HomeMy WebLinkAboutBuilding Permit #772-14 - 85 HIGH STREET 4/29/2014TOWN OF NORTH ANDOVER
APPL ATION FOR PLAN EXAMINATION
Permit NO:
Date Received
Date Issued:
IMPOR ANT: Applicant must complete all items on this page
LOCATION /
51- /L �(J e., ._
Print
Cl
PROPERTY OWNER
Print t 100 Year Old Structure yes n
MAP NO: PARCEL: ZONING DISTRICT: Historic District yef
Machine Shop Village yek no
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
V One family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
El Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTIUN OF VVUKK I u of rr_mrumivlr_u.
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
FiUU1 CJJ.
CONTRACTOR Name: �..JD41714 l/ Jnr
Address: S-414,1 _5� ,/2/7
Supervisor's Construction License: < (� Q Z _Exp. Date:
Home Improvement License: 0
Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
4
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 S.F.
Total Project Cost: $ ��� `� FEE:
Check No.: Receipt No.:
NOTE:- Persons contracting with unregis erect contractors do not have access to the guarantyfund
Signature of Agert/Qwner� Slg nature of contractor
Plans Submitted Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑
-: Plans Submitted ❑ Plans -Waived ❑..
.Certified Plot Plan ❑
Stamped Plans ❑
�T`YPE_OF;SEWERAGEDiSPrO�AL"
_ -
.
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
.Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
Food Packaging/Sales ❑
Private {septic tank, etc:_
Pdrmandnt Dempster on-site ❑
THE..FOLLODUING SECTIONS FOR =OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMME IT'S.
-DATE REJECTED-
El
EJECTED-
❑ ..
DATE APPROVED
-.0
Reviewed on Signature
Reviewed on _ Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/sAi nature & Date Driveway Permit
DPW 'To` ;2 Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPARTM,L-"NT.::=`Temp' Dumps er on site .yes no
Located atA124iMain Street "1 _ ,;.
'Fire"Dure/elate �
-
'COMMENTS ' �.
`-Di mens iOii
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
:Total land area; sq. ft.;
ELECTRICAL: Movementof.Meter..location', mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ONE LITERATURE: =Yes No
MGL.Chapter166.Section 21A -F and G min.$10041000:fine
IWy i tg ana UA I A — (t -or department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
-:The fol swing is'a=list of;the'.required.forms to be filled outfor:the appropriate:permit to'.be obtained.
R.00firg, Siding, Interior Rehabilitation Permits
Building Permit Application
o Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C'.S:L: Licenses
Copy of Contract
o Floor Plan Or Proposed Interior Work
a 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
L3 Certified Surveyed Plot Plan
u Workers Comp Affidavit
a 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)
L3 Mass check Energy Compliance Report (If Applicable)
u 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)
o Building Permit Application
u Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Copy of Contract
L3 Mass check Energy Compliance Report
L3 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 apwal 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.
Check #
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy . �$��" `—✓
Building/Frame Permit Fee
Foundation Permit Fee ,d $
Other Permit Fee $
TOTAL $
Building Inspector
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Massachusetts Home Improvement Sample Contract
This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information
Contractor Information
Name^
Com Name
liydn Cl/
tom_
Street Address (do not use a Post Office ox dr s)
C r/ Salesperson/ Owne
ame_1�1
� S
/ t
I
t
`KiL
City/Town State Zip Code
Busi rens g ustjnclude
a s eet ad ess)
N, J
(/
aytimePhone Evening PhoneCi
own
�(c%��
State Zip Code
�►
/9j9 d/
Mailing Address (It different from above)
Business Phone
I Federal Employer ID or S.S. Number
Home haprov—,.A ContmctorReg.Number
Eaphationdate
L.. requi—that most home
improvement conttacton hmve
—rid regh,rution number
The Contractor agrees to do the following work for the Homeowner:
(Describe in d it the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.)
Required Permits - The following building permits are required Pr
and will be secured by the contractor as the homeowner's agent: be
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
Start and Completion Schedule - The following schedule will
I to unless circumstances beyond the contractor's control arise
when contractor will begin contracted work.
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:
$ O upon signing contract (not to exceed 1/3 ofthe total contract price or the cost of special order items, whichever is greater)
$ by _/ /_ or upon completion of
$ by / / or upon completion of
C~ e C'rj upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfacfion)
The following material/equipment must be special $ =_4 be.paid.for__
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ o
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 ofthe 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? ❑ No ❑ Yes tall terms of the warranty must be attached to the contract)
Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
parly/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 affeement
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 slue the contractor has a valid Home Improvement Contractor Reeistration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
• Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe
third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies ofthe contract must be completed and signed. One copy should mother copy shouldalskept by the r)ntr
Homeowner's Signature
Date Date
4"'
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumers lb equired
to submit to such arbitration as provided In Massachusetts Generali Las cha ter 142A.
Homeowner's Signature tractor'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 deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at llttp://www.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
http://db.state.ma.us/homeimRrovement/licenseelist,asp
For assistance with informal mediation of disputes or to register formal complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1-11/22/2010
1
a
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 YOU
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 DESPOSE 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 AND
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.
Buyer's Signature:
(date).
Donnie Fuller
Contraction
g
Donnie Fuller Contracting
Middleton, MA 01949
978-304-1666
www.dfullercontracting.com
Page # of!
Proposal Submitted To: k ) Job Nam Job #
Address 11, � r 1 6'f � 1� n � � � f Job LoVcation
0,I X A,
IIy Date/,.5/r / Date of Plans II
Phone# ?7k ��� ,� �� Fax #
We hereby submit specifications and estimates for:
Architect
We propose reby to furnish material and labor — complete in accordance with the above specifications for the sum of:
$U " �,"v-A4744 Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully 1
executed only upon written order, and will become an extra charge over and above the Submitted- 114vbl
estimate. All agreements contingent upon strikes, accidents or delays beyond our
control. Note —this pro osal may be'Wel4rawn by us if not accepted within days.
i
ZItteptance of Proposal
The above prices, specifications and conditions are satisfactory and are
hereby accepted. You are auth rized to do the work as specified. Signature
Payments will be made a ou✓t ned above.
Date of Acceptance Signature
v
1
[,
CIA—
ZP3
VIT"1
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5
We propose reby to furnish material and labor — complete in accordance with the above specifications for the sum of:
$U " �,"v-A4744 Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully 1
executed only upon written order, and will become an extra charge over and above the Submitted- 114vbl
estimate. All agreements contingent upon strikes, accidents or delays beyond our
control. Note —this pro osal may be'Wel4rawn by us if not accepted within days.
i
ZItteptance of Proposal
The above prices, specifications and conditions are satisfactory and are
hereby accepted. You are auth rized to do the work as specified. Signature
Payments will be made a ou✓t ned above.
Date of Acceptance Signature
The Commonwealth of tVlassachusetts -
Department of ladustrigl Accidats
Office of Invesfigations
600 Washington Sheet
.Boston, .MA 02111
www mass govIdia
Workers' Compensation bsurance Affidavit: Builders/Cont°actors/Eleci-iiexans/Plib berg
Are you an employer? Check the appropriate box: Type of project (required):
1. C( I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New c6nstruction
employees (full and/or pact time).* have lured the sub -contractors
2. ['I am a sola proprietor or partner -listed on the attached sheet. 7• Remodeling
ship and`haveno.employees These sub -contractors have 8. E] Demolition
working for me in any capacity. workers' comp. insurance, 9. [] Building addition
[lb workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exexcised.their
3. ❑ I am a homeowner doing all work right of exemption per MGL 11. [(Plumbing repairs or additions
myself. Ebworkers' comp, c. 152, §1(4), andwehaveno 12,❑ Roofrepairs
insuran.cerequired.l ? employees. [No workers' 13.[] Other
comp. insurance required.]
Mny applicantthat checks box#1 must also filloutthe section below showingtheir Workers' compensationpolicy information.
'Homeowners who submitthis affidavit indicatingthey kr doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that cheAthis box must attached as additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that is providing workers' comquensation insurance formy employees 10wisthepolicy anti10 11C
information.
Insurance Company
Policy # or Ser -ins. Lic.
Expiration Date:
Job Site Address: City%StatelZip:
Attacks a copy of the workers' compensationpolley declaration page (showing the policy number and expiration date).
Failure to secure ooverage,as re%*edunder Section 25A ofMGL o.152 can lead to the imposition of eriminalpenalties of a
fine up to $1,500.00 and/or one-year imprisonment, as welt as civil penalties in the form of a STOP WORK ORDER. and a fim
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do
Phone#:
cep----11
er' the ins an Pena o fperjury drat the inform provided alio a ' ue and c
llatP•
Official use ortly. Do not write in Mis 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. CityMown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Information and Instructions
Massachusetts General Laws chapter X52 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 orimplied, oral or written."
An emPloyeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the Foregoing engaged in a joint enteiprise, and including the legal representatives of a•deceased employer, or the
receiver ox tnistee of �an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having notmore than three apartments and who resides therein,, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction orxepair 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 ofpubRe 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 tT e boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certigcate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members oxpartners, are notrequiredto carry workers, compensation insurance. If an LLC orLLP does have
employees,apolicyisxequired. Be advised Mat this affidavit maybe, submitted tothe Department of industrial
Accidents fox con&mation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the, permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of favestigations has to contact you regarding the applicant.
Please be -me 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
PORGY information (if necessary) and under "Yob Site Address" the applicant should write "all locations in (city or
town):' A copy o£ihe affidavit that has been officially stamped or marked by the city or town maybe 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 ox p ormit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves eta) said person is NOTxequired to complete this affidavit.
The Office of Investigations would tike to thank you in advance for your cooperation and shouldyou have any questions,
please do notho�itate to give us a call.
The Department's address, telephone and fax number:
The Goxr_ oxa�tealthormbmachwetts -
Deparlxaa•eut offnfttxrWal Accidenta
• (��co o�xnt�o�tiga�ox�� •
600 Wakiagm Stxeat
49 e 4q of -g 11A
Revised 5-26-05 Fax 0 617"727'77¢9
wwwaa5s,gov1dia