HomeMy WebLinkAboutBuilding Permit #458 - 6 Woodberry 12/22/2009TOWN OF NORTH ANDOVER
q5 -KAPPLICATION FOR PLAN EXAMINATION
Permit NO. Date Received -c'%
Date Issued: rL -L11 ` O
IMPORT NT: Applicant must complete all items on this nage
LOCATIO
PROPERTY OWNER '�- `& Gcr����� (,14e 1-
Print
MAP NO: _PARCEL: ZONING DISTRICT: Historic District
Machine Shop Vi
yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
OWNER: Name:
Address: L , LC:
CONTRACTOR Name:
Address: 3
utaL.rur i 1UN Ut-rVVUKK I U,t3E PERFORMED:
or Print Clearly)
,:T/T,�5���1
Supervisor's Construction License: CS 2�ek�'V Exp. Date: 6 12&
Home Improvement
Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
ty
Total Project Cost: $ FEE.: $
Check No.: Ks Receipt No.: i17�
NOTE: Persons contracting with unregistered contractors do not have access to h . uaI^a fund
Signature of Agent/Owner Signature of contractor
j
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
TanningNassage/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 Reviewed on Signature
' COMMENTS
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 USgood 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
NOTES and DATA — For department use)
❑ Notified for pickup - Date
i
Doc:.Building Permit Revised 2008
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
o 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
o 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: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
Location to wa-
No. qs Date-V�
No^TM
TOWN OF NORTH ANDOVER
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Certificate of Occupancy
$
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Building/Frame Permit Fee
$'�
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL $
Check # 4�
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Building Inspector
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One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Construction Supervisor License
- License
CS: 96154
Restriction:
00
Birthdate:
6/26/1965
Expiration:
6/26/2010 Tr# 96154
SCOTT NOVACK
33B STONECLEAVE ROAD
BOXFORD, MA 01921
Update Address and return card. Mark reason for change
Address Renewal Lost Card
DPS -CAI 0 5OM-05/05-PC8490
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
>� Registration: 151498
Expiration: 6/5/2008
Typo: DBA
SCOTT NOVACK CONSTRUCTION
SCOTT NOVACK .:
3313 STONE CLEAVE ROAD .�
BOXFORD, MA 01921 Deputy Administrator
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
Not valid without signature
712-6/10
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1V 600 Washington Street
Boston, M4 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: C ecn.
City/State/Zip: C
Phone #
Are you an employer? Check the appropriate box:
l.�am a employer with �n>—
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp,
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I L ❑ Plumbing repairs or additions
12.❑ Roof repairs
13 Other -g&:0 (-
t. v te r• M �, r t, : ,mus: also IM Oat the section beiew showing ' ei we ;c s Compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 ' surance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy It or Self -ins. Lic. OTC Expiration Date: ,5- ( 2 16
Job Site Address: City/State/Zip: A% `bc�r-VV—
Attach a copy of the workers' compensation policy 6claration 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 certify under the pat nd penaltieperjury th¢t the information provided above is trye and correct
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
2t -
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 -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. 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 pernnit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston., MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 5 -26 -OS www.mass..gov/dia
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Massachusetts Home Improvement Contract
This contract satisfies all basic requirements of the state's Home Improvement Contractor law (MGL c. 142A), but does not preclude
parties from adding language to protect their specific interests. Seek legal advice if necessary. Before agreeing to any home
improvement work on your residence you can obtain a free copy "A Consumer Guide to Home Improvement Contractor Law" by
calling the Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787.
Homeowner Information
Contractor Information
Name: Mona Leveille
Dwyer and Novack Construction
Street Address: 6 Woodberry
Scott Novack & John Dwyer
City: North Andover State: MA Zip Code:A9iV
33B Stonecleave Road Boxford, MA 01921
Daytime Phone: 978-258-5211 0194
978-887-0238 & 978-884-9625
Evening Phone:
License #: 151498/ CS 96154
Mailing Address (if different from above):
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Apyees To Do The Following Work For Homeowner.
Replace rotted corner board
Homeowner agrees to the following conditions:
Bathroom facilities must be made available for workers during the renovation. We will need access to electrical outlets and the
electrical breaker panel in the event that a breaker is tripped while running tools.
Materials Expected To Be Used:
Wood, stainless steel fasteners
The following schedule will be adhered to unless circumstances beyond the contractor's control arise:
Work scheduled to begin: 12/21/09 Expected Date of Completion: TBD
(Date Contractor will begin contracted work) (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 estimated SUM of: $1200.00.
**Extra work will be billed as time and materials, at the hourly rate of $55.00 per man hour worked. .
Payments will be made according to the following SCHEDULE:
❑ $500 initial
❑ and the remainder (which may be more or less than the estimated SUM) upon completion of the contract (*Law forbids
demanding full payment until contract is completed to both parties' satisfaction *)
***Please make all checks payable to Scott Novack, or they can be made payable to John Dwyer.****
** Extra work is defined as work not included in the original scope of the project. This includes but is not limited to things like rot,
leaks and code violations. It may also include customer requested changes. A signed change order must be executed in order to
accommodate changes to this contract. If no change order form has been executed, it is assumed that the customer is paying our above
referenced hourly rate.***
In order to meet the completion schedule, the following material/equipment must be purchased before the contracted work begins: all
materials stated in description above. (*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*)
DO NOT SIGN THIS CONTRACT IF THERE ARE #NY BLANK S ACES
Iden copies of the contract should go to the homeo ran a con r.
1,1 omen er's Signa r Contractor's Si atute
I Z lZ zc o�
Date I Date
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which
may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary
mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the
See attached notice of cancellation for an explanation of this right.
NOTE: All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place, Room 1301
Boston, MA 02108
617-727-8598
Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been
placed on the residence.
ARBITRATION
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 such dispute to a private arbitration service which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to
submit to such arbitration as provided in M.G.L c.142A.
Contractor: Homeowner:
Date: Date:
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO
ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE
ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity — 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.
Contractor's Financial Insecurity — 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 work. Withdrawal from
said account would require the signature of both parties.
THE CONTRACT MUST ALSO CONTAIN:
1) A Complete Description of any other documents which are part of the agreement;
2) A List and Description of other matters upon which the contractor and homeowner lawfully agree;
3) Any Other Provisions otherwise required by applicable laws of the Commonwealth.
Remember, the Contract must be the Complete Agreement between the contractor and the homeowner.
"/kfrM WNIVg Te4gutons an an
One Ashburton Place -Room 1301
Boston, Massachusetts 02108
Construction Supervisor License
SCOTT NOVACK
33B STONECLEAVE ROAD
BOXFORD, MA 01921
DPS -CAI 0 50M-05/06-PC8490
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:: 151498
Expiration`::.1615/2010 Tr# 268257
Type: DBA
SCOTT NOVACK CONSTRUCTION
SCOTT NOVACK
33B STONE CLEAVE ROAD
BOXFORD, MA 01921 Administrator
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
t'
Not valid without signature