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HomeMy WebLinkAboutBuilding Permit #722-11 - 15 WOOD AVENUE 4/27/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION `boa ►aQ Print PROPERTY OWNER Q c)Sor> >I b Print MAP NO:J_&_PARCEL: ZONING DISTRICT: Historic District yes 0110 Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial 53 Alteration No. of units: ❑ Commercial �I $I Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic O Well ❑ Floodplain EJWetlands 0 Watershed District. ❑Water/Sewer i DESCRIPTION OF WORK TO BE PERFORMED: ( 1 961mr, .32�.J� f y q �1 A a 1 Q1 �Q r. � G '► c�cL,, I� Identification Please Typ6 or Print Clearly) ` OWNER: Name:�_y oe r 1 Phone;g-g0 - OIC Address: I ti \Joeid No 62C_x1- A,!.ta4 a IMA CONTRACTOR Name: ��.,;� �,.!-1�r, Phone:(civ '�G�3 j Address:" ?_til _ ►C41 Ad A 00A � Supervisor's Construction License: 00 3 Exp. Date: 3✓0g/ Home Improvement License:I 86 c� Exp. Date: ��� (� old-3 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. i Total Project Cost: AlaOa 4d FEE: I Check No.: Receipt No.: C NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund SignatureofiAgentLQwnerk�,rQ�, � Signatureof�contractoc Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ f THE FOLLOWING SECTIONS FOR OFFICE USE ONLY R INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ' 1 HEALTH Reviewed on Signature I COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes 1 Planning Board Decision: Comments c Conservation Decision: Comments Water &b 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. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 I . ; 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 I ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ` ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses 1 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 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance ors special permit was required the Town clerks office must stamp the decision from the Board of Appeals P that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording j must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi a Location '}✓moi No. ) Date NaR*M TOWN OF NORTH ANDOVER O? • 1 • O� + s .� . , Certificate of Occupancy $ �uMus<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24b �16 Building Inspector vv/ 6r/ 61!11 wnLj 16: VV nAA y/0 to% a�ay Joanne A MitlS J.ne Agnoy I�O02/0�2 i ACORD... CERTIFICATE OF LIABILITY INSURANCEDATEIMINDWY1'TY) 0412712011 PRooucsa 978.686-0826 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION JOANNE K MILLS INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 166 HAVERHILL ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR METHUEN,MA 01644 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. j I INSURERS AFFORDING COVERAGE NAIC# INSURED INOURERA: N&D GROUP MUTUAL INS CO MICHAEL FIORI INsuR�Re: 23 CAROL STREET INSURERC: DRACUT,MA 01826 INSURER D: INSURER E; COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVMTHSTANDINO 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 13 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ �S •• ••,� - POLICY NVMB6R TTI EFFEOTIVE POLICY EXPIRATION DATE(MMfC21YYj LIMIT! A GENERALLIAEILITY EACHOCCURRENCE $ 'I MILLION X COMMERCIAL GENERAL LIASILITY R0651359A 09-16-10 09-15-11 RE a euronee S 50,000 CLAIMS MADE ❑X OCCUR MED EXP(Any one porton) S 5,000 PERSONAL A ADV INJURY $ _ GENERALAGGREGATE $ 2 MILLION GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGO 6 2 MILLION POLICY PR LOC AUTOMOBILE LIABILITY ANY AUTO (Ee IdnSINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS (For INJURY $ penon) HIREDAUTOS / 60DILV INJURY $ NON•OWNED AUTOS (Per eoment) PROPERTY DAMAGE (Per eccWerd) 9 OARAGELIABILITY AU_TOONLY-EA ACCIDENT $_ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCEDS/UMBRELLALIABILITY EACHOCCURREM09 6 OCCUR FICLAIMSMADE AOOREMATE $ DEOUCTISLE a _ RETENTION $ 8 WORKGRSCOMPGNOATIONAND TAT . 0TH. EMPLOYERS'LIABILITY LIM ANY PROPRIETOR/PARTNER/EXECUTIVE E-L.EACH ACC_I_DENT _ $ OPPICERfMEMBEREXCLUDED7 E.L.DISEASE•BAEMPLOYEE $ _ Ifyyea AL PRO under E.L DISEASE.POLICY LIMIT $ BPEGrIAL PROV1810N8 below OTHER DESCRIPTION OF OFERATIONG/LOCATIONS/VEHICLES I SXGLUBIONB ADDED BY ENDORGIMENT/SPECIAL PROV1910N0 i I CERTIFICATE HOLDER CANCELLATION OHOULDANY OF THE ABOVE DESCRIBED POLICIES DECANCELLED BEPORE THE EXPIRATION DATE THERGOP,TNG ISSUING INSURER KOLL ENDEAVOR TO MAIL DAYS WRITTEN TOWN OF NORTH ANDOVER NOTICG TO TNG CERTIFICATE HOLDER HAMBD TO THE LEFT,BUT FAILURE TO DO SO SHALI, BUILDING INSPECTOR IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS!AGENTS OR NORTH ANDOVER MASS 01845 REPRES@NTATIVIW AUTHORIZED REPRESENTATIVE oanne K Mills ACORD 25120011081 0 ACORD CORPORATION 1968 Frov neue galerie new york 104/27/2011 12:44 #320 P.001/001 nco CERTIFICATE OF LIABILITY INSURANCE DATE`4/27/11 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 endorsenenl(s). PRODUCER CONTACT NAME: Georgetown Insurance Agency PHONE 978 352-8000 a No: (978) 352-7719 10 West Main Street ADDRESS: info@Geon etownInsurance.com Georgetown, MA 01833 PRODUCER 10588 INSURE S AFFORDING COVERAGE NAIC 0 INSURED INSURERA:Zurich Insurance Michael Fiori INSURER B: 23 Carol St INSURER C: Dracut, MA 01826 INSURERD: INSURER E: 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 CONTRACTOR 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 OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM1DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ A GEO RENTED T COMMERCIAL GENE RAL LIABIU TY PDR MIS Me c urs e $ CLAIMS MADE F—]OCCUR MED EXP(Anyone person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GEN'LAOGR-GATE LIMITAPPUESPER PRODUCTS-COM°/OP AGO $ POLICY JECPROT LOC $ AU TOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (E a aca dent) ANYAUTO BODILY INJURY(Per person) $ ALLOWNEDAUTOS BODILY INJURY(Per accident) $ SCHEOULEDAUiCS HIRED AUTOS PROPERTY OAMAOE $ (P er accident) NONIOWNED AUTOS $ UMBRELLALIABOUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ II A WORKERS COMPENSATION 4179P334 4/1/11 4/1/12 TWO STATU- OTH- AND EMPLOYERS LIABILITY YIN1. FIR ANY PROPRIETCRPARTNER/EXECUTNE E.L.EACH ACO DE NT $ 100,000 OFFICERMIEMBER EXCLUDED? y N/A (Mandatory andNH) E.L.DISEASE-EAEMPLOYEE $ 100,OOO If yes,d escribe under DESCRIPTION OF OPERATIONSbelow F.L.DISEASE-POLI CYLIMIT $ 500,000 -F17 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more spate le required) Operations typical of a residential carpenter Fax 978-688-9542 Sole Propietor, Michael Fiori, has not made an election for coverage under the WC policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, Ma 01845 AUTHORIZED REPRESENTATIVE Mar aret Smith ©1988-2009ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The AC ORD name and logo are registered marks of ACORD From:neue galerie new york 04/27/2011 12:44 #320 P.001/00f ACORO0CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDIYVW) 4/27/11 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), AUTHOPoZED 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: Georgetown Insurance Agency PHONE FAX 10 West Main Street E�taL 978 352-8000 No: (978) 352-7719 ADDRESS: info@Georgetownlnsurance.com Georgetown, MA 01833 PRODUCER 10588 INSURE S AFFORDING COVERAGE NAIC fY INSURED INSURERA:Zurich Insurance Michael riori INSURER B: 23 Carol St INSURER C: p Dracut, Mtn 01826 1 NSURER D: 7 INSURER E: 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 OFSUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POU CY EXPLTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/Y MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERGAL GE NE RAL LIABILITY EM ES r $ CLAIMS�v1ADE OCCUR - MED EXP(Any one person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMITAPPUESPER PRODUCTS-COMP/OP AGO $ POLICY PRO- JECT F LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (E a acade nt) ANYAUTO BODIL Y INJUR Y(P er pe rson) $ ALL OWNED AUTOS — BODILYINJURY(Peraccident) $ SCHEDULED AUTOS PROPERLY DAMAGE HIRED AUTOS (P er accident) $ ^• NON-OWNED AUTOS $ UMBRELL.ALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY 4179P334 4/1/11 4/1/12 WCSTATU- 0TH- iP $ _ ANY PROPRIETORARTNER/EXECUTIVE Y/N I FIR OFFICERMIEMBER EXCLUDED? 7 N/A EL EACH ACG DE NT $ 3.00,OUt)_ (Mandatory in NH) E.L.DISEASE-EAEMPLOVEE $ 100,-Q00 If yes,describe under DESCRIPTION OF OPE RATIONS below EL DISEASE-POLICY LIMIT $ 500,0'00 DE SCRIPTION OF OPERATIONS/LOCATIONS/V EHI CUES(Attach ACORD 101,Additional Remarks Schedule,if more space is requi red) . Operations typical of a residential carpenter Fax 978-688-9542 Sole Propietor, Michael riori, has not made an election for coverage under the WC policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood street North Andover, Ma 01845 AUTHORIZED REPRESENTATIVE Margaret Smith ©1960-2009 ACORD CORPORATION. All rights res�:r od. ACORD 25(2009/09) The AC ORD name and logo are registered marks of ACORD 4 The Commonwealth of Massachusetts �r l Department of Industrial Accidents I �yj;, Office of Investigations 600 Washington Street w= Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ff Please Print Legibly Name(Business/Organization/Individual): 1[k srF�cc��sl Address2)'s � City/State/Zipv' �•r_,C, Phone #: '1 ss _. cf s Are you an employer?Check the appropriate box: Type of project(required): 1.—q I am a employer with L4 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 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.A Roof repairs (� insurance required.]t employees.[No workers' 13.El Other()r,,,5 ,•t y,h comp. insurance required.] *Any applicant that checks box#I must also fill 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 acid 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: . y.,cch i 1 Policy#or Self-ins. Lic,#: �U D A 1-1q I'l —q— \ll Expiration Date: Job Site Address:V5 41e j D u iZ City/State/Zip: /1/1 j,�.j h fo„Joipf 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 ains and penalties of perjury that the information provided above is true and correct. Signature: Date: I I Phone#: ke Q^I ' 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 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/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 5-26-05 www.mass.gov/dia Massachusetts 13ae Irrl I`ovement'Sample Contract This form o prate all basic requirements of the state's Home Ihnprovement'Contractor Law(MOL chapter]q2A),hat does not include standard lana -h.to prateck homeowners. Seek legal advice if necesenr - "Afiassechosetts consumer P o y,Any Person planning home improvements should fust obtain a co guide to home im r vement"before agreeing to any work on yourresiaence•you may obtain n free co PY of a r ' Offic of Ca¢sumer Affairs and Business Regulstinn's Consumerinformatien Hotline at 617-973-8787 or 1.888- 2a3- PY by calling the Ffomeowner Information 37s7. Contractor Information . aura - . oml?any ame •. aueehgddress(donot useaPostUthc Box address) Co¢tractor!Salaspet&aa/OwnvName • Citylfown ' State T.tpCode .' . l 2 t usjaess Address(must include a street addro;s) Daytime Phooe 0 Eveama Phone al can� :ityffown State ' Zip Code nitgAddress(11 ferentfromahove) "�''' �� 4-- • ¢siomssPhone ederalEmployer lDorS.S.Nomher ' IsarWoans Watmnri acme mi-,I Home pmvemeotCoonaeloeflea,Nmvbz tnovemmt morn-- mvea nxpualion date The Contractor agrees to do the•followba work for the Homeo net ahsnays omnaa nn,n,c,n__,Aem a r-�'�nc�rattmp ,,rsP g o du, I�W�J .. •.711�1vv1�. Requlred.permtks-Th 'a 1011owingbaildibgpmmits am required Prupmsed Start and Completion.Selredule- and%fill he secured by the contmetur as the bomeownces agent, be adhered to unless circumstances beyond the he iZO-i-co-h d arise The fplIowiag schedule will (Owners who secure their oven permits wiU be excihded from,the Guaranty Fund provisions of a.� MGL chapter 142A.)' 11 Date when contractor will begin enntrdetod worth. `1l Dite when contacted work will be aubstanpally completed. Tarok°°tract��en and Payment Schedule The connector agrees m perform t(re wort r furnish the material and labor specified above for the total sum of SOD 0 Payn{c __itta will he maM de abcording to the following schedule: upon signing'conuact(;'Otto exceed i/3 ofthe'total contract rice r ' P Ura cost of'special order'(alas,whichever is greater) by ! (�oxun°n egg I tif �. w nu t d $ r-- by (._! -or upon complotion of}\ Y�.�i ; upon completion of the conhect. (Law forbids demanding " g full paymentunol contract is completed to both a The fallowing waterlallequipmeidmust be special y party's satisfaction) Ordered before the contracted warYbegins in order S to 6e paid far to meet the completion schedule.(++) to be paid for •; - NOTES:(*)including finance charges(•+)Law yegair not -res that any deposjt or dow¢-payment required by the contractor before war:begins may at ex axcced are greater of(a)one third of the total w¢hact Pt.. or(b)the acetal cast of tory special equip,mt or custom made material which must ha special oi'deredin`dvance to meet the compictioa schedule. B rAss Warre¢h Ts an exnrseo.orrnu6 h in a . Subchntractoi econtr.ra;A Na y� nil terms of fha rrnn must ha nttac ed o aeon Oct 9 Theilized y th agrees to be solely responsible for coiapletio¢of the work described regardless of the actions ofan paily�subconnactor utilized by the contractor, Tbc contractor further agreeg to be solely'respbnsible far all a materials and laborn+tderthis eareement Y turd ContractAcceptance- entsigning, P Ymcnts to all subconhmctors for' Upttan i lien in o this other unity comes a to'uti'ng contract under law.U¢lesi otherwise Hated within flus document the corefull shall net imply that any lien or other security interesthas been placed on the residence. Review the fallowing cautions and document, carefully before sig¢ing this contrack ' notices • Don't be pressured into sigan •' ` • ke s r con c orhas g tae contract Take time to read and h a Hqma fully understand it Ask questions if something is unclear. re a f o oto R.c " do @ubconnactors to be registered with the Director ofHome Itnpmvement Contractor Registratioa You may inquire about contractor The law requires most home impraveohenteontmctors and rogistrah°nbY,'tvritiug to the Director One Ashburton Pla'Provemlt Co Bost- legistr)O8w•b calling quit 1-800-223-0933. • Does the contractor have insurance? Y g 727-3200 or cant n1ar is property insured. • see Know yourrigbts and responsihilitiesC$eat the Important Infdrtitation on the reverse side of this form and et a co Guide to the HomcImprovement Contractor Law, ' •> g py of Ute Consumer thiall may cancel this agreement if it has been sjgned at a place'ather than the conhracmrs.normal place ofbusiness,provided you nofify the rd b sarin writing at his/hermain o$-Ice or brunch ofl9ne by ordinary marl'posied,6 tele �— thirdbusiness day following,the signing of tris agreement See the attaclierl aotice ofpancellntien form far do Y gram sent orby deljdery,not later than midnight of the explanation of this light. DO NOT SIGN TRIS CONTRACT I�T]EtERE Two ideoticsl mpiu efthe•contactmust be completed and sinned.Una mpysaould an ro��AIV'Y$LANK SPACES!!! �'t �y,,, /� f wn¢Theathcr copy saeutd hek�tyy ttieeonoactor. • —.LI�J�. //J JQ.c iT Ai��.Y �,�- a • , Il'omeowner's Signature Contractors Signa re, nate Contractor Arbitration The Hame Improvement ContractorLaw provides homeowners with:the right to initiatenn arbitration action(as an. alternative to-court action)if they have a disputewith a contractor. The same right is not automatically affordeto a' contractor,however. The contractor would have to resolve any dispute he/she has with-ft 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 homeowlier by the Home hnprovemeut Contractor Law. The contractor and the h6meoumer 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 afbitration firm which has been apprpved.by the Secretary.of the,Executive Officeof Consumer Affairs and Business Regulation and the consumer shall.be required to submit to such arbitrudonas provided In Massachusett,,General Laws,chapter I42A. H'omeowner's Signature Contractor'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(M(jL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,.eden by agreement However;homeowners may be excluded from certain rights if the contractor they choose is nut 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 workmanlilce manner. Homeowners may be entitled'to other specific]pgal rights'if the contractor guarantees or provides an express vrarraniy for workmanship or materials. In addition to guarantees or warranties provided,by the contractor,all goods sold in Massachuselts cariy an implied warranty of merchantability and fitness far a particular purpose An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the term's of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questionsi about your consumd/homeowner rights,contact the Consumer Ilnfotxnatiori Hotline(listed below). Execution of Contract The contract must be executed in du ]icate and should not be signed until-a copy of all exhibits and referenced documents have been,attachi d. 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 land 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 cppy 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 paymeat schedule in cases where the homeowner deems him/herself to be fuiancially insecure.'However;in instances where a poniractor deems liinoll}erself to be financially insecure,the contractor may require that the balance of funds not yet due be placed iu ajoiut esgrow account as a prerequisite to continuing the contracted worlr.,Withdrawal.of finds 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 ot}er consumer rights,ortf you wish to obtain a free copy.of"A Consumer Guide the Improvement Contrapt'or Law,"contact: Consumer Information Hotline+ Office of Consupier Alfaits and Business'Regulatioa .10 Park Plaza,Room 5170,Boston;MA 02116 (617)973-8787'or 1-(8'88)2833757 If you want to verify the registration bf 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 Improvemenf Contractor Registration Bureau o£Building Regulations and Staridards One•Ashburtoii Place,Rootn.1,301,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 Genera] ' (617)727-8400 AND/OR -Better Business Bureau (508)652-4800 .(508)735-2548 (413)734-3114 FIORI CONSTRUCTION 23 Carol Street Construction Lie. CS104035 Dracut,MA 01826 Home Improvement Lie. 162527 i (978)265-6843 Fully Insured/Workmans Comp Work Submitted to: Rose Ventrillo Job Name: Rose Ventrillo Address: 15 Wood Avenue North Andover, MA Proposed Work to Be Performed: -Remove all layers of shingles of existing roofing. -Install new ice and water shield 6'.w from the bottom. The remaining roof will be covered in tar paper. -Install new white drip edge on all roof edges. -Install new 30 yr green architectural shingles. -Cut in and install a new cobra vent on the top of the roof. -Install-a new.stinkpipe boot on the roof. • � ____ ;.._.=�e-.tar.t et; �nney:..._ _—__--,r___-• ____ -- --- . - - - - - -Purchase a permit prior to starting the j ob. _ -Dispose of all.material in a legal manner. Total Labor and Material: $6,000 The amount of$3,000 is due upon signing this contract, receiving all roofing material, and receiving the permit. The balance is due upon completion of the roof. Date 01,'j_ =f i Signature I I I � _ � Office ot'C`on umairs Bifsiness egulation�. � j HOME IMPROVEMENT CONTRACTOR Type. ' Regi;[ration 062526 Expiration 3116!2013 DBA M HAEL.FIORi CONSTRICTION I MICHAEL FIORI 'r z 79 I I 23 CAROL ST DRACUT,MA 01826a Undersecretary 1lassadfit�crt,,-.i?e{ta Tment fitP:t 1ic �ttity I} Bo trtf of Slulttim Rt ilati I uid Statttl a tG�';', ,; �� Gons�ruction 5upe��sor Llcfnse ;} `` Licen e: CS 104035 r' FRestricoed toi 00 MICHAEL FIORI. 23 CAROL ST DRACUT,MA 018261 " 104035, I J ORTH Town of Andover ...... .... . 4 0 �' Jt( 3 LAK O dower, IVlass., d COCHICHEWICK ��• �d ADRATED �'�5 S U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 11 II THIS CERTIFIES THAT BUILDING INSPECTOR � ...... �.. r`..AIv.......................................................................................... Foundation has permission to erect........................................ buildings on ...... . ....... 1f W. 9 �� �..(�D.G[......f!�'..�.............................. Rough to be occupied as........... .. ..... . ...... .r�iAQ ... ....:........................................................ ....... Chimney provided that the persona opting this permit shall in ry 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 1 Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU ST TS ELECTRICAL INSPECTOR Rough ........... ........................................... ....... .. Service . .. ........ ..... ...... ... .... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place Rough 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. IF_sEE REVERSE SIDE Smoke Det.