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HomeMy WebLinkAboutBuilding Permit #872 - 44 OLD VILLAGE LANE 6/20/2011flit ✓ y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: C—q 2-- .. - Date Received Date Issued "2'' IMPORTANT: Applicant must complete all items on this LOCATION age © C. /v / PROPERTY OWNER ri it q Print -- --Unit # MAP NO: � I PARCEL: �f ZONING DISTRICT: Historic District yes! no � Machine Shop Village yes no 100 year-old structure ye no TYPE OF IMPROVEMENT PROPOSED USE ❑ New Building Residential Non- Residential ❑ One family ❑Addition El Alteration ❑Two or more Tamil y El Industrial No. of units: C�-k�epair, replacement El Commercial ❑ Assessory Bldg El Demolition ❑ Other ❑ Others: LJ "i alei beAcr F' ; jay.. rr it r r DESCRIPTION OF WORK TO BE PERFORMED: Ol'G- `✓ �?r D U t / I c6 I Al 17 r�� �irr - rzY / ;7 (Id en Ica'on Please i or Print e OWNER: Name:—Phone: Address: C,n yLt;li�` L1�-way ��J,U-2 -i9-G if 4 CONTRACTOR Name: Zo Phone: 00. 3 Address: 2 2-2 Supervisor's Construction License: CS �� � � � Exp. Date: Home Improvement License: �� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $_ a�/� ® 5" 9 11 FEE: $ 430 Check No.: NOTE: Persons contracting unregistere ontrac Receipt No.: tors do not have access t e g rani 7 nd Signature ofi Agent/Qwner. Signa"tur'e of contactor rJ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Dcols .� ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Durnpster on Site ❑ THE FOLLOWING SECTIONS -FOR OFFICE USE -ONLY T INTERDEPARTMENTAL SIGN,®FF - U FORM 1 PLANNING & DEVELOPMENT COMMENTS COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ =, al.v da'd.'�a.Edd3 sr..U��1ru�:u 6i.-%_Jl6j'Rca u a HEALTH Reviewed on Sicgnature COMMENTS R Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com 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 u s._ , Located at 124 Main Street `' Fire Depart inent`sig' ture/date COMMENTS 4 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, east 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 Doc:.Building Permit Revised 2011 June/mi 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, 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 Per. Addition or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ' ❑ Photo Copy of H.I.C. And C.S.L. Licenses E -i Copy Of Coni:radf * i iooi'/Lfossectioi1/Eieva,liol'1 Pjai1 &i° pioposec, vV01-d{ vV'i'ili op ii^08i" i- lar-1 Ana 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 Permi- 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 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 PAP V3 W l O Ocd V. cn 2 v� g w U U4 w am w w O . 1 U I, w cq x o W � n2 C x w a w, v m o z �i cn Q x O cn Oil U O 2 6 co 0 CD 0 v Z CD CL .0 y GCD C C C ca 0 CD �E m m 0 co CD 0 i _cc 0 CMQ C.0 o Cc a CDV c Z CD C.± y c C C _cc C. is c c as c � o c ` O N c vV •C� :� C, C ev � m C � :CCD Co -cc °3c o n N � D 183 u cm WE o.:. E 2"a 16, N h m 3 = t. y +` Q� m H m = C N c • y A O Cos I CM Ty_ O ; t = O Of A �Qcr , o 02 C. Q y m C = mCD m o Cl N Z W � 'EM c C:5 Z v�vCO o a N _ �C CDCD ��m:01 Oil U O 2 6 co 0 CD 0 v Z CD CL .0 y GCD C C C ca 0 CD �E m m 0 co CD 0 i _cc 0 CMQ C.0 o Cc a CDV c Z CD C.± y c C C _cc C. is The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: ), 6 M / e1 V Phone #: g 14f"2R 1. Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] ' 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' .- comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other ,-J -L WXQU" uux ff t must also mi out the section below showing their workers' compensation policy information. 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 for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby penalties ofperjury that the information provided aboV is true, and correct. 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector 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-contractor(s) 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 Revised 5-26-05 Fax # 617--727-7749 www.mass.gov/dia MIt,$5.tchus -tts -. Dcpartment €�i.t'uhlic Safety J3oarj of Building; Re,ulations,anil Stantlar{ls Construction Supervisor license + License: GS 87819 Restricted to': 00 ' .JOHN L. DERY..4 39 WEDGEMERE DR LOWELL, MA 01852, -a e(piration: 11/24/2011 $ ; {'nmmisioner `'f r#: 9386 HIC Registration Complaints. Page 1 of 1 The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) Mass.Gov Consumer Affairs and Business Regulation Home > Consumer > Housing Information > Home Improvement Contractor Program > HIC Registration Complaints Registration # 146415 Registrant JOHN DERY HOME 1MPROVEMENT&REPAIR Name JOHN DERY Address 39 WEDGE MERE DR. City, State, Zip LOWELL, MA, 01852 Expiration Date 4/22/2013 Status Current No complaints found for this registrant. You can also view_ arbitration and Guaranty Fund history. Back To Search ® 2011 Commonwealth of Massachusetts http://db.state.ma.us/homeimprovement/licdetails.asp?txtSearchLN=47064 6/17/2011 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. 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 or on our website. Homeowner Information Contractor Information Name„„ Com anjy Name J� Street Address (do not use a Post Office Box address) /a 1A,A.P Con r/ S lesperson/ wner Name �4 � © e Ay City/Town No / State Zip Code Business Address (must inc de a street address) 7, r? � c�Ovl 0 8 ��-� �3 c Daytime Phone Evening Phone City/Town V State Zip Code L w e /v%4s.7 ©ws Mailing Address (It different from above) Business Phone - S' ederal Employer ID or S. S. Number 1 Home I r ement Contractor Reg. Number I.aw requires that most home Expimtion date improvement contractors have a vaad registration number / L/ 6 Ll %3 i F 9/ 3 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 'Matej'als to be used, use additional sheets if necessary.) p,�q J 9 e v.r©iy /901 dl fIV � -7 iy W,0 71 --r. CXls ll o. f z- i7/ / co it elpl vim° Tie x po.r e �✓,�� �y cam, '�?�/r /A�-e xhy s/�v� ,l�f,�/ ��o � wl-;4 /�%� fi x//•i' /l ��j /fir/dI'� '� �it �l/ld�'L io ,gj- Required Permits -The following building 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?/ //1>O. 00 (*) Payments will be made according to the following schedule: $ 9 00 O Dupon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ ©b �by / / or upon completion of //. S' C $ by / /_ or upon completion of $ OD. 00 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 $V to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ 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 (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty being provided by the contractor? ❑ No ❑ Yes tall terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 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 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 THERE A tical copies of the contract be oompleted and signed One copy should go to the h or h , - P Homeowner's Signature— /,/-7 Date Date 4Y BLANK SPACESM The other copy shouldkept by the contractor. Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Re on and the consu r shall be required to sub uch arbitration rovided In Massachusetts General Laws, apt 142 . Homeowner's Signature actor's Si&fnatuV NOTICE: The signatures of the parties above apply only to the agreerh6rit of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day 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 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 Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at hllp://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 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/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp 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 or 413-734-3114 Version 2.1 -11/22/2010 Location w 4:91zk-4954= I No. 16 -.;- 2- Jor Date w I 40*Th TOWN OF NORTH ANDOVER AL Certificate of Occupancy $ Building/Frame Permit Fee $ ,v CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 4 4 ';;aBuilding Inspector