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HomeMy WebLinkAboutBuilding Permit #144 - 163 OLYMPIC LANE 8/26/2008 14ORTH BUILDING PERMIT ,,LSD 4 4,° f o 3? a,ti�. L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �► ^ �► Permit N0: y/ Date Received -aATED 9SSACNUS��( Date Issued: 46 dP� IMPORTANT Applicant must complete all items on this page NOWSJ. Mc ,10 r r ? e $ AM � >?� n, � rn� r lo r� `� '•? � � � � ` :��^� Via, 'fit �� , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other � DESCRIPTION QF WORK TO BE PREFORMED: 4 -°� Identification Please Type or Print Clearly) OWNER: Name: Phone: 2?"6��O" �G Address: 01 yam. �l 7 i,��b—�G , ,�•�, esti s fr 'a 'aa � �'V*ax � �� ��,�'�.,, .£K � rk '*�.�'i" �Nfl� y�s'� t W 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: $ O,q 5— FEE: �l �"• ° Check No.: o� a� Receipt No.: NOTE: Persons contracting wi egistered contractors do not have access to the guaranty fund S irtur c Af/Cnet �� F w, b= , 5fu-e o coact . .,:�.c..� �.r�a� t r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ � ❑ 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 DATE REJECTED DA E APPROYED CONSERVATION ❑ . 1COMMENTSILL I DATE REJECTED DATE AP ED HEALTH ❑ COMMENTS � � ,•, :/, ✓' ay c Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments i Water& Sewer Connection/Signature Date Driveway Permit Located at 384 Osgood Street.. �" t"� rye. �,� y ��� � or . `e ["_ � �IEk4p3I ,Fiv� Lod 12� 1aftxeet � M eteaersigntlede � � x � � � � �. I H', - n � f3'u`�ari �,p, „ n, 1 x.xk,�,q —.�` _... Rte'„�.�•^°b' N. �.w3. � '�:...,, ��a ��• � 1�x�,y?k»p,r��,'_�„,-«a�p�y'r p,s� 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 i 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 a Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ 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) o Building Permit Application o Certified Proposed Plot Plan u 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 Beal Jasper St -.L Saugus,MA01906 BEAL CARPENTRY Framing•Roofing•Remodeling Siding•Replacement Doors&Windows Additions&Decks Licensed g reds / � � Free Estimates In �1' 781-233-9144 .Ago. HIM i • ' F Location �e 1,21 6 // No. Date Z "�G 6P' NORTq TOWN OF NORTH ANDOVER O? V roe Certificate of Occupancy $ CHUSE<�' Building/Frame Permit Fee $ -?s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ e Check # 7�G r . . 2 1451 .Building Inspector BUILDING PERMITo "°RT"qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received 79"�R�reo "y(y �SSACHUs�� Date Issued: �`�/` i IMPORTANT:Applicant must complete all items on this page LOCATION ��--' Prin PROPERTY OWNER Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DE CRIPTION OF WORK TO,BE PREFORMED: Identificati n Pleas, Type or Print Clearly) OWNER: Name: � b7 � C`J12�W 1 Phone: Address:-/63 CONTRACTOR Name: Phone: Address: 4 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F. Total Project Cost:.$ FEE: $ (} Check No.: Receipt No.: NOTE: Persons contracting 41t 'nre is ered contractors do not have access to the guaranty fund ignature of Agent/Owner Signature of 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 FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS d r 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 yes no Located at 124 Main Street Fire Department gnature/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 - Date Doc.Building Permit Revised 2008 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 ❑ 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 li ❑ 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 lication Doc:Building Permit Application Revised 2.2008 Location/ 2 M,00 No.. lri""- Date ` ��^Th TOWN OF NORTH ANDOVER tr i Certificate of Occupancy $ - +�,s',"°'tt�'+ Building/Frame Permit Fee $ fid- sACMUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �` 21857 �--- - - Building Inspector 04-03-2009 16:57 BEAL CARPENTRY 7812339144 PAGE1 b a� &0 fR 1 U Cy 03/04/2009 3 : 24PM (GMT-05 : 00) 04-03-2009 17:00 BEAL CARPENTRY 7812339144 PAGE3 ,IV , I ,V) i I 03/04/2009 3: 24PM (GMT-05:00) t V40RTly 4'0 0 191Andover .0 No. C o dover, Mass.,0 LA /� COCMICMEWICK V 7�S RATED pP BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System Qkun 'a-at&'/__f_ BUIfDJNG INSPE,THIS CERTIFIES THAT............................................................................................................................................................... �,. 171 has permission to erect........................................ buildings on .......... .........0/9_. !!?,�c.11 ...�c..G:'�I e........................ Rough u Chi zc- to be occupied as............. ��G� f..... ,CLIC. ��'.G A.......... ...... .,ll ...................................I....... mney provided that the person accepting this permit shall in every respect conform to the terms of the application on fil 'n this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction'o i ai �`� Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Per lt. Rough PERMIT EXPIRES IN S ELECTRICAL INSPEC O UNLESS CONSTRUCT101s4 STARTS ou , Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPEC - Rough Yl/v Display in a Conspicuous Place on the Premises Do Not Remove ? el s No Lathing or Dry Wall To Be Done FIRE DEPARTWIENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. c NORTH Axid TownO ', over . 1, No. y , ZYn o dover, Mass., O LAK COC MICE WICK �• ADRATE D APa\ "`� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... .................................... '...... • .................................................. Foundation has permission to erect........................................ buildings on/0.1...... � .. ` ......•••• Rough t0 be occupied aS.... hd Chimney ...�,....... . . t............. provided that the person accepting this permit shall in every respeTf form to the terms of the application on file in Final P P P g 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 C 1 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS LESS CONSTR .' .Z&Aa Rough Service BUILDING INSPECTOR Final Occupancy 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. Smoke Det. SEE REVERSE SIDE 04-03-2009 16:59 BEAL CARPENTRY 7812339144 PAGE2 BEAL CA"ENTRY 27 Jasper street Saugus MA,01906 781-233-9144 Job location: . a- /•4rvc / o,/��f-�r Job , , description: 3vt G /( '`C 0 d&--4 LIS A f-�e- 9 ,a a�L5' IV Price`° Z -5-V L) sues Beal 03/04/2009 3 : 24PM (GMT-05 : 00) U/ PLAN NU. ZOOd PLAN NO. 7865 PLAN NO. 8445 PLAN N0. 8479. ASSIESSO,RS: � � t / MAP 1068 / 1 PARCEL 132 / LOT 27AA ZONIING: R-2 / 44,041 S.F., W FLOOD ZONES AE, X—IN & X—OUT a N FIRM: 250098 0009 C&0012 C 3 N Ln DATE: ,JUNE 2, 1993 AL t 'L JL Z AL AL AL AL LOT 28A Y ci . / / 9,3AL AWL ; .94 / �\ 9.5 es AL ,� AL e }VE` W 9 �y, �lll� � / �9 O loo Zf ty 32.7' 20 SEPTIC SYSTEM JAMEI ALOCATIM By OTHEM 27 1, o " . jf ' PLAN OF LA N ED CN t P � G NORTH ANDOVER , MA .- NO. A .I!JO. 163 OLYISIPIC LANE a JEFFREY R . Fc ROBIN ESTERIKES e � lJ RE ---.-- —..._._.e._-----------_.---_,---.., ---_—...-------._�______ Page# of pages k� Cy Proposal Submitted T Job Name Job# eTT + �� �S�P� �P Address Job Location Date f z Date of Plans N1,doi-I-z /Zr I Phone# Fax# Architect `7 i We=hereby specs i ations and estirpatlas jor. .................................................................................... ............................... _ UU t\A 5........_.. � .rR .......G ......A.c}' .. /_ 7v_.....r : , . ..�._ ........ l�c�Z _ nsY I�._ ✓t�4f�G ✓� � ._... ._._....._.__.__._._._.. _. .._S / C'... ....�' X'S °`. / J_:_Y'Y.J- !`} /(S�'CG�'r � � '✓ _. _ _.... ..._�. /,.._. w��r......./ . / _._... __.... ...-_........ _ ___-._ i `� ....._.��. _f✓�cu.rte. #� .. - 7. 5.?S ............!.- .P 1l ••1 G rc )1 _ - t �...... . ......._ __... _ ................. . ........................... . ...... ...._ ................... ..... ._..... - . ................. .._._... ............... ..................... ............ ...............�............................................. � .... ........ (/'/ t .. -_/ .. .. __...._. .. . ................................- .................... ...................... .......... ............... ........................................................ We 7;pose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: � $ Dollars with payments to b�made as follows �s�"u w�—� Sf�^-� G�,�G,�, n" ,"j e„� �� p�vty�--r-f„ aC/C/' i s pl.�s��-J, 6,�°UO(,tJ�ie, ao1Gf���.,.s�.,,.�3,W;L#1a k Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal ay be with rawn by us itiNccepted within days. Occeptance of Pro ora ' * The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature NC3819 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: r r eit- �• � ' 1 (Location of Facility) Signature of Pe Applicant Date lab/IU/lmmti UtJ:41 7Iti-OL1-01Le UUZDIrr.LU IN:n. r-kk= alrEll PATE IMWDWYYTY) -ADM, CERTIFICATE OF LIABILITY INSUFN^NCE 06/10/2008 RODUCER (978)374-6351 FAX (97$)SZa.-5127 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION :OS'rELLQ INSURANCE AGENCY ONLY ANI!CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,E1(TEND OR Z South Kimball St. _AOR THE C VE GE AFF D BY' LICI S QW. PO Box 5248 INSURERS AFFORDING COVERAGE NAIC 0 Bradford, MA 01$35 33758 aSURm baa► Carpentry ►NSUfWA; AICA Insurance Co, 27 3asper Street wrJffiRg` Saugus, MA 019016 WSURSR G' E URER DI:u INSURED ABOVE POLICY DTE DING THE RCSOF �RIIEDBEL Y BE IS0 OR ANY QEM OR O FANY CONTFA�t4R G7ER DOCUMENT WITH RESPECT TQ IMAS MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRI6EA HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONC AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN F9DUCED BY PAID CLAIMS, T N L[MrTS asRL TYPE OF INSURANCR POLM NUMBER $ EACH 00pURR0G>E GENERAL UABHJrY AABA gD $ COMMERCIAL GENERAL LIABILITY MED EXP(tiny vac porion) 3 CLAIMS MADE n OCCUR __...s. pt:R&ONAL 5 AOV IN,VURY $ 6ENERAL AGGRP3ATS S PRODUCTS•COMP/OP AC-0 s GENL A0GRWTE LIMIT APPLIES PER: POLICY FVT F--ILQc AUTOMOWLE UABIUTY (Es S►NOLE LIMIT s 8* g F.S gdgtl) ANY ALTO ALL OWNED AUTOS (per=per pe�er pINJURY g ( son) SCMEDULBP AUTOS HIREDAU105 SOOILY INJURY § (P�acculq NON-OWNED AU70$ (PPROPERTY oAMA6E £ AUTO ONLY.EA ACCIOGNT $ C,ARAGE UADTUTY EA ACG $ ANY AUTO AUTaaoN�LY. AC4 $ EACH OCCUME14CE _ gXC@S&VMBRELLA UASILITY 4 A©GRFC'A►E OCCUR CLAIMS MADE - i S DEMUCRBLE S RETENTION S ECIC WORKERSCOMPENSAnigSAND D02469p1Z007 04/`19/2008 0489/ 009EMPLOYERS'UANUTY EIL.EACENT a 100 00 A AEN PROPRI�RIP S.L.DISEASE•FU EMPLOYEE $ 0OQ OFFICEWMEMS R BXCLUDED4 - yyeess olls4e unaar s L.DISEASE-PoucY LINT s 500 00 SMAL S►ON$pek>d, OTHER DESCRtP r4ON OF OPSRAT*NS I L.C'3ATIONS 1 VE)PCL$t EXCLUSIOhl$ADDED BY ENDOR8EMEH1! fiIAL PROYI&FON8 C TIFICA DE C I N 5"OULD ANY OF THE ABOVE DUCRIBEa FOupES SE CANCSLLED 59MRE THE HE EXMMTM RATS TREOF,THE fWUING INSUM WILL ENDEAVOR TO MAIL 30_GAYS WRJrM NOTICE TO THE CLqnFIC M NDsM NA ED TO TME 10T, BIT FA LVO TO MAIL SUCH NOTICE SHALL IMPOs:NO 09LIGATION OR UA&►LTTY Town of North Andover OF ANY KIND UAON THE INSURER,ITS AGENTS OR REPRES1LNTA17VE5. North Andover, MA AUTHOF=0REPIMSENTAME William Castello g3ACORD CORPORATION 19SC ACORD 20(200908) 07-10-2008 09:12 BEAL CARPENTRY 7812339144 PAGE1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street aW Boston, MA 02111 Sv www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): R ej.4a 2 Address: ,S'r9�s PGS, City/State/Zip: S6___31__4AefPhone.#: J Are.yo n employer? Check the appropriate box: Type of project(required):. 1. am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. F-1 Demolition working for me in any capacity. employees and have workers' comp. insurance.t 9. ❑Building addition [No workers' comp. insurance P• ' required.] 5. ❑ We are a corporation and its 10.F-1 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 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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: Policy#or Self-ins. Lic.#:' 1f V G (.6d>1t(:9 440%c i—) Expiration Date:_ hfwS Joh Site Address:_ 1Y'" d.e44�ial.�j��, 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Si afore: Date: Phone#: �� !� — S/ q 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." i 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,opera'te�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, §25CM 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 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or pem>t 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. #6.17-727-4900 ext.406 or 1-877-MASSAFE ` Revised 11822-06 Fax# 617-727-7749 www.mass.govldia �__ . _ _ 13A� � i i � - _ - - -_ --- � --� �- �f i i r j � Sel f �� r i i i i I BUYER: Jeffrey ?t Robin Estorko [[Daae built in 1900 ism . L r rZ�,do 5 AN ff , N' N� 27 AA Z4� aA 7. 2 01 aa' yea• i l�a� Se �-- �� �� �y � �'G' ��„ ,(�i � r - 1 � - �- =-.4.: _ -— weir f J • 1 t .•r-.._� �� G �T a�\\y/�� 1 / `� I — � � e..�..... ' _ I ,yam Board of Building Regulations and Standards lugHOME IMP_OVEMENT CONTRACTOR Registration\-130727 Tr# 265036 Expiration :4/11/2010 ' DBA=° ^`"Types. BEAL CARPENTRYV= j- i JAMES BEAL 27 JASPER ST. Administrator �SAUGUS, MA 01906 Board of$oi in ,,���.o_� a ati`ons and tends a Construction Supervisor License Licenses CS 75111 Birthdate ',115/1965 f prra#ion 1512 .09 -;7, / T n r# 8364 JAMES S BEAL f 4 J 27 JASPERSTY;�-- SAUt;US, MA 01906 ' Comliissioner 4 EXHIBIT A Subject to 40' Drainage easement, Plan 7865 . Subject to Easement to New England Power Company, Book 776, Page 194, 204' Easement northerly of locus Book 2293 , Page 149 . Subject to abandoned railway location; Plan 2669, Subject to Massachusetts Electric Company, Book 1356 , Page 405 . Subject to New England Telegraph and Telephone Company, Book 1358 , Page 206 . Subject to Bay State Gas Company - Lawrence Division, Book 1361, Page 736 . i I