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HomeMy WebLinkAboutBuilding Permit #812 - 220 SUTTON STREET 6/15/2010Permit NO: F/2 - Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION - TrD 0St�.lD 16�"t °: a 1 pDRAT Pdn# PROPERTY OWNER OtAt-,ACe S Print MAP 210 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 DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: '1.o c _ Phone: Address: CONTRACTOR Name: UrA.fl.5 Phone: Address:. ,00 Supervisor's. Construction License: t'?CL Exp. Date: /0111 Home Improvement License. Exp. Date: ARCHITECT/ENGINEER M �GAs,&- tf 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: $ 57�10/ 00® FEE: $� D Check No.: 7-.37 Receipt No.: NOTE: Persons contracting with unre istered contractors do not have access to the guaranty f d 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 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 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 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 Doc: Building Permit Revised 2008 Location e9�20 Su#o oy S1 No. / Date b NORTIy TOWN OF NORTH ANDOVER i • * , , Certificate of Occupancy $ �►�Ss�C NUs Eta Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f Check # 2326, wilding Inspector e OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL ARCHITECT'S AFFIDAVIT PROJECT NUMBER: PROJECT TITLE: NAME OF BUILDING: PROJECT LOCATION: BEST CLEANERS 220 SUTTON STREET, NORTH ANDOVER, MA NATURE OF PROJECT: COMPLETE BUILD—OUT OF NEW RETAIL SPACE IN ACCORDANCE WITH ARTICLE 16 OF THE MASSACHUSETTS STATE BUILDING CODE I, DAVID B. BARSKY, REGISTRATION NUMBER 10079 BEING REGISTERED PROFESSIONAL ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED A PLAN OF THE EXISTING SPACE AS BUILT. FOR: THE ENTIRE PROJECT FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH PLAN(S), COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER THYAT I HAVE INSPECTED THE ABOVE NAMED PREN HAVE DETERMINED THAT THE WORK HAS BEEN DONE IN ACCO WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMT. PURSUANT TO SECTION 116.2.2 1 HAVE SUBMITTED A DRAWING INDICATES THE COMPLETED CONSTRUCTION SATISFACTORILY COMPLETED AND READY FOR OCCUPANCY. BSCRIBED AN SW N BEFORE ME THIS �_ DAY OF 2010 lvk� �SSs MY COMISSION EXPIRES N ARY PUBLIC Date.. �71-�-11 0. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that tll? .... ............ has permission to perform ... .' . .......... plumbing in the buildings of . .3 ....... at. ...... ...North Andover, Mass. Fee.//? ..... Lic. No.. .. .... ........ PLUMBING INSPIACT04 Check # 8350 r v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, Building 31— Owners Amount New Renovation ❑ Replacement ® Plans Submitted Yes ® No rarvmrrnZ+c+ r^ (Print or type) Installing Company Name Address Cec one: Certificate Corp. _ Partner. 9 - n Firm/Co. Name of.Licensed Plumber: Insurance Coverage: Indito a of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the unde igned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent F I hereby certify that all of the details and information I havepb or a ed) in above ca true and accurate to the best of my knowledge and that all plumbing work and installations un r P t Iss this application will be in compliance with all pertinent provisions of the Massachdsetts S . g d C e o 42 of the General Laws. —.7. Title City/Town APPROVED (OFFICE USE ONLY TyZf Plumbing Libeuse`� cense Nuawer Master Journeyman n i a Now ON mmm IMNNNIMNMIIMwNIMIMNIMMINNNIMMIMINNNMI zoom MUNSON WOMM ..i •i' ..............MINIM......No I • / I IMIMNNIMNIMIMIMNIMIMNNNNMI Now No I.11'IMNN0NN.IMIMNNNNNMIIMNIMIMNIMN=No 0 IMEMNMIIMMINMI NONMIIMMIMIIMNNIMMIN (Print or type) Installing Company Name Address Cec one: Certificate Corp. _ Partner. 9 - n Firm/Co. Name of.Licensed Plumber: Insurance Coverage: Indito a of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the unde igned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent F I hereby certify that all of the details and information I havepb or a ed) in above ca true and accurate to the best of my knowledge and that all plumbing work and installations un r P t Iss this application will be in compliance with all pertinent provisions of the Massachdsetts S . g d C e o 42 of the General Laws. —.7. Title City/Town APPROVED (OFFICE USE ONLY TyZf Plumbing Libeuse`� cense Nuawer Master Journeyman n Date. 7- . �/ % .......... ~O TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION �'SACHUsc� . This certifies that .. .......... (?.. .... ....... . has permission for, gas installation . U 5 7. D.n.%X�. in the buildings of ................... at 2. p... �' � .� ��--.... �� ....... , North Andover, Mass. c Fee. Lic. No..�?�. f .. �i.�. ........ GAS INSPECT Check # (7 7280 MASSACHUSETTS UNIFORM APPLICATON FOR PERMUT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS (� Building Locations d J Owner's Name New Renovation Replacement ❑ Date Plans Submitted 11 Permit # Amount $ A (Print of Name— Address ame_ Address Name of Licensed Plumber or Gas Fitter e one: Certificate Installing Company Corp. Partner. ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No O If you have checked +Les, pl ase indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0- I hereby certify that all of the details and information I have submitted best of my knowledge and that all plumbing work and installations erfi compliance with all pertinent provisions of the Massachusetts S to Gas By. Title City/Town IAYYKVVLI) (OFFICE USE ONLY) I Signatwe of Licensed ® Plumber as Fitter Master Journeyman Or Gas Fitter 16 and accurate to the heation will be in Laws. � w a U H z z �- w d x o o a a w Q H z ¢ w w > w v x x w w a° �, o z w o w x o 3 0 4 > c° c MEN ENT U0 a° BASEMENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. F L 0 0 R - - &TH. F L 0 0 R (Print of Name— Address ame_ Address Name of Licensed Plumber or Gas Fitter e one: Certificate Installing Company Corp. Partner. ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No O If you have checked +Les, pl ase indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0- I hereby certify that all of the details and information I have submitted best of my knowledge and that all plumbing work and installations erfi compliance with all pertinent provisions of the Massachusetts S to Gas By. Title City/Town IAYYKVVLI) (OFFICE USE ONLY) I Signatwe of Licensed ® Plumber as Fitter Master Journeyman Or Gas Fitter 16 and accurate to the heation will be in Laws. rr .0 I The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other T homeowners who submit this affidavit indicating they are doing all work and then hire outside contractorsmusf submit amiormJftom 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. information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Are you an employer? Check the appropriate box: 1 • ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 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.] t employees. [No workers' comp. insurance required.] "-.ai' w.phcant that checks box i must also fill out the sectiey aelev�, shat ,-•+ =7 = Insurance Company Name: 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 pains andpenalties ofperjury that the information provided above is true and correct Si ature: Date.: Phone #: FFOfficial 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 #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other T homeowners who submit this affidavit indicating they are doing all work and then hire outside contractorsmusf submit amiormJftom 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. information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Are you an employer? Check the appropriate box: 1 • ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 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.] t employees. [No workers' comp. insurance required.] "-.ai' w.phcant that checks box i must also fill out the sectiey aelev�, shat ,-•+ =7 = Insurance Company Name: 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 pains andpenalties ofperjury that the information provided above is true and correct Si ature: Date.: Phone #: FFOfficial 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 ant d 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 pe=rson 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 apartnxents 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 notbecause 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 pert or hcense :s being nq'u--st:d, not the Department. of Industrial Accidents. Should you have any questions regard""ag 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 bum leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would like to_thapk 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 Of Bee of Investigations 600 Washington Street Boston, MA 0:2111 Tel. # 617-727-49.00 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax it 617-727-7749 www.mass-gov/dia t E NORTH O 9 +,r.o ••�"15 4 ,SSACMUSE� This certifies that Date. .7j%Y U... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING r.....A. t' .......... has permission to perform .............. plumbing in the buildings of ..�!°'' ° .. 1"./.�? N :........... at. ............ North Andover, Mass. Fee 300 '7 .. Lic. NoA/ A(! ... .... .... t PLUMBIN6 INSPECTOR Check # S /) 1 11 8351 N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, Building Location New Renovation Replacement tate ]Permit # Plans Submitted Yes ® No Name of.Licensed Plumber: Insurance Coverage: Indicate the type-ck6surance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature 7. Owner Agent E I hereby certify that all of the details and information I have submitt entered) in above i ti true and accurate to the best ofmyknowledge and that all plumbing work and install a . s pe rf un P _ Issu s application will be in compliance with all pertinent provisions of the Massachus State P g C Cha er _ of the General Laws. ,.,,. Title City/Town APPROVED (OFFICE USE ONLY Ti; ofPlum�bing License ice ei e� r — Master Journeyman 1 The Commonwerclth of Massachusetts Department o f .lrradas j7 ia1Accidents Office of J-nVeSdgQtions 600 Washingion Street Boston, 1L4 02111 www-massgovidia Workers' Compensation insurance -Affidavit: Builders/Contractors { lectriciaas/Plumbers An iicant Information Please Print Leaibl, Name (Business/Organization/Individual): Address: City/State/Zip:_ Phone #: Are you an employer? Check the appropriate boa: I • ❑ I am a empIoyer with __ 4. ❑ I am a Several contractor 2. ❑employees (full and/or part-time).* - I am a sole and I have hired the sub -contractors proprietor or partner_ slip and have no employees listed on the attached sheet. I working for me in any capacity. These sub—contractors have workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its . ❑required.] I am a homeowner doing cork officers have exercised their all m set£ Y [No workers' comp. right of ex emption per MGL C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp• insurance r Type of project (required): 6. ❑ Neuf construction 7. ❑ Remodeling 8• ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs I3.❑ Other :A-" a* n?ica ± that checL, box.. , ,_gE also Lien c•.t t e sw a ee on.' y egLilred.] £iomeown= who submit this affidavit indicating th , are ao , Wg :^ weri: s' comY. ration t ,��;- � j Y" J �Contmctors that check � box n;,; -�t a -�_� __ , e1 - •••g "1• -,Mr `and then hire outside cont<zctors -4nst Submit a new amu. a„ additional sheet showinP the affidavit indi sting such. same of the sub -contractors and their work' LLM UR er walsproviding workers' compensation information, insurance for my employees- Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy -of the workers' compensation policy declaration Pape (show Failure to secure coverage as re the policy number.and expiration date) - Failure gutted under Section 25A ofMGL 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. T l_ 1 ao nereoy ceruJy under the pains and penalties of perjury th¢t the information. provided above is true and correct Siffiaturc- - Date:. _ .... . Phone #: Flssuinnu only. Do not write in this area, to be completed bi: cit), or town ofliciaL Town:1 ermitUcense # use (circle one): 1. Board of Health 2. Building Department 3. City/To 6. Other wn Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone'#: Information an d 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, txpress or implied, oral or written." An employer is defined as "an individual, partnership, associattion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including tie Iegal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association og other legal entity, employing employees. However the owner of a dwelling house having not more than three apartnz ents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainte-afire, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be: cause 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 c--anstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coimpliance 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 um-t:il 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 bores that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) and phone number(s) along with their certificates) 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 workars' comp enation 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 stire to sign and date the affidavit The affidavit should a _ ' • _ r__ . :ng q ies�.eu,' n Qt t^ be mtumeu to the city o: tovi'it that the ai.s lz* adore tilt the )erm ait'Qr IrCe�e� LC %e' ra ' —DepaTL^ a tt oI Industrial Accidents. Should you have anv eniestions regardtzg the lave ui rf you �e rqLLrred to obtaln S 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 Iegibly, 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 permittlicense 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 stampe=d 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 velure (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 Irke to than you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Deparanent'.s address, telephone.and,fag.number.__.. The Co=onw=da of Massar,,,husetts. Deparbnent of Fndugti.ad Accidents Office of Inresitaat ons 600 Wasbinataxn Street Boston, MA 02111 Tel # 617-727-4900 ext 406 or 1-9 77 -Iv- kS.SAFE Revised 5-26-05' Fw: # 6.17-727-7749 vmm,-mass._ a'ov/dla Date .. �... �f �....... . V . ryO o? �` TOWN OF NORTH ANDOVER F p • PERMIT FOR GAS INSTALLATION • > 'a 4y < Sh l SA HU - r "y This certifies that .....c,� �..f. . . has permission for, gas installation in the buildings of . ! !? t ................................. at ............ North Andover, Mass. Fee.. Lic. No..- -�-- GAS INSPECTOR Check # W) / 7281 c i S MASSACHUSETTS UNIFORM APPUCATON FORPERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSS� Building Locations Owner's Name New Renovation ❑ Replacement Permit # ? Z Amount $ 3 LCAn/d Q/VI N Plans Submitted 1-1 (Print or type) Name V A Address Name of Licensed Plumber or Gas Fitter k one: Certificate Installing Company Corp. Partner. ® Firm/Co. uL G INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No[3 If you have checked Yes, please indicate a coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond E Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 ••—•---.7 —�. •..� ...�� »..... uav ....w.uo aiau ul1 vimat1V11111aVG J best of my knowledge and that all plumbing work and installa compliance with all pertinent provisions of the Massachusetts By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber A,,,17jas Fitter Zi'c Master Journeyman in ;b�oveplTaaqptrue and accurate to the �Pued r s application will be in terms -l2 General Laws. Or Gas c � U w a W W W O FVj " Fr Ga m m U w w W) Z �" �a Z 0 Z a °" p O a F z > W F d tW- Q z '� x w a w w w H x x x w o CJ a x � 3 o °c w a o x ;1 0 .a a > o o SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. •FLOOR A (Print or type) Name V A Address Name of Licensed Plumber or Gas Fitter k one: Certificate Installing Company Corp. Partner. ® Firm/Co. uL G INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No[3 If you have checked Yes, please indicate a coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond E Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 ••—•---.7 —�. •..� ...�� »..... uav ....w.uo aiau ul1 vimat1V11111aVG J best of my knowledge and that all plumbing work and installa compliance with all pertinent provisions of the Massachusetts By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber A,,,17jas Fitter Zi'c Master Journeyman in ;b�oveplTaaqptrue and accurate to the �Pued r s application will be in terms -l2 General Laws. Or Gas '44 The Commonwealth of Massachusetts Department of industrial Accidents Office of investigations ..600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Le�bly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors !. ❑ I am a sole proprietor or partner- listed on the attached sheet I 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 itc 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [ Remodeling 8. Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other �- rr -- ­ - -: u,w:. z:ao auJ out me section aeiox• suoq irb sffi.; we :e:s' cDMPM ation policy inform a 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 -contactors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is the poligp and job site information. Insurance Company Name: Policy # or Self -ins. 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Simatwe: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): Permit/License # L 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 pe=rson in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states 'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone 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 retuned to the city or town that the application for the peramt 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 woricers' 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 pmmit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 pernmits 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 bum leaves etc.) said person is NOT required to complete this affidavit. Time 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 WashiFmgton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 v mrw mass.. aov/cha 947 Date..... `..�v... t HOR71, 1 3?°•_t``° �'� "�O� TOWN OF NORTH ANDOVER PERMIT FOR WIRING T This certifies that ................................................... ........................ has permission to perform .......� 1. C � �f ........................................................... wiring in the building of ...... it at ... �,�O....5.v�. ��'dr. �./...... , North Andover, Mass. .. ..................... . Fee ... .....�.....�.' Lie. N.'..&0.15.�}....................................../1�............ ELECTRICAL INSPECI'6R Check # �� Commonwealth of MassachusettsFoccupancy Official Use Only Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS nd Fee Checked tlravP }.1..1. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL X'ORMATION) Date: , - /Q City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Locati Sir on ( eet & Number) � ® U >l c vn S Owner or Tenant 4� y S� G t� v d>t� Owner's Address 2 on C'- Telephone No. Is this permit in conjunction with a building permit? yes No 0 (Check Appropriate Box) Purpose of Buildin g-- I L V� Utility Authorization No. Existing Service � Amps 1 /p /aovolts New Service Amps / Volts Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: of Recessed Luminaires of Luminaire Outlets No. of Luminaires of Receptacle Outlets No. of Switches No. of Ranges Overhead ❑ Undgrd,E No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Co )mpletion of the following table may be waived by rho rn—,.*,,. „r m: No. of Cel-Susp. (Paddle) Fs No. of Hot Tubs Ab Swimming Poold e ❑ No. of Oil Burners No. of Gas Burners No. of Air Coad, Tot Tac No. of Waste Disposers Cleat Pump Number Tons Totals: "- No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances j o.of Water I No. of No. of Heaters Signs Ballast No. Hydromassage Bathtubs No. of Motors Total l Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1-01 nor9 (When required by municipal policy Work to Start - = /c) Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE fff BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:, , �1�� 1 C- 2G0 LIC. NO.:. Licensee: ) te=b Signature ,-C'�'r2 (If applicable, enter "exempt " in the license nu ber line.) LIC. NO.. Address: r� �c�SC3c / 2 Bus. Tel. No.: 2 1,76QF• ?j� *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety"SLicense: AIL TelLic. No.: - IF � _ � s� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the IiabiIity insurance coveray Owner/Ag required gg ent law. By my signature below, I hereby waive this requirement. I am the (check one) [:]owner ❑ coverage normally agent. Signature Telephone No. PERMIT FEE: $ f Total sformers KVA rators KVA mergency g Units od.e ALARMS Nn. of 2^nes f Detection and itiatin Devices f Alerting Devices f Self-Cotained tion/Ale Devices Local ❑ Municipal El other Connection CW Security Systems:* No. of Devices or E dent uiv Data Wiring: s No. of Devices or Equivalent 3pTele communications Wiring: No. of Devices or E uivalent Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1-01 nor9 (When required by municipal policy Work to Start - = /c) Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE fff BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:, , �1�� 1 C- 2G0 LIC. NO.:. Licensee: ) te=b Signature ,-C'�'r2 (If applicable, enter "exempt " in the license nu ber line.) LIC. NO.. Address: r� �c�SC3c / 2 Bus. Tel. No.: 2 1,76QF• ?j� *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety"SLicense: AIL TelLic. No.: - IF � _ � s� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the IiabiIity insurance coveray Owner/Ag required gg ent law. By my signature below, I hereby waive this requirement. I am the (check one) [:]owner ❑ coverage normally agent. Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents v Office of£nvestte ations 600 R%ashington Street Boston, M.4 02111 www.massgov1&a Workers' Compensation Insurance Affidavit: Builders/Contractors/Elec Atrieians/Plumbers opiicant information PleasePrint Lev Name (Business/Orpmzafion/Individual): Addtess: City/State/Zip:_ Are you an employer? Check the appropriate boa: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet I These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § I (4), and we have no employees. [No workers' 1. LJI am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees worldng for me in any capacity. [No workers' Comp. insurance required.] ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t Phone #: comp, Insurance required.] wd,n, wmj;r�e�r +1,.+ Type of project (required): 6. ❑ New construction 7. ❑Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12 -[]Roof repairs 13. [1 Other • ...: •== . bo : r. MUS also 1M out ':CC cctim 1 Homeowners who submit this affidavit indicatingberv- do r -..swot :............. Lb i a . , at. wor'a and Then h- otnsi& eons^^to ; dust submit a new affidavit indicating such. +Coatractots that chec.'; his box must attached an additional sheet showing the name of the sub -con tractors and their workers' comp. policy information. I am an employer that is providing workers' contpenstttion insurance for my employees. Below, is the poficy and Job site information. Insurance Company Name: Policy # or Self -ins. 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). fine up to $1, Failure to $1,500.00 and/or one -500 coverage as required under Section 25A.ofMGL C. 152 can lead to the imposition of criminal penalties of a year imprisonment, as well as civil of up to $250.00 a day against the violator. Be advised that a c penalties In the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification.PY of sta^ment may be forwarded to the Office of I do hereby certify under the pains andpenalties offcrit-7y th4rr the information provided above is true and correct. Sisnaiure: Phone #: Dfficial use only. Do not write in this area, to be completed by city or town official Cita, or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. EiectricaI Inspector 5. Plumbing inspector 6. Other Contact Person: Phone #: Important: When filling out computer, use only the tab key to move your cursor - do not use the return key. rs7 awn Keep a copy for your Tiles For DEP Use: Massachusetts Department of Envirorimbrital Protection FMF# Bureau of Waste Prevention — Hazardous Waste Generator Registral Jon DEP Region: ❑ NE ❑ SE❑ CE ElWE-------------- --- I am registering as: (Very small quantity generator of hazardot.isI; vraste (less than 220 pounds or 27 gallons/month) or ❑ Very small quantity generator of waste oili (�e:'ss than 220 pounds or 27 gallons/month) or ❑ Small quantity generator of waste oil (220 i';o'2,200 pounds or 27 to 270 gallons/month) a©R name oT iviaiung aaaress Cirptown St`r street aaaress wnere waste is proaucea ReWfi-I i1m - cinnari nr ging! t� the appropriate MassDEP Region -a! Office, Attn: BWP penreg.doc • 4/06 J Waste Oil ❑ Solvent ❑ Acid or Alkali Other (name): ❑ 9 AS�� I»t-lc C ZX: F Zip code t -malt Aaaress State Zip cone SIC code Disposal, Storage, Treatment, and/or Recycling (Name of company and address where waste is taken or type OT treatment or recycling on site OT generations s&fe-ry,- kL-c-,,v 5y�c-/Lt� q a RA 13017 (en i CER T iFY I HA I UNDER PENALTY C) tj,-,k\IV i have personally examined and am i'amiiiar with me information submiiied in this documeni and= aii attachments, and that based on my inquiry of those individuals immediaieiy responsible for obtaining the information, i beiieve Thai the information is irue, accurate, and camrnlete Name oof%operator iC /k _A - Title Uate Generator Registration • Pape 1 of 3 Type of b4siness aot have a MAD. MAR, or MA5 MV Generator Registration Number (12 followed by your Area Code and Hazardous Waste Gallons per Telephone Generated (check) Month Prior to Number. Treatment, Recycling or Disposal ReWfi-I i1m - cinnari nr ging! t� the appropriate MassDEP Region -a! Office, Attn: BWP penreg.doc • 4/06 J Waste Oil ❑ Solvent ❑ Acid or Alkali Other (name): ❑ 9 AS�� I»t-lc C ZX: F Zip code t -malt Aaaress State Zip cone SIC code Disposal, Storage, Treatment, and/or Recycling (Name of company and address where waste is taken or type OT treatment or recycling on site OT generations s&fe-ry,- kL-c-,,v 5y�c-/Lt� q a RA 13017 (en i CER T iFY I HA I UNDER PENALTY C) tj,-,k\IV i have personally examined and am i'amiiiar with me information submiiied in this documeni and= aii attachments, and that based on my inquiry of those individuals immediaieiy responsible for obtaining the information, i beiieve Thai the information is irue, accurate, and camrnlete Name oof%operator iC /k _A - Title Uate Generator Registration • Pape 1 of 3 The Commonwealth of Massachusetts Department of rizdustrial -4ccidents Office of £ftvestit adons 600 Washinown Street Boston, -4" 62111 Workers' Compensation Insurance AEdai sem°ov/dna P vt: �Plicant InformatioBuilders!Contractors/Electriciaas/Plumbers n Naine (Business/Organization/Individual): Address: City/Sfiate/Zip:_ t� 1 Pbone #: A�r—e, yo an employer? Check the appropriate boa; 1 • C� 1 am a employer with 4. ❑ I am a oenerat employees (full and/or part -fie). 2. ❑ I am a contractor and I have hired the sub -contractors sole proprietor or partner- ship and have no employees listed on the attached she et I working for me in These sul�-cone have any capacity, [No workers' comp: insurance workers' comp. insurance. 5. ❑ We are a corporation required,] 3. ❑ I am a homeowner doing and its officers have e xercised their all work Myself [No workers' co � right of ex emption per MGL c• 152, § I (4), and insurance required.] t we have no employees. [No workers' Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions .11.0 Plumbing repairs or additions 12.[] Roof repairs :A-ny appIic" * that � ch COQ' Msttrance require I 13-L Other bo•,.�1 must ahso iYel nut f'nc secfia= ���!:,hog :`., :yy �] eownets who submit fids ,ffidavit indicating they are doing - , .. commie = +Contrao n that cb=L- this box must attached n additional sheshow and Y" ; W"� tbm'bixt outside conuz^tors const submit s new aoavii indicating such. m, the acme of the sub^ tra^- = m and their wart 2 n co I con an e7nPh'J'� that is psmdding workers' compensation insurance or m e pn mformaaon information. f Y mployees. Below is the poiicJ' ate, job site Insurance Company Name: 14-".ri Policy # or Self -ins. Lic. #- �'�'(� OV (1) ) (03 7 p n g Expiration Date: Job Site Address: 7i7i0 C� Attach a copy of the workers' compensation: policy declaration page (she ' CR the policy O Failure to secure coverage as required under Section 25A ofM � p°h�' number and expiration date). fine up to $ I,500.00 and/or one -yew im GL C. 152 can lead tb the imposition of criminal pnsonmeat, as well as civil penalties of a Of up to $250.00 a day against the violator. Be advised that a co P�alties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. PY of statement may be forwarded to the Office of Inc paiIlins and penalties of periurJ' *'Xt the information provided above is true aria' correct iQnature: �! / . hone Official use only. Do not write in this area, to be compl�d�4,�citor tome official City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Healtb 2. Building Department .3. Ci /Town p 6. Other' Clerk 4. Electrical Inspector 5. Plumbing Inspector Contac Person: Phone 9: DATE (MM/DD/YYYY) ACORDn CERTIFICATE OF LIABILITY INSURANCE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mathias Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE g y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 200 Sutton Street, Suite 160 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01845 710-000-JUJ.L INSURED Cast Builders Inc. 200 Sutton Street North Andover, MA 01845 nnVFRAnPR INSURERS AFFORDING COVERAGE NAIC# INSURERA: Max specialty Insurance Company INSURERS: Hartford underwriters Insurance company INSURER C: INSURER D: INSURER E: 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. INSR LTR D'LPOLICY NSRD POLICY NUMBER EFFE DATE MM DDCTIVE POLICY EXPIRATION DATE MM DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 00 ,000 PREMISES Ea occurence $ X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 CLAIMSMADE CI OCCUR PERSONAL&ADV INJURY $ 1,000,000 A Max013100002883 12/01/09 12/01/10 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OPAGG $ 2,000,000 �( POLICY jE 0 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea aCCI ent'----'— — - - - BODILYINJURY $ ALLOWNEDAUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON-OWNEDAUTOS (Peraccident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ OTHERTHAN EAACC $ ANYAUTO AUTOONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CICLAIMSMADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ WCSTATU- OTH- WORKERS COMPENSATION AND TORYLIMITS ER E.L. EACH ACCIDENT $ 100,000 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE4 $ 100,000 B OFFICER/MEMBEREXCLUDED? 6S60UB-4102P23-8 12/11/09 12/11/10 E. L. DISEASE -POLICY LIMIT 1 $ 500,000 Ifyes, describeunder SPEC IAL PROVI SION S below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Additional Insured: Winchester Hospital Dr. Lemonaire's Suite 100 Andover By -Pass North Andover, MA 01845 ACO R D 25 (2001 /08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL20 DAYS WRITTEN NOTICEJTTHIERT ICATE j/OLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMP 0 16 ION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ©ACORD CORPORATION 1988 ' t;4F>Tk TOWN OF NORTH ANDOVER OFFICE OF 4. BUILDING DEPARTMENT H 400 Osgood Street North Andover. Massachusetts 01845 D. Robert Nicetta, BuildinL, Commissioner Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION - SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 I. Steven Houle HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT Best Cleaners, 220 Sutton Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: AUTHORIZED SIGNATURE: DATE: June 10, 2010 REGISTRATION: 46743 NOTE: ENGINEER "WET STAMP" MUST BE Control Construction Form revised 11 A5.2004 THIS FORM �\�N OF',ASsgc� o� STEVEN G� R. OHOULE v No. 46743 O Opo�FC g F IONO- BOARDOF APPEALS 688-9541 CONSERVATION 688-9530 11E7"- f?,M 9540 PLANNING 688-9535 O z Cd r1 c o m c :;c o c � o � :.c y O_ C V V \ n '1 • O C mo s E D os �- c, m c : CL= c m y ' O Q� m � �• C m = c ' H A E y U. E c C O nv \^ Co m ; ya do c V y O CD 0 R 0 .� coo n m c= O C = m m 3 mom~ COD Me ;;.2 LL m �... 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