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Home My WebLink AboutBuilding Permit #095-2017 - 281 ANDOVER STREET 5/1/2018 txo RTFj BUILDING PERMIT O� etED ,6 qq TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: �x Date Received 1v gSS9CH�1`-+�� Date Issued: IMPORTANT:Applicant must complleete,afl items on this page /7 LOCATION. A/7 4)0 Ufa ST' Print PROPERTY OWNER fF ` 1,/p Print 100 Year Structure yesOno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 ❑:Septic ❑Well ❑ Floodplain' 1Netlarids Watershed:Dish ict� ®,Wafer%Sew_er�-;-- w -.� r -- � t�� ' .' •- . ..t �" 5:, ,;^ D SCRIPTION OF W RK TO BE PERFORMED: f10 P c,? /rti l/ q�o/ I v4of, e Identification- Aeage Type or Print Clearly eF70 �a OWNER: Name: Phone: Address: Contractor Name: /LfR P.� �/ti�°� ,,�c Phone: 4b3-7/; SS03 Email: 7`1, 1'14 1;�s�,�,� Address: Z�Of f 636. Supervisor's Construction License: ,,5F '/G2� ��7 Exp. Date: .I � Home Improvement License: !30 Exp. Date: ZJ ®f ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 0,00 FEE: $ 06 Check No.: Receipt No.: L NOTE;, s contr etin wath unre ed contracto 0 not hav acces guaranty fund Location No. " 7o 1-I Date • - TOWN OF NORTH ANDOVER � t ptyo its$��:= a � ,♦ '`�„ Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ Check +. J I U Building InspectoV Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWER-AGE DISPOSAL t. Public Sewer ❑' Tanning/MassageBody Art ❑ Swi,2 i 9 Pools, ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dempster on.Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF -'U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes s Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Driveway Connection/Si nature& Bate Permit a V DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes. . . no Located at - 12.4 Main Street Fire Depariiment signatureldate COMMENTS L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: ELECTRICAL: Movement of Meter location, rust 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 pick-up - Date Doc:.Building Permit Revised 2008mi I J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Inferior Rehabilitation Permits ® Building Permit Application a !"porkers Comp Affidavit ❑ Photo Copy Of H.I.C. AndfOr C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perm Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses 11 Copy Of Con-1-fact ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan Aid 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 Permii 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 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 CIerks 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.130ding Permit Revised 2008mi Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 25,000.00 m $ - $ 300.00 Plumbing Fee $ 37.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 37.50 Total fees collected $ 475.00 281 Andover Street 095-2017 on 7/29/2016 renovate 2 baths o'- pi own on over : * s �h ver, Mas S9 CONIC H!WICN S U J41 BOARD OF HEALTH Food/Kitchen PERMITLD Septic System THIS CERTIFIES THAT .....�+ I e L 1,14 �Jr� BUILDING INSPECTOR .... ... ..... ............................... ..... ................ ........ .......... . .. .. . ....... ... �.�... .. �. /�.. � ......... Foundation has permission to erect .......................... buildings on ........ (/!�..... Rough to be occupied as .........CIPAIV .... ............................... Chimney ... ....... ...............................S�cM provided that the person accepting this permit shall in every respect conform to the terms of the application 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough Service .. . . ...... ... ...... .......... ... Final BUILDING I PECTOR 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. -Cruikshank's Carpentry By signing this document you agree to the terms provided to you on the estimated proposal. Payment installments to be discussed off of the construction loan contract. During some construction projects other expenses can occur due to not knowing what can be hidden behind walls for exp.( improper framing,termite,lead or asbestos to name a few)A cost plus basis will then occur meaning cost of materials plus labor expenses by the hour at a rate of$130.For a two man crew Any products used in the project that may later have defects or malfunctions is to be processed with the manufacturer's and not the contractor. If there is any question's you have during or about the installation process please feel free to bring them to my attention. Any upgrades or extras will be discussed and agreed upon before the additional work is to be done and will be added to the contract as well as initialed signed and dated. That balance will be due before the installment process is set to begin. All estimated proposals are good for up to thirty days due to unknown market increases of material cost. 1 year labor warranty is in effect as of date of completion Materials warranty's based on manufacturers policy This contract is based on the estimate number 322 Total Renovation costs is$25,000 Plumbing costs provided by home owner Customers signature. Service Provider. The Commonwealth ofHassachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le bI Name(Business/organization/Individual): t?I&I ce2"'�� Address: C2 F Adyto rT City/State/Zip: ✓��' /�/b.; Thone #Areon an employer?Checktlierop mag Type of project(required): a employer with s employees(frill and/or part time).* 7.- []New construction I am a sole proprietor or partnership and have no employees working for mein 8. WRemodelitig any capacity.(No workers'comp.insurance required.] • 9. Demolition 3-FJ I am a homeowner doing all work myself,[No workers'comp..insurance required.] 10 [J Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or.additions proprietors with no employees. 12- Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.'[]Roof rep airs These sub-contractorshave employees andhave workers'comp.insurance. 6.FJ We are a corporation and its ofigers have exercised their right of exemption per MGL C. 14.[]Other 152,§1(4),and we have ria employees.[No workers'comp.insurance required.] `Any applicant that checks box 41 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 anew affidavit indicating such. TContractors that check this box must•a#ached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Tfthe sub-conlrac"tors fiave employees,they must provide their workeis'comp.policy number. lain an employer th at is providing workers'compensation insurance for m1'employees.'Beloit/is the policy and job site information. / Insurance Company Name: / r'�I ti r �i7 S• — Policy#or S elf-ins.Lic.#: M.4 Expiration Date: Job Site Address: / /!o/Ot/1'/ . City/State/Zip: We,- Attach e,-Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby terrify under^the pains d ltie rjury that the information provided above is'r ee and correct Signature:- Date: 6 Phone#: s Of use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# 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#: Paychex, Inc . RF 6 7/29/2016 8 : 31 : 14 AM PAGE 3/003 Fax Server r uer�s CERTIFICATE OF LIABILITY INSURANCE 07/2920116D/YYYY) 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(les)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 Paychex insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. 150 SAWGRASS DRIVE a/C°No.EXTI: 877-266-6850 A c o; 585-389-7426 ROCHESTER, NY 14620 E-MAIL ADDRESS: Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 MATTHEW CRUIKSHANK INSURER B: 14 STICKNEY BROOK ROAD BROOKLINE,NH 03033 INSURER C: INSURER D: 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 RESPECTTO 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. INSR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR VDM/DD/YYYY (M ) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED LAIMSNIAD (�CCUR PREMISES occurrence $ `[ ' MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY =PROJECT=LOC PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNEDSCHEDULED BODILY INJURY $ AUTOS O AUTOS (Per person) O NON-OWNED BODILY INJURY HIRED AUTOS AUTOS (Per accldenl) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR O OCCUR EACH OCCURRENCE $ EXCESS LIAR OCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION ANDX WC STATU- OE,EMPLOYERS'LIABILITY MAWC700838 03/07/2016 03/07/2017 E.L.EACH ACCIDENT $ 100,000.00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N E.L.DISEASE-EA EMPLOYEE $ 100,000.00 (Mandatory In NH) YLI N/A E.L.DISEASE-POLICY LIMIT $ 500,000.00 If yes,d—ibe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) 281 ANDOVER STREET CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1600 OSTOODEN SUITE 2053 DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY NORTH ANDOVER,MA 01845 PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C%��e Coarrarrrerrruerrtf�c-f^/��cciiac�r%efli t. —Office of Consuz r Affairs&Busioess Regulation - .SME IMP-90VEMENT CONTRACTOR rr:gistratior.: '513000 Type: Expiration .11,7,20'18: DBS, ^.i'.UIKSKAnKs CARPENTRY iVIA iTHEW CRUIKSFC9yK_... 14 STICKNEY BROOKRD s.--- BROOKLINE,NH 03033 Undersecretary- . LLOZ/9L/0'0 ietiai�ktu;� uot} �Idx� `i�t.re •y .r 3- dw o HIS ampion a Te � I LSZZOL V� asua�►� SPS'PU SI-Ion'tr£t"!BuI ri a csLc_ 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 apse) i ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 OTE: 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 Of Contract Floor/Cross Section/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 2012 IECC Energy code 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 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:Building Permit Revised 2014 TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION Permit N0._Zk1_Z,?_ Date Received Date Issued: DHORTANT:A phcant must complete all items on this page LOCATION A 8 Z— PROPERTOWNER Q' R P Y• a,S C,&"-)�� Print MAP NO:0�6•0 PARCEL: CrW8 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition El Two or more family ❑Industrial )1 Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ (I Other ` �+ : Watershed District' We := -� -��-�-��.� -- h�.,_ .,� ..i [7I�1ood lain � �❑;,Wetlands�z5." � ,` t ; S eptici 0. W. e + �. t� �� rf +Y c iT t#� s+ -i... stS•+�-'{.� `.r�t i E'` t y��k� AMaTeSevaer DES CP U,111 ON Ofi WORD TO ►3E PER.aO' ,D: I (identification P)ease Type or Print Clearly) OWNER: Name: lfat� a4 & 2 Phone: 2��m Address: CONTRACTOR Name: T �? Phone: �• Address: b <U Pe G�t- Supervisor's Construction License: Exp. Date: JJ Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: to 4, 3 Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$12.00 PFR$1 00Q.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ 17"/7 o l9 FEE: $ Check No.: ! Receipt No.: �--- NOTE: Persons contracting with unregistered contractors d no ave c the:.//�q//�///��/_tan ,fund -_—_—_---i--- • �S-:tcganr_a_•t'u=-re=r:.os"fiAgeri�0?"in'rie_ M__-,_2 — _— - _rsatuc .or: - — --- r, -- ----- _,:9=,-,--.--.__-•—_•---.._.__ - - - -- - - - _ I Location 4)e l & doV0)Z 54-7, a No. Date NORTp TOWN OF NORTH ANDOVER 41 � e 9 ie Certificate of Occupancy $ s,CMUSE`� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ fATOTAL $ Check # 24517 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tannia0aassage/BodyArt ❑ SwimmmgPools ❑ 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 i COMMENTS HEALTH Reviewed on Signature COMMENTS _a 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: Signatare: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 1.24 Main Street ; Fire Department signature/date COMMENTS NORTH Town of 0 V0 No. /G 7, 4- �,` - o , lover, Mass., l Y 0 t- LAKE COCHICHEWI': O�S RATED � � BOARD OF HEALTH P� Food/Kitchen ERMIT T D Septic System BUILDING INSPECTOR Q G� THISCERTIFIES THAT.............. A�. ..... ........ .... �...y...........��..................................................................... Foundation has permission to erect................ ....................... buildings on ... .�.....A40JJ.01.� ..... !�..................... Rough to be occupied as .0 v Chimney provided that the person accepting t is permit shall in every respect conf to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final I O PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR i UNLESS CONSTRU T TS Rough ................ ............ Service BUILDING INSPECTOR Final Occupancy Permit Required to 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. i . Massachusetts Home Improvement Sample Contract 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 iSeek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide toHome 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 or on our website. . Homeowner Information Contractor Information Name Company Name Street Address(do not use a Post Office Box address) Cofitractor/Salesp-e�rs+on. Owner Name Ci Piown / �/Q ty State Zip Code ty Business Address(must include a street addre s) __OA-bll�plek 19/446T/ 40 Daytime Phone Evening Phones City/Town State Zip Code 4DL acs �; 3 Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date Lew requires that most home improvement contractors have n vnlid registration number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) to as Required Permits-The followin 1buildin S g permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 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: O Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by /_ or upon completion of $ by //_ or upon completion of $ upon completion of the contract. (Law forbids demanding full payment until contract 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 meet the completion schedul'e.(•1*) $ to be paid for 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 1(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. Ex ress Warranty-Is an express warran beinprovide d b the contractor? ❑No ❑Yes all 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 father agrees to be solely responsible for all payments to all subcontractors for materials and labor under this a ee6rit 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 lienor other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract) ll • 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 alvalid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be re istered with the Director of Home Improvement Contractor Registration. You may inquire about contractor i registration by writing o the Dlg`ector at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • 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 not 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 ane explanation on of this riht. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES!!! g Two identical copies of the contract must be completed and signed. One copy should go tot ho owner. The other copy should be t by the contractor. Homeowner's Si ature ntractor's Signature Date Date 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 contr'a'ctor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. i 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 firms 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 General Laws, chapter 142A. Homeowner'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(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement.I 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 rescission 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 fields not yet duel 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 Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation j 10 Park Plaza,Room 5170,Boston,MA 02116 j 617-973-8787, 888-283-3757 or visit the OCABR website at httD://www.m'ass.gov/ocabr/ I 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, ciohtact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation gu on 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ i Go online to view the status of a Home Improvement Contractor's Registration: htip:Hdb.state.ma.us/hol-neimprovement/licenseelist.asl2 For assistance with informal mediation of disputes or to register formal complaints against i a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau j 508-652-4800,508-755-2548 or 413-734-3114 j Version 2.1-11/22/2010 / aculuca /'.. Lr registration valid for individal use only Office o Co me &Business Regulation before the expiration date. If found return toulation. Office of Consumer.Affairs and;Business Reg E.IMPROVEMENTOONTRACTOR Type uite 5170 . 10 Par4Plaza 2 16 = Registration: 150796 Individual Boston,M -51212012 Expiration:,,,;:- FREDRICK A GODBYR FREDRICK GODBYR a g 332 MAMMOTH RD`. Not va id without signature PELHAM,NH 03076 _i•._: Undersecretary '= Massachusetts- Departme'rit of Public Safety i Board of Buildinl- Re(,dations and Standilyds Construction Supervisor License, License: CS 92009 FREDERICK A GODBYR 22 MOUNT VERNON PELHAM, NH 03076 c-- _J""�" 'yam Expiration: 5/5/2013 ('umutisi �icr Tr#: 15565 Iii The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02I11 V www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/ContractorsAFIectricians)Plumbers Applicant Information Please Print Legibly Na1ue(Business/Organization/Individual): , / l� Address:r700IL�L�/�l/ -/V 4A1 City/State/Zip:�� 1 Phone#:_ Are you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with -:2- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).-I have hired the sub-contractors 2.ElI am a sole proprietor or partner- listed on the attached sheet.t 7• [_J 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 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.❑Roofrepairs insurance required.]i employees.NO workers' comp.insurance required.] Un Other *Any applicant that checks box#1 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 and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance f or my employees. Below is the policy and job site information. Insurance Company Name: T1,A /I/ e r/ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X:dolhe7rebyc 1•t under th its dpenalt' ofperju that the informationprovided above is true and correct. SDate: Phone#: [[Offuse only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# fIcial ssuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persoin: Phone#: