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HomeMy WebLinkAboutBuilding Permit #432-2017 - 1211 OSGOOD STREET 10/24/2016 BUILDING PERMIT oF�iLeo ,6 �ti ( I TOWN OF NORTH ANDOV '- ER o - AL,�lyAPPLICATION FOR PLAN EXAMINATION Permit No#: G� Date Received �, """TED SSACHUS Date Issued: 119 2 �W46 IMPORTANT:Applicant must complete all items on this page LOCATI®Nq nt c c PROPERTY OWNER , _ Pant: 1DD�YearSt iicture y s Y n& MAP .PARCEL:. ZONING DISTRICT:. __ Hisfonc Dstr�ct yes.. no Maehme Shop.Villagg yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: vCommercial ❑ Repair, replacement ❑Assessory Bldg _ tethers: ❑ Demolition R6-Z�TeWl?.4 __ �_�-- Septic O Well Floodplain Wetlands L7 Watershed District ❑-WaterlSewer DESCRIPTION OF WORK TO BE PERFORMED: ?:�2 0 V/ ISr,4-eC_ 7T s5 /Z Identifica ion- Please Type or Print Clearly f� ��� �� OWNER: Name: �EZ� 'S �0�4-�T" 3, � Phone: 6 Address: Contractor'Name: �'lf���'Yt r"//Z 1'��C1�1 b ei/247Z Z.. Email Address:. Supervisor's, Construction=L-icense: !'Yl�¢. _ ._Exp: Date: Horne Improvement License:. . ._ . _ Expo Date: ARCHITECT/ENGINEER 9013 155WX/ '1'1 Phone: (( 1-2;�I( 2,33 i�, Address: L UZtJ�� r v 'h_Reg. No.61.4 C G1�- SV- FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �O©C� ©� FEE: $ Check No.: 132 J`©l Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of AgentlOwner Signature of contractor Plans Submitted Plans Wajved :❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL I i Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ � I 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Siqnature COMMENTS 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 es .._ _ l _ Y.. rood Fire. Department,signatiare/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 NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Peivoit Revised 2014 i Building Department artment 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 ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a 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 Doe:Building Permit Revised 2.014 Location 27 No. r7 ' � 4 Date /D Z4 zm!�7 • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I Check# JM(/ cam'" Building Inspector NORTH q i Town of 6 ndover O No. 43Z - 2.4t7t42911 79 - O &—-A h ver, Mass C0C"1C"1 WKII 1_ S U BOARD OF HEALTH Food/Kitchen PERMIT. ' T L D Septic System THIS CERTIFIES THAT ....... ,�... A.*Y.... � BUILDING INSPECTOR ...�.7.. Foundation has permission to erect .......................... buildings on � ..... ,�,�.,�P......�►. ...�,,,,,, ...................................................... Rough to be occupied as !�►�.. ... � 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 UNLESS CONSTR ION Rough Service ... BUILDING INSP......E..... OR.... Final 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. 6f��3Z412QilZGUQL�GGl2 d�Ci/G'L(?/J1CGC/�r�jS ef2e 95 FP6(rev.3/00) v APPLICATION FOR PERMIT City or Town =SAFEER Date EStartt In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made GORHAM FIRE APPLIANCE by 20 urn�.,�e+ (o�7 Y 72 :���'� �f/t3T1;V.4/1- ` ft y.MA 02169 (Full name of person,Firm or Corporation) Address (Street or P.O.Box)(City or Town) For permission to (state clearly purpose for which permit is requested) 7--0 72' ✓l/ 2 c S - S 4 Name of competent operator(If Applicable) /vLO23 &M///f I(14 Cert. No. Sr� Date Issued-rejected By X72kL4,;,l (Signature of Applica f D ——————ate of expiration Fee $ Paid Due ---------------------------- ��ri��e -02 FP6(rev.3/00) �. 00,—/ LJ&4 A-taa,, (9&at, -D"O-177 j � t PERMIT City or Town C" DIG SAFE NUMBER Date Start Date: 31Permit Number(if applicable) In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted GORHAM FIRE APPLIANCE 'K t0 nne urn ni (Full name of person,Firm or Corporation) 4 for Quincy. 02169 F/RS Y S TE�W- 11VSTA L L— . . Restrictions: ///M 12 > at dS G-ooz (Give location by street and no.,or describe in such manner as to provide adequate identification of location) Fee Paid$ This Permit will expire on Signature of Official Granting Permit Title NO This permit must be conspicuously posted upon the premises 11—'AA /) C /, ri-i\ A AAA AA/a nsrL � i i 4 Engineer and Architect Specifications g0je4*1w 041 TO DISCHARGE „r : PIPING cam. i TO REMOTE MANUAL — 5 PULL STATION TO / TO GAS VALVE , FUSIBLE LINKS SHUT-OFF f i ® CI C OO D B OPTIONAL MINIATURE SWITCH 28.125 CONNECTION A� 002841 PC y Flow Mounting oouaez Model Point Bracket No. A B C D Capacity Weight Used 13.125 10.625PCL-300 9.00 25.06 30.81 22.75 10 53 lbs. MB-15 (FRONT) TO GAS (SIDE) PCL-460 10.00 25.06 30.81 122.75 15 83 lbs. MB-15 V' SHUT-OFF FEL-600l10.00 35.81 41.56 133.50 20 108 lbs. MB-1 c i General reignition. Expanded capability provides remote manual actuation,gas equipment shutdown,and electrical system shutdown.This optional The Kitchen Knight®II Restaurant Kitchen Fire Suppression System is equipment will enhance the basic system functions and be applicable a pre-engineered solution to appliance and ventilating hood and duct when designing custom configurations to suit a particular customer's grease fires.The system is designed to maximize hazard protection, needs and/or comply with local codes. reliability,and installation efficiency.Automatic or manual system activation releases a throttle discharge of potassium carbonate Suggested Architect's Specifications solution on the protected area in the form of fine droplets to suppress the fire and help prevent reignition after the discharge is complete. The fire suppression system should be of the stored pressure,wet chemical pre-engineered fixed nozzle type manufactured by System Operation Pyro-Chem.A carbon dioxide cartridge is designed in compliance with Military Specification"MIL-C-601G",and shall be used as the P The Kitchen KnightTm Restaurant Kitchen Fire Suppression System pneumatic releasing device for the system.The cartridge shall be an has been designed for protecting kitchen hood,plenum,exhaust duct, integral part of the control head assembly.The wet chemical storage grease filters,and cooking appliances(such as fryers,griddles, cylinder shall be D.O.T.-rated for stored pressure of 225 psig,and a rangetops,upright broilers,charbroilers and woks)from grease fires. pressure gage shall be provided on the cylinder valve for visual The versatile state-of-the-art wet chemical distribution technique, inspection.The system shall be capable of automatic and manual combined with dual, independent activation capability-automatic actuation.Automatic actuation shall be provided by an appropriate fusible link or manual release—provides efficient, reliable protection number of fuse link detectors mounted in series on a stainless steel the moment a fire is detected.Once initiated,the pressurized wet wire input line to the control head. Manual actuation shall be provided chemical extinguishing agent cylinder discharges a potassium by turning a handle on the primary head and/or by an optional remote carbonate solution through a pre-engineered piping network and out pull station with a dedicated stainless steel input line to the control the discharge nozzles.The wet chemical discharge pattern is head. maintained for a duration of time to ensure suppression and inhibit e pyr®. r ��� One Stanton Street Marinette,WI 54143 ' s PC2001192s 't s fro �e�hcrixfiin�nC ��cz�o� V FPS(MV.3/00) ° ✓ .V. J '� ,ER City or Town Date In'ac cordance with the provisions . , ^lication is hereby made by �-'; : _. -2 2-5-7 8 S Address C,� - .� h For permission to(state clearly p: Name of competent operator(If P.; Date Issued-rejected -- a'',� 47, Data of expiration Due • ——————— ———-- ___----------- r � Y FPO(m,.3100) City or Town JM1 DER Date Permit Number(if applicable) - In accordance with the provisions o ' _-_this permit is granted to for FM S T-fe__ � Restrictions: at Fee Paid$ Signature of Official Granting Permit NO This permit m,- .remises p ' fc� ■ 16Q 7 'yrom Install Date.St'22/16 Gorham Fire App!'!��.!iu-Ci! Bellas Roast Beef 288 Willaril X31 Chem 1211 Osgood St Quincy,M A 02'i Nokul--w v Bob '14arry -5785 nnail.comi Untitled System Untitled Layout 18 x 16 in. 228 x14 in Du 16 x 16 in. 4" i C 3 1r, Pyro. Install Date: 8/22/16 Gorham Fire Appliance Co 2. Chert Bellas Roast Beef 288 Willard St 1211 Osgood St Quincy, MA 02169 i No Andover, MA x Bob Gorham Harry 617-472-5785 617-791-8282 gorhamfire@hotmaii.com MACC#54 Notes Fusible Links: _>To determine actual fusible link ratings,temperature readings must be taken during peak cooking time. Untitled Layout: Note 1 =>Nozzle: 1H x 2:(Hood:Single Bank)nozzle position:2 in.from back edge of filter, 1/3rd down from vertical height,0-6 in.of end of plenum(or module),aimed down the length of the plenum. Note 2=>Nozzle:2H x 3:(Fryer:3 vats)nozzle position:24-48 in.,anywhere within perimeter of hazard area,24-48 in,above cooking surface,aimed at center of cooking area Note 3=>Nozzle:2H x 2:(Griddle)nozzle position:2448 in.,0 to 6 in.from short side of hazard area,24-48.in.above cooking surface,aimed at center of hazard area. 1".tz ,i \1-_Ll_. 2'1,. 1. irl-_-n__:t__�_ _ t,. __:.• .36 _t-.-- - cl-____a ,,,,,, , - ,,,,� ,,,.„ ,„ ,.�,,,,,.,.,,.,,,.,,..c�z,;,p,,,,,.;o-,. .,-.8 ir., ,,,, .,:::,y,.orr.er o.„a��..arca,3b-Y8 in.above the cooking surface and aim ed at center of broiler surface 5 ^r+gc:b burners:Additional nozzle combinations are possible for this range.Please refer to the manual. Notc 6_> 1_ 1_. •+1 _n. P-..__. l 31 AP., , 34 -4� on hazard size.Aimed straight down anywhere}xiifltin 2 lyn iPfnP l in raAinc of haoar 7 arno--rt-Arline. N(1TF:}vho+ oi,.o h;Jl+Yr- -_-___r.- -- - > - rangc .,n._.._ 1_•.__.. _(_•_._�_,v:In +l ,;;lo 3 of 5 CC-000054 Fire Equipment Certificate of Competency Robert M. ' S Fox Hol : Expiration Date 09/03!2017 State Fire Marshal v Fire Equipment Cp, i��,,���e of Registration This is to certify that iry?gcpr Fire Equip "'" `�i: ? s�tts.,Jaws and regulations a ►� )lC Ytl• 5 1 40�e!'eby issued to: Expiration Date: 11/14120$ Y- R' ttbtltlt�s'df Secondary License Type: Gorham Fire Appliance Cti�' �II e Facilities 288 Willard St -'#2 Ortib Fire Extinguishers ,?-4A,*. ec(..jI iHazard(Engineered) West Quincy MA 02169 0:4!44:-5'•pecial•Hazard(Pre-Engineered) . � Stade Fire Marshal the status of this Certificate at www.mass.gov/dfs Post in a conspicuous place. Verify C•~, r fr �::,. ':!, 'xt; r.. :r' 1. �,: .. .'p�'!1') . •fA . ��/P�ZQ/I /Jy�P/JZ�ta�Ct/!e CJ E9'?lGCPiS - V��uC P Q�>t/t� CJ LCGr�Vg7 e l�/t'LC7/l%SfZtzG v . FP6(rev.3/00) i �. 00X -1025, e Rte c� , Q&s�I0'1775 APPLICATION FOR PERMIT '�j�� DIG SAFE NUMBER City or Town � /�/ /1�r�17/' � Date Start Date: In accordance with the provisions of M.G.L. Chapter 148,as provided in Section application is hereby made GORHAM FIRE APPLIANCE by 288 VOW e• (017 Y72 -5:7 F� Ofty.MA VG�69 (Full name of person,Frrm or Corporation) Address (Street or P.O.Box)(City or Town) For permission to (state clearly purpose for which permit is requested) 'T© f 2 0 [/'/ L~tll C % ' ✓�� .2 c s S Name of competent operator(If Applicable) /3023 6:16,R414-01 Cert. No. Sr� Date Issued-rejected By (Signature ApplicarV -q Date of expiration --------- Fee Due ------ $ Paid ------ -------- 29� FP6(rev.3/00) lV. 73ox m25, C%& RoadC �Qz(f, of&W x/775 PERMIT City or Town 4. 1vC DIG SA=NUMBER Date CStartate: Permit Number(if applicable) In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted GORHAM FIRE APPLIANCE t0 nnn ueu_ St _ _� s (Full name of person,Firm or Corporation) Quincy,llQA 02169 for FIR E s KS TEfW /4/4 ZA c � Restrictions: N F PA -:� 1 ' L 300 at C� d O l� ��- (Give location by street and no.,or describe in such manner as to provide adequate identification of location) Fee Paid$ This Permit will expire on Signature of Official Granting Permit Title N* This permit must be conspicuously posted upon the premises 11660 Vs GV_6 i� A6 41041V17 Engineer and Kitchen Knight 11 �i, Che Architect �# Specifications Jn ® < "#Rd TO DISCHARGE PIPING ! Ivy TO REMOTE MANUAL PULL STATION TO 1 TO GAS VALVE FUSIBLE i/ SHUT-OFF LINKS ® O C B OO D R \OPTIONAL MINIATURE SWITCH 28.125 CONNECTION A� oozaa,rc Flow Mounting 04882 Model Point Bracket No. A B C D Capacity Weight Used �ts.12s _ 10.625 .1 PCL-300 8.00 25.06 30.81 22.75 10 53 lbs. MB-15 (FRONT) TOGAS (SIDE) PCL-460 10.00 25.06 30.81 22.75 15 83 lbs. MB-15 SHUT-OFF PCL-600 10.00 35.81 41.56 33.50 20 108 lbs. MB-1 General reignition. Expanded capability provides remote manual actuation,gas equipment shutdown,and electrical system shutdown.This optional The Kitchen Knight@ 11 Restaurant Kitchen Fire Suppression System is equipment will enhance the basic system functions and be applicable a pre-engineered solution to appliance and ventilating hood and duct when designing custom configurations to suit a particular customer's -grease fires.The system is designed to maximize hazard protection, needs and/or comply with local codes. reliability,and installation efficiency.Automatic or manual system activation releases a throttle discharge of potassium carbonate Suggested Architect's Specifications solution on the protected area in the form of fine droplets to suppress the fire and help prevent reignition after the discharge is complete. The fire suppression system should be of the stored pressure,wet chemical pre-engineered fixed nozzle type manufactured by System Operation Pyro-Chem.A carbon dioxide cartridge is designed in compliance with Military Specification"MIL-C-601 G",and shall be used as the The Kitchen KnightTm Restaurant Kitchen Fire Suppression System pneumatic releasing device for the system.The cartridge shall be an has been designed for protecting kitchen hood,plenum,exhaust duct, integral part of the control head assembly.The wet chemical storage grease filters,and cooking appliances(such as fryers,griddles, cylinder shall be D-O.T.-rated for stored pressure of 225 psig,and a rangetops,upright broilers,charbroilers and woks)from grease fires. pressure gage shall be provided on the cylinder valve for visual The versatile state-of-the-art wet chemical distribution technique, inspection.The system shall be capable of automatic and manual combined with dual,independent activation capability-automatic actuation.Automatic actuation shall be provided by an appropriate fusible link or manual release—provides efficient,reliable protection number of fuse link detectors mounted in series on a stainless steel the moment a fire is detected.Once initiated,the pressurized wet ,,vire input line to the control head. Manual actuation shall be provided chemical extinguishing agent cylinder discharges a potassium by turning a handle on the primary head and/or by an optional remote carbonate solution through a pre-engineered piping network and out pull station with a dedicated stainless steel input line to the control the discharge nozzles.The wet chemical discharge pattern is head. maintained for a duration of time to ensure suppression and inhibit 1 Pyr 6 SO heOne Stanton Street Marinette,WI 54143 ,iYtxh»: PC2001192 LJ m Q, a� �ei�xfiir;�2C r FP6(rev.3=) ✓ j ?/775 City or Town t'U M s ER Date In accordance with the provisions c _ _ application is hereby made bys'78� Address For permission to(state clearly p,,,p / 6 //l/,s'%f7 LC. Name of competent operator(If A- Date Issued-rejected _ z 1 L Data of expiration —T Due FPB(rev.3=) City or Town ' F;EE 'LUMBER Date –- Permit Number(if applicable) In accordance with the provisions of this permit is granted to for S T:Z/,'. Restrictions: /) F/5�+ " at (Mve location by s" f ll�,)I bca tion) Fee Paid$ Signature of Official Granting Permit 10 This permit mu. L'ir_ premises r 1 , o C t e Im Install/Date-8/22116 Gorham Fire kiplil,:utt Ov y ® Bellas Roast Beef 288 Wil ini S, �i 1211 Osgood S ISR Quincy, ^ D2:5c; No Andc._-,f:'.. :. Bob G=.._... Harry rII7-.4-77 5785 �1?71-x282 :_l: .:,..-_^'. aii.con; Uritit:ed System Untitled Layout 15 x 15 n. �T J �m iz�xza,n. 16 x 16 x16 in. J rl6vs�`-«m n:• .A:S1 ng. �_ ... ._ ... ... .. ... v .. _. �2 Cil lid: _. __..... .. _.. c -. � � � � -_ n •, .. 22 2 J 5 �L{ � + Install Date: 8/22/16 Gorham Fire Appliance Co Bellas Roast Beef 288 Willard St Chemo 1211 Osgood St Quincy, MA 02169 No Andover, MA x Bob Gorham Harry 617-472-5785 617-791-8282 gorhamfire@hotmail.com MACC#54 Notes Fusible Links: _>To determine actual fusible link ratings,temperature readings must be taken during peak cooking time. Untitled Layout: Note 1 =>Nozzle: 1 H x 2:(Hood:Single Bank)nozzle position:2 in.from back edge of filter, 1/3rd down from vertical height,0-6 in.of end of plenum(or module),aimed down the length of the plenum. Note 2=>Nozzle:2H x 3:(Fryer:3 vats)nozzle position:2448 in.,anywhere within perimeter of hazard area,24-48 in.above cooking surface,aimed at center of cooking area Note 3=>Nozzle:2H x 2:(Griddle)nozzle position:24-48 in.,0 to 6 in.from short side of hazard area,24-48 in.above cooking surface,aimed at center of hazard area. Plct;, � ":,�,z.e:211 x lcl---nr3ilc:`--:,zz.c----;a-,:35:8 ir.,-b:vz alp'cum of hazard arca,3b-48 in.above the cooking surface and aimed at center �.... ,.. Y.�. y g of broiler surface 'rote 5 R--ngc:6-w--.ncrs:Additional nozzle combinations are possible for this range.Please refer to the manual. NotC b->Ni--_l_:1:.Tt.TL: 3 , 3 -:v s.....................:.b.,._,.«- , ..........._..__.� ...... ,.._.:._.�.�« ._:a:.__ , on hazard size.Aimed straight do'�xln ar±;-,vhere within a undefined;n.r di--of ha>ar`i a—----,l;nn !xT0TF_ pcso3of5 The Commonwealth of Massachusetts F Department oflndustrialAccidents 1 Congress Street,Sdite 100 Boston,MA 02114-2017 qr www mass.gov/dia • OR.11 SV.yt VPolkers'Compensation Insurance Affitdavitt:Buildexs/Contxactors/Ii lectricians/Plnmbers. TO BE FILED WITH TEE PERMTTT'NG ATJ rHORI�'X. P.le e Print Le 'bl ApOcant Information Name(Business/Organization/Individual)- Address: City/State/Zip: Phone Are yon an employer?Check the approp tate box: Type of project(required): em to ees full and/or part-time)." 7. ❑Ne�i'c6nstriiction l,�aemployerwith�_ P Y 2.❑I am a sole proprietor or partnership and have no employees Working for mein 8. Remo deliiig any capacity.[No workers'comp.insurance required.] 9. Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 ElBuilding addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will I1.❑Electrical repor additions ensure that all contractors either have workers'compensation insurance or are sole ays proprietors with no employees. 12;Q Plurriblxlg repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.M�ther 6.Q We are a corporation and its,officers have exercised their rigbt of exemption per MGL c. Ate` n J 152,§1(4),and vae have no employees.[No workers'comp.insurance required-] *Any applicant that checks box#1 must also fill out the section belo�w�so k��men hire outside eir workers' oontracttroors must submiinformation.new affidavit indicating such L. Homeowners who submit•tlus adavit indicating they g Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not(hose entities,have employees. Ifthe sub contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing avorkers'compensation insurance for my employees. Below is the policy and job site information. ,�/s _ Insurance Company Name: 9 }} /E Policy#or Self-ins.Lic.#: Ll q j 3 � S 7 Expiration Date: \� . � � e Job Site Address: / I �S&d /� L City/State/Zip:/l/L1 �'`J �a�f 1 '�I Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp iuration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$I,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. epains andpenalties of perjury that the information provided above X do hereby certify under tliis true and correct. Date: Si ature: Phone#: l 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): L1. oard ofIfealth 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector ther Phone#-tact Person------ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their ernpl6yees. 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 ritten-An employer is'defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enferprise,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 requ&ed." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub contractors)name(s),address(es)and phone number(s)along with their certificates)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•Acc4dents. Should you have any questions regarding the law or if you are required to obtain a vrorkers' 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 Min 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 stamp ed 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-I5 wwwmass.gov/dia J t, �fae!irse�to�C�re C9i�r�roas 'p CC-000054 Fire Equipment Certificate of Competency ; a Robert M Expiration Date 09/03/2017 State Fire Marshal V 9/vvv Fire Equipment �C1 �.I� e of Registration This is to certify that iry�agcfWt ,, g Fire Equip ) qtW aws and regulations a 'MR0EiA 40ge y Issued to: Expiration Date: 11/14/20," s< R' tamrrs'di secondary License Type: .: tt Gorham Fire Appliance CO," if telrve Facilities 288 Willard St 4,44:4peckli'l-lazard ,7.0 OrtztblO Fire Extinguishers (Engineered) West Quincy MA 02169 -'44:OpePial'Hazard(Pre-Engineered) State Fire Marshal Post in a conspicuous place. Verify the status of this C ertificate at www.mass.gov/dfs ?= i,•+, .o-Y'' - ''SSU :.y��d"{�',Fd r ' �' t�.;���yavr,�$r s.{,>��F ,,y„ . 'n,+�f'� �t �,F� `:. 'i;,•.;.:• Vii