Loading...
HomeMy WebLinkAboutBuilding Permit #388-13 - 21 SAWYER ROAD 11/8/2012 TOWN OF NORTH ANDOVER Dpi APPLICATION FOR PLAN EXAMINATION Permit NO: 0 U Date Received Date Issued; lar - IMPORTANT: A licant must complete all items on this page LOCATION �• �"'J"t fit' Q,�D Print PROPERTY OWNER �'1tZ;1�e<lr1 LAe/V \,q Print 100 Year Old Structure yes no MAP NO: 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 ';Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: RCnt3.; ��tE ��Mc�v►✓1 Identification Please Type or Print Clearly) OWNER: Name: -1�ub�M �rAe,^J Phone: Address: SAW 'Rc CONTRACTOR Name: A3L,. Phone: c(-I?) NA G(of(o Address: SPU Apy, %�5 L Supervisor's Construction License: `SIV\Q Exp. Date: (IV lZ, Home Improvement License: Vii ��a' Exp. Date: 1) {'L ARCHITECT/ENGINEER tJ 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: $ 5 a���� FEE: $ 1} Check No.: ?32 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access7n7 fund Signature of Agent/Owner Signature of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan f Stamped Plans ❑ 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 i 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 t Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW'Tow; Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Departinent 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, roast or service drop requires approval of Electrical Inspector Yes No DARKER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use I I i ® Notified for pickup - Date Doc.Building Permit Revised 2010 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 Doe: Doc.Building Permit Revised 2012 ' r' Location .;2.1 No. Date • ' TOWN OF NORTH ANDOVER • ��ft:C1,ID rC4� ♦ . Certificate of Occupancy $ a � k Building/Frame Permit Fee $ 60—' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# _712 , 25932 Building' Inspector Enter construction cost for fee cal - North Andover Fee Calcination Construction Cost $ 5'5,000.00 m $ - $ 60.00 Plumbing Fee $ 7.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 7.50 Total fees collected $ 175.00 21 Sawyer Road 388-13 on 11/8/2012 Renovate bathroom I � 1 _ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 ]*Tome Improvement Contractor Registration Registration: 137552 U Type: Private Corporatlon Expiration: 11/26/2012 Tr# 205622 NORTH ANDOVER BUILDING CORP r ° t A JOHN LEEMAN .,. : ,, - - ----- --- ��.�� ---- 4; P.O. BOX 132 N. ANDOVER, MA 01845 �- ---- - _. = Update Address and return card.Mark reason for change. DPS-CAI c'y 50M•04/04-G101216 E] Address [_] Renewal Ej Employment (] Lost Card Massachusetts Rome Improvement Samplep Contract This form satisfies all basic requirements of the slate's Home Improvement Contractor Law(MGL chapter 142A),but does not includes zlg home improvements should first obtain a copy of"A tandard language to protect homeowners. Seek legal advice if necessary. Any person plamli Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3157 or on our website. HOMeowner Information Coniractor hforlmbation Name Company Name (�w.(y �j A Street Address(do not use aPost Office Box address) Contracto/Salesperson/OwnerName City/Town State Zip Code Bpsiness Address(must include et address) �. PW�axr �� 0.i NS' --7 P11 lav Cr Daytime Phone Evening Phone City/Town State Zip Code Mailing Address(It different from above) Business Phone Federal Employer M or S.S.Number Law requires that most home HomeImprovementconhactorReg:Number Expiration date • improvement contractors have a valid registration number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,useadditional sheets if necessary.) 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 contractor's control arise (Owners who secure their own permits will be excluded from.the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price 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: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / ox upon completion of $--_ by I I or upon completion of $ � 0 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both . p patty's satisfaction) • The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(-'s°) $ to be paid for NOTES:(*)Including all finance charges('1°°i°)Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-js an M 11!CsS W1rl airy beiritr DrOyidrrl by bhn ContC LCfor jo Subcontractors The contractor agrees to be solely responsible for completiioon of tNQ he work described regardless of the actions yes.6ill terms Rof mythirdontractl party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this a Bement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document, contfact shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices the carefully before signing this contract. o Don`t be pressured into signing the contract.Tahoe time to read and fully understand it. Ask questions if something is unclear., Make sure the contractor has a valid Home Tm rovement Contractor Registration. The Iaw requires most home improvement contractors and subcontractors to be registered With the Director ofHome Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 ParkPlaza,Room 5170,Boston,MA.02116 or by calling 617-973-8787 or 888-283-3757. o Does the contractor have insurance? Aslc the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. o Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel 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 main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight ofthe third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT'SIG•N'II TS CONTRACT IF TBERE ARE ANY]BJL ri Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy slri�o�SPACESeptbytle H! Ilomeowne Signature Contractor's Si ature 'Date Date i Contractor Arbitration The Home Impiovement Contractor Law provides homeowners with the right to initiate an arbitration action(as an 'alternative to cont 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 with a 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 fn7m 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.. Homeowner`s Signature Contractor's Signature NOTICE:The signatures of the parties above apply only-to the agreement of the pities 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 (i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed 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 described,in a timely and worlamanlike manner. Homeowners may be entitled to other specific legal rights 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 theoriginal contract must be in writing and agreed to by both parties. Con-h--acted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission 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 him/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 feuds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiends from said account would require the signatures of both parties. Additional Wormation •If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Baston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at 1,W://wvryv.mass.gov/ocabr/ 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 Office of Constiumer Affairs and-Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the I-RC website at bM://www..nass.Pov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: . hit7)://db.state.ma.usli.omeimurovem ent/licenseelist.as p For assistance with informal mediation of disputes or to register formal complaints against a b mess, cal Consumer Complaint Section Office of the Attorney General 617-727-8400 „ AND/OR Better Business Bureau 508-652-4.800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 r y -Massachusetts-. Departirtcnt fit Public S:Ter, Buaid uf.E uildhtg, ttcrulatinns�and Stand.irds Construction Supervisor License License: CS 82815 Restricted to: 00 JOHN R LEEMAN JR - 70 PILLON ROAD 4 MICrON, MA 02188 Expiration: 5/18!201:2 Tr#: 27393 (l,uunis�iunci. . CEATIFICATE OF LtABILI.TY IN'S URANC;E — — —— — — _e.�.�_ _ ' 1'IIIf! u4JRTIpIL'ACfE IJ IutiVED AO A t1pTTCR OY TNCORIIATION ONf.Y ACID CON!'ERG NO RIGHTa UPON TIH; CL"RTICIClITO HOLDli TNIII M11i ICA'1C DOES HOT AFFIRMATIVELY OR NROATIMY AMEND, [SXTISND OR ALTER THE COVCRAOE AFFORDED BY TIIE POLICIES BELOW. THIS CCRTIFICATC OF INr,URANCE DOEM NOT CONSTITUTR A CONTRACT RVTWFCN THE X5JUVIN4 INSURER(S), AUTHORISED REPRIMENTATIVE OR PRODVCER, AND THE CERTIFICATE HOLDER, IIfPONTANTt I! the certificate holder is an ADDITIONAL INSURED, the policy(Aas) must be endorsod, I! OUDROOATION IS WAIYVD,susubjept 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 endoreemont(s), MTM Insurance AssOCiates LLCrAi- 575 Chickering Road P•Nt)'•i — (A/C_He), North Andover, MA 01865 ADDRNIII _ `i•anpufra CUSIM I [DK. North Andover Building Corp 1wlin:A At A.I.M, Mutual Insurance Co 70 Pillon Road IHNURl:K Ht /HIURCR Co Milton, MA 02186 HIKUPYK Dt INSUNER C, ' COVERAGES CERTIFICATE NUMBM REVISION NULBERI TlitR`as TO cORRrIf�TlIAT%rN�"`F��'icioe O�INISVIIABEi--LIS�i�HAV�ltiE1��AVlL�-TO TNS IlTftillrp M/R'AGO A60V6 FOR 'i'i11�F0�,ICY l�RI00 SNOSCII'T'CD. NOTWITNNTANDINO ANY RNQV21DZMT, TORN 03 CONDITION OF ANY CONTRACT OR OTNOR DOCUNONT WITH RESPECT TO WHICH THIS CERTIFICATE MAY f1E INNURD OR MAY PERTAIN, TNR INSURANCE AFFOADOD EY THS! POLICIOS DENCRI50D HEREIN IN SUBJECT TD ALL THE TOMS, EXCLUSIONS AND CONDITIONS OF MVCH POLICIES. L73ITS SHOWN 14AY 11AVE BEER REDUCED SY PAID CLAniv, inrPOLICY NUMER POLICY OFF POLICY RXP LIIdITS TYPO OF INSURANCE v+nPoeMYYvI tm,nrKmm't dehcitAt P,ACN DCCUKANCa ❑<[M1Nar IAL 4M)AL LIABILITY \ UAItAOL t0 MtIN}gyp�J`— —•—`--'�'�•�—" CN{711 XCK IN a•q-01 t..".) ❑❑fLAtltl ig61 C3 67M' MCD KKV (Any Dne Perpnn) 1 ❑ -aNNKDNAL F ADV{WUpY aHN'1.AIMPEIIATH LIMIT AI'CLIND N).t I:RNNpN,AUDRKHATC 1 ❑P7LIrY ❑ppr�Ip CT ❑LSO wicluvTI- CrUtF/ar AUN CUID tpCD E1HULl:Llnit•��-�_ ❑ANY AUTO leo-ec00-0 ❑ALL«yNND AUT! UtlDSLY INJURY (per penin) 1 111+:II9DUI,90 AUYm DUDi LY winlY(pet ea!tdtvdl 1 ❑HIatlD AUt�C 4'IIIIpiNFT bN1A!iK-'•' (Uer atrtdn 1 ...� aet•LA GIAP � Un —'-.""•_____. _ —�_..,�,�..,— __.___.r_�____. ..1'.AfN vCC11RRPNCK 711% h11i LtAN ❑ CLAIMS MAUN ANNRCDAIN ; DNWTIDLC / ❑I+NTx HT1 oN t - - - yW. "'�`��""�• WONXORS COt�OMs)1TICN V •�t•I�pp------ Nnl_ AND QALOYEES LIABILITY - MKf L1NtH 1�K THE PR?+PRIMNN R/PARTIIERS/ __._. ----- EXECUTIVE ON'PICKRN ARC K.1.. NAv"ACCIDNXT W 1 100,000_ A _.__----- [� 1tIC]. Q ex+ 1 7023267012010 P,.L. DrxraxA -Pm•IfY LmtT 1 500,000 11/11/2010 11/11/2011 P,.L. 0M.A11C -NA CI91.011KN a 100,000 CERTIFICATE HOLDER CANCELLATION -y SHOULD ANY OP THE ABOVE DNSCRINOD POLICIEN an cAxczLL00 DOFORE TNN O%PIRATIQN DATE THtstor, NOTION WILL 58 MIMED IN ACC'OPOANCO WITH TNI POLICY PROVISIONS. AU1NUXl yLO RCpNKAC.NYAtIVK ,�--- - 2011-10.2514:51 OTF Fax Machine 10 - Page 3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT. 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: '�,\ Sciw�j P(- YEA City/State/Zip: k) . 4.,JW)\g_(' �Acl. Phone#: Ct1* �b bll C1(44 Are you-An employer?Check the appropriate box: Type of project(required): P� 1. am a employer with (6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# 7• emodeling 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.❑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.]i employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 1 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: A M 1'1y1Va_-, Policy#or Self-ins.Lic.#: '1013 Ay"l b0tUkExpiration Date: I( 11l t2 Job Site Address:_ 510 4,LC aA City/State/Zip: G� . /�'�' K4,,,J- 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 cert' er the pains and s of perjury that the information provided above is true and correct. Signature: Date: It Phone okutu Official ctse only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.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 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 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. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia � NORTy Town o 1E 1, sAndover No. Y h ver, Mass, O/� LAKE COC"CNIWICK V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT . C c� ��y .......:..................................................................................................L............... BUILDING INSPECTOR has permission to erect .......................... buildings on . / S�u'` �/ Foundation Rough to be occupied as .............:........... :':�o �' C-:.....! fl?: .... .... . ...................................... .. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Final Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS FRough ................... .... .. . . /+� ...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner ` I Street No. SEE REVERSE SIDE Smoke Det.