HomeMy WebLinkAboutBuilding Permit #841-16 - 58 OLD VILLAGE LANE 1/27/2016L_
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BUILDING
PERMIT O
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:
L/U'�jQ ! Date Received �1 poRA7Eo°P
gssacous�c
Date Issued:
MtANT: Applicant must complete all items on this page
LOCATION I (z � '''
Print 41
PROPERTY OWNER ��L d e t/L i
Print 100 Year Structure ye no
�AP PARCEL:ZONING DISTRICT:—Historic Machine Shop Village y s i nistrict S noo
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
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❑ t- L] W7
PROPOSED USE
Residential
One family
❑ Two or more family
No. of units:
❑ Assessory Bldg —
❑ Other
DESCRIPTIO
Identification - Please
OWNER: Name: i'I_� .0 C I
Address: S 1lIA
Contractor Name:
Email: ✓�'I I ' „�
Address: R
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
�` Wetlands5 I4 ❑ 111/ate�rshyed` ®strict
f
RIS TO BE PERFORMED: n
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- � i ` ✓ Jam' � -I- i �l -
Type or Print Clearly / I� �C/ / - 7(
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Supervisor's Construction icense:G7SFYI a5a3Dq Exp. Date: l
Home Improvement License: Q 3 Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
FEE: $ (�
Total Project Cost: $ A:7 ` , r.
Check No.: Receipt No.:
NOTE: Persons contracti. g with unregistered contractors do not have access to thegu +u fund
Plans Submitted ❑ Plans WaiveA Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Mas sageBody 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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
?oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
`Planning Board Decision:
Comments
ci onservation Decision: Comments
A
Water & Sewer Connection/signature � Date Driveway Permit
DPW Town Engineer: Signature:_
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r Located 384 Osgood Street
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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
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
4. Building Permit Application
4, Workers Comp Affidavit
� Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4, Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products .
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
46 Workers Comp Affidavit
.,4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
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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 llntormatton
Name
Comp ame
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Street Address (do not use a Post Office Box address)
Co tract r/ Salesperson/ Owner
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City/t'own State Zip Code
Business Address (must include a street address)
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Daytime Phone Evening Plrone
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City own /�
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State Zip Code
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Mailing Address (It different from above)
Business Phone
Peacial Employer ID or S.S. Number
Home Improvement ContmMorReg.Number
ate
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improvement—f—tomb
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n valid regisinficn nombrr
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The Contractor agrees to do the following work for the Homeowner: U r
(Describe in detail the work to commpLIeted, specify!the type, brand, andgradeof materials to be use additional sheets if necessary.)
1,0 Ce t� I � ("PSI i �1(s45 wilier, D' yV, Q
Required Pert its -The following building perrhits are required Proposed Start and Completion Schedule -The following schedule will
and will be secured by the contractor as the homeowners agent: be ad ered to unless circumstances beyond the contractors control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of 1 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
Payments will be made according to the following schedule:
$ 1 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
$ \ Aby _/ / or upon completion of <!:2kL (�Y✓'� I/ 1
or upon completion of
v -
$� pon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
v �-
The following material/equipment must be special 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? ZrNo []Yes (all terms of the warrantv 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 mad 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 ofthis right.
D2 NO GN THIS CONTRACT IF THERE ARE AN Y BLANK SFA( ESN!
identical c espf tl contract must be completed and signed. One copy should go to the homeowner. The other copy sho a kept lry the ntractor.
onteowner's S ature Contr ctor's Signature
Date
Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowrier 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 Contractor's Signature
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. 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 deerns 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 litip://www.mass.aov/ocabl-/
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 Horne Improvement Contractor's Registration:
fittp://db.state.ma.us/homeiniprovement/iicenseelist.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
508-6524800, 508-755-2548 or 413-734-3114
Version 2.1 - 11/22/20 10
The Commonwealth of Massachusetts
.IDepadMent of IndustrialAceldents
H 1 Congress Street, Suite 100
r .Boston, MA. 02.14 2017
y9t www.mass govIdla
Workers' Compensation Insurance Affidavit:]Builders/Contractors/Electricians]Plumbers.
TO BE IEtILED WITH THE (PERMITTING .A.UTHOMY. ,
Name (Business/Organization/lndividnat):K-4
Address: l V"
City/State/Zip: V u�� Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with • employees (full and/or part-time).*
2. U I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.[] I am a homeowner doing all work myse1Z [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers' compensation insurance or are sole
5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors bade employees and have workers' comp. insurance.#
6oWe are a corporation and its ofdigers have exercised their right o£ exemption per MGL c.
152,§1(4),,,d we have nq,empI "y 5. [No workers' comp. insurance required.]
0
Type of project (Iequired):
1. 0 New construction
8. [] Remodelirig
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
13. 0 Roof repairs �
14,E] Other
`Any applicant that checks l'ox#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 anew afff davit indicating such.
rContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-coniractors have employees,'they must provide their workers' comp. policy number.
lam an employer gZat is pidvidirIg worlcers'compensation insurance for my employees ' below is the policy and job site
l
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 expir anon date).
Failure to secure coverage as required under MGL c. 1.52, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance
coverage verification.
p aro herehy cert uryder the ai a rallies o it', ; that the ' If Ymution provided above is true and correct.
official use only. Do notwrzte 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 emvloyees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract bf Hire,
expres's 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 anotherwho 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-coniractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. L-imited-Liability-Companies-(L•-L-C)-or-L-invitedL-iab�ilityPTYMrs imps (LLPY-witfno e�oyees o erih 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 Depaziment of Industrial
Accidents for confi in.ation of insurance coverage. Also be sure to sign and date the affidavit. The aifildavit'should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidenis. Should you have any questions regarding the law ox if you'are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self ihr ured 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 "fob 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. Anew 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
TeX. ,# 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617•-727-7749
Revised 02-23-15 www.mass.gov/dia
0
} U>ze ipdnvM"WiaedIll ola&aacl oe&J ,
— - Office of Consumer Affairs & Business Regulation �I
- HOME IMPROVEMENT CONTRACTOR
! a Registration: '-_105931 Type:
Expiration `1/1512018 Individual
l i THOMAS HURLEY 1 is
Thomas Hurley
70 ARLINGTON RD r !4
WOBURN, MA 01801 Undersecretary
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSFA-052309.
Construction Supervisor 1 & 2
Family "^
THOMAS M HURLEY
70 ARLINGTON ROAD
WOBURN MA 01801
CA_ Expiration:
Commissioner 01/14/2017
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Location
Date
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Check 4t
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TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee ;XzR(
Foundation Permit Fee $
Other Permit Fee $
TOTAL $--�
Building Inspector