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HomeMy WebLinkAboutBuilding Permit #374-13 - 225 MARBLERIDGE ROAD 10/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION'S cid t1CtIr1C',rL '�(Cv. Imo) tt. {4� PROPERTY OWNER. . — _. �- Print sin 100 Year OId Structure ye no MARUA PARCEL r ZONING DISTRICT Historic DistriO yes no Machme�Shop_Village; yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building %0_ne family ❑Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic- ❑Well D Floodplain Wetlands. ❑ Watershed District' ❑;Water/..Sewer - DESCRIPTION OF WORK TO BE PERFORMED: Remod�eA Q`5 FI czar path s•L`3ofr\- Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR` Name:_ _ h- _-_ Phone-- -- Add ress:- Supervlsor's�Construction License -_ _.,A _ Exp. Pate Home Improvement License; - _ - _ .•� _-_ Exp Date. _- _- _ -_-.- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �bbo FEE: $ 'ta .LZ Check No.: :3A5i:L Receipt No.: d-U-` 6 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature��of Agent/Owner _ � �� ,�S�g�ature�of contractor��=-:. ° _ �� r:�.� Plans Submitted �� Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The fohowing is' list of the required forms to be filled outfor the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire-Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 apwal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 . t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ °. 1WE'OF:SEWERAGEDISPDSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools r •! f Well ❑ _ Tobacco.Sales ❑ Food Packaging/Sales 11 Private(septic tank,etc..- ❑ -- .. :.Permanent Dumpster ori Site ❑ THE FOLLOWING SECTIONS FOR OFFICE.USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATEAPPROVED PLANNING & DEVELOPMENT'' ❑ ❑ COMMENTS I 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 Tow;! Engineer: Signature: Located 384 Osgood Street 'FIREDEPARTMAT - Temp- Dumpsteron'site yes no Located at 124Mair .Street. Fire partme►�t sigriatia'r`eldate r .,_� 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 i ® Notified for pickup - Date Doc.Building Permit Revised 2010 I i Location 1 No. -( � Date�t 'I "f • - TOWN OF NORTH ANDOVER f d• . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# J 26987 Building Inspector November 3,2015 Michelle Fox 225 Marbleridge Rd. North Andover,Ma 01845 To whom it may concern, t release the plumber Rick Bowman and the electrician,Joe Blanchett of A.B.Custom Carpentry from the permit taken for a bathroom remodel. All work performed going forward will be done by Pegasus Design-to-Build. I can be contacted at 978-828-5880 if there are any questions. Thank you, Michelle Fox 92ZJII� Date..................... ..................... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING C U ........... This certifies that ............................... ............................................. has permission to performe.A(,.—t.-,k-j ......��'. ..... .............. ......................... ...... ............... wiring in the building of........::. ................................................................... .............. .. at .....Q......... �5........M k..tc)��4 cox.p. J.:.,North Andover,Mass. ......... .... Fee.. .............Lic.No�37? ........ ............................................................ ELECTRICAL INSPECTOR Check# 12 7 5 P //�� pp�� Print Form ' C.ommonwea&o f Vaijac4aielb Official.Use Only, c� Permit No. � �� ✓ V eC partment ol3ire�eru[c¢9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leave blank) 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 PRINT IN INK OR TYPE ALL INFORMATION) Date:9/19/2014 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. Location(Street&Number) 225 Marbleridge Rd Owner or Tenant Michelle Fox Telephone No. 978-828-5880 Owner's Address Same Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Single dwelling Utility Authorization No. 179-141-70 Existing Service 100 Amps 120 / 240 Volts Overhead ❑✓ Undgrd❑ No.of Meters 1 New Service 200 Amps 120 / 240 Volts Overhead Q Undgrd❑ No.of Meters 1 Number of Feeders and Ampacity Single Phase 4aut AL g Location and Nature of Proposed Electrical Work: Electric Service entrance and panel upgrade Completion qf thefiollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I Number I Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other, Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Signs No.of Devices or Equivalent ' V Heaters Ballasts --" No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: N/A (When required by municipal policy.) Work to Start:9/16/2014 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 ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: Steven C Papuchis Lic. Electrician LIC.NO.: E-37256 Licensee: Same as above Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tei.No.: 978-815-4625 Address: 93 Central St, Peabody Ma.01960 Alt.Tel.No.: *Per M.G.L. c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 55.00 if The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations klip 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly uchis Li teven C Pa c.Electrician Name (Business/Organization/Individual): f Sp Address: 493 Central St. City/State/Zip: Peabody Ma,01960 _ Phone #: 978-815-4625 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 1 4. 0 I am a general contractor and I 6. E]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. 1 7 Remodeling ship and have no employees These sub-contractors have 8. E]Demolition workingfor me in an capacity. workers' comp.insurance. Y p h'• 9. ID Building addition [No workers' comp. insurance 5. E3We are a corporation and its required.] 10. Electrical repairs or additions officers have exercised their 3.E3 I am a homeowner doing all work right of exemption per MGL 1 I. i©Plumbing repairs or additions myself. [No workers' comp. c. 1.52, §1(4),and we have no 12.[0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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: - ravelers Insurance v Policy#or Self-ins.Lic.#: �CalParente ente Insurace 978-531-8854 Expiration Date: 12/2014 __ a. 22 5 Marbleridge Road,_North Andover M 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 and penalties of perjury that the information provided above is true and correct. Si 9/1 4 Signature: Date: - --- - Phone#: -815-4625 i Oficial 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#: { 9/22/2014 Division of Professional Licensure:License Search Tie.Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) t Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home> Division of Professional Licensure> ONLINE SERVICES .....................................................................................................................................................--........................................................................................................................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name: STEVEN C. PAPUCHIS REFERENCES& PEABODY, MA RELATED INFO NEW SEARCH Disclaimer Regarding — � �— ------- ----- Website License Searches Licensing Board: ELECTRICIANS Glossary of License Status Codes License Type: JOURNEYMAN ELECTRICIAN III TYPE CLASS: E More... License Number: 37256 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 9/13/1994 Exam Date: 8/6/1994 i School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, September 22, 2014 at 11:12:21 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type_class=_E&license_number=000037256&color—blue&lb=EL 1/1 Date. --�2.4-A................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 13S,CHU 11 This certifies that k C ........................................................ tIA has permission to perfoiin ...........f 0-Id.bO.r-1...... ... ....... ......... ..... ................ .............. ... ... wiring in the building of...... . ......................................................................................... a. at ............ .......................................C-.!l........................ North Andover,Mass. Fee.....��q.7..........Lic.No:.......—Ii, ......... ......... .... 0 CTOV bq 13'; Check 12470 Official Use Only Commonwealth of Massachusetts ��1 Department of Fire Services Permit No. 0 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: O City or Town of. NORTH ANDOVER To the Ins ector f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ;Z 5 MCtr-L Jp-t S�a� Owner or Tenant _ l�� / ��( Telephone No. Owner's Address �G,tr►� Is this permit in conjunction with a building permit? Yes VI No ❑ (Check Appropriate Box) Purpose of Building ( (,,i Utility Authorization No. Existing Service Amps / olts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �wy�/t 66*t,-00� J GiG� 2r�� Completion o the o llo zw' n table maybe waivedby the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA i No.of LuminairesSwimming Pool Above El ❑ o.o Emergency Lighting rnd. rnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number I.Tons KW No.of Self-Contained Totals:I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection \ j No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 1 No.of Devices or Equivalent OTHER: � ;' T X,7cC7�ejr 1OvrC� -f Gi GI Attach additional detail' desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ' 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 JR1 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties o perjury,that the information on this application is true and complete. FIRM NAME: C P VC A t S- Z1,- LIC.NO.: f Licensee: Signature LIC.NO.: (If applicable,enter "exempt"in the liters number lin Bus.Tel.No.: Address: 6O A d Alt.Tel.No.• *Per M.G.L e. 147,s.57-61,security work requires DepartmAt of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ '57 Signature Telephone No. 02441 1,J b l �Mc�.L �firr R J✓OM nONWEaLTH of MASSA6HUS v BOARD OF ELECTRICIANS ISSUES THE FOLLOWING-: LICENSE. AS A REG >•OURNEYMAN,;ELECTR1Gt'AN �. ..STEVEN C PAPUCHIS 93 CENTRAL ST PEABOQY 14A 01960-4315 37256 E 0713116 .: 39557 S • :DRIVER'S LICENSE .K 639IFS • 1-14-201411-IGS, r z cuss REST NGT SU Du B 5.10 m — STEVEN C 43 CENTRAL ST J PEABWY MA ,1 10232 ,40 7' TOWN OF NORTH ANDOVER oF ,..o . otic ° p PERMIT FOR PLUMBING gBACMus� This certifies that........!`...!...............OW U+t ......................:........................................... has permission .. .to perform .1...... i.Y. .... .... ..........:. .. plumbing in the buildings�of. n�?' h! r��' ,.. ....... , at.......2 -J.5........� G^1tsn lK�....�. .......9 N h ndover, Mass. r Fee.! 1. rP.....L1C. NO. .� �. PL&BWG I SPEC TOR.................... Check# `�' MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY M1 P --11 MA DATE /G PERMIT# JOBSITEADDRESS 1 ,22 S~ � � OWNER'S NAME��J� POWNER ADDRESS TELE_____ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 50-- PRINT iPRINT CLEARLY NEW: RENOVATION:REPLACEMENT:Q PLANS SUBMITTED: YES® NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ( __- } ( J _ ! p _.,,,..___ DEDICATED SPECIAL WASTE SYSTEM 1 DEDICATED GAS/OIL/SAND STEM DEDICATED GREASE SYSTEM _--} DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM i } ( ^} _--_-_,! ( ! _ DISHWASHER ( _ _._f ! DRINKING FOUNTAIN J _-----._.► .__._ J ! ._.,.._( ( ► J J __._.-. } f ___...._J _ ( ...__..._I FOOD DISPOSER FLOOR/AREA DRAIN -( --- _1 INTERCEPTOR(INTERIOR) J _.___._f ___._} ____ -----._! KITCHEN SINK LAVATORY _:___-_.__( ROOF DRAINI---- SHOWER STALLSERVICE/MOP SINK TOILET URINAL _WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _} OTHER � I 1 _( INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES0-"N0 Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _i BOND 0 N OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the r Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to ip,4st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ci al provision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME - _ C LICENSE# 3 SIGNATURE IVIP f`BJP CORPORATION FJ1#©PARTNERSHIPD# s LLC[�f#I j COMPANY NAME �,yL,q�/ / ADDRESS CITY �� _ .-__ _JSTATE _a ZIP ®/ 3.1— [I TEL FAX _ CELL EMAIL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES 10"1/// Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � r P w.11 t The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,M4 02111 UV www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): gnu a-�riri Address: City/State/Zip: G��' , —Phone 4:_ 9X�655,?t47 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ` 6. FJ New construction employees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. F1 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 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.[J Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State1Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Y 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 w Investigations of the DIA for insurance coverage verification. X do hereby certi er ins nd nalti o erjury that the information provided above is true and correct. Si azure: Date: l% j 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 ane): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Informati®n 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 ofhire,- 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. De advised that this affidavit maybe 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 retained 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 r 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 Ma ssachu setts Department of Industrial Accidents Office.of Investigations 600 Washington Street Boston,,MA 02111 TO,#617-727-4900 ext 406 or 1-877.7MASSA]FE Revised 5-26-05 Fax#617-727-7749 v ww.Mass,govfdia i Enter construction cost for fee cal - North Andover Fee Cakulafion Construction Cost 8,000.00 m $ - $ 96.00 Plumbing Fee $ 12.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 12.00 Total fees collected $ 220.00 225 Marbleridge Road 347-13 on 10/15/13 Remodel @nd Floor Bath NORTH Town of t : �' . Andover O No. 3ql.,. Iq - Y O tAN■ h , ver, Mass, lolls ) I- r NIC nt-ICM y1' A04A rE D s U BOARD OF HEALTH Food/Kitchen PERMIT T� � ®®�� L.D Septic System THIS CERTIFIES THAT M.1 ....... ...................... BUILDING INSPECTOR ��,/ has permission to erect .......................... buildings on C ....... 4:l: ... ...lam. - Foundation Rough to be occupied as 4 ` .......&.4.4. ................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final - PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR f�- UNLESS CONSTRUCTION AR S Rough Service ........................ ................. . .................. 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 Street No. Smoke Det. SEE REVERSE SIDE NORTH Town of n O �+ No. 3qT. 1qz o ��K. h , ver, Mass, O COCNICNlwKu 1_ �,9 A°RATED S U BOARD OF HEALTH Food/Kitchen PERMIT T, LD � � ®®�� Septic System THIS CERTIFIES THAT 444,"` `.'....... 5BUILDING INSPECTOR has permission to erect buildings on41: .`{.�... ,,, Foundation .......................... .. ........ .... dRough to be occupied as ..... .�.�........ . ....�.......&.41.L.............. .......¢ .. .................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final - qb. PERMIT EXPIRES IN 6 MONTHS. ELECTRICAL INSPECTOR UNLESS CONSTRUCTION FAR SRough Service ........................ .................. .................... Fina _ 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 Street No. Smoke Det. SEE REVERSE SIDE ' =°Ex nr 6 aHa TORN OF NORTH ANDOVER . of OFFICE OF BUILDING DEPARTMENT ,A _1600 Qsgood Street Build 0 1 7�Ssacnus��t North Andover,Massachu efts 0184te 536 �RATie'4��V 5 Gerald A.Brown _ Inspector ofEuiTelephone� ne(97E)698-9545 HOMEOWNER•LTCENSE BXEMpTION Fax (978)688-9542 IBT D)NG PERMIT APPLICATION 1'leasenrint DATE: 10-15 t3 JOB LOCATION: ods' '.HCxrUu4i 0, Number Street Address Map/'Lot 1JOMEOWNER k F-ox Name. Home Phone Work Phone PRESENT MAILING ADDRESS C ky Towi lJ'(� �� o 1 C ci J 7ip Code The current exemption for tw homeoners"was extended to hiclude owner-occupied dwellings to i�vo units ox less and to allow su;h horneo� eis to engage an n—ividual.for hire who does not possess a License,provided that the owner acts as supervisor). State Building (Code Section I0S.3.5.1) DEFINITION OFHOMEOWNER Person s ()who awns a parcel of land on which he/she resides or intends to reside,on which(here is,oris intended to be,a one or two family structures. A person who constructs more that one home in a which there Orio*d shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State BuildingCo Applicable codes,by-laws,rules and regulations, e and other The undersigned"homeowner"certifies that he/she tmderstands the To of North Andover Building Department minimurn inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 'BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-953i The Commonwealth o Massachusetts _ _onwea .f Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02.111 www.mass gov/dia Workers' Compensation Insurance Affidavit:BuildersIcon.tractors[Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Tndividual):_ b,t CJ)QA _ a,),— Address: aa5 "(xrwC C City/State/Zip: , p��IL M Phone#: cn f �13� 04 0--' VJ . . Are you an employer?Check the appropriate box: Type.of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time). x have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. 9, F1 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions - 'required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL ILL]Plumbing repairs or additions �mys elf.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[j Othex' *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they tLi a doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. .t am an employer that is providing workerscompensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name:. Policy 4 or Self-ins.Lic.4: ExpirationDate: Yob 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 requiredunder 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. Ido hereby caro under the pains and penalties ofpexjury Aat the information provided above is true and correct. -. Si ature: I rte- R"__ Date: Phone 4: 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone M. 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 ofpublic 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 maybe submitted to the Department of Industrial Accidents for confnmation 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-andprinted legibly: The Department fias 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. Anew affidavit must be filled out each year.Where a homeowner 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. Tho CQmmonwo-ali o 1l�iassar>7v.,sPtts - DopartMent offadustdal.A.celdoilts Off oe of Intvestigations 600 Wasbingtou Stzcet Boston}MA.02111 Tel,#617-727-4100 oyd406 or 1,-S77,MASS.ABF, Revised 5-26-05 B 6X7"727-7 749