Loading...
HomeMy WebLinkAboutBuilding Permit #693 - 1600 OSGOOD STREET 4/2/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: �01-1 2-- IMPORTANT:Applicant must complete all items on this page LOCATION Qe9 IZA-- -/0- Priut PROPERTY OWNER D Print MAP N0: PARCEL: ZONING DISTRICT: Historic District yes no Ma;L� Machine Shop Village yes no dV 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other s; '�` � §S+�'• i`. •�r.�,��r�v�.Fa erb� �)--'` �±y. �x"�t- t< � �ptic ®W°ell ' ; �'��� ���p,tEloodplam� ���Weilands , ;r .r,; F, a s c M y{ter "�Ty$ (5 - +j/�t ; '$' � z'Sti'S# <,�+ �.� t .�§�ai�•' r{ .r. Water/S�werrf" € ic s'�i� z "_`_i#'_'twc. t...`-' ,,t�' .�. _r_:<•. .. r f.� _.z k�J..i _- DESCRIPTION OF WORK TO BE PERFORMED: 1 J 'La, 2,, sc,44 G r dentification Pleas a or Print dearK, OWNER: Name.- Y,2.,521-0 Phone: /a I Address: �,coc,�-- �— j CONTRACTOR Name: % Phone: 6;,g- ��3 e Address: Supervisor's Construction License: �4 9-49 ez�) Exp. Date: i Home Improvement License: Exp. Date: ARCHITECTIENGINEER_2t �&2-f- Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$7000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. I Total Project Cost: $ ` FEE: $ 2Ra '�©� a � Check No.: Receipt No.: CPS 3 " DOTE: Persons—coni gist red contractors do not have access to the guaranty fund i, �.Sgnafure;of 'c Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody.Art ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent.Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS e CONSERVATION Reviewed on Signature - COMMENTS HEALTH Reviewed on Signature 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 Dumps r on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq.ft.: I 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 20117une/mi r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. ` Roofing, 4 Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit a Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i ,Addition or Decks a Building Permit Application a Certified Surveyed.Plot Plan a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ff ❑ 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) M ❑ 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 a Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 Yn all cases if a variance or special permit was required the Town CIerks 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: D oc.Building Permit Revised 2008mi ONO oT��h r; fr ..f"r ,sS.,4c i CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 693-12 on 4/2/2012 Date: October 15, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood Street, Building #20, 3rd Floor— ' Mentor Networks MAY BE OCCUPIED AS Office Space_IN ACCORDANCE WITH THE PROVISIONS OF THE`MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER.REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzy Properties/Mentor Network 1600 Osgood Street, Bldg. 20,3rd Floor t North Andover,MA 01845 Building Inspector Fee: PrePaid Receipt: 25377 Check : 8778 i I ,i _,o ove r No. - _ IL LAKE o , # over, Mass., • COC MICME WICK V^ O RATED PP � BOARD OF HEALTH PERMIT . T D Food/Kitchen Septic System ... ..... � , ABU I i. LDING INSPECTOR THIS CERTIFIES THAT. OZ1.11:4f �0.�.. .......M.CA4.1.6.r......P0 � ... Foundation buildings on .... ..... r C has permission to erect....... ........................ g �,'bD.c�...Q. .... !8.�f...........�. ..��d Fra, ough t0 be occupied aS.. . . -- h' ney p a O!'r!rt� .✓ .....................:........................................................... provided that the person cepting this permit s all in every respect conform to the terms of the application on file in 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?: %. �� L' /2 Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTI ST4t:z= S ELECTRICAL INSPEJOR O 0 ou ...........UILDING SPECT RO % ( `� Occupancy Permit Required to Occupy Building —t� P A_cough GAS INSPECTO dT ---_c gip- Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingor D Wall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE- SIDE Smoke Det. i GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY 0K)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat,elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-_Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heat support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-',stairways, under beams Attic Access. (min.22x30 w/3'headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. of required glazing shall be openable. Bedrooms required min.20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. , Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging, clean joints, 8"solid @ combust. DECKS: Lag to house, provide flashing. +� Rails min. 36"high, Baluster max space 5"on cente . Over 8' above grade, use 6x6 posts w/lateral bracing Lag all posts and rails. \� Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupyin structure. Temporary Stairs required for inspection. Q� Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupying structure. �. Q FILA September 14, 2012 u..a.QA.e-rtcv Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, Massachusetts 01845 Re: Mentor Network space interior office expansion/fit-up project Floor 3,Building 20, Ozzy Properties 1600 Osgood Street,North Andover, MA Dear Mr. Brown: Based on site visits through 08/06/12, the Mentor Network space interior office expansion/fit-up, floor 3, Building 20, Ozzy Properties, 1600 Osgood Street,North Andover,MA has been reviewed by us, and to the best of our knowledge and ability,this project has proceeded according to the drawings dated 03/12/12 with 04/19/12 revisions,prepared by this firm: R. Rumpf&Associates, Inc. Furthermore,this project is substantially complete and ready for occupancy. If you have any questions regarding this project,please call my office. Sincerely yours, � 3 Ac�rr;� , �0 5294 SALEM, SteZ6ectct ermore '�\ MASS. Pro ct TA SWL/occtltrl R. Rumvf& Associastes, Inc. Engineering, &Architecture 75 North Street Box 4483 Salem, Massachusetts 01970-6483 978.740.5025 978.740.5026 fax FILL September 14,2012 �t-Fs'+AiA.�t�i Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover,Massachusetts 01845 Re: Mentor Network space interior office expansion/fit-up project Floor 3, Building 20, Ozzy Properties 1600 Osgood Street,North Andover, MA Dear Mr. Brown: Based on site visits through 08/06/12,the Mentor Network space interior office expansion/fit-up, floor 3,Building 20, Ozzy Properties, 1600 Osgood Street,North Andover,MA has been reviewed by us, and to the best of our knowledge and ability,this project has proceeded according to the drawings dated 03/12/12 with 04/19/12 revisions,prepared by this firm: R. Rumpf&Associates, Inc. Furthermore,this project is substantially complete and ready for occupancy. If you have any questions regarding this project,please call my office., Sincerely yours, r•_T d. U� V E�1 . f: Ste W ermore ` MASS. t'i�\ 1�Y'�tie Pro ct Ar tect SWL/occtltrl R. Rumpf& Associastes, Inc. Engineering, &Architecture 75 North Street Box 4483 Salem,Massachusetts 01970-6483 978.740.5025 978.740.5026 fax RT T0VM Of z ove .,' ... 0 No. - �►,`.(( 0 LAK Ado , '� dover, Mass., o�• �- E I� COCKICKEwICK V 7��RATED P' � BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECT THIS CERTIFIES THAT. ^ •••• oundation BUI OR has permission to erect....... . .......................... buildings on .1.600 Q.. .... a �O(...Vrror�r' Rough 0 to be occupied as.......d ..... Off•�t 1 .✓ .......................................:..::.................:.................... Chimney provided that the person cepting this permits all in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR i { VIOLATION of the Zoning or Building Regulations Voids this"Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRtJCTI ST TS ELECTRICAL INSPECTOR 3 LJIv ES Rough — 0 O�•0f..... .............................. .... ..... Service BUILDING SPECTOR Final { Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough p 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. Jan, 20. 2011 9 33A No, 1791 P. 1 p,. OFFICE OF BUILDING INSPECTOR Se�L • TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: " PROJECT TITLE: PROJECT LOCATION: NAME OF BUILDING.,----- NATURE OF PROJECT IN AC RDA CE WITHTICLE 116 OF THE MASSACHUSETTS STATE-BUI N C DE, t, REGISTRATION NO. BEING A REGISTERED PROFESSIONAL-1=•P161t�EC-fi�IARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PIANS, COMPUTATIONS'AND SPECIFICATIONS-CONCERNING: ENTIRE PROJECT Q ARCHITECTURAL. STRUCTURAL MECHANICAL 0 FIRE PROTECTION ELECTRICAL. d OTHER(SPECIFY) FOk.THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE,SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND'PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDINO IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 1le.0 1. Review,for conformance to the design concept,shop drawings,samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at Intervals appropriate to the stage of construction to become,generally familiar withBthe progress and quality of the work and to determine,In general,If the work is being performed In a manner consistent with the construction documents. PURSUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL'SUQMIT A FINAL REPORT AS TO THE SATISFACl'ORY COMPLETION AND READINESS OF THE PROJECT FOR OCC Y SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF s uRF F.Ch NOTARY PUBLIC MY COMMISSION EXPIRES -kO �`� 03/23/2012 14:05 9786833147 + Q� CERTIFICATE OF LIABILITY INSURANCE 3/23/2012 ) T413 CoRTIFIcATiE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT114CATE HO(DIM THIS CERTIFICATE DOLES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOROE,D BY THE POLICIES BELOW. THIS CIERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REePRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; if ttre cerli tete,holdor is an ADDITIONAL INSURED,the pollcy(I")must be ondorsed. if SURROGATION IS WAIVED,subjw to the fArms And cowiltions of the polloy,certain poft%o may require an ondamelf(ertt. A staltement on this oertiftsts does not ean'Ibr rights to tho CeAiflaalto holder IN lieu of such endors_m n(s). PRODUCER NAME: M P ROBERTS IIS AGCY INC �O a�1 (978)693-807 c N,:(978)683-3147 106�0t�Os��goa3 Street sa.mike@ rcbertsinsurance.com North Andover, MA 01845 I S A NO COV E NAlaq raaURER(1 arCR61 ERAo INSURER A;MERCHANTS INSURANCE INSURED 00WV,:t ,RT CONjTRUCTION CO. , INC. INSURERMAXI NSURAKCE 175 BRADY AVENUE INSURER 0: INS RER b SALEM, NN 03079 IN URER E; IN3UR^R 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 REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE; TERMS, EXCLUSIONS AND CONDITIONS OR SUCH POLICIES.LIMITS SHOWN MAY HAVE;SEEN REDUCED BY PAID CLAIMS. 1L R TYPE C1 INSURANCE R y,yp POLICY NUMBER ID /YYY EFF LIMITS GENERAL LIABILITY EACH OCCURRENCE Is 1,000.000 Y COMMERCIAL GENERAL LIABILITY PREMISES(ES oourrenqel 100 000 CLAWS-MADE 1 -'I OCCUR MED EXP(Any one person) S s 000 A _ CHP9151606 03/23/12 03/23/13 PERSONAL&ADV INJURY $ 1,000,000 _ GENERAL AGGREGATE s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG R 2, 01000 POUCY 0',a 0 LOC S AUTOMOBILE LIABRfTY NGLnIMIT Aocid tIF. S ,000 000 • 1 AALt.OWN10 SCH ULED CAP1054994 03/31/12 03/31/13 BOAILY iNtURY{PerA•raon) $ A AUTOSN AUT PBODILY INJURY(Par aWdent) $ HIRED AUTOS X 'ON-OW"'� Paf Blxldent S S R UMBRELLA LIA3 IX I OCCUREACH OCCURRENCE S 1,000,000 A EXCESS LIAR CLAIMfi.b1ApE C1�P9Z203>� 03/23/12 03/ 3/19 _AGGREGATE DED RE'IENT1Q $ S WO RKERS COMPEN3A 1 �ATU 1 AND EMPLOYER&LIABILITY YIN 026/1 2 T UM R nNr PRlroRiPARrNERIGRECUTIVtE DOW 9277 11 10/ 6 12 C22 / B aFFICERIMr,M81:R exc4uoC07 � NrA E,L,EACHACCIDENT W 1000 000 It1 epi d t i"a E.L.DISEASE-EA EMPLOYES 1 000 000 i 3cRI�PTION OF OKRATIONs below E.L.DISEASE-POLICY 61MIT S 1 000 r 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddtWral Ramadtg Wr>dule,If more spade i6 roquired) M CERTIFICATE HOLDER IS NAND AZ ADDITIONAL. INSURED AS PER TIM TERMS OF THE WRITTEN CONTRACT AND AS PPR THEIR INTEREST IN TIM INSURED'S OPERATIONS. PRIMARY AND NON-CONTRISItP.i*ORY WORDING APPLIESU CERTIFICATE HOLDER CANCELLATION OZZY PROPERTIES TNC,DtwER OFFICE SHOULD ANY OF TI4E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PARC 14LC,1600 OSGOOD ST LLC, THE EXPIRATION DATE THEREOF, NOTICE WILL BE: DELIVERED IN HERITWE P7,ACE ALC,ZORCON LP,21 ACCOROANCE WITH THE POLICY PROVISIONS. HOWE ST LP,C/O OzzY pROPERTIES 1600 OSGOOD STRUT AUTHORIZED REPRESENTATNE NORTH ANt]OVER, MA 01845 A4 av,&;Z�= d.�1986-2010 A RD O I htB rB9erved. ACORD25(20101(3) The ACORD name and logo are tegistOMO(nark$of ACORD AA- The Commonwealth of Massachusetts c w Department of Industrial Accidents laLi I Office of Investigations 600 Washington Street 1 Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibly Name(Business/Organization/Individual):� A c e Address:_ City/State/Zip: :5 r7 e .e!4,4 Phone Are you an employer?Check the appropriate box: Type of project(required): 1.[9 Yama,employer with ( — !_5— 4. ❑ I am a general contractor and I 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. # ❑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 10.0 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' comp. insurance required.] 1311 Other *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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: z� t'' 1-4 sz, Policy#or Self-ins.Lic.#: l J (.t� L _ Expiration Date: I Job Site Address: 2 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.' Signature: / Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offrcial. 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 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 numbers)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 pen-nit/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 pen-nit 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.#617-7274900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass.gov#dia i Massachusetts- Department of Public SafetN Board of BuildingRegulations and Standards Construction Supervisor License License: CS 48M s} TADELISZ DOWGIERT 175 BRADY AVE H SALEM, NH 03079 Expiration: 10/29/2013 ~(bmmissiuncr Tr#: 5561 I /Ml-vTolL Al-e7x-�OfLA Location/e�'dd dV�yU,A $7 2V-- Wlt f No. Date �� NOR7M TOWN OF NORTH ANDOVER O F 2 Y * ; ; Certificate of Occupancy $ �ss��M�st<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ti TOTAL $ Check # � 2 r� 0 Building Inspector