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HomeMy WebLinkAboutBuilding Permit #702-11 - 46 SHANNON LANE 4/19/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: — I J Date Received Date I TANT: Applicant must complete all items on this LOCATION 7 try 4,6re Print PROPERTY OWNER —Te Flc P)� KwLe . Print MAP N01 ,DM PARCEL: f,�� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resicl,ential Non- Residential ❑ New Building Fv6ne family ❑ /ldition ❑Two or more family El Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: ❑ Demolition ❑ Other ❑ S.eptic 'QWell f 11 Floodplain, OWbtland§: 0, Watershedi District 0 Water/Sewer- OWNER: Name: Address: '—( U DESCRIPTION OF WORK TO BE PERFORMED: _ ,Identification Please Type or Print Clearly) C L-, •.e - CONTRACTOR Name: 5 V --V lI L Phone: —t� l -1(Qf7-1313 Address: C-101! 04 I-AkLtr Supervisor's Construction License: Cob ) aS Exp. Date: Home Improvement License: �\1 S3 (1:2 Exp. Date ARCHITECT/ENGINEER S 1 S) az-� I1 Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: ` Receipt No.: )40— a4 NOTE: Persons contracting with unregistered contractors do not have access to the guar,agty fund ,Signature of Agent/Owner Signature ofcontracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories:_______ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. 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 Doc:.Building Permit Revised 2008mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy 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 ❑ 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: Ail 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 Doe: Doc.Building Permit Revised 2008mi Location W_'--���—Glfro h bL- No. Date J�,h% NORTIr TOWN OF NORTH ANDOVER 0 •. �w D i • Certificate of Occupancy $ s�CNus,�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1d�2 Check # 2 4 Building Inspector ' CHRISTOPHER J MELILLO 179A LAKESHORE ROAD BOXFORD, MA 01921 : Homeowner Information Coniractokr information e71lh J,,, StreetAddress (do not a Post Office Box address) �u acro So' sp on/ OwnerNsme / ,.� Ct frown �' State ' Zip CJJodeJJ usin—esss Address (mus include a street addre4s) 17 1_Q'ityfr�ovrn Dayurl Phone Evening phone .��_ • gailing State Zip Code© Address (I(0 Mt different from above) aV "1 C1 f usiMqui Phone ederal EmployerIDor SS. Nttmher G las requires that amort home iw- noow pcov®ey CoopyGor ae� Hoot Iov<mmteowrarrarsh,vea 'I yxpmlianditn The Contractor agrees to do the'following worlc for the Homeo e m e r and ma(atradoo amnia ' ner: ^+j/i, l 7 �� comp a secs g e e, [an , _! . .. . o mate ass- a pe - e ece - wu"c� Si)) Required.> ermlts -The followinQbuiltiing permits are required Proposed Start and Completian Schedule - The fallowing schedule will and ��yyill he secured by the contractor as the homeownet's agent, be adhered to unless circumstances beyond the connactoi's control arise (OvJners who secure their own pprmits will be exelpded from the Guarnnt3i Fund provisions of 4 10 ODate when contractor will begin conttacted work MGL chapter 142A.) ' rh1 i/ Date when contracted work will be substantially completed. • p Total Contract Price'and Payment Schedule The Contractor agroes• to pF orm the work, furnish the material and labor specified above for the total sum oI p �, tj()() ,LXX Payl will be made according to the following schedule: %00- l0 upon signing'contract (rat to exceed 113 of tbo'total contract rice or • p the cost of'special order items, whichever is greater) UOM'00hY $ f' r or upon compledonnf P" 1% � tJ• ($'1S 53f9I by / ' / .or upon completion of �,UtJ upon completion of the contract (Como forbids demanding full paymentun 'l contract is completed to both patty's satisfaction) Tho following inaterial/equipmeat must be special ordered before the contracted wart begins in order �-" to be paid for �) to meet the completion schjedul-- to ha Paid e,(+w) for ]MOTES: M Including all finance charges(") ~ not exceed the arge one-thisd of the to4a ( ) taw requires that any depositor down -payment required by the contractor before wort; begins may which must be special o d(ered:in Advance to meet thcontract p ti aoscheduler (b) tileactual cost °f ti;uy special equipmeut or custom mado on � � • rnvme I to coo act No Yes Subc ntractors - 7'het:ontractor agrees to be solely responsible for completion of tbo work described regardless of the actions of any third 1 terms of the tt ust a attar ed o the cantrnet patty%ubcontractor utilized by rho contractor, The contractor further hgree$ to be solely- Of for all a e lobo underthis a semens p ,menu to all subcontractors for c onttact Acceptance -Upon signing, this do becomes a Binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any ]ten or other security intcresthas Been placed on the residence, Review the following oautions and notices carefully before signing this confrack • Don't be pressured into signing the contract• Take timo to read and full and • ' ke sur eco frac hes a valid Home T,,, Y emtan l it. Ask questions if something is unclear, subcontractors to be registered with the Director ofHotne Improvemcnt Contractor Re The law requires most home improvement contractors and >`ogtsnntton 3 �wridng to the Director at One Ashburton Place Roo gtstratt°n, Y°U may inquire about contractor 1'-8�!)-223-t)933. , m 1301, Boston, MA 02log or by calling 617-727-32p0 t • Docs the contractor have insurance? Check to see that your contractor is properly insured ' Know your rights and responsibilities, l;esti ft important p rtant Info Guide to the Home•Improvement Contractor law, mladon an the reverse side of this form and get a copy of the Consumer .; You may cancel this agreement if it has been signed at a place olrier• than the contractor's normal lac contractor in writing at his/her ma office or branch office by ordinary mail'posted, b tele place ofbusiness, provided you notify the third business day following.the signing of this agreement See the attuched notice of cancellation form f grano so d lievrcpl , not i of this right. DO NOT SIGN T$[S CO ry, not later than midnight of the Two i&afi'�l N'I'RACT iff' T]f3E d l�tYr T �T � a 6 t. deatical copies Of nhai tmustbe oora leted andai 'RE A x B�-�E'11VI1. SrA�'ES: � �. p gn �o eopyshould go to the hoincownce The other co' V ahoutd be kept by the contrartor. w4as ign to Contractor's Sisrutture ` r Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with-'ei right to initiate an arbitration action alternative to.court aedi on)'if they have a dispute with a contractor. The same right is not automatically affordes to a' contractor, however. The contractor would have to resolve any dispute Wshe has with a homeowner in court unless both parties agree to the optional clause provided below. Timis clause would give the contractor the same ri ht to arbitration as`is afforded to the h6meowper by the Home Improvement Contractor Law, g ` .; The contractor and the homeowner hereby mutually agree concerning this contract, the contracforrm�ay sulimit thispute to a privat afbitratint fi1im which has be contractor has 7zdrspute the Secretary. oftheExecutive Office.of Consumer Affairs and $usiness Regulation and the consumer s to submit to such arbitration .at provided In Massachusetts General Laws, chapter WA. 1 omeowner's Signature NOTICE: The si a Contractor's Signature signatures tures 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 sFction is not separately signed by the parties. .. Homeowner`s Riglits ' A homeowner's rights vender the Home Improvement protetion Contractor Law (jV1C}L chapteg 142A)and other consumer laws' (i.e.1ViGL chapter 93A) may not be waived in any way, .ellen by agreement: However; homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law, Homeowbers who secure their own building permits are automatically excluded from all Guira.ntyVund provisions of 'thd Home Improvement Contractor Law. The contractor is responsible for completing the work as describe timely and workmanlike manner. Homeowners may be entitled'to otherspecific 1 al ri hts if the contractor in a or provides an express warraniy for workmanship or materials. In addition to �g g guarantees contractor, all goods sold in Ivlassachusetts c p ty guarantees or warranties pro the arty an fin lied wmmn of merchantability and fitness for a parde lar purpose; An enumeration of other matters •on which the homeowner and contractor lawfully agree maybe added to the terna5 of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions! about Your c6nsum6r/homeowner nights, contact the Consumer Information Hotline (listed below). Execution of Contract p The contract must be executed in du licgte 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 ownerrand the othef 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 tuitil both parties have received a fully executed copy of the contract,. and the three day recission period has expired. Accelerated Pmiyments A contractor may not demand' a p yments in advance of the dates specified on the payment schedule in cases wherrp the homeowner deems him/hemselfto be fuiancially insecure. However; in instances where a contractor deems himAj:erself -to be financially insecure, the contractor mtry require that the balance of funds not yet due be placed iri a oint esqrpw account as a preirequ.isite to continuing the contracted work, Withdrawal of funds from said account -would require the signatures ofboth parties, Additional )immformation If you have general questions or need additional information about the Home Improvement Contractor Law on of e consutner rights, ortf you wish, to obtain a free copy ,of "A Consumer Guide to the $one Improvement ContraGtior Law," contact: Consumer Irirormation Hotlibe Office of Consumer Affairs and Business'kegulation .10 Park Plaza, Room 5170, Boston MA 02116 (617) 973-8787or 1(8.88) 2833757 If you want to "ri fY there registration bf atcontractor or if you have quesdofls or need additional infortnadon about the contractor registrafion component of -the Rome'Improvement ComtractorLaw, contact: specifically y Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One•Ashburtofi Place, koom.1301, Boston, Ivle, 02108 ` (617) 727-3200 or. 1-800-223-0933. For assistance with informal mediation of disputes or to register formal con lain • P is against a business, call: ' Consumer Complaint Section Office of the Attorney General ' (617) 727-8400 AND/OR •Beher Business Butedu (508) 652-4800 .(508) 7�5-2548 (413) 734-3114 ' m x m m X m v m v a. d CosCD n Z y r c o. =r c y 0 Ov CD Q� O s crCDd CDo CD C CD CCDO) CO CO) O CO CD 5 - CO) CO) O CD d 3® Zcl CD st CD a. d CosCD n Z y r c o. =r c y 0 Ov CD Q� O s crCDd CDo CD C CD CCDO) CO CO) O CO CD 5 - Q C CO) O CD Opcn � 3® Zcl CD st CD w CD = CD =� 0 0 0 a _CD C co fg- oma: CD �d o� cn O cn cn 0 O Z O O O _ m O a to CDm 0 y O Ci CA VJ co .y O CS y = ao�m y O m dC m m • y ..�C a �� y .ted* m y d� CD = = m ` -�Omy O y 7� C', r► Ism: n 0�_ zsy.0 O C7 mom �_ R: aCA O C m y c O CD CL C� d y 0' d w Q C p - ro CL Opcn � 3® m .c y •� f w CD = I r CLt w O =� C/) b (n y 0 0 a _CD co fg- oma: moo: CDo ==: v CCD O) 0 CD C `" m � CD 0 rt � p - ro CL=. Opcn � ZI Com: G w n �7 Pd 00 CP I r CLt w O 0 rt � p - ro N Opcn � ZI G w n �7 Pd 00 CP I r CLt w O C� ►-+ C/) b (n y 0 0 a O O ro y C CD rA W v ON 0 0 c t' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please PrintLe2ibl, Name (Business/Organization/Individual): Address: 171,`'1, A- City/State/Zip: 1>tlQu owni,- Are you an employer? Check the appropriate box: 1. 2. 3. ❑ I am a employer with �mployees (full and/or part-time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] LJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t i Phone (--I 64z:>-1313 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ 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 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 *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 for my employees. Below is the policy and job site information. Insurance Company Name: 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 c u r the pain an nalties of perjury that the information provided f above is true and correct.' Si natur _ _ Date: -1 t5bio l t Phone #: 7D (.�p 1 `-1(,p 0-( -31-1 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 #: The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations `� �•' `' 600 Washington Street Boston, MA 02111 t' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please PrintLe2ibl, Name (Business/Organization/Individual): Address: 171,`'1, A- City/State/Zip: 1>tlQu owni,- Are you an employer? Check the appropriate box: 1. 2. 3. ❑ I am a employer with �mployees (full and/or part-time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] LJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t i Phone (--I 64z:>-1313 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ 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 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 *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 for my employees. Below is the policy and job site information. Insurance Company Name: 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 c u r the pain an nalties of perjury that the information provided f above is true and correct.' Si natur _ _ Date: -1 t5bio l t Phone #: 7D (.�p 1 `-1(,p 0-( -31-1 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-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 pen -nit 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 pen-nit/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-MASSAFB Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia