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HomeMy WebLinkAboutBuilding Permit #828 - 100 ANDOVER BY-PASS 6/23/2010 r10RT►1 BUILDING PERMIT a�A'c TOWN OF NORTH ANDOVER o? APPLICATION FOR PLAN EXAMINATION ~ 7D o Permit NO: Date Received 4raD Date Issued: d �SS IMPORTANT:Applicant must complete all items on this page LOCATION ;--�� Print PROPERTY OWNER M l i f V 1 VL' 1A "7,d>&JPrintf L.�[ MAP 210 QING PARCEL:oa'� ZONING � .DISTRICT: Historic District yes no !Machine Shap 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: l molition Other pticWell Floodplain Wetlands Watershed District ater/Sewer DESCRIPTION OF WORK TO BE PREFORMED: �c`►�o Ug,��� �2. LEr-ro.�4 i a�.r=s Identification Pease Type or Print Clearly) OWNER: Name: WINC-14c nd,L ,� �� Phone: Address: g"� }�k4 Udo"--.o ��- . d I i-j c L9 C5 /� fi CONTRACTOR Name: t,."a5?- +�� .. Phone: q t 5 S Address:' Supervisor's Construction License: O'er') 1 Exp. Date: Home Improvement License: Exp. Date: ARCHI TECT/ENG I NEERCaC.06"t L-A* AffSl6 Phone: (-03 43 2 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: $_ 2eO,0(�O FEE: $ �1'� 0 Check No.: LTJ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce the guaranty f s gnature of Agent/Ovvner Signature of contractor Location No. Date �pRTM TOWN OF NORTH ANDOVER + s /Q • � ; , Certificate of Occupancy $ Or SACNUSEt�' Building/Frame Permit Fee $ 116 0 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1,0 2 3 O ��l Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans e 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 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature �,OMMENTS t Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124;Main Street Fire Department signature/date 'COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21 A—F and G min.$100-$1000 fine NOTES and DATA— For department use i i ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 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 o 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan j ❑ Photo of H.I.C. And C.S.L. Licenses E ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals i 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 h Doc:Building Permit Revised 2008 ` I NORTH 0 0 _ over -It .. 7 C% ::- o dover, Mass., CO CHIC KEWICK ^ RATED 7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... K ..r11 .-..q 000 ��c if .............. .. ......... Foundation has permission to erect..............:......................... buildings on 1 -. �>,. ................ ug to be occupied as... r�t'� / .`. .� ..`.... .�al....�../,e'�1���..��.......... ... ......... . .... ....... c � n y provided that the arson acce tm this ermit shall in eve respect conform to the terms of the application on file in P P P 9 P �I final 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 INSP C�TlL, VIOLATION of the Zoning or Building Regulations Voids this Permit. .27vq L _`'_ / inac1,/-L PERMIT EXPIRES IN 6 MONTHS ` ELECTRICAL INSPECTOR j UNLESS CONSTRUCTIO TARTS Rough ................................ Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. O Street No. SEE REVERSE SIDE smoke GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS:(Minimum) Excavation,Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Re'^--as required s or straps in-pipe/stonelfabric filtedcover and outlet connection. .plates between floor joist ,dns for plumbing,heat,elec,etc. ,(stair stringers. irners and center bearing partitions. ,j to provide full bearing at rafter cuts. � d Valley rafters-watch bearing at walls. ige&Hip-Provide proper connections. :;athedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. f) Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. - Girts-solid brick or steel plate bearing at foundations 7 air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. j Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w13'headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of'0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. Y2 of required glazing shall be openable. Bedrooms required min.20x24 egress window or door. Vent attic spaces-"proper vent",soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish 4 Smooth parging,clean joints,8"solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36`high, Baluster max space 5"on center. ..p Over 8'above grade, use 6x6 posts w/lateral bracing. , Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. "o. Q_\1, FINISH: Handrails returned to wall/newall post. IZ5 Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupving structure. i NORTF! Tomm of over No. 4 _ WY-7 o dover, Mass.,tL- LAK COC MIC MEWICK S RATED BOARD OF HEALTH i Food/Kitchen Septic System PERMIT T D THIS CERTIFIES THAT '� BUILDING INSPECTOR . .......�C..S�..!.�.�...... ..�r�.J.G!!r`/....... .�...���............................................................. �........... F ' oundatton has permission to erect..............:......................... buildings on . a .. �t!Gl'a�'r.":�.. `. .�_1............... Rough �� P� l� "y Chimney tobe occupied as........ ..... , .� /L...:.......1 .......... ..1............................................................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough .... Service BUILDING INSPECTOR Final Occupancy Permit Required to Oxupy Building GAS INSPECTOR Rough Display in. a Conspicuous Place on the Premises — Do Not Remove Final No Lathingor D Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner, Street No. SEE REVERSE SIDE smoke Det. ALDAROLA DESIGN A S S O C I A T E S , P C Architecture ❑ Interior Design ARCHITECTURAL AFFIDAVIT Project Number: AV I Date: Q Project Title: rjl�j/GI-�N kl�Ml� L�{1� Project Location: prj �ooymr.f�f-wo: Ilan � Name of Building: Scope of Project: gJW�j 1'0 gT, 6� yds I, Joseph V. Caldarola, MA Registration No. 7728 being a registered professional architect have prepared or directly supervised the preparation of the architectural design plans, computations and specifications for the above named project and that, to the best of my knowledge, belief and understanding such plans, computations and specifications meet the applicable provisions of the 7th Edition of the Massachusetts State Building Code. I shall perform the necessary professional services and be present on the construction site as needed to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in section 116.2.2 pursuant to section 116.4: 1. Review, for conformance to the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. Upon completion of the work, I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. Signed b Date: l0 2 Architect's stam m ? � 4 Birch Street,Derry, NH 03038 (603)432-8404 (Fox)432-2706 j ORD D6/22/201 ATE(MM/DD/YYYY) AC CERTIFICATE OF LIABILITY INSURANCE T2 2 1 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mathias Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 200 Sutton Street, Suite 160 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01845 978-688-5531 INSURERS AFFORDING COVERAGE NAIC# INSURED Cast Builders Inc. INSURERA: Max specialty Insurance Company 200 Sutton Street INSURER B: Hartford Underwriters Insurance Company North Andover, MA 01845 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ODL POLICY EFFECTIVE POLICY EXPIRATION LTR NSRD P IN POLICY NUMBER DATE MM D DATE MM DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 X COMMERCIAL GENERAL LIABILITY EI PREMISES Ea occurence $ CLAIMSMADE x OCCUR MED EXP(Anyone person) $ 5 000 A MaxO13100002883 12/01/09 12/01/10 PERSONAL&ADV INJURY $ 1,000,OOO GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMIT APPLIESPER: X POLICY : PRODUCTS-COMP(OPAGG $ 2,000,000 JE� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) ALL OW N ED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OW N EDAUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EA ACC $ AUTOONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CI CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS DOM PENSATI ON AND WCSTATU- I OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIEfOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBEREXCLUDED7 6S60UB-4102P23-8 12/11/09 12/11/10 E.L.DISEASE-EA EMPLOYE5$ J.00F000 If yes,describe under SPECIAL PROVISIONSbelcw E.L.DISEASE-POLICY LIMIT 1$ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL20 DAYS WRITTEN I NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 120 Main Street IMPOSE NO OBLjQajjQF OR LIABIL1TY 9F ANY KIND UPON THE INSURER,ITS AGENTS OR North Andover, MA 01845 REP NT AUTHO ACORD25(2001/08) ©ACORD CORPORATION 1988 1 ELECTRICAL DESIGN AFFIDAVIT Permit No.: To the Commissioner, Inspectional Service Department: RE: OB/GYN Woman's Care I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at: 100 Andover By-pass, North Andover, MA are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. -�N OF Mq�s9cyG -Mass. Reg. No.A Lic. #41825 Engineer z� DA EL A. J' Fitzemeyer&Tocci Associates, Inc. L Company F 92 Montvale Ave., Suite 4100, Stoneham MA 02180 �F8 81 0 NAI-EN Address (781) 481-0210 Phone (Registration Stamp) Signature: Date: 6/1/10 Then pers ally appeared the above-named Daniel A. Hurley, P.E., and made oath that the above statement by him is true. Before me Jill Anderson, Notary Public My commission expires November 14, 2014 Sworn before me at Stoneham, Middlesex County, Massachusetts, this, the 1 S'day of June, 2010 I' PLUMBING/FI RE PROTECTION DESIGN AFFIDAVIT Permit No.: To the Commissioner, Inspectional Service Department: RE: OB/GYN Woman's Care I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at: 100 Andover By-pass, North Andover, MA are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. I Stephen J. Montibello, P. E. - MA Lic. #39310 a .4 Engineer- Mass. Reg. No. rr J Fitzemeyer&Tocci Associates, Inc. MONTMELL0 NA CHANIC Company 39310 92 Montvale Ave.. Suite 4100, Stoneham, MA 02180 SION Address (781)481-0210 (Registration Stamp) Phone Signature: Date: 6/1/10 Then personally appeared the above-named Stephen J. Montibello, P.E., and made oath that the above statement by him is true. Before me, Jill Anderson, Notary Public My commission expires November 14, 2014 Sworn before me at Stoneham, Middlesex County, Massachusetts, this, the 15`day of June, 2010 i v i I MECHANICAL DESIGN AFFIDAVIT Permit No.: To the Commissioner, Inspectional Service Department: RE: OB/GYN Woman's Care I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at: 100 Andover By-pass, North Andover, MA are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. I ASH OF Joshua W. Smith, P. E. - MA Lic. #46292 e��P Mass Engineer- Mass. Reg. No. JOHUA W. MIPJ 9�yN Fitzemever&Tocci Associates, Inc. MECHANICAL Company No.46292 v, 9°�Fs�c TQA ��� 92 Montvale Ave., Suite 4100, Stoneham, MA 02180 s L E Address (781)481-0210 (Registration Sta Phone Signature: Date: 6/1/10 Then perso ly appeared the above-named Joshua W. Smith, P.E., and made oath that the above statement by him is true. Before me, Jill Anderson, Notary Public My commission expires November 14, 2014 Sworn before me at Stoneham, Middlesex County, Massachusetts, this, the 1"day of June, 2010 I ACOR CERTIFICATE OF LIABILITY INSURANCE DATE,MM/°D/YYYY) 22/201 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mathias Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 200 Sutton Street, Suite 160 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01845 978-688-5531 INSURERS AFFORDING COVERAGE NAIC# INSURED Cast Builders Inc. INSURER A: Max Specialty Insurance Company 200 Sutton Street INSURER 8: Bartford Underwriters Insurance Company North Andover, MA 01845 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D'L POLICY EFFECTIVE POLICYEXPIRATION LTR NSRD p C POLICY NUMBER GATE MM D DAT MM DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY ELI PREMISES(Ea occ $ CLAIMSMADE CI OCCUR MED EXP(Any one person) $ 5 OOO A _ MaXO13100002883 12/01/09 12/01/10 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER '. PRODUCTS-COMP/OPAGG $ 2,000,000 xPOLICY JJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) li ALL OW N ED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) i HIRED AUTOS B erarci ent) JURY NON-OWNEDAUTOS � (Peraccident) $ PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO-ONLY-EA ACCIDENT $ I ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGG $ I' EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ III OCCUR E CLAIMSMADE AGGREGATE $ II, $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCSTATU- CTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ loo 000 B OFFICER/MEMBEREXCLUDED? 6S60UB-4102P23-8 12/11/09 12/11/10 E.L.DISEASE-EA EMPLOYE $ 100 000 If yes.describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN 120 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO 0 L OR LIABI Y F ANY KIND UPON THE INSURER.ITS AGENTS OR North Andover, MA 01845 j REP NT d I '. .� AUTHO �7� ACORD25(2001/08) ©ACORD CORPORATION 1988 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASS CHUSETTS 7 Z 3 �- Date Building Location U ev O V "�7wners Name Al (1r Permit# Amount L/2 0 �sType of Occupancy New Renovation ❑ Replacement ❑ Plans Submitted Yes No FIXTURES z _Z rA a W wA A Pg E„ W r0 q '� x Pg Ha H � SMBM >AwM M WER MR9R 41H ROCR 5MRUR si RaR 7M>10M mmom (Print or type) t ec one: . Certificate Installing Company Name Corp. Address ` Partner. Business Telephone 0 El Firm/Co. Name ofLicensed Plumber: Insurance Coverage: Indicqft type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the and igned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 7 Owner Agent I hereby certify that all of the details and information I have subm' o ente in above appli and accurate to the best of my knowledge and that all plumbing work and installa' ns p un er P t ed t s lication will be in compliance with all pertinent provisions of the Massachus Stat u ing od pter o e General Laws. By: igna s Type of Plumbing Lice Title City/Town License NoWner Master Journeyman APPROVED(OFFICE USE ONLY Date.U,? 3 �v NORTH TOWN OF NORTH ANDOVER i. 00 PERMIT FOR PLUMBING �. ,SSAC14US� This certifies that . . .<., .�`` . . . .�.?. . . . . . . . . . . . . . . . . . . . . has permission to perform . . . plumbing in the buildings of . . . . /1 �G N'. . . . . —: at . .A�Q . �.�ct� h f Orth Andover, Mass. W ... . PLUMBING IN PECTOR Check y 8336 The Commanweidth of Massachusetts i Department o f rndustiial Accidentsbr � .flz f£nvesggations 600 Wasizington Street kip OStOn, AU 02111 www-nxas�govidia Workers' Compensation Insurance Affidavit. B,ceders/Contr'actors/ lectrYciaas/Plumbers Au lieant Tnformafion PIease Print Legibly Name(Business/Organization/Indivi(lual): V ^ • Address: ��,s ��- • City/State/Zip: /� - _2 Phone#: - �3 J Are you an employer?Check the appropriate boa: l•❑ I am a employer with 4. ❑ I am a treraType of project(required): employees(full and/or part-time).* have hie d the contractor and I 6 ❑ New construe ' e sub contractors tion ?•❑ I am a sole proprietor ar partner_ listed on the attached sheet 6 Remodeling ship and have no employees These subs-contractors have working for mein any capacity. workers' com . ' ❑Demolition p insurance. 9. ❑Building [No workers'comp.insurance 5. We are a corporation and its _ b addition � r required.] Officers have exercised their I O.0 Electrical repairs or additions 3.0.I am a homeowner doing all work right of exemption per MGL .11-0 Plumbing repairs or additions myself [No workers'comp. • c. 152,§I(4) and we have no insttrance required] t employees. [No workers' 17 0 Roof repairs comp.insurance required.] 13.0 Others .� I aPP-TrCBSt th°t ch--k°Fro:.41 •..t••—'°.L f1�1Lt L`'Lp ECC E=CLf`*..C O4,'SRQ�•••..•.r' Homeowners who submit f ds affidavit indiWin h a g wviii aid then fiireoutside conuzcto s did ,u'u;uit a new amoa +Contrsctors that cbw:,t,;;her Y•s at aches as additional sheet showing the vit i,a m ing such. i name of the sub-contractors and tfieu.workers'comp.poUcy information. I am an employer that is providing workers'compensation i information. nsurance for rrsy employees Below is the policy and job site _ Insurance Company Name: V F, . I i Policy#or Self-ins.Lic.# Expiration Date: Job Site Address. 741V TridT' a City/State/Zip: d Attach a copy of the workers'compensation pog declaration.page(sho�.ng the policy number•and expiration dot ]. Failure to secure coverage as required under Section 25A ofMGL 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 of up to$250:00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of a fine Investigations of the D for insurance cov v tion I do her cerfifp nose pat e s perjury th4rr the informatioj7.provided above is true and correct Simla e: _ •• ? ' - Date:.. �•.._."� U Phone#: Official use only. Do not write in this area, to be completed bj,c°)or foN,n ofjicinl City or Town: Permit/Llcense# Issuiag Authority(circle one): I.Board of Health 2.Building,Department 3. City/Town Clerk 4.Electrical InspElmbin-Ingpctor6. Other Contact laerson. Phone•#: i Information an- d k' structi®ns Massachusetts General Laws chapter 152 requires all employers to provide workocrs'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 em is defined as"an individual,partnership,associ action,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including tee legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association ox-other legal entity,employing employees. However the owner of a dwelling house having not more than three apartroL eats and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte3aance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be cause of suchemployment be deemed to be.an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing'aaency shall withhold-the issuance or renewal of a license or permit to operate abusiness 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.performanee of public work unto acceptable evidence of compliance with the insur-ame 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 numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other thou the members or partners,.are not required to carry workers'comp ration 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 Accidrn s for c��onfirmaiion of insurance coverage. .Also be stare to sign and date the affidavit The affidavit should Ile returned t4 the vitt'or tornfII dict the aur"' caiion lr it the per nh or 1 c roe q ti`erny*regasesfed,not theDepart yeRt Of Industrial Accidents. Should vnr,have any ouingdonq Teg dLo{Le taw ui u t' 2 r:Yew ed to obtain a woexe& compensation policy,please call the Department at the numbe=r listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition;an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under`.`Job Site Address"the applicant should write"all locations in (city or town).".A copy of the affidavit that has been officially stampe=d or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future perznits or licenses. A new affidavit must be filled out each . . year.Where a home owner or citizbn 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 f6r your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,ielephone.and.fagnumber.__.. The Commonwealh of Massachusetts. V Department OfIndustria1 Accidents 4fbice of 19resti rati mos Q ' 640 Washingbn Street ROSton,MA 02111 r L D Tel 4 617-727-4900 ext4406 ar 1-977-NL4S.SAFE l Fay:#6.17-727-7749 Revised{-2F-QS ' ' • VrVM1M ss._gov/dia