HomeMy WebLinkAboutBuilding Permit #832 - 255 MASSACHUSETTS AVENUE 6/4/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: V00 J_?
IMIPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
UOne family
OWNER: Name:—
0 Addition
El Two or more family
0 Industrial
El Alteration
No. of units:
0 Commercial
PfRepair, replacement
El Assessory Bldg
11 Others:
D Demolition
El Other
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DESCRIPTION OF WORK TO BE PERFORMED:
a,
Identification Please Type or Print Clearly)
OWNER: Name:—
Phone:
Address: I
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ARCHITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
,W
'Total Project Cost: $ FEE: $
Check No.: Z04 �o 2 —Receipt No.:
NOTE: Persons contracting with un is con tors do not have access to the guarantyfund
;"Si, "Otbria 'Of.. enubwo
Ski, u re of c ra
Plans Su bmitted Plans WaiY6 11 Certified _. Plot .. PI a n Stamped Plans El
Building Department
The foli�-awinj is a -list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofirig, 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
10TE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
u Building Permit Application
L3 Certified Surveyed Plot Plan
o Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
Ei 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
OTE: 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
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
rmist be subrn'Ated with the building application
Doc: Doc.Building Permit Revised 2012
Plans Submitted D
Plans Waived -11 Certified Plot Plan 11 Stamped Plans F1
TYPE.-OF-SEWERAGE.DISPOSAL
Public Sewer
TanningIMassage/Body Art ' El.
-Swimming Pools
Well El
Tobacco Sales
Food Packaging/Sales D
Private (septic tank, etc, E]
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED - DATEAPPROVED
PLANNING & DEVELOPMENT El T1
COMMENTS
CONSERVATION
COMMENTS
H,
H E A',' T '
COMMENTS
Reviewed on Si-qnature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfrecelpt submitted yes_. -
Planning Board Decision:
Comments
Conservation Decision: Comments
Water Sewer Con necti on/Signature & Date
Driveway Permit
DPW To-jv;2 tugineer: Signkfire:
LOcatea 6M USgooci btreet
FIRE -EINT' Te'Ob"D'ump§ter on sit
e yes ._no
'�bcated at"! 24 Main Strd.et
Fire Qeparfihefit.s1gii WrOldatb
a
COMMENfS*
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 21 A —F and G min.$100-$1000 fine
Doc.Building Pennit Revised 2010
Locatio
N o.
Dat�-/�/�-
TOWN OF NORTH ANDOVER
Certificate oi Occupancy $
Building/Frame Permit Fee
d
Foundation Permit Fee F -b
Other Permit Fee $
TOTAL $
Check 6-*� 6-4"-
26471 1 Building Inspector
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Enter constr - uction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
—$ 1 %000.00
m
$ -
$
228.00
Plumbing Fee
$
28.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
28.50
Total fees collected
$
385.00
255 Mass Avenue
832-13 on 6/4/2013
New Kitchen Cabinets,
Tile Kitchen and Bathroom Floor
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The Commonwealth ofMassachusetts
Department ofIndustriqlAccidints
12 Office ofInvestigations
600 Washington Street
Boston., MA 02111
vwW.mass.gov1d1a
Workers' Compensation Insurance Affidavit: BufldersfContractor�[ElelctriciansfPlumbers
Ap-plicant Information Please Print Ledb
&)A '14 r
Name (Business/Organizationlfndividual): LAkA
Address: �D6;' C-PeSS -ST,
Phone#:
Are you an employer? Check the appropriate box: -
I - D I am a employer with 4. El lam a general contractor and I
employees (M and/or part-time).*
2. U11 am a sole �ropiietor or partner-
ship and'have no employees
working for me in any capacity.
[No workers' comp. insurance
required.)
3.E1 lamahomeowner-doingallwork
myself. [No workers' comp.
hisurance required.] t
have, ned the sub-coiitraGtors
listed on the attached sheet.
These sub -contractors have
workers, comp. insurance.
5. D We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance requiredJ
Typp of project (required):
6. New OASttuction
7. Remodeling
8. E] Demolition
9-. [].Building addition
10.[] E lectrical repaks or additions
1I.ElPlumbing repairs or additions
12111 Roof repairs
13.E1 Other
'�Any applicant that checks box#1 must also fill outthesectionbelow showing their workers I compensation policy information. indicating such.
I Homeowners who submit this affidavit indicating they ire doing allworkand then hire outside contractors must submit a now affidavit
tContractors that check this box must affached an additional sheet showing the name of the sub-contraotors and their workers' comp. policy information.
lara an employer that 1sprovialng Workers'compensation insuranceformy enployeeN. Be10JP is the.POMY GnJi0b site
information.
Insurance Company
Policy 4 or Self -ins. Lic.
Expiration Date: ------------ =
Job Site Address-, pity/StatelZip:
Aftach a copy of the workerO comp ensation policy fleclaration page (showing the policy number and expiration dvife).
Fail -are to secure coverage as requiredunder Section 25A ofMGL 0. 152 can lead to the imposition of criminal penalties of a
fine up to $1,50 0.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOp. WORK ORDER and a:rma
ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwardedto the Office of
Investigations of the DIA for insurance coverage verification.
I do h'erAy c ertify u n der A e F a in s an dp en a [ties ofp erju ry t7l at t7l e inform ation pro vided a b o v e is tru e an d c o rrec t
Sim i)ate: C, �o a l.'a
Phone 4: 2- 1 Z 7.0
Official use only. Do not tPrite in this area, to be conpletedly chY or toWil Official
City or Town: Permit[License#
Issuing Authority (circle one):
I.Board of Health 2. Building Departnient3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions.
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an em
. ployee is defined as "...everyperson in the service of another under any contract ofhiro,.
express or implied, oral or written.,,
An ein
,vloydis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engagedlu ajoint enterprise, and including the legal representatives of a deceased employer, or the
r0ccivcr or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house, havmig not more than three apartments and who resides therein, or the occupant of the
dwelling house 6f another who employs persons to do maintenance, construction or repair work on such dwelUng house
or on the grounds or building appurtenant thereto shall not because of such employment be doemod 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 forany
applicant who has not produced acceptable evidence of compliance with the insurance coverage requ,ired."
Additionally, MGL chapter 15�, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic; work until acce lee on 0 PR nce with the insurance
ptab vid c of com. a
requirements of this chapter have been presented to the contracting authority."
ApplicaUs
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to �our situation and, if
necessary, supply sub-contractor(s) name(s), address(es) andphone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cany workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirm�ation of insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should
be returned to the city or town that thic 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 aworkers'
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 printedlegibly. Tfie Department has provided a space at the bottom
of the affidaWt for you to fill out in the ev6nt the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in & penrit/lice'nse number which will be used as a referenc.o number. la addition, anappliGant
that,�Wst submit multiple pamit(liccuse applications "Many given year, need only submit one affidavit indicating current
Policy information (ifnecessary) and under "Job Site Address" . the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has b can officially stamp ed or marked by the city or town may b a provided to the
applicant as proof that a valid affidavit ii on Me -for future permits or licenses. A new affidavit must be filleLd out each
year. %ere a homeowner or citizen is obtaining a license or'p-ermit not related to any business or commercial venture
0.e. a dog license orp"armit to bum leaves etc) said person is NOTrequired to complete this affidavit.'
The Office ofInvestigations' would like to thank you in advance for your cooperation and should you have any questions,
pleas a do not hesitfte to give us a call.
The Department's address, telephone and fax number.
The Cowmojawoajt� of Yas�or,-h-v
Dapartraeut offadugrial Acoldonts
Ofte offlimilgatiolls
60 0 Wwhingtaa Sfx��- t
Bostp, MA 021 It
TO, # 617-72.7,49 0 0 Qxt 4 0 6 or 1-8 77-�MAS SAFE
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This folm satis:Res all b ements of the s�ate!s Home Improvement Contractor Law (MGL . chapter 142A), but does not include standard
language to protect homeowners. See] legal advice if necessary. Any person planning home improvements should Erst obtain a copy of "A
Massachusetts Consumer Guide to Hojae Improvementubefore, agreeing to any work on your residence. You may obtala a free copy by callilig the
Office of Consumer Affairs and Business Pcgulation!s Consumer InfolmationHotline at 617-973-8787 or 1-888-283.-3157 or on our w6bsite.
Homeowner information *Contractor Imformition —
StreetAddress
CdO nOtUsO a �P=Officc Box address)
City/Town
LJ1 UtA —
Mytime Phone �
C / � — zo/— r
state 'Zip—C—ode
Mailing Address (It different from
d ;Z i S—�Z
��ig —phone -
L tx — I
Uontractorl Salesperson/ Owner�Name
T7,,e-,,oA)^- J/*
J�Psmess Auctress (mast includea street address)
X0
5� 6T,
Cityllown State Zip Code
Business 3ne Federal Employer ID or S.S. Number
L -,1W requires t1i.1t raost 110me Explmfion date
ImPrOWInent C ntractors have
a willd registratZon nu inber c�
The Contractor agrees to do thb following work for the Homeowner:
(Describe in detail the worjc to Completed, sPecifYingthc tYPe, brand, and grade Of materials to be U�ed, ji-s_eadditional she
,S
,l e
--C - �,-S,
k� �Z-
Re4uir Permits -- T'he followiig building permits are required Proposed St' art and Completion, Schedule - . The following schedule Will
and will be secured by thecontractor as -the homeovmer's agent: be adhered to unless circumstances beyond the contractoes control arise
(Owners who secure their Own Permits:WiR be
excluded from the Guaranty Fund pro-,isions of �J' Date when contractor Will begin contracted wor1c.
MGL chapter 142A.)
—V—LDj—'I/--]Date when contracted work will be substantially completed.
Amu' u0nixactvrice and Payment Schedule
The Contractor agrees to p erfolm the wOr1c, fmnish the material and labor specffi- ed above for the total sum of.
Payments will bemade according to the following schedule: -4A� �- �(*)
$AX,S0—, Okupon sigriing contract (not to exceed 1/3 of tile total contract price pr the cost of special order items,
or upon completion of 4-94p-
$ by or upon compl�tion of
e, i
upoll completion Ofthe contract. (Law forbids demanding
fan Paymcn5tRUZ-GG�tract is completedto both partys satisfaction)
The f0llOwing material/equiPment must be special to be for
ordered before the contracted work begins in order 'or
to meet the completion o Xbbe paid for
NOTE, S: (1) Including all finance, charges (**) Lawrequires that any deposit or down -payment required bythe contractor beforeworkb may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of my special equipment or custom megaffidesmaterial
which must be special ordered in advance to meet the completion schedule.
larranty being provided by the Contmetor? F, -yes 11
Subcontractors - The contractor agrees to be solely resp - MICS "Ilte soithewnrran,-Vznustb�.���
PartYlsubcontractor utilized by th onsible for Completion ofthe Work described regardless ofthe actions Ofanythird
c Contractor. The c0ntraOtOr further agrees to be solely responsible for a paymentsto
materials and labor 'Under this aM6em It aJl subcontractors for
Contract Acceptance - Upon signing, this document becomes abinding
contract -qhaU not imply that MY lien or o erse contract under laW. Unless otherwise noted within this doc lr�
his contract. en placed On the residence. Pleview the f011Owing cautions and notices
carefally before signing t th curitY interest has be ume the
• Don!t be pressured into
0 s'guing the contract, Take time to read and fuliTtInderstand it Ask questions if something is unclear..
Make s Me—t—he colitractothas a valid Rome I IL tr gistrati
mProvementCon _actorRe on. The law requires most home improvement contractors and
subcontractors to be registered with the Director ofi-lome improvement Contractor Registration. You may inquire about contractor
registration by writing to tha Director at 10 Par1CPlaZa, Room 5170, Boston, MA 02116 or by calling
• Does the contractor have insurance? 617-973-8787 or 888-283-3757.
Ask the Contractor for his insurance company information so that you cau confirm coverage, or asic to
see a copy of a "Proof of Insurance' document
aOw Your lights and responsibilities. 1�ead the Important Information
oil the reverse side Of this form and get a copy of the Consumer
Guide to the Rome Improvemml Contractor Law.
Youmay cancel this agreement if ithas been signed at aplace other than the contractor's normal place of business, provided younotifythe
contractor in writing at his/her main OfF, cc or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midmight Ofthe
third business day follo wing the signing ofthis agreement See the attached notice Of cancellation form for an explanation ofthis right
DO NOTSIGN TMIS (UONTRACT IF THERE ARE ANY IMAM< SPACE SM
Two identical copies ofthe contract must be completed and signed. One COPY should go to the homeovmr. The other COPY Should be kept by the contractor.
Homeowner's Si ature
Uontractor's Signatare
'Date
Date
Confracior Arbifxifion
The Home Impiovement Contractor Law provides homeowners with the riglit to initiate an arbitration action (as an.
'alternative to court action) if they have a dispute with a contractor. The same right is not automaticpUy affordedto a
conttactor, 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 azf�orded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby �nutually 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 ffim which has been approved by
the SecretaT of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitra�qz asprovided In Massachusetts General Laws, chapter 142A..
Contractof s Sigriatare . .
di
R61-C(3�vnees Sipatw
NOTICE: The SignatL Kes-of the 'parties above apply only -to the agreement of the parties to alternative sp to
resolution initiated by the contractor, The homeowner may initiate alternative dispute resolution even where t1ais
section is not separately signed by the parties.
Homeowner's Rights
A homeowtier's rights under the Home Improvement Contractor Law (MOL 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 prpperly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excludedfrom all. Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as ' describecL in a
timely and workmanMce manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmatiship or materials. In addition to gaarantees or warranties
provided by the contractor, all goods sold -in Massachusetts carry an impliedwarrauty of merchantability and fitness for
a particular purpose. An enumeration of other matters on -which ffe homeowner and contractor lawfally agree may �e
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�our . 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 e-Aibits and referenced
documents have been attached. Parties axe also advised not to sign the document un -til all blank sections have been
ffiled in or marked as void, deleted, or not applicable. One original signed co-py of the contract with attachm6nts -is to
be gi7en to the owner and the other kept by the contractor. Any modification:�-o the. original contract must be in writing
and agreed to by both parties. Contracted work may not be J -=tilbothpardes have received afu�y Z=,Lted Qopy of
9111
the contract, and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand PaYments in advance ofthe dates specified on the.payment scliedule 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 thatthe balance of ftds not yet due be placed in ajoint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fimdp from said account would require the
signatures of both parties.
AAditional Wormation In th
If you. have general questions or need additional intbrmation about the Home iprovement Contractor Law or o er
consumer rights, or if you. wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Impiovement"
contact:
Consumer In ormation Hotline
Office of Consumer Affairs and Business Regulation
10 Paric Plaza, Room 5 170, Boston, MA 02116
. 617-973-8787, 8 88-283-3757 or visit the OCABR website at liZ://wv�Nv-.mmL.,90—v/oc,-Lbr/
If you want to verify the registration of a contractor or if you have questions or need additional irdormatim specifically
ab out the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
office of Consumer Affairs and3usiness Regulation
16 ParkPlaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the I -11C website at b=-//Evnv,.inass.gov/oc r/
Go online to view the status of a Home Improvement Contractor's Registration:
Wi)-//db.state.rn,,i.tis�iol-neum 3rovel-ne-nt/lice-nseelist.,:qsl)
F or assistance wiffi informal mediation of disputes or to re isier formal complaints against a business, call:
91
Consumer Complaint Section
Officp of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114. Version 2.1 - 11/22/2010