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HomeMy WebLinkAboutBuilding Permit #593-14 - 1010 JOHNSON STREET 2/12/2014 TOWN OF NORTH ANDOVER I PPLICATION FOR PLAN EXAMINATION Permit NO: ` Date Received Date Issued: I P RTANT: Applicant must complete all items on this page LOCATION �aA/ r G �rint PROPERTY OWNER. Print 10 ar Old ye fqD� MAP NO: _PARCEL: ��� ZONING DISTRICT: Hi t i yes M i illage �o� TYPE OF IMPROVEMENT PROPOSED USE C Residential - tial ❑ New Building ❑ One family 1 ,2v ❑A Oition ❑Two or more family ❑ Indus Iteration No. of units:' ❑ Commerc' ❑ Repair, replacement ❑Assessory Bldg -d Others: ❑ Demolition ❑ Other NJ q El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: il�'���U/G� �G✓�' �4.Sj7n/G G��u�E?� �/aGrC tyi�df�o.✓ 0�aid .�`�fr2 Gf ff1te 1*71e~ 1140.0 0 Gk02**W4 'Gf,Q Identification Please Type or Print Clearly) OWNER: Name: :r66 Phone: Address: 4/r/ CONTRACTOR Name: / .arE GGA Phone: "7w,;z-7zol i Address: 1�3 �f?•r/ d �i�uG/ ,f a��� Supervisor's Construction License: /��/Ool/Z Exp. Date: Z� i Home Improvement License: Exp. Date:- # ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASE N$125.00 PER S.F. f T Total Project Cost: $ /oY�Z FEE: $ 9 Check No.: 1�-�� Receipt No.: NOTE: Persons contracting ith unregistered contractors do not have access Zth :r; fund Signature of Agent/Owner Sig nature of contractor Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -TYPE:OF-SEWERAGE.DiSPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc.. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY AhT ftDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I .CONSERVATION Reviewed on Signature COMMENTS \Nk- HEALTH Reviewed on Signature I ,.. I COMMENTS t t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature cis Date Driveway Permit i DPW'lbw;: Engineer: Signature: 1 Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no � Located at 124 Mair Street Fire Departinerit9ignature/date - I } COMMENTS_ i 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 NOTES and DATA— (For de artment use SVrU LQ n is 44 '1A)XAd 0V1 — L-( 6 U Notified for pickup - Date { i Doc.Building Permit Revised 2010 Building Department The fol[�wing is-`a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuanc of Bldg Permit Addition Or Decks r ❑ Building Permit Application ❑ Certified Surveyed Plot Plan - ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses I ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Wo r With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applic ble) �� ❑ Engineering Affidavits for Engineered products 9 NOTE: All dumpster permits require sign off from Fire Departm t �, rr u�4 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 y ❑ 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw 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.Building permit Revised 2012 Location No. Date l . - TOWN OF NORTH ANDOVER Certificate of Occupancy $:, Building/Frame Permit Fee $� Foundation Permit Fee $�— Other Permit Fee $ TOTAL $ Check# `' �" Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 10,432.00 m $ - $ 125.18 Plumbing Fee $ 15.65 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.65 Total fees collected $ 256.48 1010 Johnson Street 293-14 on 2/12/2014 Storage Area surars 187.77' 503'04'40"E LOT AREA 47,930 S.F.f Ex. Retaining Wall 122.0' /EX. Wooden Handicap Ramp Ex. 1.7' x 1.7' Ex. 1.7' x 1.7' Conc. Post Conc. Post Ex. .Deck �Ex. 1 1/2 Story ''Wood Frame Structure 's—� CJi 31.1' 17.5CL� Ex. Conc. Wall 10" Thick Z Note: Proposed Addition to be Constructed on Ex. Conc. Wolf �rn (in Red) orn 'a OD rn 126.2' i �. S'02'33'33"E p 177.18' ZONING INFORMATION: JOHNSON STREET ZONING DISTRICT : R2 MIN. BLDG. SETBACKS: PLOT PLAN OF LAND FRONT : 30 FEET SIDE : 30 FEET 1010 JOHNSON STREET REAR 30 FEET NORTH ANDOVER, MASS. ASSESSOR INFORMATION: IK OF MAP 107A PARCEL 137 ti PREPARED BY: DEED REFERENCE: o� BOOK: 12359 PAGE: 15 H SULLIVAN !ENGINEERING GROUP', LLC. 13M 22 MOUNT VERNON ROAD OWNER INFORMATION: E�tSTt�4 ,c4 BOXFORD, MA 01921 ROBERT COOKSON � ��1AHpg� (978) 352-7871 1010 JOHNSON STREET f NORTH ANDOVER, MA 01845 SCALE: 1"=40' DATE: 11/12/13 - ---l_ ix to g's7 .�KEYs7�a.N� a�6�x' ' • v�i�Ci/�JG� /�' !/°' � l ---� � ,---; ;—;—� 1— M! �, i � � —� -- ! j i I I I I I I I i i : _ ----- _ --- -- I --SI// 4 _,-'L-•-- - i I i ! I I I ' -• i- ` '._ ..-_._ ! T /CAL,FI7-114S J _ I -a- i RAFTER- 2X10.. / ok . _ 1-. �- -- -- --- -- --- •---- --- -I '-! � � I � i ' � I �j l j I I ' ♦ � + � I I j I I I , J Q fiF� � I � + j ! j ! ,' , F i I- � � I � i ;; I � � � i I � ; ' I ' -1- r-I-I- F--,- I-!--�---i-t-- i �-I----�- � _t_ I I. .j i�•�,_�_-. �- �"_ � -, �. � i j ._i -�� - - --- - — Y Oa D ! _ I I I /y_ I I I I I I I i �- j r , –i-- -t- -:�-',,' --�-*--�_-� � -j--- -• --�.�-I---� -;-�--�-�----.. --r- r'----i---i-,I --I� ----1I----`-i-- ; -- -'i -T---i--, -,--�_-_�1. : - I . I I i I i ! i I I i- I WA � K —!- 0 ^ � i - k F NO"�RTFj Town of t ndover 0 0 No. ' MY, = - h , ver, Mass, �t COCN'C.1W'CK �0 7,9 A�RArED ►Pp,�,(5 S V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .6.Q'6...... Q •••••.. BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on ../040.... �,I ...... •......••• Rough to be occupied as .... f� .. ... ..�.........%Jrr2s ................... Chimney provided that the person ac this permit shall in every respect conform of the application Final pro p g p 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHSt ELECTRICAL INSPECTOR UNLESS CONSTRUCT I S 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. Smoke Det. SEE REVERSE SIDE FILE:V:\2000s\2016-Stora a Bunker Andover.k1A Dw Sheet Sels 20165-Structural dwqs.dwu PLOT DATE: 1/10/2014 1:04 PM SAVE DATE: 1/10/2014 1:04 PM Z O N Z E D S Z 179 Om R O O ri N N M Z C> O C O � Z � M M z O M n W I � N � m mN 55M cn mm ^ v nOv v °m° y r C') =i C 4 no N r 0 Z I r p U)C Z W C N C Z Z >00 T C Z W (n O >00 >00 ' I N D m D ct II' Z T H- n C1 CD 71 O D v z 15'-10°t (W.F.) �n ov OOMMpN� zFri 1:1 c7 N y $ zm z � z rter�** T a c7m D S1135�a r-v Bergman & es' Inc. DRAWN BY: CHECKED BY: APPROVED BY: bgineers' � H. NGUYEN P. BERGMAN P. BERGMAN DATE: ISSUE FOR: PROJECT NO.: 20 WASHINGTON STREET 01/10/14 CONSTRUCTION 2016 HAVERHILL, MA 01832-5524 DRAWING NO.: DRAWING TITLE: (978) 372-1125 TEL �� FRAMING PLAN (978) 372-1130 FAX SHEET 1 OF 2 COMM RESIDENCE- 1010 JOHNSON ST.ANDOVER,W a` FILE:V:2000s 2016-Storage Bunker.Andover.MA Dw Sheet Sets 2016S-Structural dwqs.dwo PLOT DAT: r io 2014 em PM SAVE DATE: 1/10/2014 r:01 PN rn VIII x Ln --t rn .-1 N a X m X rte— N W co C� O Z U) rn O Z C7 O Z N � n C7 � D m _ C) p \ O to N O x a � x Z C/O r M Z� C) c> a x N a rn v X O y 0 m o n Z � p N Z P a) r x =i M m COMMO�,� =1 I II I l l l m S113Sn —II p ILII o M Bergman & Associates, Inc. DRAWN BY: CHECKED BY: APPROVED BY: agineers'�'`J H. NGUYEN P. BERGMAN P. BERGMAN DATE: ISSUE FOR: PROJECT NO.: 20 WASHINGTON STREET 01/10/14 CONSTRUCTION 2016 HAVERHILL, MA 01832-5524 DRAWING NO.: DRAWING TITLE: (978) 372-1125 TEL �^ FRAMING SECTION (978) 372-1130 FAX L SHEET 2 OF 2 OMGM R<SUNM- 1010 JOHNSON ST,ANDOVER, MA Cell:978-604-5243 143 Main Street Office:978-207-0326 North Reading,MA Fax:978-207-0329 _004� mat,d)acehomemedics.com `` Proposal.Submitted To: www.acchomemedics.com Ace l® Bob Cookson HIC Lic. # 153165 1010 Johnson Street Construction Super.Lic.#100212 Home Medics, LLC North Andover,MAO 1845 C:978-691-5000 Estimate/Agreement#:2071B REMODEL + BUILD REPAIR EM:cooksden a)verizon.net Date:August 7,2013. Job Location: fT'e AceeptlllasterCard& Visa 1010 Johnson Street North Andover,MAO 1845 Cost Estimate/Agreement for Services BSB.i - NAT179i11-7 = Rear Garage Construction Carpentry,Construction At the back of the home,we will:Remove and replace the existing sill plates(sill under existing beam may be upsized to 2x12 in $5250 and Administration order to better center the beam and wall);add sill sealer;frame roof and side walls of garage above concrete block walls per plan; install non-operating picture window on door side;install roof sheathing and asphalt shingle roofing per plan(50 yr.shingles);tie new roof into existing house;flash and seal properly;patch existing aluminum siding as is necessary;install fiber cement siding on the two new garage walls.Inclusive of proactive communication with clients and suppliers as well as permitting,administration, coordination and supervision of entire project. verhead Door Supply and installation of new 7'H,flush steel garage door without a remote,with interior deadbolts. 950 Masonry Masonry work to:fill existing concrete blocks with concrete;stucco the back sides of the exposed existing concrete blocks. 1400 Building Materials Framing lumber,sheathing,roofing,ice and water shield,flashing,sill sealer,fiber cement siding,non-operating window $2700 allowance of$280),fasteners,adhesive and other related building materials. Building Permit Fee Allowance for building permit fee;based on$12/$1000 of project cost. $132 Total:$10432 Additional Terms and Conditions:113 due upon start,113 due when framing is complete;1/6 due prior to completion;balance due upon completion.Prices are based on standard removal& installation.Additional work may be required due to conditions that we cannot see or predict,changes to the scope of work or to the finalization or modification ofspecifications.Any work over and above that described here will be billed accordingly.Proposal is valid for 30 days from submittal.We may take pictures ofour work Ifyou do not want these pictures shared,please initial here. Hello Bob, Thank you very much for the opportunity to perform work at your home.We are very grateful and hope to be able to provide you with our services. When you have a chance to review the information,please let me know your thoughts and howyou would like to proceed Thank you very much.It would be our privilege to serve you. .Sincerely, Mathew Previte Ace Home Medics,LLC Thank you very much for your consideration. We greatly appreciate your business and look forward to providing you with exceptional quality, in a professional, neat,timely and efficient manner. Our number one goal is your complete satisfaction. Accepted: The above prices, specifications and Q 1 1 conditions are satisfactory and are hereby accepted. Sig baie Ace Home Medics, LLC is authorized to do the work as specified. Payment will be made as outlined Si nature Date above. A Ottiee of Consumer Affairs&Business R.egulation'. R ME#AIIPROVEMENT CONTRACTOR egistration: 153165 Tvo: xp#rat#on: 111612014 DESA MAT PREVITE HOME MEDIC MATTHEW PREVITE' 57 HAROLD PARKER ROAD Q _ ANDOVER,MA 01810 Undersecretary Massachusetts-Department of Public Safety Board of Building Regulations and Standards , ('i�#utructiuitS'uher'+i ill- License:CS-100212 b Tmw S P t)iv r 57 HARCiLD.PAR ANDOVER I#A02ll<N l ;. T r� iia $k Expiration . Commissioner 03/23=14 OP ID:SR AC"R EV DATE IMMIDDNYYYI ti,,,_..�- CERTIFICATE OF LIABILITY INSURANCE 0111312014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER: IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DUf90 x.Jankowski ITIS Agcy LLC PHONE FAX 198 Massachusetts Avenue AIC No Ext: {A7C Nol. North Andover,MA 018455 EJMIL ---....____...._..__ Durso Sr Jankowski Ins.Agcy. ADDRESS; PRODUCER PR /I_4 -- v- CUSTOMER 10#:- _ INSURERS)AFFORDING COVERAGE NAtC# INSURED Dice Home Medics LLC —� -INSURERA: 57 Harold Parker Road Andover,MA 01810 INSURERS: INSURER C:Utica Mutual lnsurance Company INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREIAENT, 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. DOE{NSR TYPE OF IH SURANCE + I POLICY EFF i POLICY EXP LIMITS LTR POLICY NUMBER MMlIIDNYYY i MMJDD GENERAL LIABILITY 'EACH OCCURRENCE $ 1,000,00 s — —-- C X COMMERCIAL GENERAL LIABILITY E ?� 114687243 0912712013'j 09/27/2014!(''PREMISES[Ea nccrrence_,_ S 600,00 1 CLAIMS-MADE X OCCUR !� ; � i y MED EXP(Any one person) _S _.__.._..__10'00 ............( E ( p PERSONAL&ADV'INJURY IS 1,000,00 ! { GENERALAGGREGATE �S 2,000,00( ._.._ __....,._._ — i GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COIVIPiOPAGG j5 _ �- 2,00400 POLICY! PRO- jFCTLOC $ AUTOMOBILE LIABILITY 'COMBINED SINGLE LIMIT ; (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED AUTOS 'BODILY INJURY!Per accident) $ SCHEDULED AUTOS BODILY INJURY ' - PROPERTY DAMAGE I HIRED AUTOS (PER ACCIDENT) $ --- — NON-OWNED AUTOS i ? 5 I UMBRELLA LIA$ OCCUR EACH OCCURRENCE 5 EXCESSLIAB CLAIMS-ivvIADE I {. I AGGREGATE 5 ---_- - ----I --- DEDUCTIBLE 1 RETENTION 5 j$ ;WORKERS COMPENSATION { 'WC STATU- t OTH-I x AND EMPLOYERS'LIABILITY Y F N !TORY LIMITS 1 — 1,400,00 C =.ANY PROPRIETOR/PARTNER/EXECUTIVE ; 4fi87246 09/27/2013 109/27/2014!E L EACH ACCIDENT 5 OFFICERtMEMBER EXCLUDED? F NIA' } ..-. - (Mandatory in NH) i 1 EA.DISEASE-EA EMPLOYE - '1,000 00 It yes,describe under ( --- _..__ .. ...-._:. DESCRIPTION OF OPERATIONS belovd E.L.DISEASE-POLICY LIMIT I S 1,400,00 r DESCRIPTION OF OPERATtONS 1 LOCATIONS l VEHICLES (Attach ACORD 101.Additional Remarks Schedule,if more space is required) carpentry- CERTIFICATE HOLDER CANCELLATION NORTHI3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2049109) The ACORD name and logo are registered marks of ACORD W ✓✓ ✓ v I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Flame (Business/Organization/Individual): Af�.46_A"l le-S LLc Address: /y3 AAA sT City/State/Zip: /, �awl"N p/A� 046� Phone#: 7111 Zdl�"03Z 4- Aire t• A�an employer? Check the appropriate bog: 4. I am a general contractor and I Type of project(required): 1. I am a employer with S 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ emodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9. f—I Building addition [No workers' comp. insurance comp. insurance.+' required.] 5. 7 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box'1 must also fill out the section below showing their workers'compensation policy information. 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,the},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: 077ro+ At rY1fL Policy# or Self-ins.Lic. #: I(ak 7_z1(p Expiration Date: Job Site Address: 190,14, 4z40!Sd.✓ City/State/Zip: •i A ON+� 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 cerd&u er t e a{ns nd penalties of perjury that the information provided above is true and correct. Signature: JWMI Date: 2 /� Phone#,: '� - G321i 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#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 15f 600 Washington Street Boston,MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): /45- Ay& Al WzeSr Zee- Address: LCAddress: f y-3 �/h�✓ `d'T City/State/Zip: /M1,1em &W6, ?A D 46,41 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.1/J 1 am a employer with� 4. ❑ I am a general contractor and I ` 6. ❑New construction employees(full and/or p time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7 Remodeling 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.❑ 1 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 Aire 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:- d�4w /,c6. Policy#or Self-ins.Lic.#: /71106t/C 3.53/01 Expiration Date: Z /3 d/pd elf• Job Site Address: ��D/}.�'y`�y�✓ Jr�f City/State/Zip: /f�R 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 DTA for insurance coverage verification. I do hereby cer ' un t1 p ns nd penalties ofperjury that the information provide727-3 o ' true and correct. Signature: Date: Phone#: 914)1•�j?_0 306 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 bean 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 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-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 permithicense 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 Cornx-Aonwealth of Massachusetts Department of Industrial Accidents Office of InVestigatio_ns 600 Washington Street Bostonr MA 02111 Tel.#617-727-4900 ext 406 or 1-877rMASSAEE Revised 5-26-05 Fax#617-727-7749 vW W-mass.govfdia �'��r�r tir riri•irrrr vrl/�Ike" /'�'��r.i�ryr•�rr1�://! - Z" Office of Consumer Affairs 8¢BnsiIke"Regulation. a _ rME IMPROVEMENT CONTRACTOR egistration; 153165 Type: ,. r .ptraUon: . 41/612014 DBA MAT PREVITE HOME M€DId MATTHEW PREVITE.. 57 HAROLD.PARKER ROAD ANDOVER,MA 01810 Undersecretary Massachusetts-Department of Public Safety Board of Building Regulations and Standards t'iui�trittiun Sxyien i5ur License:CS400212 `�may.t i;y MATHM S P-"V1TR,- 1 57 11"01ZAR f01 ANDOVER�A 6 °J�-�►•- t4��' Expiration Commissioner 03/23/2014 4 ♦ A k 5 • � - T.6a*m N X f = ] a¢ - CONSERVATION DEPARTMENT Community Development Division September 13,2006 Mr. Robert Cookson 1010 Johnson Street North Andover,MA 01845 RE: SITE INSPECTION- 1010 Johnson Street,North Andover,MA Dear Mr. Cookson, This letter has been prepared to document my inspection on Monday, September 11,2006 at the above-referenced property.The purpose of the inspection was to investigate the activities that were being conducted and to also identify the location of the adjacent wetland resource area. It is my understanding that you are building a retaining wall along the left side of your house where the walkout basement door is.You will do all the work,by hand. It was noted that dirt had been recently excavated and is stockpiled along the existing tree line.This is the only machine work that need to be done. Furthermore,it was determined that the wetland area is located about 85-feet from the limit of work. As discussed, any work proposed within 100-feet of a jurisdictional wetland resource area must be preceded by the appropriate application filing (whichever is appropriate)before the North Andover Conservation Commission (NACC),per MA Wetlands Protection Act-M.G.L. c.131,§40 and the North Andover Wetlands Bylaw (C.178 of the Code of North Andover). In addition,the NACC enforces a 25-foot No Disturbance Zone and a 50-foot No Build Zone from the edgeof a wetland resource. Due to the proximity of the edge of the wetland and the limit of work,as well as the existing topography,this department will not requite you to obtain a permit for the construction of the retaining wall. However,you will be required to install erosion control along the edge of work and soil stockpiling area to contain the material from migrating towards the resource area.The location of the erosion control was identified with you during our onsite meeting. Please feel free to contact me should you have any questions or would like to go over any items outhned'in this letter.Thanking you in advance for your anticipated cooperation with this matter. Respectfully,, Pamela A. Merrill Conservation Associate 1600 Osgood Street,Building 20,Suite 2-36,North Andover,Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web www.http://www.townofnorthandover.com/conservel.htm