HomeMy WebLinkAboutBuilding Permit #089-16 - 80 BONNY LANE 7/22/2015 x Q
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BUILDING PERMIT 3� • * :• °0
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: D r Date Received
� �1SSA5 t�
Date Issued: L S CHl1
IMPORTANT:Applicant must complete all items on this page
LOCATION ` O 1a YOmn4 Va"L
Print
PROPERTY OWNER L-17r 5
Print
MAP NO: V ;�l PARCEL: y S ZONING DISTRICT: 121 Historic District yeso
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
RVAlteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
U Septic ❑Well U Floodplain U Wetlands ❑
p Watershed District
U Water/Sewer
M ak...� cZl�-ex��-,y►^� k� �r-+� .��rcy-1 r-� rea� bat c�x1�
Identification Please Type or Print Clearly)
OWNER: Name: W�\\�a v, Lens Phone: I 9'�A- 3100 nL,%�
Address:
CONTRACTOR Name: Phone: 1003-401-0310
't ,pb.Q-��- K,n-��a.�'�r
Address:
�► nna.r.�rv�e.� �.�- '"Ra.,.�� n � 03017
Supervisor's Construction License: .ExpDate: ,.
CS —dqa 5 2 S-`1 -ao�S
Home Improvement License: Exp. Date:
1-& 11 WS 3-5
ARCHITECT/ENGINEER 36-\r) O T-00r\k-ll Phone:
Address: Cor-o�Gh,i�-, GfAL-o -v S\res Reg. No.
I a FEE SCHEDULE.B&kDINC PERMIT.V2.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F.
Total Project Cost: $ �f,� � FEE: $ /J-2—
Check
Check No.: i(e,z _z- TReceipt No.: 5 04-4
NOTE: Persons contracting with unregistered contractors do not have access td the guaranty fund
Signature of Agent/Owner = - Signature of contractor
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BUILDING PERMIT 0 Na oT b�+
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received �9'DR�rED Pa.
SSACHU`��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP 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
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed:District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email: i
Address:
i
Supervisor's Construction License: Exp. Date:
-Home Improvement License: 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.
Total Project Cost: $ FEE. $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ownc�_ _ Signature of contractoi. `
BUILDING PERMIT oF�tteo V%ORTIl,6�ti
TOWN OF NORTH ANDOVER 02 y
APPLICATION FOR PLAN EXAMINATION '' ' F4070
rDate
Date Received ��°� ;
ACHUS�t��
ATED
IMPORTANT: Applicant must complete all items on this page
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP 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
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
EJ Septic 0 Well ❑ Floodplain 0 Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
-Home Improvement License: 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.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
�;innature of cr . Sinnature of contractor
Location bonr%v\
No. Date
2Z ��
• - TOWN OF NORTH ANDOVER
LED76y .
•
Certificate of Occupancy $
e ,
Building/Frame Permit Fee $ '
e
Foundation Permit Fee
Other Permit Fee
TOTAL $
Check#
., Building Inspector
LL)
Plans Submitted w❑ 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 ❑
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM
i
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
f
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:
_.. - 384
FIR-A PAR�TMEN�T Tempi®umpster on site ,yesa _ _ snoo F� "
Located Osgood Street
- • - -
a
+ Lo_ sated at.12.4iMainStieet• _ - _ - -
FiretDepartmentsagnafure/date: _-
__.
COMMENTS
Plans Submitted C❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanaing/MassageBody 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 Siqnature
C6MMENTS
HEALTH
Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wafter& Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
F.IRE-�DEPARTIMENT - Temppumpster ontsite;
Of
1$J9
Dimension
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Number of Stories: Total square feet of floor area, based on Exterior dimensions.
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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
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NOTES and DATA— (For department use)
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❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit 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
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
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
OTE: 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)
,4 Copy of Contract
16 2012 I ECC Energy code
4 Engineering Affidavits for Engineered products
OTE: 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
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Doc:Building Permit Revised 2014
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11 BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
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BUILDING INSPECTOR
THIS CERTIFIES THAT ........... . L ............................................................
has permission to erect ........... Foundation
............... buildings ...a-0....... ....1,410to-0p g ��.�� ............... Rough
to be occupied as ...... ... .�.1... �w. w ...... .w........ Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN WONT S ELECTRICAL INSPECTOR
UNLESS CONSTRUC ST Rough
Service
............ ... ..... ..................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. - Burner
Street No.
Smoke Det.
V1
significant improvement without having this reviewed by an architect or other design
professional is probably the first cousin to that lawyer! Capisci?)
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Homeowner Information
Name:
+
William Lins'&Rebekah Peironio
Street Address: (notpost office box)
80 Bop4 Lane I „
City/Town a State Zip Code+
North Andover MA 01845 p
Contractor Information +
Company Name: ,
Contractor/Owner NameOt
Robert Kristiansen Jr.
Business Street Address
7 Manor View Dr.
City/Town StatedZip Coe : "� • " '� ` qE, `
Raymond NH 03077
Note: You need full.names,federal4d#,and addresses(not PO Boxes) of the parties, ,
which must appear in the contract.�•Don't•forget to-include names of any salespersons }
involved and Contractor's Registration Number(on the first page of contract)), ,, •, i
Salesperson(s): Contractor Registration#:
Exp. Date:
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MASSACHUSETTS HOME IMPROVEMENT SAMPLE CONTRACT WITH
COMMENTS
By Attorney Jonathan Sauer
(Note: This form of contract generally follows the requirements of the Massachusetts
Home Improvement Contractor Statutes and is based on information obtained from State°
website(s),the accuracy of which is not guaranteed in any way by Jonathan Sauer or by
Sauer& Sauer. You may wish to see http://www.mass.gov/Eoca/docs/sampcont.pdL
Further, no warranty or representation is made by Jonathan Sauer or by Sauer& Sauer or
by its attorneys and employees that this form complies with any or all applicable
statutes/regulations/applicable court cases and this form is solely provideil and can only be
received or used for educational purposes only and/or for general information and is not
being provided for the purposes of the giving of any legal advice. Be advised'that-legal
requirements can be subject to changes in the underlying state statutes, regulations and as
decisions are issued by Massachusetts courts,which events can`happen as frequently as
daily. Seek legal advice if you do not understand your legal rights,or obligations under
these legal authorities,which are substantial and complicated. This contract does not
preclude parties from adding language to protect their specific interests. Specific trades
may have specific requirements,including specific permitting and the acceptability of `
materials by local inspectors,which should be considered for inclusion in your contract.
Information contained in "Notes" are for guidance only and are not intended to be part of
the actual contract form. This form in its present format is substantially longer than your
actual contract because of all of the explanatory material. Please note that there will be a
requirement(s) that certain information appears on the first page of the contract(i.e. the
notice of the right of cancellation)so that the contract length should be adjusted,to ideet
such requirement(s). Please note that this form does not specifically favor either
contractors or homeowners and the form might be adjusted, as long as it is done so
permissibly,in either's direction. It should be understood,however, that such permissible
changes may be more liberally made in favor of the rights and obligations of homeowners,
whom these statutes and legal authorities seek to protect. Contractors: The
Commonwealth of Massachusetts is ver serious about your compliance with these
requirements. Violations of these requirements,particularly deliberate ones, may be
found in court to be unfair and deceptive trade practices under MGL C.93A;subjecting
you to double or triple actual damages and responsibility for the homeowners' counsel fees
in any legal action surrounding this contract form and relationship. Further, there is legal
authority which says that a homeowner may cancel a home improvement contract at any
time-until the contractor provides the h6meowner with a contract meeting the laws' several
requirements. fin all of my years.of reviewing home improvement contracts prepared by
home improvement contractors,'I have not found even one that fully complies with all of
these various requirements and most are not even close. Consumers: Before agreeing to
any home improvement work on your residence,you may wish to obtain a free copy of"a
Consumer's Guide to Home Improvement Contractor Law" by calling the Office of
Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787. Also,
consumers/homeowners,there is an old saying that an attorney who represents himself in a
legal action has a fool for a client. From my viewpoint with 34 years of experience,a
homeowner who allows the contractor to prepare the plans and specifications for any
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Expected Date of Completion: (Note: This is the date when contracted work will be
substantially completed, meaning that the work is sufficiently'completed to a point of
completion where'the home improvement can be used'or occupied by'the'homeowner.)
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to provide the work, furnish the material and labor specified above for the
sum of$ 11,000.00 (Include all finance charges in this amount.)
Payments will be made according to the following SCHEDULE:
$_2750.00 upon signing the contract.
(Note: the deposit shall not exceed 1/310if the total'contract price OR-the cost of special
order items,whichever is greater.) `
$'2750.00 •by ' /'' / or uponcompletion of
_Framing
$_2750.00 by / / or upon completion of
_Decking
$_2750.00 upon completion of the contract. (Note: The law forbids
demanding full payment until the contract is completed to both parties satisfaction..Put
another way,if the homeowner is'not satisfied with the contractor's services,the.contractor
isnot entitled to final payment.) '
Ino order to meet the completion schedule, the'fol'lo'wing material/equipment must be special'
f' , rrr: 1.
ordered before the contracted work begins: ,
DO NOT'SIGN THIS'CONTRACT IF THEREARE ANY BLANK SPACES
(Note: Identical copies of the,contract should go,to the homeowner and the contractor.)
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Homeowner's Signature Contractor's Signature.
�r.. 't:lt, n, ', t`.• 'tr;I,
Date Date
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WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor agrees to do the following work for homeowner:,Remodel existing front porch and
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rear balcony to'match,plans provided by owner. Incor1' porate'P I Structural arch into gable ends of
roofs covering porch and balcony(see attached pl'ans).Replace existing Knee walls with vinyl
railings.Replace existing decking with hardwood. Replace or go over existing pine ceiling with
hardwood. Cover existin Post/Stringers and risers with MDF or
PVC.
(Note: Describe in DETAIL the work to be completed. The less description you have,
the more potential ambiguity there is in your contract. Like anything else, `the devil is in
the details'.)
Materials Expected to be used:_Stock Vinyl railings. (IPE)Hardwood,(AZEK)or similar,PVC
trim. Standard MDF sheathing.
(Note: Provide'aTDETAI)LED description of materials to be used, specifying the type,
brand,and grade of those materials. Contractors, remember-that homeowners will alwa s
want you to supply the very best materials. While you ma have i 'diced a Ford Focus 'tlie''
Y PP Y I'3' Y Y P • � Y
are thinking you are going to supply a Lincoln Town Car. So,inclusion of a description of.
your materials protects you from"claims`that the material's don't comply with the contract.
Homeowners, remember that contractors are used to the idea'of supplying the'bare
minimum materials that will comply with the contract documents inasmuch as the criteria
for contract award is generally to be the low bidder. Therefore, if you specifically require
a certain level of quality of materials,this is where you want to provide for this. Contracts
must include details of work to be performed and materials to be used. Every contract
must include total amount agreed to be paid, a time schedule of payments and dollar
amount of those payments -including finance charges. Always include the dates work is to
begin and end. All contracts over$1000.00 must be in writing.Always include the dates
work is to begin and end. The date of the execution of the contract must be in the contract
and on the form. The following schedule will be adhered to unless circumstances beyond
the contractor's control arise.)
Work Scheduled To Begin: (Note: This is the date contractor will begin contracted
work.) L
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homeowner to get a different contractor. A good and substantial warranty should be seen
as effective marketing. Providing an insurance certificate to the homeowner for his job
without his having.to demand it should be seen•in,the same light. Remember, a principal
marketing concept•is that everyone knows two hundred and fifty people. And,all '
a 1, " 1 �.. r , if'1'1
homeowners have a ready pool of pfotential;customers. Ttiey are otherwise known as
neighbors
Please note that all home improvement contractors and subcontractor shall be registered and any'
inquiries about a contractor or subcontractor relating to registration should be directed to:
Director;Home.Improvement Contractor Registration, One Ashburton Place, Room 1310,
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 Regulation and the consumer shall be required to submit to such
arbitration as provided for in MGL C.-142A:
Contractor: ' ,V0jV0 Homeowner: •Fi '" '
Date: . t . 'Date' - . • •�e ;
NOTICE! the signatures of the parties above-apply only to`the agreeirient 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 it cases'where the homeowner deems him/herself to be
financially insecure.
Cont'ractor'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 the contracted work. Withdrawal from said
account would require the signatures'of both parties.
OTHER CONTRACTUAL'DOCUMENTS
This contract includes as contract documents the following additional enumerated documents:
(Note: If you•interid,for a proposal to be part of the contract or specific plans and
specifications or catalogue cuts to'be part of the contract, be sure to reference them here.
As a matter of contract'law;where there 'is a proposal and then is a subsequent contract-
6
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You may cancel this agreement if it has been signed by a party thereto at�a place other than
at the address of the seller,which may be his main office or branch thereof,provided you
t
notify the seller in writing at his main office or branch by ordihary'inail posted, by
telegram sent or' by delivei*,not taterthan midnight of'the third business day following the
signing of the agreement. See attached notice of cancellation for an explanation of this
right.
(Note: by law,this previous statement must'appear on the front'pagg of the contract in
immediate proximity to the space provided for buyer's signature and must beat least ten
point bold type.)
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REQUIRED PERMITS t
The following building permits are required: It is the
obligation of the contractor to secure such permits as the homeowner's agent and any costs
which contractor.will incur in doing so are included in the price for this'job as set forth above.
Please'note that homeowners who secure their own permits or deal with unregistered contractors
are excluded from the Guaranty Fund provisions of MGL C. 142A. (Note: List any and all
necessary construction-related permits. Each contract must contain a clause informing
the owner of their rights related to permits and the Guaranty Fund. The law requires clear
and conspicuous notice of all warranties supplied by the contractor. It should be pointed
out that a one year warranty from the date of completion on all labor and materials
supplied by the contractor is probably the minimum provision consistent with industry
practice. To the extent that some of the contractor's warranty comes from the contractor
and some;of the warranty comes from the manufacturer(i,e.roofing materials,
replacement windows)the warranty should be very specific as to who is supplying what.
Each contract must contain a clear and conspicuous notice of where inquiries about
registered contractors and subcontractors should be directed. Every contract must state
whether there is alien or security interest on the residence as a result of the contract.
Consumers may initiate arbitration under,the Home Improvement Contractor Law
whether or not a clause describing arbitration is included in the contract. Contractors may
initiate arbitration under the Home,Improvement Contractor Law.only if there is a specific
separate provision in the contract in,which the consumer agrees to arbitration.)
Is an EXPRESS WARRANTY being provided by the,contractor? ,No_*• _Yes
The following warranty will be provided by,the contractor under this contract:
,
(Note: All terms of the warranty must be described above or otherwise attached to-the ,
contract. Contractors,if you indicated that you,are not providing a warrantyw(or,one of
less than one year) and I represented the,homeowner,`I would,without,exception advise the
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which both parties sign which does not reference the proposal,the proposal has no
remaining contractual,significance.or effect.unless it is specificallylincorporated as a
contract,document in the contract.). , . , r ;i
` '.!! '• ' ,. � .ra.. •r .etc.. . s r ;., ..
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR
OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY
YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS
EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS
FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE,AND
ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE
CANCELLED.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR
RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY
GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF
YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE
RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE
SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF
CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY
FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE
SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO
DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS
UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED A DATED
COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR
SEND A TELEGRAM TO (Name of Seller), AT(Address of Seller's Place of Business)NOT
LATER THAN MIDNIGHT OF (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
(Note: Contracts must have TWO identical copies of this form attached to the contract.
The language of the-Notice of Cancellation must be`at least in ten point boldface type. The
Notice of Cancellation must be on separate sheets of paper and easily detachable's'o'that it
may be easily separated from the contract and returned to the contractor if a consumer
chooses to cancel-the contract. No work may begin until the time period specified in this
notice has expired.)
(Copyright, Jonathan Sauer, 2010)
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CONSTRUCTION FNGINEIERING SERVICES As
12 Pleasant S#aet svcabm
NEWBURYPORT. MASSACHUSETTS 01950 CALO"IM eiTE
Phone (979) 4GS-2216
Fax (979)463.3522 acaa-rw a�,ra
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERM[TTING AUTHORITY.
Annlicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip:kka t (t-o^'d' v ` Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.Eam a employer with employees(full and/or part-time).s T.` Q New construction
2. I am a sole proprietor or partnership and have no employees working for me in '8. ii/Remodeling
any capacity.[No workers'comp.insurance required.]
In I am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. Q Demolition
10E]Building addition
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.E]We are a corporation and its officers have exercised their right of•exemption per MGL c. ME]Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*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 anew affidavit indicating such.
ttontractors 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 subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: I j
Policy#or Self-ins.Lie,#: 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 MGL c.152,§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.
I do hereby certio under theyypains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#:
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 M
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 entelprise,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 shallwithhold 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 cant'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 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
i.
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 permittlicense 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900.-ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
1 Massachusetts -Department of Nuonc SaTety
Hoard of�iutiatno Reuuianocs and atanaards
Construction Supervisor Ilk
License: CS-072583 _
ROBERT E ICIUSTUNSEN JR
PO BOX 2353 _ _ e
Seabrook NH 03874
,I Ilk EzpiraTion
Commissioner 05/07/2016
office of consuTner Affairs&Business Regulation
TOME IMPROVEMENT CONTRACTOR Type:
� tegistration: 1.81148
ITO
Individual
Expiration:. `3/5/2017
ROBERT E.KRISTIANSEN JR.
ROBERT KRISTIANSEN JR.
7 MANORVIEW DRIVE -c- - "'---
RAYMOND,NH 03077 Undersecretary
® MAPFRE The Commerce Insurance Companysm
Citation Insurance Company'"'
11 Gore Road,Webster,Massachusetts 01570
Commerce
N s u e w nr c e- 508.949.15001 www.commerceinsurance.com
December 15, 2014
BUILDING COMMISSIONER or Board of Health or
INSPECTOR OF BUILDINGS Board of Selectmen
TOWN/CITY HALL Town/City Hall
NORTH ANDOVER MAO1845
RE: Our Insured: REBEKAH PETRONIO/WILLIAM LINS
Property Address: 80 BONNY LANE
Policyk BDBKLX
Date of Loss: 11/28/2014
Filek JTKC08-HJXTN2
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
SUSAN JOHNDROW Telephone: (508)949-1500 Ext: 15193
Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext:15193
On this date, I cause copies of this notice to.be sent to the persons indicated above, at the
address above, by first class mail.
December 15, 2014
CIC 254 (Rev.4/95) MAIL 506