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HomeMy WebLinkAboutBuilding Permit #297 - 200 SUTTON STREET 10/13/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Q Date Received 10—J09 Date Issued: Q /� IM ORTANT:Applicant must complete all items on this page LOCATION a Print PROPERTY OWNER h'I1 - Pnt 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 Fliiodplain1Wetlands : Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 'TnGo ISw SH*0J 6n fitp Q.TVA F:�► c? 7rz ory a%i-t % Identificat' n Please Type or Print Clearly) OWNER: Name: + .ab Phone: b - L-Z,6 Address: CONTRACTOR Name: AjI < Phone:?S7 ' S`�C dC-) Address: �zt �=�- Supervisor's Construction License: Exp. Hate: x Home Improvement License: Exp. Date: q "I Z) ARCHITECT/ENGINEER /U/f} 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. flu Total Project Cost: $�, 6ag FEE: $ /06 ej.-- Check No.: :�J D y Receipt No.: 172�_114 NOTE: Persons contracting with unregistered contractors do not have access to t ranty fund Signature of Agent/Owner Signature of contractorv'': a 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 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 DEPARTMENTTernp Dumpster on site yes no Located'at 124 Main street Fire Department signature/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 ❑ 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: Doc.Building Permit Revised 2008 O LocationoO No.. 7 Date �oRTM TOWN OF NORTH ANDOVER N • G9 ' Certificate of Occupancy $ CHU Building/Frame Permit Fee $ 1, 06 V. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # v� 22526 Building Inspector Model: 60 R EZG KOHLERPOWER SYSTEMS 208.600 Gas �09001 Standard Features V JO POWER S��TERS, �fJw • Kohler Co. provides one-source responsibility for the t• NATIONALLY REGISTERED generating system and accessories. • The generator set and its components are Ratings Range prototype-tested,factory-built, and production-tested. 60 Hz • The 60 Hz generator set offers a UL 2200 listing. Standby: kW 49-64 • The generator set accepts rated load in one step. WA 49-80 • The 60 Hz generator set meets NFPA 110, Level 1,when equipped with the necessary accessories and installed per NFPA standards. • The 60 Hz generator set engine is certified by the Environmental Protection Agency(EPA)to conform to Tier 1 stationary spark-ignited emissions regulations. • A one-year limited warranty covers all systems and components. Two-,five-,and ten-year extended warranties are also available. • Alternator features: _,....._ ..... ,I,; � a o The unique Fast-Response' 11 excitation system 1 I delivers excellent voltage response and short-circuit A�t capability using a permanent magnet(PM)-excited alternator. Ta ^ V. o The brushless,rotating-field alternator has broadrange 1II }i IMreconnectability. .,., • Other features: o Controllers are available for all applications. See -: _ controller features inside. o The electronic, isochronous governor incorporates an integrated drive-by-wire throttle body actuator delivering precise frequency regulation. Generator Set Ratings Natural Gas LP Gas 130°C Rise 130°C Rise Standby Rating Standby Rating Alternator Voltage Ph Hz kW/kVA Amps kW/kVA Amps 120/208 3 60 60/75 208 60/75 208 127/220 3 60 60/75 197 61/76 200 120/240 3 60 60/75 180 60/75 180 4P8 120/240 1 60 49/49 204 49/49 204 ' 139/240 3 60 60/75 180 62/78 186 220/380 3 60 55/69 104 55/69 104 277/480 3 60 60/75 90 62/78 93 347/600 3 60 60/75 72 62/78 75 120/208 3 60 60/75 208 63/79 219 127/220 3 60 60/75 197 64/80 210 120/240 3 60 60/75 180 63/79 189 4S7 120/240 1 60 57/57 238 59/59 246 139/240 3 60 60/75 180 64/80 192 220/380 3 60 60/75 114 63/79 120 277/480 3 60 60/75 90 64/80 96 347/600 3 60 60/75 72 64/80 77 4Q10 120/240 1 60 55/55 229 55/55 229 4V9 120/240 1 60 60/60 250 60/60 250 RATINGS:All three-phase units are rated at 0.8 power factor.All single-phase units are rated at 1.0 power factor.Standby Ratings: Standby ratings apply to installations served by a reliable utility source. The standby rating is applicable to varying loads for the duration of a power outage. There is no overload capability for this rating. Ratings are in accordance with ISO-3046/1,BS 5514,AS 2789,and DIN 6271. Prime Power Ratings: Prime power ratings apply to installations where utility power is unavailable or unreliable. At varying load,the number of generator set operating hours is unlimited. A 10%overload capacity is available for one hour in twelve.Ratings are in accordance with ISO-8528/1,overload power in accordance with ISO-3046/1,BS 5514,AS 2789,and DIN 6271.For limited running time and base load ratings,consult the factory. Obtain the technical information bulletin(TIB-101)on ratings guidelines for the complete ratings definitions. The generator set manufacturer reserves the right to change the design or specifications without notice and without any obligation or liability whatsoever.GENERAL GUIDELINES FOR DERATION:Altitude:Derate 1.3%per 100 m(328 ft.)elevation above 200 m(656 ft.).Temperature:Derate 3.0%per 10°C(18°F)temperature above 25°C(77°F).Dual fuel engines are optimized to run on the primary fuel(natural gas)and,as a result,the LPG ratings may not be attained. For dual fuel engines,use the natural gas ratings for both the primary and secondary fuels. G4-132 (60REZG) 2/09 Alternator Specifications Specifications Alternator • NEMA MG1, IEEE, and ANSI standards compliance for Manufacturer Kohler temperature rise and motor starting. Type 4-Pole, Rotating-Field • Sustained short-circuit current of up to 300%of the rated Exciter type Brushless,Permanent- current for up t0 10 seconds. Magnet Leads:quantity,type • Sustained short-circuit current enabling downstream circuit 4P8,4S7 12,Reconnectable breakers to trip without collapsing the alternator field. 4Q10,4V9 4, 110-120/220-240 • Self-ventilated and dripproof construction. Voltage regulator Solid State,Volts/Hz Insulation: NEMA MG1 • Vacuum-impregnated windings with fungus-resistant epoxy Material Class H varnish for dependability and long life. Temperature rise 130°C,Standby Bearing:quantity,type 1,Sealed • Superior voltage waveform from a two-thirds pitch stator and Coupling Flexible Disc skewed rotor. Amortisseur windings Full • Fast-Response"" II brushless alternator with brushless Voltage regulation,no-load to full-load exciter for excellent load response. Permanent magnet(PM)alternator t2%Average 550 controller(with 0.5%drift due to temperature variation) 3-Phase Sensing,10.25% Unbalanced load capability 100%of Rated Standby Current One-step load acceptance 100%of Rating Peak motor starting kVA: (35%dip for voltages below) 480 V 4P8(12 lead) 210 480 V 4S7(12 lead) 270 240 V 4Q10(4 lead) 155 240 V 4V9(4 lead) 246 Application Data Engine Engine Electrical Engine Specifications Engine Electrical System Manufacturer General Motors Ignition system Electronic Engine:model,type Industrial Powertrain Battery charging alternator: Vortec 5.7 L,4-Cycle Ground (negative/positive) Negative Natural Aspiration Volts(DC) 12 Cylinder arrangement V-8 Ampere rating 70 Displacement,L(cu.in.) 5.7(350) Starter motor rated voltage(DC) 12 Bore and stroke,mm(in.) 101.6 x 88.4(4.00 x 3.48) Battery,recommended cold cranking Compression ratio 9.1:1 amps(CCA): Piston speed,m/min. (ft./min.) 318(1044) Main bearings: quantity,type 5,M400 Copper Lead Qty.,rating for-18°C(0°F) One,630 Rated rpm 1800 Battery voltage(DC) 12 Max.power at rated rpm,kW(HP) 78.3(105) Fuel Cylinder head material Cast Iron Piston type and material High Silicon Aluminum Fuel System Crankshaft material Nodular Iron Fuel type LP Gas or Valve(exhaust)material Forged Steel Natural Gas Governor type Electronic Fuel supply line inlet 1 NPTF Frequency regulation,no-load to full-load Isochronous Natural gas/LPG fuel supply pressure, Frequency regulation,steady state t0.5% measured at the generator set fuel inlet Frequency Field-Convertible downstream of any fuel system Air cleaner type,all models Dry equipment accessories,kPa(in.H2O) 1.74-2.74(7-11) Exhaust Fuel Composition Limits* Nat.Gas LP Gas Exhaust System Methane,%by volume 90 min. — Ethane,%by volume 4.0 max. — Exhaust manifold type Dry Propane,%by volume 1.0 max. 85 min. Exhaust flow at rated kW,m3/min.(cfm) 16.4(580) Propene,%by volume 0.1 max. 5.0 max. Exhaust temperature at rated kW,dry C4 and higher,%by volume 0.3 max. 2.5 max. exhaust, 'C( F) 649(1200) Sulfur,ppm mass 25 max. Maximum allowable back pressure, Lower heating value, kPa(in.Hg) 10.2(3.0) kJ/m3(Btu/ft3),min. 26.6(890) 67.5(2260) Exhaust outlet size at engine hookup, mm(in.) 76(3.0)OD * Fuels with other compositions may be acceptable. If your fuel is outside the listed specifications,contact your local distributor for further analysis and advice. G4-132 (60REZG) 2/09 Application Data Lubrication Fuel Consumption§ Lubricating System Natural Gas,m3/hr.(cfh)at%load Standby Rating Type Full Pressure 100% 22.4.(790) Oil pan capacity,L(qt.) 4.7(5.0) 75% 19.4(685) Oil pan capacity with filter,L(qt.) 6.2(6.5) 50% 14.7(520) Oil filter:quantity,type 1,Cartridge 25% 9.9(350) Cooling LP Gas,m3/hr.(cfh)at%load Standby Rating 100% 9.3(330) Radiator System 75% 7.1 (250) Ambient temperature, °C(°F)* 50(122) 50% 5.4(190) Engine jacket water capacity,L(gal.) 6.8(1.8) 25% 3.8(135) Radiator system capacity,including § Fuel consumption is based on 1015 Btu/standard cu.ft.natural gas. engine,L(gal.) 20.8(5.5) Engine jacket water flow, Lpm(gpm) 117.3(31) LP vapor conversion factors: Heat rejected to cooling water at rated 8.58 ft,3=1 Ib. kW,dry exhaust,kW(Btu/min.) 54.8(3120) 0.535 m3=1 kg. Water pump type Centrifugal 36.39 ft.3=1 gal. Fan diameter,including blades,mm(in.) 533(21) Fan,kWm(HP) 4.5(6.0) Max.restriction of cooling air,intake and Controllers discharge side of radiator,kPa(in.H20) 0.125(0.5) * Enclosure with enclosed silencer reduces ambient temperature ——i capability by 5°C(9°F). I g ��— Ilr �;fJd Operation Requirements Air Requirements Radiator-cooled cooling air, Decision-Maker 550 Controller m3/min. (scfm)= 170(6000) Audiovisual annunciation with NFPA 110 Level 1 capability. Combustion air,m3/min.(cfm) 5.2(185) Programmable microprocessor logic and digital display features. Heat rejected to ambient air: Alternator safeguard circuit protection. Engine, t (Btu/min.) 30.9(1760) 12-or 24-volt engine electrical system capability. Alternator,kW(Btu/min.) 7.7(440) Remote start,remote annunciation,and remote communication options. Refer to G6-46 for additional controller features and accessories. Air density=1.20 kg/m3(0.075 Ibm/ft3) L�O 0- Decision-Maker" —Decision-Maker°3+,16-Light Controller Audiovisual annunciation with NFPA 110 Level 1 capability. Microprocessor logic,AC meters,and engine gauge features. 12-or 24-volt engine electrical system capability. Remote start,prime power,and remote annunciation options. Refer to G6-30 for additional controller features and accessories. G4-132 (60REZG) 2/09 KOHLER CO.,Kohler,Wisconsin 53044 USA Kohler Power Systems Phone 920-565-3381,Fax 920-459-1646 Asia Pacific Headquarters For the nearest sales and service outlet in the 7 Jurong Pier Road US and Canada,phone 1-800-544-2444 Singapore 619159 KohlerPower.com Phone(65)6264-6422,Fax(65)6264-6455 Additional Standard Features Miscellaneous • Alternator Protection(standard with 550 controller) ❑ Air Cleaner Restrictor Indicator • Battery Rack and Cables ❑ Engine Fluids(oil and coolant)Added • Electronic, Isochronous Governor ❑ Rated Power Factor Testing • Gas Fuel System(includes fuel mixer,secondary gas regulator, ❑ Rodent Guards gas solenoid valve,and flexible fuel line between the engine and the skid-mounted fuel system components) Literature • Integral Vibration Isolation ❑ General Maintenance • Local Emergency Stop ❑ NFPA 110 ❑ • Oil Drain Extension Overhaul Production • Operation and Installation Literature Warranty Available Options ❑ 2-Year Basic Approvals and Listings ❑ 2-Year Prime ❑ CSA Approval ❑ 5-Year Basic ❑ UL2200 Listing L) 5-Year Comprehensive Enclosed Unit cl Other Options ❑ Sound Enclosure(with enclosed critical silencer) ❑ Weather Enclosure(with enclosed critical silencer) ❑ Open Unit ❑ ❑ Exhaust Silencer,Critical (kits: PA-324468,PA-352663) ❑ ❑ Flexible Exhaust Connector,Stainless Steel ❑ Fuel System 71 ❑ Flexible Fuel Line (required when the generator set skid is spring mounted) ❑ Gas Filter ❑ Secondary Gas Solenoid Valve Controller(550 and 16-Light) ❑ Common Failure Relay ❑ Communication Products and PC Software(550 controller only) ❑ Customer Connection ❑ Dry Contact(isolated alarm) ❑ Engine Prealarm Sender Dimensions and Weights ❑ Remote Annunciator Panel Overall Size,L x W x H,mm(in.): ❑ Remote Audiovisual Alarm Panel 4P8/4V9: Wide Skid 2200 x 1040 x 1172(86.6 x 40.9 x 46.1) ❑ Remote Emergency Stop Narrow Skid 2200 x 865 x 1172(86.6 x 34.0 x 46.1) 4S7/4C 10: Wide Skid 2200 x 1040 x 1211 (86.6 x 40.9 x 47.7) ❑ Remote Mounting Cable Narrow Skid 2200 x 865 x 1211 (86.6 x 34.0 x 47.7) ❑ Run Relay Weight(radiator model),wet,kg(lb.): 4P8/4V9: 755(1665) Cooling System 4S7/4010: 813(1793) ❑ Block Heater [recommended for ambient temperatures below 10°C(50°F)] Electrical System F1 Alternator Strip Heater H ❑ Battery ❑ Battery Charger,Equalize/Float Type ❑ Battery Heater 0 ❑ Line Circuit Breaker(NEMA1 enclosure) ❑ Line Circuit Breaker with Shunt Trip(NEMAi enclosure) NOTE:This rawing is provided for reference only and should not be used for planning ❑ Safeguard Breaker(available with 16-light controller) installation. Contact your local distributor for more detailed information. DISTRIBUTED BY: ©2009 by Kohler Co. All rights reserved. G4-132 (60REZG) 2/09 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration; 160883 Exp�rattnn 9f8/2010 Trg 274419 Type: DBA - DANIELS ELECTRIC LLC STEPHEN DANIELS - ,s 109 SCHOOL ST 3l�I�TE e GROVELAND,MA 01834 Administrator COMMONWEALTH OF MASSACHUSETTS � i REGISTEREDOF MASTER ELECTRICIAN ISSUES THIS LICENSE TO • I DANIELS ELECTRIC COMPANY LLC STEPHEN J DANIELS 109 SCHOOL STREET ' SUITE APT 1 .GROVELAND MA 01834-162 j 16467 A 0 7/31/10 294344 I COMMONWEALTH OF MASSACHUSETTS • • • ..• ® y OF ELECTRICIANS ?!( AS A REG JOURNEYMAN ELECTRICIAN 33 ISSUES THIS LICENSE TO i STEPHEN J DANIELS Q' 2I 109 SCHOOL STREET :SUITE APT 1 GROVELAND MA 01834-1628� 1i . 2,8346 E 07/31/10302526 ,i •-.••• •- ..� v.r , rwrr rvi.u.wuuu 11YJ 7IGJCIL/jz IC I U 'J(b,3(W46k! P.1 ACORN® ���tF� ®ATE( IDINYYYY) - CATS E LIABILITY INSURANCE 8/21/2009 PROMMR (9761372-5921 rAZ: (5741)521-0242 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IEaTt7 d 1ffir;I rowe Agency, znC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 293 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND,'EXTEND OR ALTER THE COVERAGE AFFORDED ST THE POLICIES BELOW. E2�>i weLand'I XL 01334 INSURERS AFFORDING COVERAGE NAIL� INSURED INSURER A:ftt:LEOP 9l Griang'e matual Ing. 14788 DA=ELS ZL==ZC compmr MC INSURER B:RkxS/Marketing 8a Placing 105 SCHOOL STR=T INSURER C: —� INSURER D. LREMM INSURERS: C:oVERAGES... .. 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, lNgR POLICY PALE Y EXPI TION PdILIGY NUP�ER _. .. . . ..LITS GENERAL LIABILITY EACH OCCURRENCE S _ 1,000,000 X COMMERCIAL GENERALLIOLETY P�EEbdLSES r S 5001000 CLAIMS MADE ®OCCUR OFTS709 7f 25f 2009 712512020 MED EXP one ) 6 10�00.0 PERSONAL&ADV NJURY 9_..___X,000,000 GENERAL AGGREGATE S � 000 000- GIRI'LAGGREGATEIiMTAPPLESPER, PRO0UeTS-CDMPIOPAGO S __21 Q,®0 000 Z POxY PRO LDC AUT BELE UA04-ITY COMBINED SINGLE LIMIT ANY AUTO (Ea 80601m) $ ALL OWED AUTOS BODILY WMRY SCHEDULED AUTOS (Pet Rsteon) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Pot e�lAolfi) S PROPERTY DAMAGE 6 (Pm eetldW0 GARAGE LIABILITY AUTO ONLY•EA ACCIDENT 9 AITY AUTO EA ACC S EOTHER THAN AUTOONLY: AGO S EXCESS I LIABILITY EACH OCCURRENCE S OCCUR FICLAIMS MADE AGGREGATE DEO'iJCT18l£ S �' RETENTION L S WORKERS COMPENSATION ATT!• OTk- ANSA SIVLOYERS'LIABILITY y.f N ANY 'METOWPARTNSR(E=UTM= �E.L.EACH ACCIDENT S 500,000 OFFICE MBER EXCLUDED? - (MMeft�n mfitm►ry ®0720305- 604 5112.12009 5/11/2010 E.L.DISEASE•EA EMP LAYE S 5001000 SaEGaeser visiONSbataw E.E.1 00,000 OTHER , Y E08CMI'TION OF C6'FM71ONS I LOCATM6I VW CLES!M=USIONFo ADDED BY 9ftD0RSSM2NTlSPFClALPROMtM8 CERTIFICATE HOLDER CANCELLATION . .. ..-„ ::,.�:. .... :tea::. ....,.wx�.: ,rF%s z.., ,.. .,...:...:,. ..+,, ....:. .,-Es. s._.,..... ,•;:F.,a.-�. _. .:,: SHOULD tAY4AF THE ABSbFIE®ESCRIEEO�Ld OECAidCELLF.O ES£FORE THE E`sTIPIRATEpN OA'M THEREOF.THE ISSUING INSURER ALL ENDEAVOR TO tWL 10DAYS bYRtTTEN NOTICE TO THE CERMRCATE HOLDER WAM TO THE LEM,OUT FAILURE TO DO 80 SHALL IMPOSE b 0 N OR LIABILITY OF ANY IOND UPON THE INSURER,ITS AGENTS OR REP TA AUTM D SEPoTATHlE ACORO 25(2009101) ` 019864000 AOORD ORATION. AK fights reaer ved. INS02E t2i t) The ACOPD 19me and logo eea mgI%tmd marks®t ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, ALL-02111 www.mass.gov/dia, Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): :DaA � � C Address: log sc—ILGzA City/State/Zip: crILzACity/State/Zip:4�rPhone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.Main a employer with 4. ❑ I am a general contractor and 1 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.$ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions required.] officers have exercised their 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' 13.❑ Other comp. insurance required.] An- putout u.a,checks box 9. ....=also..Il out the section below showing their workers'Compensation policy information. - t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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 Self4ns.Lic.#: 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 ce un the pains and penalties of perjury that the information provided above is true and correct Sip-nature: Date: Phone#: 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' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may 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 Iicense 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 'yeat. 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 bum 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 l3artmen f ep t o Industrial Accidents: Office of Investigations 600 Washington.Street Boston?MA 0.2111 Tel. € 617-7274900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mas.s.gov/cha v4ORTH ONM Of Andover 0 No. cP- 0 - LCA.Kr over, Mass., COC H 11 ".C. 00ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System xx BUILDING INSPECTOR THIS CERTIFIES THAT............... S61 Foundation has permission to erect........................................ buildings on .';?...1:2P........................... to be occupied as..................... 0...... ;;............................... ........... Rough 'a(70, Chimney provided that the person accepting this permit shall in every res**p'*e*'c*t*"c**o*'n*'fo"r�l�i� ihWi�e'rms of the ap plication on file** 1n � Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction 0 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 CONSTRUCTION STARTS Rough 4 ""eo BUILDING00� ............... .................................. ....... Service ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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