Loading...
HomeMy WebLinkAboutBuilding Permit #855 - 19 OLYMPIC LANE 6/4/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO - —,S— Date Received—( (�r 1 l( Date Issued: ` — I Z IMPORTANT: Applicant must complete all items on this page LOCATION 1 C/i/Z�p /QC- LAN e. Print PROPERTY OWNER 73re oda r, Print MAP NO;ld 04 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ElAssessory Bldg ElOthers: ❑ Demolition ❑ Other O'Sept�c> OkWell ❑�Floodplaui ©1WWand'st yVatersl edkD� �trict,, t DESCRIPTIO OF WO K TO BE PERFORMED: R -e pAg ce-- ;? f eyu c—, s 11AY-eN 4ick OWNER: N tification Please Type or Print Clearly) ct. 9 DoinEN/C T•e/-r'QN© VCL Address: /F ©/Y//°/C' Lgac---' rrld4 aoL) S rHe wi�i% : 9 71? 686 --A� 9 CONTRACTOR Name: ,8R�9DLEy �F 1120W'erS W Phone:(!�,;-?-3 3 --7 Fc� Address: ;2c;?.- Supervisor's 202 Supervisor's Construction License: Exp. Date: Home Improvement License: %o2 v2 7 7 (-/P )Exp. Date: ARCHITECT/ENGINEER /V//4 Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ / P % 0 p FEE: $ ' Check No.: Receipt No.: S 3 NOTE: Persons contracting with unregistered contractors do not have acc ss to the guar my fund --- ----------- ;�- ------ _ - - -- - - - ----sir-•----•--- Signature of ontractor Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Sw'mr� g 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 PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH f COMMENTS DATE APPROVED Reviewed on Signature - Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: — Com 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 signature/date COMIVMNTS 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 Q. Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Muss 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building permit Revised 2008mi Location No. 9!;��7 Date /02 - Check # 25349 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL eVL-4e�-7� 1%4 Building Inspector . . W o A d O as Uvhh� aV+ � o v, a W Z "� � O z � T W Z / :3 0`• c AG 004 U W U ;c g O u V � W w � M O z cn 6�J o o cn Z 0 U Cl) 0 co co O v Z CD CL O y O C IO Cm O '� OLA co •E m m co 0 CD CD O.a Cl CD Q cvv o a � v�Q y C CD ccC C.2 .FL O w co tsC C.2 V! � C C C is 0 W LU U) W. W 19 /WU UI c 02 •m 0`• c ;c g : c �0 0 C H C.3 V J o�co • N � SL E Q 02 a co 0 °' :o u � CL E m m a cm m N C 32 •� son" m y O G Em v mo C a� N O CD cc cm C C N Q acz C3cmy O Ci•�Z O ' Q d � y m C C •O _ � r0+ mCOD mw c a N m N m WO yO, flC _... •N me r •� W •E dt C ES V •y . Z o C013 a m� �� C—Le Z 0 U Cl) 0 co co O v Z CD CL O y O C IO Cm O '� OLA co •E m m co 0 CD CD O.a Cl CD Q cvv o a � v�Q y C CD ccC C.2 .FL O w co tsC C.2 V! � C C C is 0 W LU U) W. W 19 /WU UI ) § § 2 (\ { / D m ) ( § } \m 2 m m o o = » \/0 OD o / c2;a e/ � G)C- ƒkJ . � D m 72 §\2 § e § \ \ § \ ( ^ ( ƒ $ §.4. _ - v � v Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has witli� homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. —" a/lA/1,iNO — 5W W1� Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (Le. MGL chapter 93A) may not be waived in any way, even by agreement However, homeowner; may be excluded from certain rights if the contractor they choose is not properly registered as prescrrbed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as descnbed, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal nights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,. all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed cottv of the contract, and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hint/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consume rights, or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law," contact: Consume' Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (6I 7) 973-8787 or 1-(888) 2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508) 652-4800 (508)755-2548 (413) 734-3114 Massachusetts Home Improvement ikoria Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice If necessary. Any person planning home improvements should first obtain a copy of"a Massachusetts consumer guide to home improvement" before agreeing to any work on your residence. You may obtain a free copy by calling Ute Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888.283-3757. Homeowner Information _ rte.,+. • f, . t. r . _ . __ /�1eNa6- 7e rf 9wo ✓o.- St, Address (do nut use a Post Office Box address) / 9 eIV ob ie" L-:5lA/,0 State Zip Code o, f�N�/ave� c Phone h=.,...;".. ah,,.... 4AW I'o,(,verr ntractor/ Salesperson/ Owner Name mess Address t,,Mst include a sneer address) R "eon State Trp Cude 4�1� 9 g® Mailing Address (it tiitferppt from e) usin Phone edaal Employer ID or S.S. Number has rePnses tba moa b— vn- Hook t raaaaam keg. N. tisrmarm dm Pommt oomnpas b�vca ` The Contractor agues to do the following work for the Homeo(Cana, Ron ner77�:es >� o� 7 ? �-• /rp '� �� 1M - 3 - Zel3 O Se/ja0,e QN hi eA-- e-F'%a4-�1°-12- 1'-ell/gee- C -12d r C /-110604 eb2 5)d// jyl Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the eommetor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of ` J" l oLte when contractor will b MGL chapter 142A.) , _ • .' begin contracted work when contracted work will be substantially completed. Total Contract Prier and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: ! ��+• (.) Payments will be made according to the following schedule: S , upon signing contract (not to exceed 1/3 of the total contract price 1 the cost of special order i ©©� / s ;cats, whichever is grea/ter)) S try (� l I� or Uponcompletion-ofDelnd, hejujet jrq o 4///ij -'0PV A -!/V e%Y odD � !_ by C // 9, 6a orupon completion of $ 7Do upon completion of the contact (Law forbids demanding full payment until contract is completed to bout mP parry's satisfaction) The following materiaUequipmaot must be special b to be paid for _�V f ordered before the contracted work begins in order S to >K paid for to meet the completion schedule.('•) NOTES: (•) Including RD finance charges (••) law requires that any deposit or down -payment required by the contractor may before work be not exceed the greater of (a) one-third of the total contact price m (b) the aomal cost of any special equipment or custom made material which must be special ordered in advance to meet the wmplction schedule. Sobcootraetors-Thecontractora - " •` ail c tfrewa mu atter the agrees to be solely responsible for completion of the work described regardless of the actions of any third Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all s payments to all subcontractors for Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the res carefully before signing this contract idence. Review the fotlowing cautions and notices • Don't be pressured into signing the contract Take time to toad and fully understand it Ask questions if something is unclear. • Make sure the contractor hes a valid Home t veto t ConM o The law requites most home improvement contractors and subcontractors to be registered with the Director of Home improvement Contractor Registration_ registration gist 2108 You may inquire about 0 contractor gt try writing to the Director at One Ashburton Place, Room 1301, Boston. MA 02108 or by calling 677-727-3200 or 1-80D-223-0933.. • Does the contractor have insurance? Check to see that your contractor is Pro• Know your rights and responsibilities. Read the Important Information on thereeyverse sins ide of this form and get a copy of the Consumer Guide to the Homer improvement Contractor Law. You may Caren) this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her train office or branch office by ordinary mail poste third business day following d by telegram sent or by delivery, not tater than midnight of the Ute signing of tris agrecmCol. See the attached notice of cancellation form for an explanation of this right DO NOT SIGN TFUS CONTRACT IF THERE ARE ANY BLANK SPACESnt Two idemiot owpiec of the mtmaa must be evntpleted and signed One WPY should o to the y l � g homcowna. The other copy %should be letyt by�the �com�npo�r. Homeowner's //i���Z�/ i•r�%Z�-"�'v Dau Contractor's Sifmamre &- y- trot ,-/ /� Date POWDBA1 OP ID: ST 14<7"RCERTIFICATE OF LIABILITY INSURANCE DAT06104/12 YY) 06/04/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 603-382-9211 THE JOSEPH S. HILLS AGENCY INC 129 MAIN STREET, PO BOX 300 603-382-3387 PLAISTOW, NH 03865-0300 CONTACT NAME: WCNNo Ext): A/C, /C No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # 02/04/12 INSURER A: Main Street America Assurance 29939 EACH OCCURRENCE $ 1,000,00 INSURED Bradley Powers, Jr. dba Brad Powers Construction 22 Wyman's Landing INSURER B: INSURER C: Danville, NH 03819 INSURER D: INSURER E: $ INSURER F: AUTOMOBILE COVERAGES CERTIFICATE NUMBER: 12-002 REVISION NUMRFR- 001 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 OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL UB POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR MPB9290S 02/04/12 02/04/13 EACH OCCURRENCE $ 1,000,00 DAMAGE To RENTED - PREMISES Ea occurrence $ 500,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYFX PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDFSCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY Pid$ (Per accent) PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU-OTH- TORY IMI R E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Carpentry residential Job: 19 Olympic Lane NOANDV1 Town of North Andover Attn: Brian Leith 1600 Osgood Street Bldg #20 Suite 2-36 N. Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRES E NTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts r Department oflndustrialAccidents ,L 1. i Jl Office of Investigations N i �. 600 Washington Street f MA Boston, 02111 ;, •Jwala �`J ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLegibly Name (Business/Organization/Individual): � A W e rS Address: o2 bt/Nl'1 qyS L`;~'11, ej City/State/Zip: r),qN V 1,11e �t%W 0,7S'1% Phone ##.LL/a 0?3 5 — % pdPep Are you an employer? Check the appropriate box: 1. ❑ I ama' employer with 4. ❑ I am a general contractor and I e}riployees (full and/or part-time).* have hired the sub -contractors 2. II am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. kRemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ 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 anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 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 p ainswqp enalties ofpefjury that the information provided above is true and correct C Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and. who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to 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' compensationaffidavit 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 cant' 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 confinnation 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,-penmit/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 pen -nits 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 Tnvestiptions 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877 MASSAFB Revised 5-26-05 Fax ## 617-727-7749 www.mass.gov/dia DateJ -. & "OR AV TOWN OF N04H ANDOVER PERMIT FOR PLUMBING This certifies that ./-V ................ has permission to perform ...... ....................... plumbing in the buildings of . 1 1". 1'.,- Al ............... at. P -I .. C, ( 'x —!/p ....... . . North Andover, Mass. Fee.-�." ....... Lic. No.. I .. ...... ....... PLUMBING INSPECTOR Check # I )- -� I -� 78-14 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locationr y ©4 YDate G� Owners NameYtR 4:p41A Permit # 20 l y Type of Occu anc %��S , Amount a G New ri Renovation Replacement Plans Submitted Yes No ❑ FIXTURES :•moo a i ee� •,� erg i ee. i ee� ,i ee e e e'• i er. (Print or type) R Check on Installing Company Name C— A / I&L' A C -y #T- ' Certificate n ����� Address v, 1 ��E L%' 6 /V11L Partner. . NJ 6 LJOP— , N. usmess lelephone r-1 Firm/Co. Name of Licensed Plumber: ^� Fi-- u lwc' Insurance Coverage• Indicate the t e of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity rl Bond Insurance Waiver. I, the undersigned, have been made aware that thelicensee of this application does not have any one of the above three insurance Signature Owner ❑ I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and instal compliance with all pertinent provisions of the Massachusetts By: igna ure ZZ Title Typ of X City/Town 4-SC�� �--APPROVED (OFFICE USE ONLY um Agent ❑ (or entered) in above application are true and accurate to the ormed under Permit Issued for this application will be in mt n d .,and Chapter 142 of the General Laws. License — Master Journeyman ❑