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HomeMy WebLinkAboutBuilding Permit #383 - 1048 GREAT POND ROAD 11/14/2007 BUILDING PERMIT NORTH A `fit,lD ib• ti° TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION « Permit NO: Date Received / �SSACHU5�� Date Issued: d �I/ IMPORTANT:Applicant must complete all items on this page LOCATION P .n-tAv W PROPERTY OW " Arcl, " Part � v M MAP NO: -PARCEL: ZONING`DISTRICT:` Hist6dc District. Yes o 5 Machine Sfiflpilage yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family ditio Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assesso ryBldg Others: Demolition Other Septic 497W611 Floodplain Wetlands . Watershed bstrict. -. Watbr/Sewer kr DESCRIPTI N OF WOR TO BE PREFORMED: 8 �Nr n�entific o PI se Type or Print Clearly) Q OWNER: Name: /�lq�GoQiC.� Phone: g70 /od2 Address: b e D up �* �3O CONTRACTOR Name: l.' l' one: tP ' , Address; tj eig Supe rvisor's"£Construction License .,)> p ,w E�cp Date d 4 Home Improvement License 1 qcp.',Dated; a. ARCHITECT/ENGINEER Phone: 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: $7an0,00 FEE: $ �X-1 A� v Check No.: 3 Receipt No.: 0?3---o d NOTE: Persons contracting with unregistered contractors do not have access to the-guarantyfu �9.�.. , .g � Signature ©f;contractor; 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 INTERDEPARTMENTAL SIGN'OFF - U xFO!RM ' DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATEAPPROVED ` HEALTH ' �,. •-- , >, � ;t-<.�� .:.'� + �`+, . COMMENTS J Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Si nature&Date DZeway Permit Located at 384 Osgood Street FIRE DEPARTMENT -Tem hum: s#er on#site " P p Yes° no Located-at 124Main.Street -; Fire Department signaturelctate - COMMENTS ,_. `L 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 department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 ❑ 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 o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And 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 ❑ 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 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location A l If No. Date NORTh TOWN OF NORTH ANDOVER O Certificate of Occupancy "^° E<� Building/Frame Permit Fee $ ACMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I 20798 I Building Inspector 40'-0' -. 13'-1 1/2" 26-10 1/2'! I - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I E I I Owner : Pam & Marc Rudick 1048 4•\QtA .Scwv? 40 I I "Great pond Rd. S► cuttAat_ -TVs I Co�&AMr,�S `'�'1 T&T 1 `o cn cn I UTILITY I 12'-5"x 16'-6" �-�� I Contractor : Arthur Watson Tel. # rn,�u.,�.. 3to k'59 x 12" cn --�---to 1'5/',+X 14" LVL �T-t�) 3`h 0 �a�.\ Footings I o 603-661-5360 A. F. Watson Is-1114,xoz�wL. Beam F ,SZ����s t I I N General Contracting — _ CD l o 0 " CD ! I I I _ 1 j ► " -eV s�ti QrcS Ross-� N - - �i�Ar. it ts-- va I 2" x 12" @ 16" O. C. �> ��; S (TT e) I I Foun ation Plan / floor framing W 14x. GARAGE Q-E.'P D�T�1�< f� I n .NL-T� i� tca I 25'-10"x 28'_81' S' �c�cz vA-6oSF cit I I I I I LIVING AREA , SA�nocciA 398 sq ft R 0.339 '°oF Gfs1ER���s``� . a I P Garage door headers Gr-\un . 2 � cn L(\n _' --k x 111 -`��� QTAT) 1 i I Fsso�ati Ln ( _ I J I 5- )M -1)161oZ 81-0" 5'-1 1/2" 6'-10 1/2" 121_011 8'-0" 13'-1 1/2" 26-10 1/2" • 40'-0" 40'-0" 13'-1 1/2" 26-10 1/2" r' r — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — - II I I ( I Owner : Pam & Marc Rudick 1048 - f T,.�»ts -".�►as�� I Great pond Rd. b I 4­6 S-r9u<:rQ9-A` U) e61krr&r"-ftA-TeS- LITY 12'-5Ix 16 6" fl II I ` ►°��t�1 t`S Suf��adZ� I 3t,�;X e;x 12" ' I r„ Contractor : Arthur Watson Tel. # Footings t 3-tom/4 x t4 t�tI o 603-661-5360 A. F. Watson IiA&A VIM_ _. ._�'� =�� F-5L I co General Contracting o 0 M - N �T QssL►v+a�A� `4 0 SLKrc�?4-L fl�ST' MOTCn C �'EArn 2.. x 12" 16" O. C. e�Q u.� 14�c�� ��z-t I @ -« Foundation Plan / floor framing GARAGE Zfl I 25'-10" x 28'-8" N 5-ry C.Au.ti t LIVING AREA �ssq 398 sq ft �� A aroRF� WIA�T t�� I I o occ►A _ I CTURA 11 11 If I � - oU 3287 L y L i P Garage door headers ��A�6 ��w. : Z- t��'' t�`l "�v� I �, ( 4 x I I ,�, ova - - -- - - - -g — — — c-� — — — — — — — — — -rS SUC_y 'T60 S T2,1 C_—rLj cLpt.— SPEC-5 8'-0" 5'-1 1/2" 6'-10 1/2' 12'-0" 8'-0" �laa ►�.FST�ao G�� -t,r1 QC_ 13'-1 1/2" 26-10 1/2" 40'-0" li:,- nS 1-10-7 ,5. OF PROFESSIONAL c STRUCTURAL ENGINEERM E.HAMPSFM.NH Q , P.O.BOX 958 ;; ;� v RE J. �� DESIGN SERVICES IVO FAX M3) STRUNo CT o� �fcIsTEh�y ,� i-' Au Xc au&rte, MIk TITLE FSSIOIM ��!!s4 i tnL �w •�►. �,,, T�1�At1�R EST. jos 3 SUBJECT SHEET 114. DESIGNED BY ATE.1CHECLED BY DATE_,._...,._ 4%Ltu.L-L rnm,_ 9/16" 0 HOLES FOR 1/2" 0 BOLTS '� r Abp tsSL O ZV Q.C. STAGGERED FOR TOP FOPOF SAF I PLATE- NAILER 2x6(TYPICAL) / N 11mbe � 11.A1U �c�C.iR L.4a.14.t.. STRUCTURAL STEEL SUPPORT BEAM �J !!' CB/2xL� It 1S" B.nss_V--vat. -g TACK WELD I �� + i N v Q 4! 0 SCHED. 40 .. ..�. 2 STEEL POST (TYP) TOP OF ^�- d FOUNDATION P) r OR PAD TACK WELD 2 5�a�x$,• CAP Pt rF SMP PRllltu4 R /2"x5"x5" L1,C.Ka rL BOLT$ tH��'Tt�I�ILt4� �utp mALL. I Bt►�z P��z t X�r t110 DETAI L-A (I&PLACES) PROFESSIONAL STRUCTURAL.ENGINEERING P.O. BOX 958 �CI DESIGN SERVICES E. HAMPSTEAD,NH 03826 (603)324.5540 1J�1 C IQ— Acc- FAX (603)329-6406 RESIDENTIAL• COMMERCIAL•INDUSTRIALS &fajm.Ao Ntpvjl.yl f TITLE " •FA F T EST .�JOB N0 ` ® 3 SUBJECT_ �C ��s°1 e e r(Mt :.. SHEET NO . r 17 DESIGNED BY _.,_.,. ATE ��� �� CHECKED BY DATE tAm x W.�.= VL x°LTA S 1eL � � 1f La I A- t Af Cb c, 3 ru..-. AL CC A J. � UCTURAL 0. 287 EGI O SIONAI F ('• PROFESSIONAL P.O. BOX 958iA K. STRUCTURAL_ENGINEERING Pofs DESIGN SERVICES E. HAMPSTEAD,NH 03828 `" ` (603)329-5540 ® FAX (603)329-6406 Q 1pic-1 � 4 ® I Pew Com.. j RESIDENTIAL.• COMMERCIAL•INDUSTRIAL � � � hwo 1 EST �tk TITLE ! 1 t� �, ! 6t>"�f JOB'S N0 . ,RC1 SUBJECT �T�11�d� . �1` ��1°t1 , SH£ET N0. DESIGNED BY DATE -1I � �01 CBECKED BY DATE 61 )1A A FA U-1&_rrl U"L'X't� =- . 1 wk A-* �16 OF ts LV RE J. T dl!z k N ) CGIA -.4 URAL o. 332 F fCl RE' Slo>aa �' 4ea"04&ad PROFESSIONAL P.O. BOX 958 STRUCTURAL ENGINEERING E.HAMPSTEAD,NH 03826 B l DESfGN SERVICES (603) 325.5540 FAX (6133)329-6406 RESIDENTIAL• COMMERCIAL•INDUSTRIAL m &Rv"-t , aD tam TITLE EST )JOB J No SUBJECT— Km w � e c c-r SHEET N0. DESIGNED BY DATE.2 CHECKED BY DATE I f OL ---------------- Izb 9 o� s Rif a e t tt t CCI R 332 JAR C d` t F ISU ��� e OF PROFESSIONAL P.O. BOX 958 .� STRUCTURAL ENGINEERING E.HAMPSTEAD,NH 43826 SAL ORE�. �G DESIGN SERVICES (603) 3MS540 c, CLIA - FAX (603)329-6406R IMP, �. RESIDENTIAL• COMMERCIAL 2871 f ISTEF�� �SS�it��,� ti� u TITLE l .� (\ f k� �t t S� , EST .) NO JOB SUBJECT E�"i 'd�1� ! ►tea � 1 T SHEET NO. DESIGNED BY DATE CHECKED CHECKED BY DATE x • 0,0 &M4a&4aft& !T� (�l i. �ttl OF ! PROFESSIONAL �c STRUCTURAL ENCHNEERINa E NAMP'STEAD.NH 0310 g v PE J �� DESIGN SERVICES M) N0 y Axe?mss STRUCrU131 RE � �: . 6a4L G¢s-c►-c l6ab Ra S101VAL TITLE;—�.,,...�1�� t..�..._�*. r;, ,& A �1af EST•t 110. .7 SUBJECT— JOB SHEET 110. DESICNED BY ATB 1) ...CHECZED BY DATE..._...,,_. falmauac 3111:giL.a --, r'r, 9/16" 0 HOLES FOR 1/2" 0 BOLTS '� r Abl W(- O 24' O.C. STAGGERED FOR TOP PLATE NAILER 2x6(TYPICAL) i — FOP�-+OF51 F �r ` t E3*.LDu' /z 11,e,\" r s c� tL t..4�.1 tiL 4j , - /-k �T STRUCTURAL STEEL SUPPORT BEAM a �J L., UUML F&ST C�A�P.L9IE 6AS L yt-wrc i R 1/2"x5' x5" .' 9 TACK WELD I � G ! i „ 1 1 q-4! 0 SCHED. 40 2 STEEL POST (TYP) TOP OF FOUNDATION " P) OR PAD TACK WELDCAI! PI AlE t 1/2"x5"x5" ��Chefl Sal.1'f i . � B1►�Z P��AT L OETAI L-A (7-PLACES) -_ NO 5,C A Lr NOTE- THIS PLAN NOT TO BE USED FOR TITLE INSURANCE PURPOSES, NOR FOR N/F ASSESSORS: RECONSTRUCT/ON OF BOUNDARY LINES. S.B. FRENCH REALTY TRUST 260.00' 3y9*• MAP 103, LOTS 27 & 133 8i Q LOT 25W w 0 Ln R-1 RESIDENCE DISTRICT 2 STORY W N J w WOOD FRAME WA TERSHED DIS TRIC T GARAGE/BARN c u REFERENCES. 1\01 0 66 �. N 32 2 - I L.C. CER T ,¢11802 0 #1048A ,,;i s.s #1048 64' 9 `' 0 L.C.C. 16372-J G� 2 1/2 STORY `� � i 2 STORY -'K3 r DWELLING RECORD OWNER. DWELLING 0 , MARC & PAMELA RUD/CK 1046 GREA T POND ROAD Gj• g►T w NORTH ANDOVER, MA 2 r' < .NOTES• 36� PROPOSED 1) THIS PLAN /S PREPARED TO SHOW LOT 35 PORTICO N THE AS-BUIL T LOCA T/ON OF THE • AREA = 6.35 t AC. -H co rn 3 CAR GARAGE / BARN AND THE (C.B.A. = 6.0 f AC.) N 1 o o PROPOSED PORT/CO. Z •• 0 � s W W 0 � 0 2 1/2 STORY '' 2) HOUSE NUMBER 1046 AND LAKE Y = Q 0 Ict DWELLING ARE SCALED FROM L.C.C. 16372 G. QU < 0 --� my ry - - 209.05' _ 196.44' �. •� U 0 352.74 u ' O . , 0 �8�9, 11186 Q � o N/F .. , • , BLUE HERON REALTY ,TRUST OSPREY REALTY TRUST PLOT PLAN l CERTIFY TO THE NORTH ANDOVER LOT ZS Q OF LAND /N BUILD/NG INSPECTOR THAT THE NORTH ANDOVER, MA STRUCTURE OWN HEREON ARE 0 ^1 PREPARED FOR L DCA TE u ROUND AS SHOWN. scorn MARC RUD/CK I� o� �� �. J&SERT. h �, SCALE.- I " = 100' OCTOBER 31, 2007 a No.487M7 ���ESS10gp0 50 100 200 400 115AHANCOCK SURVEY ASSOCIATES, INC. Ii S' 0 7 f85 CENTRE STREET, DANVERS, MASSACHUSETTS 01923 yVO/CE 978-777-3050 FAX 978-774-7816 PROFES�SIO�NAL LAND SUR V YDR CHECKED BY- 7379 r I Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration 18848 s Exp�rat►on 4�j28/2009 Tr# s 128808 r TYpe DBA A.F. WATSON GENCONT w, ARTHURACTING WATSON � � � 3 EDGEMONT ST DERRY, NH 0038 •+Q a;,: Adt— mini— �smvnu�izu`ealtli v,, 11OA0 OF BUILDING REGULATIOkIS License; CONSTRUCTION SUPERVISOR j Number C8- 063168 I Sirthda I� te=: 02f12/9956 „�; Expires: 02/12/2008 Tr. no-- 17019 I � I�stnctecJ f 1 G ;r 4 ARTHUR F WATSON x3 I 3 EDGEMONT ST I DERRY, NH 03038 Mm ioner..��",��: _.. ORTH T. own oAndover No. 3 83 o dove r, Mass., C% 1110i= LAME COCMICMEWICK 7,p AERATED p'P�,��y S$ BOARD OF HEALTH Food/Kitchen PERM.. IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........1......44.4....... ................ ................ .......................................... .. Foundation has permission to erect........................................ buildings on ...l..d ...... .4......... .,��!.:.'�. .. .... n ..... .� Rough to be occupied as.........occup P!.^.4. .Q........��.. ........ ........�..���..:................................................................... Chimney provided that the person accepting Phis�.permit shall in eve 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 CONSTRUCTI TS Rough .......... ....... ........................................... ..................... Service BUILDING Final OccupC rwy Permit Required t0 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 Street No. SEE REVERSE SIDE Smoke Det. A. F. Watson General Contracting Estimate 3 Edgemont Street Derry,NH 03038 DATE ESTIMATE# Tel. 603-437-6134 11/13/2007 1348 NAME/ADDRESS Mr.Marc Rudick 1046 Greatpond Road North Andover Ma.01845-1204 TERMS PROJECT Due on receipt Portico Entry ITEM DESCRIPTION QTY COST TOTAL labor Carpenter's labor 90 40.00 3,600.00 Materials General Contractors Materials 3,000.00 3,000.00 Subtotal labor&Materials - 6,600.00 Cont.fee Contractors 10%Fee profit+overhead 10.00% 660.00 i THANK-YOU A.F.WATSON TOT L $7,260.00 OWNERS SIGNATURE SIGNATURE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 aM ,� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): 0.etj Corm 09 Address: eA OLAt 5 . City/State/Zip: 0_;059 Phone.#: Ca03 4'8_7 Q3f A,re_,yoou an employer?Check the appropriate box: Type of project(required)': 1.L`1 1 am a employer with ' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[_ Other j 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 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: it.,(` Policy#or Self-ins. Lic.#: Expiration Date: �� d� 6 o� Job Site Address: � �U l W �'�CJ� 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 ce u he pains a penal ' o perjury that the information provided above is true and correct. Si atuie: Date: l0 d 7 _ Phone k 43�T G 1 J Offtcial,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 ContactPerson: 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 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 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 permitllicense 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 burn 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 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 Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia NO TE.- THIS PLAN NOT TO BE USED FOR TITLE INSURANCE PURPOSES, NOR FOR N/F ASSESSORS.• RECONSTRUCTION OF BOUNDARY L/NES. S.B. FRENCH REALTY TRUST 260.00' 3g0 MAP 103, LOTS 27 & 133 8t � 0 c� LOT 25 i NCAR-1 RESIDENCE DISTRICT 2 STORYJ w WOOD FRAME N WA TERSHED DIS TRIC T GARAGE/BARN G N /PE/�'IP�N�`�S• _ - - L.C. CERT ,#11802 #1048A a; 8.s #1048 64' 9o L.C.C. 16372-J G� 2 1/2 STORY `� i i 2 STORY O RECORD OWNER., DWELLING � ► DWELLING Z MARC & PAMELA RUO/CK 1046 GREA T POND ROAD G>• BIT ERNE �- NORTH ANDOVER, MA CA �6� Z PROPOSED co LOT 35 8 xa 1) THIS PLAN IS PREPARED TO SHOW • AREA = 6.35 f AC. PORTICO m THE AS-BUIL T LOCA 77ON OF THE co rn 3 CAR GARAGE / BARN AND THE Y 0 (C.B.A. = 6.0 f AC.) N o o PROPOSED POR77CO. 023' 0 •• 0 2 1/2 STORY '-' 2) HOUSE NUMBER 1046 AND LAKE Y = a- DWELLING CTI ARE SCALED FROM L.C.C. 16372 G. _ 0 . ,� p 4' • 209.05' 196.44' �. U Q S 352.7 � � � 0 N/F BLUE HERON REALTY TRUST t PLOT PLAN OSPREY REALTY TRUST OF LAND /N I CERTIFY TO THE NORTH ANDOVER � BUILD/NG INSPECTOR 7HA T THE 0 LOT 28 ,��, NORTH ANDOVER, MA STRUC7UR OWN HEREON ARE A PREPARED FOR LOCA T ROUND AS SHOWN. �° SCOTT MARC RUD/CK T H v SCALE.• 1 R. " = 100' OCTOBER 31, 2007 ANa �7 0 50 100 200 400 SURVEY ASSOCIATES, INC. 07 HSA11ANCOCK 185 CENTRE STREET, DANVERS, MASSACHUSETTS 01923 PROFESSIONAL LAND SURVEYOR VO/CE 97B-777-3050 FAX 978-774-7816 CHECKED BY. 7379 i