HomeMy WebLinkAboutBuilding Permit #864-13 - 58 MAY STREET 6/12/2013Permit
Date Iss
LOCA
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT: App
�v ,
Date Received
must complete all items on this
2
ain`t
PROPERTY OWNER /"/Cc�P_ 1 tin T ► n
Print 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
5�9epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
54,10k Per,
OWNER: Name: Hadel t
Address: �,)6 mc* 5f
CONTRACTOR Name
Address: is
or Print Clearly)
-
b4rPC&11
l Phone: (oo
Supervisor's Construction License: _ ?26966 Exp. Date:
Home Improvement License: JJ Exp. Date:�}[� `� 7
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
I
FEE SCHEDULE. BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ I
Check No.: 1 ZZ Receipt No.: 0��.
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
_Signature'of -Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
I
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/BodyArt ❑ ..
.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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
f
COMMENTS
DATE APPROVED
❑
Reviewed on Signature
Reviewed on Siqnature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comm
l
Conservation Decision: Comments
Water & Sewer Connection/Signature &Date Driveway Permit
DPW Tow;! Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT_ - Temp Dumpster on site yes no
Located at'124 MainStreet
Fire Departrnerit signatureldate
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
Nu i t5 ana UA. I A — wor aeaartment use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The fol:?vying is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
Li Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
a Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
Li Building Permit Application
Li Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
L3 Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 Copy of Contract
o Mass check Energy Compliance Report
o 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 apt, al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location-)
No. 13 Date
Check # -2�z
2 1 1-, �
66 -j
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ )1 /7
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
168 Maple Street
Methuen, MA 01844
(978) 683-5127 FAMILY
ROOFERS & PAINTERS
Bill To:
Address: �--�`✓►
Phone: S� AL
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ALL WORKMANSHIP GUARANTEED 10 YEARS
ESTIMATE
INITIAL DEPOSIT
1ST PAYMENT
2ND PAYMENT#y
FINAL PAYMENT f
Q"'w OUW"
lzRllefis
James Debreceni
L C # 99685
HIC # 122385
(Confraetor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action. (as an
'alternative to cotut action) if they have a dispute with a contractor. The same right is not automatically affordedto a
contractor, however. The contractor would have to resolve any dispute he/she has with a homeowne* .an court unless
both parries 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 flim which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the constuner shall be required
to submit to such arbitration as Provided In Massachusetts General Laws, chapter 14.2A.
Homeowner's Signature
NOTICE: signatures
The si t res of the parties above apply onlyto the agreement of the paid to alternative dispute
resolution initiated by the contractor: The homeowner may initiate alterative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Florae Improvement Contractor L4.w(MGL chapter 14.2A) 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.
HomeowrrerS who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contactor is responsible for completing the work as described, in a
timely and worlsmanli%e manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for worlcmanship or materials. In addition to
es or warranties
provided by the contractor, all goods sold -in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enlicontract
as 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 yo have
questions about your consumer/homeowner rights, contact the Consumer Information I�0 sumliae (listed below).
Execution of Contract
The contract must be executed in clit licate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Pax -ties 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 tine other kept by the conte. actor. Any modifleation to tile, original contract must be in writing
and agreed to by bosh parties. Contracted work may not begin until both parities 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
to be financially insecure,
a contractor deems him/herseinsecure,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 worlc. Withdrawal, of fiinds from said aeeouunt would require the
signatures of both parties.
:Additional Wora:mation
If you have general questions or need additional in: oOrmation about the Home Improvement Contractor Law or other
consluuer rights, or if you wish to obtain a free copy of "A Massachusetts Consulmer Glade to Dome Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza*, Room 5 170,13Qston, �2116
617-973-8787, 888-283-3757 or'visitt the OCABRsitttiv.ma
SS/OCabrI
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contrll
actor registration component of the Holme Improvement Contractor Law, contact: y
Director of Dome improvement Contractor Registration
OL -flee of Consumer Affairs and•Bu.siness Regulation
16 Park Plaza, Room 5170, Boston, MA 02116
617-9 7.87, 888-283-3757 or visit the HIC website at l,�tc ://w v 7„1ss aov/ocabi/
Go online to view the stt atus of a Home Improvemeht Contractor's Registration.:
1 �://db.state.ma.us/IZo7neinnprovement/]icemeelist.as
For assistance with informal mediation of disputes or to xegisler formal. complaints against a business call:
Consumer Complaint Section.
OfRce of the Attoiney General.
617-727-8400
AND/OR
Better Business Bureau
508-652-4.800, 508-755 254.8 or 413-734-3114
Version 2.1-11/22/2010
e-Unprovemen Saini4e eC
This form satisfies all basic requirements of the slate's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
Ianguage to protect homeowners. Seek Iegal advice if necessary. An
Massachusetts Consumer Guide to Home Improvement" before agreeingto any orI son planning
n yourmresidenrce. You ma obtain freeovements should first t co a copy
p c lallin 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.g
HOMeowner worm.' -'on 'Contractor ]mforni<atton
Street Address (do not pse apost Office Box address)
City/Town
y�
__`` � Stat/eZip Code
k. & CIG s �/y .
Day7ti(me Phone EveningPhone
Mailing Address (It different from above)
r
Address (must #clude.astreet
"y"lu`"m State Zip Code
Business Phone � � •- %� 7 federal I;n�I�vrr m or S.S. Number
ZI"Ipw niresfltatmost home °"`•accoricegayomber Expiradondate
improvement contractors havc �1
n valid registration numhcr � J�
The Contractor agrees to do the following work for the Homeowner: c 0 /hi
(Descn'be in detailthe worlcto completed, specifyingthe type, brand, and grade of materials to be used, use additional sheets ifnecessa
' 5 r1vo pL r"'s .
Required Permits -
The following building permits are required
and will be secured by the contractor as•the homeowner's agent:
(Owners who secure their own perlmaits:viii be
excluded from the Guaranty ]F"unci provisions of
MGL chapter 142A.)
Proposed Start and Completion, Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
AA4J/L_Date when contractor will begin contracted work.
0-14a—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.
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, ms, whichever is greater)
by / / or upon completion of
----- by or upon completion of
$ `> upon completion ofthe contract, (Law forbids demanding full. payment until contract is completed to both p 's satisfaction
The following material/equipmentmust bespecial $ )
ordered before the contracted work begins in order to be paid for
to meet the completion schedule. $
to be paid for
NQDTBS: ('i) Including all finance charges Law requires that any deposit or down-payment
not exceed the greater of (a) one third of the total contract price or (U) thactual cost of
by the contractor before workbegins may
which must be special ordered in advance to meet the completion schedule. Y special equipment or custom made material
— - --••- •-�••• �• ��,��u u >:ne contractor? I_I No L"f •yes ail terms ofthe warren must ben ttached to the contract
Subcontractors -The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
parterialL ontractorbor utilized is the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
aterials and labor under this a cement
Contract Acceptance -Upon signing, this document becomes abinding 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.
o• Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear,
aloe sure the contractor has a valid Home Im rovement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be re n
be—registered with the Director ofiome Improvement Contractor Registration. You may inquire about contractor
o
registration by writing to the Director at 10 Padcplaza, Room 5170, •Roston, MA .02116 or by calling .617-973-8787 or 888-283-3757.
Does the contractor have insurance? Askthe Contractor for his in
see a copy of a "proof of insurance" document. surance company information so that you can confirm coverage, or aslc to
• Know your tights and responsibilities. Read the Important Infotunation on the reverse side of this form and get a copy of the Consumer
Guide to the Rome 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 no 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 Seethe attached notice of cancellation form for an explanation er this right
DO NOTSZGN T -MS CONTRACT lt+' TI[ERE
Two identical copies ofthe contract must be completed and signed. One c ARE ANY 4LAIMC SJPACES � 11
opy should go to the homeowner. The other copy should be kept by the contractor,
el
.t1omeowner's Signaiuie "'
4conor's Signature
'Date
Date
The Commonwealth ofMassachusetts , -
Department of IndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Address:
City/Stale/Zip: /"Ie 1"h /"I Phone #•_
Are you an employer? Check th appropriate box:
Type of project (required):
1. [9 am a employer with
4. ❑ X am a general contractor and 1
6. ❑ New construction
_
employees (full and/or parklm.e) *
2. ❑ I am a soleprcprietor orpartner-
have hireathe sub -contractors
listed on the attached sheet. I
�• Remodeling
ship and'have no employees
'these sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance,
5. ❑ We area corporation and its
9. C] Building addition
[No workers' comp. insurance
officers have exercised their
10.❑ Electrical repairs or additions
required.]
3. ❑ Zama homeowner doing allwork
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.oof repairs
wired.
insurance required.]
employees. [No workers'
13.❑Other
come. insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they s're doing all work and then hire outside contractors must submit an affidavit indicating such.
tContractors that check this box must attached anadditional 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 CompanyName:. /
Policy # or Self -ins. Lie.. #:�� � irationDate:
Job Site Address: �0 0 l� `S� Citylstate/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 wellas 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 sof
Investigations of the DIA for insurance coverage verification.
Xtlo Taerehy/r rte under �1� andpenalties perjury that the information provided above is fftu�e and correct. -
4ionafiirP•\/�#J"!/ [ Q.4��51�& Date -< /
Phone4: 0 ?_�7 6_X
Official use only. Do not write in this area, to he completed by city or town official.
City or Town: PermitMeense
Issuing Authority (circle one):
X. Board of Health 2. Building Department 3. CitylTown CIerk 4. EIectrical Inspector 5. PIumbing Inspector
6. Other -
Information and 'Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an 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 df 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, MCL 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 -contractors) name(s), address(es) andphone numbers) along with their certificates) 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. ifanLLC orLLP does have
employees, a policy is required. $e 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 xetumed 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 requited 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 affil davit 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. Anew affidavit must be filled out each
Year. Where a home owner or citizen is obtaining a license it tor permit not related to any business or commercial venture
(i.e, a dog license orpermo 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 Corr monwajt� of M-a..ssa chweats
Department ofZndust&I Ace�de�ts
Ofte ofIA-Vestigatious.
604'4ashigtotxeet
Boston? . O21 1 X
TQI, # 6],7„727T,-4940 oyt 4O6 or Z-g77�M SS.AFg
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