HomeMy WebLinkAboutBuilding Permit #783 - 574 OSGOOD STREET 4/30/2012TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
El One family
El Addition
El Two or more family
El Industrial
0 Alteration
No. of units:
El Commercial
11 Repair, replacement
El Assessory Bldg
0 Others:
D Demolition
11 Other
I.Floddplai M
❑ Watershedlbi n
X6
DESCRIPTION,OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
AAA ----
ARCH ITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT. VZOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons conirdcting with unregistered contractors do not have access to tfiegiiar".fund
M
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 Reviewed on Signature
COMMENTS
HEALTH,
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Conne'ction/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
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.$10041000 fine
NOTES and DATA — (For department use
U Notified for pickup - Date
Doc.Building Permit Revised 2008
1
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
DOTE: 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
V®TE: 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
N ®TE: 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: INSPECTIONAL, SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location,5?/ OZ,3 0.0 w .f r_
No. Date .3Q Z --
Check # 5 0
25248
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Feet $,,.►
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
The Commonwealth of Massachusetts -
Department of Industrigl Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsfFIectricians/.'lumbers
City/State/Zip;
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. [1 New construction
employees (full and/orpart-time).*
I am a sole proprietor or partner-
have Hired the sub -contractors
listed on the attached sheet. x
7. ❑ Remodeling
Ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
ME] Electrical repairs or additions
required.]
officers have exercised their
3. ❑ I am a homeowner, doing all work
right of exemption per MGL
11 -El Plumbing repairs or additions
Y [N p
myself. o workers' comp.
c. 152, 1 4), and we have no
§ (
12.❑ Roofxepairs
insurance required.] i
employees. [No workers'
13.❑ Other
comp. insurance required.]
'.Any applicant that checks box#1 must also fill outthe section belUw showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they Ste doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 requiredunder 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
.fine
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 DTA for insurance coverage verification.
Ido hereby certf der thepai andpenalties ofperjury that the informationprovidedabove is true and correct
Si ature: Date: 1_05-0
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 CIerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instruction's
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 ofhire,•
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.aceeptable 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. Han LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 orpermit to bum 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 anal fax number:
The GoMyAozlwealth of Massachusotts
Department of Industadal Accidauts
4f£tce QUIRVestigatlo.w
600 washiwoa Street
Boston, MA, 427. It
Tel, # 617-727-4900 ext 406 or 1-877-MASS.A.F.�
Revised 5-26-05 Fax 0 617727-7749
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Additions Decks
Kitchens Sun Rooms
Bathrooms Pall B. Robinson Porches
P Frame to PROPOSAL
g, Fir\isln "PROPOSAL NO.
R. Remode\ing
General Contractor SHEET NO.
Roofing 978-692-0512 Basements
Siding Remodeling
Doors Tile & Hardwood DATE 0 c
Windows Flooring
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT
NAMENAME
r f e F ` 2�
ADDRESS ADDRESS
CITY, ST, ZIP a'%(� CITY, ST, ZIP
PHONE NO. PHONE NO.
We hereby propose to fUrnish the materials and perform the Obor necessary for the completion of
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o--T3-4�1Ole
e
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications
submitted for above work and completed in a substntial workmanlike manner for the manner for the sum of
with payments to be made as follows Dollars ($ 1
� W
Respectfully submitted
Any alteration or deviation from above specifications involving
extra costs will be executed only written order, and will become
an extra charge over and above the estimate. All agreements Per
contingent upon strikes, accidents, or delays beyond our control.
Note - This proposal may be withdrawn
by us if not accepted within days
r
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Signatu
Date Signatu
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
Company Name
- V ",;?
Street Address (do not use a Post Office Box address)
Contractor/ Sd person/ Owner Name
S7qr aS
City/Town State Zip Code
Busines Address (must include a street address)
01
Daytim Phone Evening Phone
Vis$ -44�� s 4 4745
City/Town State Zip Code
b��✓� V 0/
Mailing Address (It different from above)
Business Phone I Federal Employer ID or S.S. Number
Law requires that most home
Home Improvement Contractor Reg. Number
Expiration date.
improvement contractors have
a valid registration number
41&,? /0
Y
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.)
1511Ae'_' mirrdaws
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 ��-/RDate when contractor will begin contracted work.
MGL chapter 142A.) /
'/Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule jQ oQ� cy
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum o£ / / ( )
Payments will be made according to the following schedule:
$ A9S"oi6,0 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 $r 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? d 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 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 ARE ANY BLANK SPACES!!!
Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other opy should be kept by the contractor.
Homeowner's SignatureCot Tractor s tgnature
/ �
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 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 Regulation and the consumer shall be required
to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A.
Homeowner's Signature Corhactor's Si ature
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. 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 http://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 littp://www.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
littp:Hdb.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
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