HomeMy WebLinkAboutBuilding Permit #686 - 100 OLD VILLAGE LANE 4/18/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
MPORT NT:Applicant must com lete all items on this page
v -
LOCATION!
TPrint.
PROPERTY OWNER -
��� r TPrint 1 oo Year bid Structure yes o,
MAP NO: PARCEL: ZONINGDISTRICT: Historic District yes no
Machine Shop.Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building X One family
❑Addition ❑Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
0 Septic: ❑Well ❑ Floodplain. ❑Wetlands ❑ Watershed District:
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERF nOR1 ED:
✓!
r• Q g,
(.Wi Nec.J r�" TIJ�eS
Identification Please Type or Print Clearly)
OWNER: Name: Sri Se,n Phone: �� 90�
Address:
CONTRACTOR Name: Phone: �r U S'7Ljs
Af
i
Address:
Supervisor's Construction License: 16 a 3 Exp. Date: /�/dt _ );z6n
Home Improvement'License: l b - Exp. Date: 72S ho 1
ARCHITECT/ENGINEER Phone:
'+ Address: Reg. No. j
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ �-
i
i Check No.: Receipt No.:—,'36'� o.
NOTE: Persons contr cting kith u registered contractors do not have access to the guaranty fund
4
SignatUha of Agent/Owne .Signature of contractor
Plans Submitted ❑ lans Waive Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Swimming Pools 0
Tanning/Massage/Body Art ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales D
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
I
CONSERVATION Reviewed on Signature
I
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
i
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 Towo Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTM�-NT - Temp Dumpster on site yes no
Located at 124.Mairi Street
Fire Departiner t.signature/date `
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
MOTES and DATA— For department use
B Notified for pickup - Date
i
Doc.Building Permit Revised 2010
I
I
Building Department
artment
The foliowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
I
Roofing, Siding, Interior Rehabilitation Permits
i
o Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit f
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)
o 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
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ 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 app,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm* ted with the building application
Doc: Doc.Bui?ding permit Revised 2012
I
Enter construction cost for fee cal- North Andover Fee Calculation
Construction Cost
$ 51555.00 m
$ - $ 66.66
Plumbing Fee $ 8.33
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 8.33
Total fees collected $ 183.33
100 Old Village Lane
686-13 on 4/18/2013
Remodel First Floor Bath
NORTH
-own of
: a ndover
No. 3 -
4 h ver, Mass, Ll
COCKIC"IWKK y1'
�9 AoRATE1) PPy
S V
BOARD OF HEALTH
Food/Kitchen
PE R.. MI. T Septic System
THIS CERTIFIES THAT � .......................�'`��°` BUILDING INSPECTOR
rr II Foundation
has permission to erect .......................... buildings on .Jap.......�.?.1d....Q!1 .vZ,...�.......
I I -
Rough
to be occupied as ...... .......
...� T......n0o.n,7:......&tfc................................ 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 6 MONTHS ELECTRICAL INSPECTOR
(0 UNLESS CONSTRUCTIO TAR S
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.
SEE REVERSE SIDE. Smoke Det.
Massaclhusc.� s $tome Improvement Sam. • le Contract
This foam satisfies all basic requirements of the state's Home Improvement Contractor Law GL chapter
language to r (M ter 142A but doe
protect homeowners. SeeIc legal advice if necessa An p )� s not include standard
Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residencovements should first obtain a e.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 1-888-28 -
3.3757 or on our website.
Homeowner information Contractor In folmition
Name
Company Name
Street Address(do notuse aPost ffice Box address
Contractor/ esperson/ wnerNa,
City/Town Statb Zip CodeBpsmess Affilress(must include a street address)
c Qc l S
Daytime Phone Evening Phone City/Town State Zip Code
73 ewe D c� f
Mailing A dress(It different from above) Business Phone
federal Employer M or S.S.Number
Law requires that most home FlomeImpmvementcontmctorReg:Number Expiration date
,
improvement contractors have
a valid registration number
The Contractor agrees to do the following work for the Homeowner:
(Describe in detailthe workto completed,specifyingthe type,brand,and grade of materials to be used,use additional sheets ifnecessarv.)
✓cVAt>unC�a sof k vkcytc, 5 f-t e�r�elw d V\- 4,�\e- F1' (15
ZC A� C�_
ke)w er 5 Ifu-C<
Required Permits-The foligv ing building permits are required Proposed Start and Completion Schedule-'The following schedule will
and will be secured by the.contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who Secure their own permits•wvffl be
excluded from the Guaranty Fund provisions of -7 Date when contractor will.begin contracted work.
MGLchapter 142A.)
_J/__ -Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: :l
Payments will be made according to the following schedule:
$ _ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater)
by 3 or upon completion of E
$--�-� L— by 1 / or upon completion of e-
--�� pcompletion !�
upon ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) .
The following material/equipment must be special $ to be paid for
ordered before the contracted work begins in order
to meet the completion khedule.(*'"-) $ to be paid for
NOTE'S:(1)Including all finance charges('l*)Law requires that any deposit or down-payment required by the contractor before work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Bx ress Warran -Is an ea ress warran heir rovided b the contractor? No ❑•Yes ail terms of the warran must be attached to the contract
Subcontractors-The contractor agrees to b.e solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor, The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor undLr-fLis,agr6ement
Contract Acceptance-Upon signing,this document becomes abinding contract under law. Unless otherwise noted within document,the
contract shall not imply tat any lien or other security interest has been placed onthe residence. Review the following cautions and notices
carefully before signing this contract.
e Don.'tbe pressuredinto sig
• ning the contract.Take time to read and fully understand it. Ask questions if something is unclear.,
Make sure the contractor has a valid Home IMprovement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor
registration by writing to the�Director at 10 ParlcPlaza,Room 5170,$oston,MA.021 6 or by calling 617-973-8787 or 888-283-3757.
o Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm,coverage,or aslc to
see a copy of a"Proof of insurance'document.
o 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 of
the
third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this right
DO NOT'SIGN TMIS CONTRACT IF THERE ARE ANY IBLANK SPACE SM
Two identical copies of the contract must be completed and signed, one copy should go to the homeowner. The other copy sliouldbe lcept by the contractor.
Homeowners Signature
Contra s Signature
f 3
'Date
Date
Contractor Arbitxafion
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 affordedto 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. Thus 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 film 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 In Massachusetts General Laws, chapter 142A..
Homeowner's Signature Contractors 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.
3Eomeowner'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 exchided'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 worlanaanlike 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 emuneration 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 da licate 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 theoriginal 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 j oint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fiends from said account would require the
signatures of both parties.
:Additional Information
If you have general questions or need additional information about the Harm 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 OCABRwebsite at1liltp://ww,,v.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 Horne 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, 888283-3757 or visit the BIC website at bM-//wyAv.mass.gov/ocabr/
/wyAv.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration: .
111.1)://db.state.ma.us/-tomeimt_rovement/licen.seelist.asn
For assistance with informal mediation of disputes or to regisi:er 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
—K--N—C3819/T-3850-3-part carbonless contractors proposal
'P ro p oat Page# of pages
1
L,' C -_t:47 /b s 3 G
PROPOSAL SUBMITTED T0: n JOB NA JOB#
ADDRESS JOB LOCATION
DATE DATE OF PLANS
f r er
PHONE# FAX# ARCHITECT
e hereby submit specifications and estimates for: -__....... __— __ _ _ ________
........ .................
—
.._ _n sojoo^'--—
---
___ _ — — -
_-------------...........—
7x�e pr ose hereby to furnish material and labor–complete in accordance with the above specifications for the sum of:
Dollars
with payments to be made as follows: / ��\n i s %z Sd%a C C� �t �� vin
Any alteration or deviation from above specifications involving extra costs Respectfully IA,,,,�will be executed only upon written order,and will become an extra charge submitted
over and above the estimate. All agreements contingent upon strikes,
accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
Rcceptonce of Propo al
The above prices,specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified.
Payments will b a s outline ,bove. Signature
Date of Acceptance Signature ov AA
A-NC3819/T-3850 09-11
Ali wort shall be comp( ' • i ' 1 lr...,r , . 1 ,. ',r, , , ; ,
ctcc. I'1 a �ro�.�ti' •,rr;�l m�• 'l Id t ( „l�,i;:n.e '�I+. >:I ,,u•..,n�r tt�tr”
and other adplicahl,, lags.
�' ;il: .t . �ti,:ir�tl 'r, i .t I 't ,' I' ." • �! eel � '.lit :- , r .I -1 r .
i!_1111(4.10 .A :a\•1 'O r'a ),Ill S:` l l'
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t ,� � :1ti. , ' i , Ir_illt �1., � I,I � ;,-�� .'1'l•:;' J' �� 'rl . ' C• ..'i... � r i� It
of 'hi, ('L),,i act
a. nto.- 1111 , tLlrnls I t 1-, , • tilr1` Ili It L,-'`. Ill .rt 'Lr Ft l V ltL {.f: 0'
m.tterlals PTLti1'IdtJ alt 1!W t,,ili O't ;le!tt ,t lt!!' �I' Irl S�1,1!; be di.t
�. AH ('h;nge Ordcr, and;or;e.,i lilltr-.:.:' 1.lilrlt AL.;), lull be Ir- ter ,l o.r .'(1 ,fent-d b\ l-o—
Owner and Contractor.
b. Contractor v alrints it is a(}e(lrlatcly ,ns,,red ft injul'y to its emp'oNee' .lnd ct,hc•r, incurring Ic,s
or injury as a result of the acts of Contractor or its employees and subcontractors.
7. Contractor shall, at its own expense, obtain all permits necessary for the work to be performed.
8. Contractor agrees to remove all debris and leave; the premises in broom-clean condition.
9. In the event owner shall fail to pay any periodic or installment payment due hereunder, Contractor
may cease work without breach pending payment or resolution of any dispute. Failure to make
payment within _ days from the due date of payment shall be deemed a material breach
of this contract.
10. All disputes hereunder shall be resolved by binding arbitrallon in accordance Leith the rule, ofthc
American Arbitration Association.
11. Contractor shall not be liable: for any delay due to circumstances beyond its control including
strikes, casualty or general unavailability of materials.
12. Contractor warrants all work for a period of days following completion.
Note: This form is not a substitute for the advice of an attorney. Legal advice of any nature should be sought from competent,
independent, legal counsel in the relevant jurisdiction.Absolutely no warranties are made regarding the suitability of this fore
for any particular purpose.
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual): � s o'
Address: LL'NJ
City/State/Zip: A /�v����41te— Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I ama,employer with 4. ❑ I am a general contractor and I 6. ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors E]Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam 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.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 requiredunder 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.
1 do hereby certto under the sins and penalises ofperjury that the information provided above is true and correct. -
Signature: Date:
7
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the 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
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture
(i.e.a dog license or permit to 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,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The CoMMORWealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston}MA 02111
TeX.#617-7274900 ext 406 or 1.-877:MASSAFE
Revised 5-26-05 Fax#617-727-7749
wwwanass,gov/dia
Location
No. Date 1#///,j x3
* • TOWN OF NORTH ANDOVER
• 4�A1L1s'tl'� 9�
♦ c
e
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# ,ter _;
26303 Building Inspector