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HomeMy WebLinkAboutBuilding Permit #667 - 1 Berekley Road 5/12/2008BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �SSACH' Date Issued: ' IMPORTANT: Applicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE - '*LOCATION` Non- Residential wV famil ,PROP.ERTY OWNER ] rs Industrial Alteration No. of units: Ra int TeLair, re lacemen MAP N0= �w = :PARCEL: ZONING L)IST.RICT: G 'Historic -District ,yes Rno Septic . Well. P k ° x u ,Machine Shop Village yes - TYPE OF IMPROVEMENT PROPOSED USE Residenti 1 Non- Residential New Buildingne famil Addition Two or more family Industrial Alteration No. of units: Commercial TeLair, re lacemen Assessory Bldg Others: Demolition Other Septic . Well. P Floodplain-Wetiarids' Watershed bistrict T Wates/Sewer. UEscRIPTION OF WORK TO BE PREFORMED: n f _. _ / i Identification Please Type or Print Clearly) OWNER: Name: � ��/ E. ���w Phone: 9 79 - 2S? -,?12Z ARCHITECT/ENGINEER Address: Phone: 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: $ ':ST no FEE: $ Check No.: ��� Receipt No.: CP NOTE: Persons contracting -with unregistered contractors do not have access to the guaranty fund Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ CH Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 i 1 50 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Pub=Sewer Tanning/Massage/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 i DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS_ Ij HEALTH COMMENTS Reviewed on Signature M Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments IL Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 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 III ❑ 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 j36 �,.�I s em., His- ty 91 b._ G'!4 5 4 $? I Additio� Or Decks ❑ Building Permit Application I ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And I'I 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 II ❑ Engineering Affidavits for Ehgineered 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 thatIthe 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 IDoc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 11 Revised 2.2008 C2 m c c� CD ` C N � C 0. v •a'fl C m MO ; w cc :off N � EQ '^ i C vJ c� a z E c c� V m c E mm � N= vJ C=M ca C • C m O C N N C 1=N CLCm a H - t = O Of CD ca dC= C� o �+ CSM CC.3 N o C c m o c Q ya m C O = m t- o s COD ,a t rr H •C3 Ct C Z oc E���v, CZ y a m� ID o:0 I N , C F-4 z u 4 v ®I 0 co O co L }C± v CD Z p, O CO) C CA CD I Q 2 CO CD CD Cm CD i O CL �a C ZIts .. CD CL G) CA C c C m CL CO) LU 0 CA U) W LLI lz ujW � � O x � F A a v X w° ,v. cin A C -o w° C2 U Cd w a°' x w9' a�4 aa A cn O cn C2 m c c� CD ` C N � C 0. v •a'fl C m MO ; w cc :off N � EQ '^ i C vJ c� a z E c c� V m c E mm � N= vJ C=M ca C • C m O C N N C 1=N CLCm a H - t = O Of CD ca dC= C� o �+ CSM CC.3 N o C c m o c Q ya m C O = m t- o s COD ,a t rr H •C3 Ct C Z oc E���v, CZ y a m� ID o:0 I N , C F-4 z u 4 v ®I 0 co O co L }C± v CD Z p, O CO) C CA CD I Q 2 CO CD CD Cm CD i O CL �a C ZIts .. CD CL G) CA C c C m CL CO) LU 0 CA U) W LLI lz ujW The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street e<V Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Dein S i p L Address: I j3 ee jCel 1,44 4 V CA City/State/Zip: i4a�oNue 1�Yp lad Phone.#: Are you an employer? Check the appropriate box: L ❑ I am a employer with ' 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: ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3.VI am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' . insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [1 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 -contractors 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: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 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 certnder the pais and penalties of perjury that the information provided above is true and correct Phone #: 97k ; te�`'7--& — City or Town: Da e: area, to be completed by city or town official, Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other 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." !` ;i • 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 ortrustee 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,opera'te>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 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 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom lof 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, 1,,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. # 617-727-4900 ext 406 or 1-877-MASSAFE 4i Fax # 617-727-7749 Revised 11,22-06 www.mass.govldia *ONTO# TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax '(978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please p DATE: X=--j/—,0f JOB LOCATION: eele Number Street Address t Maps& 61'.leer-15" HONEOWNERp (-� �S r Name Home Phone Work Phone PRESENT MAILING ADDRESS fy, A -j u Q4 City Town state Zip Code The current exemption for "homeowners" was Wended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Budding (Code Section 108.3.5.1) DEF NIT ION OF HONSOWNER. Person(s) who owns a parcel of land on which he/she resides or intends to reside, on winch there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable coder., by-laws, rules and regulations. The undersigned -homeowner- certifies that he(she undmiands the Town of North Andover Building Department Minimum inspection procedures and requirements and that he/she will comply with said pmoodures and 7—HiMMOWNERS SIGNATURE I APPROVAL OF BUILDING OFFICIAL Revind 10.2005 -m Hom—mw F--nO- BOARD OF kPPE.U-S 699-9541 C(-).,`,9ERN'.1F1()N 6,88-9530 ITEAL111 688-9540 PLA-NNNG (,88-9535 E -Mail Terri.Soodridge@ nemoves.com Office 978/687-4465 x163 Picture Pretty Ranch! RESIDENTIAL BROKERAGE 100 Andover Bypass North Andover, MA 01845 978-687-4465 Nortb Andover Berkeley Road, r Beautiful Contemporary Ranch in top location! This picture pretty ranch has lots of style! Open concept living room/dining room has cathedral ceiling and opens to step-down family room with floor to ceiling fireplace, built in bookcases and sliders to wrap-around deck. Two bedrooms and bath on first floor & 2 additional bedrooms and bath on lower level. Very special! Fireplaces..... :1 Rooms............. :Range ...................... Yes `bish'washer.............. Yes ,Deck............................ Yes Storage Shed: ... Yes PROPERTY Style..........:: "..:"Ranch Rooms............. 7 Bedrooms.......... 2+ Baths, .............. 2 full Heat .............. HWBB Basement.,._,.... Full/partially finished Listing # . 30657023 Internet #:...::. 101667 Disclosure: Bulkhead ROOMS Living Room ............ 15x23 Cath Ceilings Family Room, ......... 11x19 Cath Cell, Deck Kitchen.. .. Yes Master Bedroom::.::. 12xl l Second Bedroom...... 1Ox11 Third Bedroom........ 11x10 Fourth Bedroom...... 7x10 Play Room .............. 10x20 Lower level LISTING Listing Agent...... Terri Goodridge Lot Size ............. 12,555.sq ft.. Living Area:........ 1,116 sq. ft. Assessment..:.::... $207,600 Taxes..... $2,607.96 Sewer/Water......... Town Book/Page............ ,03641/0170 Disclosure: Bulkhead door needs repair. { ,ncy Disclosure Brokers/Salespersons represent the Seller, not the Buyer in the marketing, negotiating and sale of property, unless otherwise disclosed. However, the ker or Salesperson has an ethical and legal obligation to show honesty and fairness to the Buyer in all transactions. dtor Disclaimer information supplied by Owner. No attempt has been made to verify same. Sales offerings are made subject to errors, omissions, change of price, prior . or withdrawal without notice. SATISFACTORY OPERATION OF ANY SYSTEM. THE BUYER SHOULD INDEPENDENTLY VERIFY ALL INFORMATION BEFORE PURCHASE. Property Address J t YES NO t/ MJWK TITTLE/GONINGBUILDING/INFORMATION YES NO UNKN 1. Seller/Owners.. � , —i --F, ` 12 . - 1410 Wl m w Lx- How long owned? 0 /Vo - SATISFACTORY OPERATION OF ANY SYSTEM. THE BUYER SHOULD INDEPENDENTLY VERIFY ALL INFORMATION BEFORE PURCHASE. Property Address J ANSWERS YES NO UNKN MJWK TITTLE/GONINGBUILDING/INFORMATION YES NO UNKN 1. Seller/Owners.. � , —i --F, ` 12 . - 1410 Wl m w Lx- How long owned? 0 /Vo - ❑ 2. How long occupied? 1 Approximate year built? 19 10 _ t O [ 9 7 7 ❑ ❑ ❑ 3. Have you been advised of any title problems or limitations (for example, deed restriction, lot line dispute, order of con- ditions)? If yes, please explain N ort ❑ ❑ ❑ a) Do you ow of agy easements, common driveway, or rig of w ? If yes, explain ZVA au J Ara -Q, 4. Zoning classificat n of property (if known) G 5 l D IV T ❑ ❑ ❑ 5. Has your city/town issued a notice of any violation which is still outstanding? If yes, explain ❑ ❑ ❑ a) Have you been advised that the current use is norkcon� ing in any way? Explain ❑ ❑ ❑ 6. Do you know of any variances or special permits? Explain O ❑ ❑ ❑ r 7. During Seller's ownership, has work been done for which a permit was required? If yes, explain. ❑ ❑ ❑ ❑ ❑ ❑ a) Were permits obtained? b) Was the work approved by inspector? _ ��'-', ❑ ❑ ❑ c) Is there an outstanding notice of any building code violation? Yes No_I�L OExplain ❑ ❑ ❑ ❑ ❑ ❑ YES NO UNKN ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 8. Have you been informed that any part of the property is in a designated flood zone or wetlands? Explain NO (See Flood Zone disclosure Page 3) 9. Water drainage problems? Explain Qj O II. SYSTEM UTILITIES INFORMATION DO YOU KNOW OF ANY CURRENT PROBLEMS WITH ANY SYSTEMS LISTED BELOW? 10. Has there ever been an UNDERGROUND FUEL TANK? O If yes, is it still in use? If not used, was it removed? (See Hazardous Materials Disclosure Page 3) 11. HEATING SYSTEM: Problems? Explain a) iuenury any unneawu room or ai b) Approximate date of last service c) Reason 101 12 DOMESTIC HOT WATER: Typed L F-:' 5 S Age Problems? Explain _ Burners owned or rented 13. SEWAGE SYSTEM: Problems? Explain C -- Type: Municipal Sewer L 5> Private If private, describe type of system: (cesspool,septic tank, etc.) Name of service company ✓ Date it was last pumped / Frequency During your ownership has sewage backed up into house or onto yard? Yes No Explain Is system shared with other homes? Date a Title 5 inspection last performed Copy, attached. Yes No—LZ 14. PLUMBING SYSTEM: Problems/Leaks/Freezing? Explain Bathroom ventilation problems? Explain t3 O 15. DRINKING WATER SOURCE: Public�,1� Private If peri te: a) Location NO, �0 b) Date last tested Report: Attached Not att ch d ❑ ❑ ❑ c) Water quality problems? Explain 10 ❑ ❑ ❑ d) Water quantity problems? Explain e) Flow rate (gal. min.) f) Age of pump ❑ ❑ ❑ ) Is there a fill ation system? Age/Type of filtration system SELLER'S INITIALS BUYER'S INITIALS MA —AC—HUS 113 ASSOCIATION Q �f REALTOW — MASSFORMS" REALTOR' oo wmoim �eeorlde 9t�odnd Lyl ritaee Forr 1 of 3 FORM NO. 700 'ANSWERS YES NO UNKN ❑ ❑ ❑ 16. ELECTRICAL SYSTEM: Problems? Explain 1W, ❑ ❑ ❑ 20. FOUNDATION/ SLAB: 17. APPLIANCES: List appliances that are included !!�i J V' CW 4 ❑ ❑ Problems? Explain ❑ ❑ ❑ Any known problems? iJ 9 ❑ ❑ ❑ If yes, explain 18. SECURITY SYSTEM: None-1,4Type Age Company ❑ ❑ ❑ ❑ ❑ ❑ Problems? Explain ❑ ❑ ❑ 19. AIR CONDITIONING: Central Window 4 t Other None ❑ I ❑ I ❑ Problems? Explain YES I NO uNKN III. BUILDING/STRUCTURAL IMPROVEMENTS INFORMATION ❑ ❑ ❑ 20. FOUNDATION/ SLAB: ❑ ❑ ❑ Problems? Explain 21. BASEMENT. Water 13 o Seepage Dampness _ Explain amount, frequency, and location �i E 5 D1L-kA U 1 ❑ ❑ ❑ ❑ ❑ ❑ a) Sump Pump? If yes, age 4_ location Problems ❑ ❑ ❑ 22. ROOF: ❑ ❑ ❑ Problems? Explain tJ E 11J Location of leaks/problems - ❑ Has UFFI (Urea Formaldehyde Foam Insulation) ever been ( stalled? If yes, location ❑ ❑ ❑ I.1 EY 23. CHIMNEY/FIREPLACE: Date last cleaned -U -ii �e- Problems? 'Ne-,) ❑ ❑ ❑ Wood/Coal/ Pellet Stove in compliajj��ce wi installation regulati ns/codeJb aws� ❑ ❑ ❑ If not, explain /iM- - M s 24. History of smoke / fire damage to structure, if any? Explain tJ .9 ❑ ❑ ❑ (See Asbestos disclosure Page 3) ❑ ❑ 25. FLOORS: Type of floors under carpet/linoleum? ki 1yf Lo W N ❑ ❑ ❑ Problems with floors (buckling, sagging, etc.)? Explain rt 0 ❑ ❑ ❑ 26. WALLS: ❑ ❑ ❑ a) INTERIOR Walls: Problems? Explain ❑ ❑ ❑ b) EXTERIOR Walls: Problems? Explain tj oy W S l D I N ❑ ❑ ❑ 27. WINDOWS / SLIDING DOORS / DOORS: ❑ ❑ ❑ Problems or leaks? Explain SJ O ❑ ❑ ❑ 28. INSULATION: Does house have insulation? If yes, type �Q�_ Date installed cation ❑ ❑ Has UFFI (Urea Formaldehyde Foam Insulation) ever been ( stalled? If yes, location ❑ ❑ ❑ Has testing for UFFI been performed? If yes attach report. (See UFFI disclosure Page 3) ❑ ❑ ❑ 29. ASBESTOS: Do you know whether asbestos is present in exterior shingles, pipecovering or boiler insulation?_N 0 ❑ ❑ ❑ Has a fiber count been performed? 4 If yes, attach copy 9v (See Asbestos disclosure Page 3) ❑ ❑ 34. GARAGE / SHED / OR OTHER STRUCTURE: Problems? Explain N ❑ ❑ ❑ 30. LEAD PAINT: Is lead paint present? If yes, locations (attach copy of inspection reports) (A) IQ If yes, describe abatement plan/interim controls, if any ❑ ❑ ❑ Has paint been encapsulated? If yes, when and by whom? (See Lead Paint disclosure Page 3) ❑ ❑ ❑ 31. RADON: Has test for radon been performed? If yes attach copy (See Radon disclosure Page 3) ❑ ❑ ❑ 32. INSECTS: History of Termites/Wood Destroying Insects or Rodent Problems? If yes, explain treatment and dates W (See Chlordane disclosure Page 3) ❑ ❑ ❑ 33. SWIMMING POOL/ JACUZZI: Problems? Explain �O Name of Service Company ❑ ❑ ❑ 34. GARAGE / SHED / OR OTHER STRUCTURE: Problems? Explain N YES, NO UNKN IV. MISCELLANEOUS INFORMATION ❑ :� [I❑ 35. Do you know of any other problems which may affect the value or use of the property which may not be obvious S rve"biiye (' YES I NO I UNKN V. CONDOMINIUM INFORMATION ❑ ❑ ❑ 36. If converted to condominium, are documents recorded (Master deed/Unit deed etc.)? ❑ ❑ ❑ 37. PARKING: Is parking space included? If yes, is it deeded, exclusive easement or common? ❑ ❑ ❑ 38. CONDO FEES: Current monthly fees for Unit are $ ❑ ❑ ❑ Heat included? Yes No ❑ ❑ ❑ Electricity included? Yes No ❑ ❑ ❑ 39. RESERVE FUND: Has an advance payment been made to a condo reserve fund? f yes, how much $ SELLER'S INITIALS BUYER'S INITIALS MASSACHUSETTS 113 ASSS�AL O�C�I.A+TION REALTOR' Of l�C OW 0 com- 2of3 MASSFORMS" 9hEewlde Shnd�rd ReY FA.W Form ANSWERS 'rYES I NO I UNKN ❑ ❑ ❑ ❑ ❑ 140. CONDO ASSOC. INFO: Is owners' association currently involved in any litigation? If yes, explain ❑ 141. Have you been advised of any matter which is likely to result in a special assessment or substantially increase condo- minium fees? Explain YES I NO I UN" VI. RENTAL PROPERTY INFORMATION VII. ACKNOWLEDGEMENTS Seller(s) hereby acknowledge that the information set forth above is true and accurate to the best of my (our) knowledge. I (we) fur- ther agree to defend and indemnify the broker(s) and any subagents for disclosure of any of the information contained herein. Seller(s) further acknowledge receipt of copy of Seller's Statement of Property Condition. Date Seller Seller Buyer/Prospective Buyer acknowledges receipt of Seller's Statement of Property Condition before purchase. Buyer acknowledges that Broker has not verified the information herein and Buyer has been advised to verify information independently. Date Buyer Buyer VIII. EXPLANATORY MATERIAL The following clauses are provided for descriptive purposes only. For detailed information, consult the Massachusetts Department of Public Health, the Massachusetts Department of Environmental Protection, or other appropriate agency, or your attorney. A. Flood Hazard Insurance Disclosure Clause (Question #8) The lender may require Flood Hazard Insurance as a condition of the mortgage loan if the lender determines that the premises is in a flood hazard zone. B. Hazardous Materials Disclosure Clause (Question #10) In certain circumstances Massachusetts law can hold an owner of real estate liable to pay for the cost of removing hazardous or toxic materials from real estate and for damages resulting from the release of such materials, according to the Massachusetts Oil and Hazardous Material Release and Response Act, General Laws, Chapter 21E. The buyer acknowledges that he may have the property professionally inspected for the presence of, or the substantial likelihood of release of oil or hazardous material and such proof of inspection may be required as a prerequisite for financing the property. C. Urea -Formaldehyde Foam Insulation Disclosure Clause (Question #28) The buyer acknowledges that he has been advised that Urea Formaldehyde Foam Insulation (UFFI) has been declared by the Massachusetts Department of Public Health (DPH) to be a banned hazardous substance and that new installation is prohibited. Where UFFI was previously installed, the seller is required to advise the buyer (1) where such UFFI is located and, if known, when it was installed; (2) a copy of test results concerning the air level of formaldehyde, and ,:(3).4;copy,,ofinform4ion:&om,the:DPH-concerningUFFI,and,wks., .r_« formaldehyde levels. Under certain circumstances the cost of removal may be reimbursed. Exposure to hazardous levels of formaldehyde may cause personal injuries, including headaches, nausea or cancer. The buyer acknowledges that he has been advised to consult the DPH or his attorney for further information. D. Asbestos Disclosure Clause (Question #29) The United States Consumer Product Safety Commission has main- tained that asbestos materials are hazardous if they release separate fibers which can be inhaled. Asbestos is a common insulation material on heating pipes, boilers, and furnaces. It may also be present in certain types of floor and ceiling materials, shingles, plaster products, cements and other building materials. The buyer may have the property profes- sionally inspected for the ence of asbestos and if repair or removal SELLER'S INITIALS BUYER' of asbestos is desired, proper safety guidelines must be observed. E. Lead Paint Disclosure Clause (Question #30) Whenever a child under six years of age resides in any residential premises in which any paint, plaster or other accessible material con- tains dangerous levels of lead, the owner is required by law, to remove all said paint, plaster or cover with appropriate materials so as to make in inaccessible to a child under six years of age. Consumption of lead is poisonous and may cause serious personal injury. Whenever such resi- dential premises containing dangerous levels of lead undergoes a change of ownership, as a result, a child under six years of age will become a resident, the new owner is required by law to remove said paint, plaster cover or encapsulate it with appropriate materials so as to make it inaccessible to such child. Buyer should receive information pamphlet from Department of Public Health. F. Radon Disclosure Clause (Question #31) Radon is an odorless, colorless, tasteless gas produced naturally in the ground by the normal decay of uranium and radium. Radon can lead to the development of radioactive particles which can be inhaled. Studies indicate the result of extended exposure to high levels of radon may increase the risk of developing lung cancer. G. Chlordane Disclosure Clause (Question #32) Pesticide products containing chlordane were banned in Massachusetts on June .11, 1985, following a,determination by the Department46f1F66d-and'Agric`ult6re that the use of chlordane may cause unreasonable adverse effects on the environment including risk of cancer. Although existing data does not conclusively prove that signifi- cant health effects have occurred as a direct result of chlordane use, the long-term potential health risks are such that is prudent public health policy, according to the Department, to eliminate the further introduc- tion of chlordane into the environment. H. Fair Housing Notice It is unlawful to discriminate on the basis of race, color, religious creed, national origin, age, gender, sex, ancestry, marital status, veteran status, sexual orientation, disability, presence of a child, receipt of pub- lic assistance or other protected classification in the sale or rental of covered housing. S INITIALS 113 MASSACHUSETTS ASSOCIATION Q MASSFORMS- �.`J��T Rn` REALTOR' Of+REALTORS* ®:o.,vtlp�.m�O Suoe.we sune.re RalFinee corm 3of3 42. NUMBER OF UNITS: ❑ ❑ ❑ Has a unit been added/subdivided since original construction? If yes, was a permit for new/added unit obtained? 43. RENTS: Number of units occupied Rents $ /month Expiration date of each lease ❑ ❑ ❑ Any tenants without leases? ❑ ❑ ❑ Is owner holding last month's rent security deposit? If yes, has interest been paid? If security deposit held attach a copy of statements of condition. Attached Not Attached ❑ ❑ ❑ 44. Is there any outstanding notice of any sanitary code violation? Yes No Explain VII. ACKNOWLEDGEMENTS Seller(s) hereby acknowledge that the information set forth above is true and accurate to the best of my (our) knowledge. I (we) fur- ther agree to defend and indemnify the broker(s) and any subagents for disclosure of any of the information contained herein. Seller(s) further acknowledge receipt of copy of Seller's Statement of Property Condition. Date Seller Seller Buyer/Prospective Buyer acknowledges receipt of Seller's Statement of Property Condition before purchase. Buyer acknowledges that Broker has not verified the information herein and Buyer has been advised to verify information independently. Date Buyer Buyer VIII. EXPLANATORY MATERIAL The following clauses are provided for descriptive purposes only. For detailed information, consult the Massachusetts Department of Public Health, the Massachusetts Department of Environmental Protection, or other appropriate agency, or your attorney. A. Flood Hazard Insurance Disclosure Clause (Question #8) The lender may require Flood Hazard Insurance as a condition of the mortgage loan if the lender determines that the premises is in a flood hazard zone. B. Hazardous Materials Disclosure Clause (Question #10) In certain circumstances Massachusetts law can hold an owner of real estate liable to pay for the cost of removing hazardous or toxic materials from real estate and for damages resulting from the release of such materials, according to the Massachusetts Oil and Hazardous Material Release and Response Act, General Laws, Chapter 21E. The buyer acknowledges that he may have the property professionally inspected for the presence of, or the substantial likelihood of release of oil or hazardous material and such proof of inspection may be required as a prerequisite for financing the property. C. Urea -Formaldehyde Foam Insulation Disclosure Clause (Question #28) The buyer acknowledges that he has been advised that Urea Formaldehyde Foam Insulation (UFFI) has been declared by the Massachusetts Department of Public Health (DPH) to be a banned hazardous substance and that new installation is prohibited. Where UFFI was previously installed, the seller is required to advise the buyer (1) where such UFFI is located and, if known, when it was installed; (2) a copy of test results concerning the air level of formaldehyde, and ,:(3).4;copy,,ofinform4ion:&om,the:DPH-concerningUFFI,and,wks., .r_« formaldehyde levels. Under certain circumstances the cost of removal may be reimbursed. Exposure to hazardous levels of formaldehyde may cause personal injuries, including headaches, nausea or cancer. The buyer acknowledges that he has been advised to consult the DPH or his attorney for further information. D. Asbestos Disclosure Clause (Question #29) The United States Consumer Product Safety Commission has main- tained that asbestos materials are hazardous if they release separate fibers which can be inhaled. Asbestos is a common insulation material on heating pipes, boilers, and furnaces. It may also be present in certain types of floor and ceiling materials, shingles, plaster products, cements and other building materials. The buyer may have the property profes- sionally inspected for the ence of asbestos and if repair or removal SELLER'S INITIALS BUYER' of asbestos is desired, proper safety guidelines must be observed. E. Lead Paint Disclosure Clause (Question #30) Whenever a child under six years of age resides in any residential premises in which any paint, plaster or other accessible material con- tains dangerous levels of lead, the owner is required by law, to remove all said paint, plaster or cover with appropriate materials so as to make in inaccessible to a child under six years of age. Consumption of lead is poisonous and may cause serious personal injury. Whenever such resi- dential premises containing dangerous levels of lead undergoes a change of ownership, as a result, a child under six years of age will become a resident, the new owner is required by law to remove said paint, plaster cover or encapsulate it with appropriate materials so as to make it inaccessible to such child. Buyer should receive information pamphlet from Department of Public Health. F. Radon Disclosure Clause (Question #31) Radon is an odorless, colorless, tasteless gas produced naturally in the ground by the normal decay of uranium and radium. Radon can lead to the development of radioactive particles which can be inhaled. Studies indicate the result of extended exposure to high levels of radon may increase the risk of developing lung cancer. G. Chlordane Disclosure Clause (Question #32) Pesticide products containing chlordane were banned in Massachusetts on June .11, 1985, following a,determination by the Department46f1F66d-and'Agric`ult6re that the use of chlordane may cause unreasonable adverse effects on the environment including risk of cancer. Although existing data does not conclusively prove that signifi- cant health effects have occurred as a direct result of chlordane use, the long-term potential health risks are such that is prudent public health policy, according to the Department, to eliminate the further introduc- tion of chlordane into the environment. H. Fair Housing Notice It is unlawful to discriminate on the basis of race, color, religious creed, national origin, age, gender, sex, ancestry, marital status, veteran status, sexual orientation, disability, presence of a child, receipt of pub- lic assistance or other protected classification in the sale or rental of covered housing. S INITIALS 113 MASSACHUSETTS ASSOCIATION Q MASSFORMS- �.`J��T Rn` REALTOR' Of+REALTORS* ®:o.,vtlp�.m�O Suoe.we sune.re RalFinee corm 3of3 P J � R O 1 STORY i REGISTRY: —SS EL.X I ►J Z K7,H, TITLE REFERENCE: BK, 3 64'I, P& ISO PLAN REFERENCE: P I, Iy0 .= O Z3 S- -7 O' gER KCLEY This plan was not prepared from an instrument survey. Offsets and distances shown should not be used to establish property lines. This plan is intended for mortgage purposes only. I certify that the structure shown on this Plan in conformance with zoning setbacks in effect at the time of construction. , I certify that the parcel shown is NO i located within a flood hazard area as depicted on HUD Flood Insurance Rate Maps for Community No: 2- '0 O �) 6 CAMERON BROTHERS INC. [- Job No. 11 Touro Ave. Medford, MA (781) 324-9566 RO /xD I I MORTGAGE INSPECTION PLAN LOCATION 1 R ER K Et_.EY ED, � a 87H A'W'Q V EER) M A SCALE: I i! _© DATE: CERTIFIED TO: o m e t- i 'n 0,/) C e a E 1' I CCS