Replace window and door trim with Hardie trim Remove trim Seal and install 2 car garage door trim 30 Windows/Door units Freeze 10" freeze board across bottom and under soffit 1 470.00 470.00 No work shall begin prior to contract being signed by both parties.Warranty period is I year on workmanship defects and material is manufacturers warranties. Payment schedule is: 50%is required to begin work.35%once 75%of Total work has been cornpleted,15%upon completion.Payments made to Professiona! Building Services by PMC.All changes.additions,deletions to scope of work MUST be submitted through a change order and agreed/signed by both Customer: parties.Customer agrees to pay(up or down)where allowance was allocated.Construction dumpster is for the sole use of contractor. We will not be held responsible for any driveway. lawn or any other damage by dumpster placement T or equipment. All money owed will be charged 1.5%monthly(18%annually)until payment in hill has been received. Contractor: Work scheduled to begin on and be completed by Page 2 Date: Building Services by PMC Estimate Date Estimate# Due Date Road 79t Qnse#: CS97650 5/13/2011 1962 5/13/2011 - 03} 898-2977 _ "l Name/Address: Michael & Heather Ursu 303) 890-3931 114 Vest Way te@professionalbuildingservices.com North Andover, MA 01845 • )fessionaibuiidin services.com G�SERVICES) Description Qty Cost Total Building Permits: to be pulled at no charge but contractor will be reimbursed for fee to 0.00 0.00 town. Trash container to be allowed on-site. All waste and trash disposal - included 1 0.00 No work shall beGin prior to contract being signed by both parties.Warranty period is 1 year on workmanship detects and material is manufacturers warranties. Payment schedule is: 50%is required to begin work,35%once 75%of Total work has been completed,]5010 upon completion.Payments made to Professional Building Services by I'MC.All changes,additions,deletions to scope of work MUST be submitted through a change order and agreed/signed by both Customer: parties.Customer agrees to pay(up or down)where allowance was allocated.Construction dumpster is for the sole use oPcontractor. We will not be held responsible for any driveway, lawn or any ot]- r damage by dumpster placement or equipment.All money owed will be charged 1.5%monthly(18%annually) until payment in Hill has been received. Contractor: Work scheduled to begin on and be completed b} Page 1 Date: Professional Building Services by PMC Date Estimate# Due Date 9 Olde Woode Road Salem, NH 03079 M nse#: CS97650 5/18/2011 1966 5/18/2011 Phone# 603 898-2977 Name/Address: Michael & Heather Ursu Fax# (603) 890-3931 D !° � 114 Vest Way - h E-Mail pete@professionalbuildingservices.com r — – North rt Andover, MA 01845 Web Site rofessionalbuildin services.com G SERVICES, Description Qty Cost Total WINDOW over garage replacement: 1 225.00 225.00 Harvey will cover window under warranty. Replacement unit will be same specifications Will be installed by Professional Building Services. All discounts applied Disposal -will fit in existing dumpster used for siding disposal. 1 0.00 0.00 If can not fit, please at$75 disposal fee No work shall begin prior to contract being signed by both parties.Warranty period i I year on workmanship defects and material is manufacturers warranties. Payment schedule is: 50%is required to begin work,35%once 75%of Total - $225.00 work has been completed.15%upon completion.Payments made to Professional Building Services by PMC.All changes,additions.deletions to scope of work MUST be submitted through a change order and agreed/signed by both Customer: _ parties.Customer agrees to pay(up or down)where allowance was allocated.Construction dumpster is for the sole use of contractor. We will not be held responsible for any driveway, lawn or any other damage by dumpster placement �C�?�� or equipment. All money owed will be charged 1.5%monthly(18%annually)until payment in full has been received. Contractor: Work scheduled to begin on and be completed bN Date: _�_� Director of Home Improvement Contractor Registration Bureau of Building Regulation's 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 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 n-9,1-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 arbitration as provided In Massachusetts Gener I Laws,chapter 142A. 6le-o4kI A C o eowner's Signature c 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 fora 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. Additional Information If you have general questions or need additional information 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: Wake 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. DO NOT SIGN THIS CONTRACT IF THE ARE ANY BLANK SPACES!!! T o identical copies of the contract must be completed and signed.One copy should go o the weer.The other copy should be kept by the contractor. i 111� a eowner Signature 'Contractor's Signature << ( A61 Date Date NORTH TO" Of _ 7 K E O # dover, Mass., ' COCMICMEWICK AORATED P �C S V BOARD OF HEALTH Food/Kitchen Septic System PERMIT. T BUILDING INSPECTOR THISCERTIFIES THAT..... .......... ..... .. .........U.11C �.............................................................................. Foundation has permission to erect........................................ buildings on ...I.01.......u4^T..... .dt. .......................... Rough ...Sold l j*wl .....Qal.�...... ........ Il�t....� � Cto be occupied asChimney provided that the person acceptin�thii� ermif shall in every respect conform tthe 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 3�► . PERMIT EXPIRES IN 6 ` ONTI S ELECTRICAL INSPECTOR UNLESS CONSTRUC ON TARTS Rough Service BUIL CTOR Final Occupancy Permit Required t0 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. Rie Commonwealth of Massachusetts t Department of Industrial Accidents � 1hF I 1T Office oflnvestigations 1 �•' 600 Wasli I it II IF i ington Street Boston,MA 02111 www.massgov/dica Y, • Workers, Compensation insurance Affidavit:Builders/Contractor•s[Electricians/Flumbers Applicant Information . Please Print ire 'bl Name(Business/Organization/Individual): C- - Address: City/State/Zip: ', �� IV cf a3v`7I Phone,#: '/'� c) 7 7 Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with _ 4. El am a general contractor and I 6• ❑•New construction ernployees(full and/or part-time)* have hired the sub-contractors 2.❑ I aia a sole proprietor or partner- listed on the attached sheet.1 7. F1Remodeling ship and have no employees These sub-contractors have 8, []Demolition working forme in any capacity, workers'comp,insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL - 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 1,52,§1(4),and we have no 12.E]Roofrepairs " insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also,fill out the section below showingtheir workers'compensation policy information. f Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: A re T67 0(� Policy#or Self-ins.Lia y W E6 / 00 1 Expiration Date: Job Site Address: // City/State/Zip: �^7t� OH 03 d Attach a copy of the workerscompensation 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby 'y un erthepains andpenalties ofpesjury that informationpro videdabove is true andcofrect.' Si ature Date: 6 /9//J Phone#: 1 C(^l Official use only. Do not write in.this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(cireIe one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6 .Other Contact Person: Phone#: Information and Instructi®ns . 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 e1uployer is defined as"an individual,partnership,association,corporation or other legal entify,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 aparhnents and who resides therein,or the occupant:of the dwelling house ofanother 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 bean employer." MGL chapter 152,§25C(6)also states that"every state or local Iicensing 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PIease 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 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/lieense number which will be used as a reference number. Irl addition,an applicant that must submit multiplOTermit/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 inust be f11ed out each mit not related to any business or commercial venture year. Where a home owner or citizen is obtaining a license or per (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 DeFartMiat of Industrial AcoideEnts Office of Tnvestiptions 640 Washington Street - Boston,MA 02111 Tel.#617-7274900 X 446 or 1-877-1 ASSAFE Revised 5-26-05 Fax#1:617-727-7749 www mass.govldia Mamas a h_usetts Home Improvement Contract This form satisfies all basic requirements ' q is 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. Homeowner Information Contractor Information Name MICHAEL AND HEAI'HERURSU Company Name 114 VEST WAY PROFESSIONAL BUILDING SERVICES/PETER CIARALDI Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name NORTI I ANDOVER MA 01845 9 OLDE WOODE RD City/Town State Zip Code Business Address(must include a street address) 978-208-7779 -SALEM NH 01845 Daytime Phone Evening PhoneCity/Town State Zip Code Mailing Address at different from above) Business Phone Federal Employer ID or S.S.Number 603-898-2977 20-5303576 Law requires that most home Home Improvement Contractor Expiration Date Improvement contractors have a valid reg.number Registration number CS97650 7/12 The Contractor agrees to do the following work for the Homeown r: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,ust additional sheets if necessa.) SEE ATTACHED DETAIL Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following and will be secured by the contractor as the homeowner's agent, schedule will be adhered to unless circumstances beyond Owners who secure their own permits will be the contractors control arise excluded from the Guaranty Fund provisions of i Date when contractor will begin contracted work. MGL chapter 142A.) 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: $52,850.77 (*) Payments will be made according to the following schedule: $_17,611.92 upon signing contract(not to exceed 1/3 of the total contract price oLthe cost of special order items,whichever is greater) $_17,616,92_by or upon completion of_REAR WALL REPAIR,WINDOW REPLACEMENT,SIDING STARTED $_17.616.93 by /�/ or upon completion of_SIGN-OFF OF BUILDING PERMIT BY TOWN OFFICIALS $ upon completion of the contract.(Law forbids demanding full payment 41 c ntract is completed to both party's satisfaction) The following material/equipment must be special$ to be paid for ordered before the contracted work begins in order$ to be paid for to meet the completion schedule.(**) 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. Exniesc Warranty-Ts an express warranty heiug nrovirled hype enntractor9 No Yes ( ta 1 terms of the warranty must be attnPhed to the rnntr��l 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.