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HomeMy WebLinkAboutBuilding Permit #550 - 25 DUDLEY STREET 3/16/2010 BUILDING PERMIT o* NORT/1t,�o ,6 gti TOWN OF NORTH ANDOVER o? b�''`- .6 0° APPLICATION FOR PLAN EXAMINATION Permit NO: �� Date Received �SSACHUS�� Date Issued: (( IMPORTANT:`Applicant must complete all items on this page LOCATION 7 e 9+ Print PROPERTY OWNER G t C -- Print MAP 210 _PARCEL:ZONING DISTRICT:_Historic District yes nog, 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 BEP FORMED: f Identification Please Type or Print Clearly) OWNER: Name: 1� Phone: z_ Address: CONTRACTOR Name:_ &4u J OJ,-ea - Phone: Address: 9 -� Dy ut d 14, 11 f aAu'ow M`t Supervisor's Construction License: 0 36 Exp. Date: 6-q `10 Home Improvement'License:--JL--73 �1 Exp. Date: 1 ` Z 6 " /C 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: $ S�S 2�� w FEE: $ /k Check No.: �� Receipt No.: 2Z NOTE: Persons contrdcting with unregistered contractors do not have access to the guara fu J Signature of Agent/Owner Signature of contractor /' Location C>?j )Q (L — No. Date4zv---'10 MaRTh TOWN OF NORTH ANDOVER 3? ' • -0 00 a • Certificate of Occupancy $ sAC MUs t� Building/Frame Permit Fee $ DSD .• Foundation Permit Fee $ — Other Permit Fee $ TOTAL $ Check # —) V 22Lb5 Building Inspector 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 Packagin' &]� s 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 f ' 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 y-Temp"Dumpster on site yes no Located at 114 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 0 Notified for pickup - Date Doc.Building Permit Revised 2010 1 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 T- - — - -- 54 The Commonwealth of Massachusetts Department o f fitdustrial Accidents Office of Lnvestigations 600 Washington Street Boston, MA 02111 www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): J O Address: 7 City/State/Zip:_ /� �lti�� �Y1� Phone#:_I 7 r Armee you an employer?Check the appropriate box: [2.[] •L�f 1 am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. New construction I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. 8' ❑Demolition P [No workers comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition 3.❑ required.] officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions Myself [No workers'comp. C. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12-E]Roof repairs comp.insurance required] 13.❑Other `.'ny a,plic n'-that checl~<box 41 est zero iti cut Ewe sect on ezeeow how^a�taeir wori a s'comg �Vou uor cc Homeowners who submit this affidavit indicating they,are doing alI work and thea hire outside contractors must.submit aYnew affidavit indicating such. tConiractors that check this box must attached an additional sheet showing the name of the sub_contractors and their workers'comp.policy information. am information.an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site Insurance Company Name: 5 �2 -Y �0� Ci �u Policy#or Self-ins.Lie.#:_ C) Expiration Date: Z `v Sob Site Address: 2 City/State/Zip:Attach a copy of the workers'compensation olicy declaration page(showing the Policy number�/��U�z /'/). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to thimposition 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 ofthis statement may Investigations of the DIA for insurance coverage verification be forwarded to the Office of I do herebycofy under the a* s an pen 'es of perjury that the information provided above is true and correct. Si ature: V Date: Phone#: J 9-7 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.PIumbing Inspector 6. Other Contact Person Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartaxents 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 it license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requests,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition;an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. # 617-727-4900 ext406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 wvm%mass-govfdia NORT#i Townof No. A K E dover, Mass., COCMIC ME WICK V^ ADRATED `r BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... f Foundation hasermission to erect ............................... buildings on .(X... fc�... . .........-........................................ Rough to be occupied as.......31 .,Wt..... ...........................................................:.......................... ..... .................... Chimney �4� provided that the person accepting this permit shall in everyrespect conform to the terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST TS Rough ................................................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. 13d� o� V � ;liT�fiJC(s �r�s�d HOME IMPROVEMENT CONTRACTOR Registration: 117359 Expiration: 9/26/2010 Tr# 274439 E ' Type,"SBA; JONES&CO Ii €.. -P.. BRADLEY JONES +�` 97 DRUID HILL R6;; '� 7,;-. METHUEN,MA Administrator +" llussitchusetts- Department of Public Safet% Board of Building Regulations and Standards Construction Supervisor License License: CS 36863 Restricted"to: 00 BRADLEY J JONES 97 DRUID HILL RD METHUEN, MA 01844 Expiration: 6/4/2010 ( unmissi ater Tr#: 25382 ` Y Jones & Co. Estimate General Contractors 97 Druid Hill Rd. DATE ESTIMATE NO. Methuen Mass. 01844 2/21/2010 453 Tel 1978 688 7307 NAME/ADDRESS Gayle Apkarian&Rene Slack 25 Duddley St. N Andover Ma 01844 TERMS PROJECT DESCRIPTION COST TOTAL Scope of estimate work on the second floor bathroom. Your copy not the Scope of repair for Insurance Co Plumbing by Sal Scope of work 1,840.00 1,840.00 Disconnect the water supply and the drains from the tub,remove the tub,Remove the toilet(to be reinstalled if possible) Open up the floor remove any lead drains or traps that pertain to the toilet or the tub. Cut into the cast iron if needed to allow drainage for the toilet,new 2"drain for the shower and properly vent it out. Install a Simmons single handle shower valve Toilet reinstall the same toilet Sal will install new water supplies hidden to the shower valve Notes; 1. It is highly recommended that you upgrade the toilet at this time. There are visible cracks in the porcelain. It probably uses 3 gallons+per flush instead of 1.5 gallons per flush, We can get a new toilet in a 14"Rough but if Sal is redoing the toilet drain and the floor framing allow's him to set the drain to 12"rough that is a much more common install. The right rough in should not stick out more than your existing bowl. If you do upgrade your toilet you can purchase it&a seat we already have labor to put one back. 2.All fixtures are based on basic chrome. TOTAL SIGNATURE Pagel Jones &Co. Estimate General Contractors 97 Druid Hill Rd. DATE ESTIMATE NO. Methuen Mass. 01844 2/21/2010 453 Tel 1978 688 7307 NAME/ADDRESS Gayle Apkarian&Rene Slack 25 Duddley St. N Andover Ma 01844 TERMS PROJECT DESCRIPTION COST TOTAL Jones&Co Scope of work. 3,360.00 3,360.00 We will remove the actual tub with Sal in pieces. We will cut the floor under the shower pan area and around the toilet to expose the drains. After the plumbing is properly redone we will sheath the floor with Advantec We will blend in the existing tongue&groove flooring up to the edge of the shower. We will supply a custom sized copper pan to fit the floor area. We will slope and pour concrete into the base. We will frame a curb at the entry to the shower. We will remove the window from the wall in the shower area,insulate it,board up the exterior,and blend the siding so you can not tell it was there ( painting not included) TOTAL SIGNATURE Page 2 Jones & Co. Estimate General Contractors 97 Druid Hill Rd. DATE ESTIMATE NO. Methuen Mass. 01844 2/21/2010 453 Tel 1978 688 7307 NAME/ADDRESS Gayle Apkarian&Rene Slack 25 Duddley St. N Andover Ma 01844 TERMS PROJECT DESCRIPTION COST TOTAL Note the tiled area will be up the wall 78" We will cover the entire stall with Permaboard. We will install wall tile on the walls and ceiling with a finished edge or cap tile( 6 x 6 Self Spacing White wall tile) You may pick a contrasting color to use as a boarder row or chair rail or a checker board to break up the solid white. Floor tile will be a 2x2 mosaic sheet product The Threshold entry into this shower will be a continuous 6"wide pc of marble All tile will be grouted Notes: 1.The labor to install tile is based on a self spacing tile. Should you choose a rile that requires spacers when setting or any elaborate deco tile that will increase the install cost. 2.Our goal is to re-tooth the tongue and groove flooring back in around the toilet area using what was removed from under the shower,should we need to purchase a bundle of Maple or Southern Yellow Pine that cost will be additional. 3.Should you wish to have a lowered ceiling built over the shower stall(84") and tiled Add$325.00 initial Includes all materials to do the work described above,Labor,Building/Plumbing Permits, Debri Removal No Painting has been included. No Shower Door Enclosure No Tension Shower Rod No Hand Held Sprayer No Grab Bars No inset shelves or soap dishes ect. No vanities TOTAL SIGNATURE Page 3 Jones &Co. Esti m ate General Contractors 97 Druid Hill Rd. DATE ESTIMATE NO. Methuen Mass. 01844 2/21/2010 453 Tel 1978 688 7307 NAME/ADDRESS Gayle Apkarian&Rene Slack 25 Duddley St N Andover Ma 01844 TERMS PROJECT DESCRIPTION COST TOTAL Window over the sink area @ this time you know what a window will run you if you go with an Anderson A Series Awning(with a black exterior) ordered as a new construction window with the largest possible rough opening to fit the existing frame opening without re-framing Labor&materials to trim the inside similar in appearance and also similar in appearance on the outside If you purchase the window and have it on site Add this cost to install and trim it $ initia Lower the ceiling over the shower and tile the ceiling 325.00 325.00 Terms Deposit$3,000.00 Payment when shower is tiled and working$2,525.00 Please read&sign both copies upon acceptance of this proposal,keep one copy for your records and return the other,as it is required when applying for a permit x Z14,(1-- 11 4161.6"t x TOTAL $5,525.00 SIGNATURE Page 4 t Date. ....�1• ••• •• NORTM TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION . y SAC NUSE�t This certifies that . l C�j /2(� G,, 70 has permission for gas installation .c6e4 .Ate. . / � PX��/4 tJ in the buildings of � Ll. .r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d/ s— at c 2T. .:.1�. . l. . . . , North Andover, Mass. Fee. Fee. . . Lic. No.. . . . . . . . . . . . . . . . . . . . . . . .\ / GAS INSPECTOR Check# (y/ Z 69 /- 7ot 1 f MAS,SACHUSE'M UNIFORM APPUCA-rON FOR PUMU TO DO GAS FZTTTIN (Type or print) C' NORTH ANDOVER, MASSACHUSETTS Dater Building Locations CA ID Lam. Permit# Y Owner's Name _ ` Amount$ New Renovation / � �� /r Replacement D Plans Submitted ❑ � a w w U F � Q � w z w � � � � � � . c _z a �° 'z o w .� w rA SU B -BASEM ENT + L g 00 BASE M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR TH . FLOOR 6TH . FLOOR 7TH . FLOOR. STH . FLO.O R. (Print or type) Name /L C Check one: Certificate Installing Company Address ❑ Corp. •L pas ❑ Partner. usmess 'e ep ne Name ofLicensed Plumber'or Gas Fitter E:a FirWCo. INSURANCE COVERAGE I have a current liability insurance,policy or it's substantial equivalent. Check one- If you have checked es please indicate the type coverage by checking the appropriate by 13 No � Yes Liability insurance policy ❑ Other type of indemnity ❑ Bond13 ' Owner's Insurance Waiver I am aware that the licensee does n-avee the insurance coverage re b Mass. General Laws,and that my signature on this.permit application waives this requirement. g require by Chapter 142 of the Signature of Owner or Owner's Agent Check one: I hereby certify that all of the details and information I have submitted Owner Agent best of my knowledge and that all plumbing work and instal}ations a (or entered)in above application compliance with all pertinent provisions of the Massachusetts State pp are plirue and accurate to the P as code under Permit Issued for this application will be in Gas Code and Chap�142of the General Laws. B y: Si nature of g Licensed Plumber Or Gas Fitter own Plumber ��� Gas Fitter License umber Master ED(OFFICE USE ONLY) � Journeyman ' l De artmenf o�cicrn o1 MassachusetZc 11 P .f I�ndurtria114ccidents. ✓fli r D,f cce o f Investigations 600 Was hzzton Street BostoaL, MA 0 111 c , Workers, Compensation Insurance .Rid iss.goj'/din A Iica.nt Information ��'It. 13uiiders/Contractors/Electri6ians/piumbers Name (Busirl=/Or Please Print Le�ibiF= gantza#ion/individaal): �G� � , Address: ` City/Siete/Zip: 01P Are you an employer?Check the appropriate box: 1.❑ I an, a employer with 4. [] I nth a _ Type of project employees(full and/ part-time).* have hired the sub Ortorsr and t ❑ New c, (required); 2.1, am a sole r6' onstr action proprietor or Partner- listed am the attached sheet I 7• ❑ Remodeling. ship and have no employees These sub- worl ing for me in any capacity. workers, comp.cOntractors have ❑ insurance, g' Demolition [No workers'comp. insurance S..❑ We area regtared.] Officers corporation and its 9' 'Building addifi-on 3•❑ I am a homeowner doing all work ri ht of ex-ve exercised.their 10: ❑ Electrical repairs or additions myself. [No.workers' mptton Per MGL 11.� PlcnnbinQ r„ insurance required.) t pOTT�P c. IS2, Z(4),and we have no repairs or additions employees. [No workers' 12,❑ Roof repairs camp. insurance required.] 13.❑Other *Ani,appticant.thar checks box#I.must also fill out the section below showing th-ir workers' 'r iomcowuera whu submit•f3ris adavir iniiicatir�t}iey ere sairg t`tu,,r compensation policy irtiormation. xContracwts Iha(died:this'vox musi Eh arm had an additional sheet showireg rci �hire outside'contt�u:iurs roust auimrii a new atnriavit indietin the name of the sui;-contactors and their work=, o ' acoh, I am an ernplo3,� Qi is Providirro woriers'cren-�er`er�o�., ncros'comp.poiie�,imamration. 4formatiorz tazsurance jor ng,emp&ryees Belo►r, rs the Poficj,and job site Insurance Company Name: Policy#or Self-.ins. Lic. a- Expiration Date: Job Site Address: Attach a copy of the workers' compensation" CitYIS /Zip: /�/p ANca/pt p,/J policy declatation Pabe(sh o Failure to secure covers owiQg the policy number and expiration date] coverage as required under Section 25A of MGL c. 152 can lead to the imposition'of criminal fine up to 5'1,500.00 and/or one-year imprisonment,as well of up to.5250.00 a day as evil Penalties in the form of a STOP WORT;ORDER of a 3 against the violator. Be advised that a copy of this statement may RDER and a fine Investigations of the,DIA for insimmm coverage venficati.orn. be forwarded to the Office of I do hereby,certify under the pains andjo=aldas o Signature: e 'q , P r! r,I J'i at the information Provided above is true and correct � Phone#: ? '3�. r j0/2 Date: `j 0 Official use onip. Do nn1 write in this area, to be.corrrpleted.b, 3 qty or town official City or Town: Issuing Autbo Permit/L,icense 4 e � (circle one): L Board of Health 2. Building Department 3. C' 1T fi. Other3 °wn Clerk 4. Electrical Inspector S. Plumbing b Inspector Contact Person: Phone tr xnivi waLIVU cane tustrucrions Massachusetts General.Laws chapter 152 requires all enZployers 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 inclucizr:g the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associati on or other legal entity,employing employees. However the owner of a dwelling house having not more than.three ap,—Irtments 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 10ca1 licensing agency shall withholid the issuanmor renewal of a license or permit.to operate-a hm0ness or- to construct huiidiva"s io the commonwealth for any applicant who has not prodnced acceptable evidence of compliance with the insurance coverage required." Additionally, MOL chapter 152, 925C(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 lire contracting authority.". Applicants Please fill out the workers' compensation affidavit compZ-etely,by checking the boxes that apply to your situation.and,if necessary,supply sub-contractor(s)name(s), address(es) arnd phone nurnber(s)along with their certificates)of insurance. Limited Liability Companies (LLC)or.Limited Liability Partnerships(LLP)with no employees otherthan the members or.partners,are not required to carry workerscompensation insurance. If an LLC or LLP does have_. employees, a policy is required_ Be advised.that this affid-a.vit may.be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. ;Also be sure to sign and date the.affidavit. The affidavitshouid 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 reg�ding the.}ata,or.if you are rrquir„d to obtain a workers' compensation p'oiicy;please call the Department at the nrxarnlrr.lis zd below. Self insured companies should enter their self-insurance license number on the amroariate line. City or Town Ofnciais Please be sure that the affidavit.is complete and printed le iib}v. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office Of-Investigations has to contact you regarding the applicant: Please be sure to fill in the permittlicense.number which will be used as a reference number. In addition, an applicant that must submit multiple permitllice;nse applications in arty given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Adciresg"the applicantshould write"al] 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 Iicenses. A new affidavit must be. filled out each year. V%rhere a home owner or citi=n is obtaining a licenses or permit not related to any business or commercial venture (i.e. a.clog license or permit to burn*leaves etc.)said panotn is NOT required to complete this affidavit. The 01�ce 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 Departnent's address,telephone and far, number. The CommonweaL.1th of Massaehusetts Department OfLmdusetrial Accidents Office of lEavestigstiions 600 'Wasl Lfi-IL Strerwt Boston; MA 02111 Tel. # 617-727-4900 eart 406 or 1-9.77-Ivip,SSAFE Revised 5-26=05 Fax#61 7-?2.7-7749 v'ur'ur'_mass.c ov/dia Date HORTM 1 .` 3?�f � •�;.,�oo` TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 010 ,SSACHUS� This certifies that . . . J I B . . . . . . . . . . . . . . .! . . F. . ./.� . . . . . . . . has permission to perform . .�-�.': . . �?�f.".° `I. .�• . . . .. . . .".`. . . plumbing in the buildings of . . f? /?0.1.l. µ. . . . . . . . . . . . . . . . . . at . . . .... . . . . . . . . . . .. North Andover, Mass. Fee-2 Lic. No.2,IC. .`�. . . . . . . . :�... . . . !r .� : . . . . . . PLUMBING INSPE&OR Check # Z 8223 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location hx2m Ali(__ sI Owners Name L,-,- 4�/(� qjl Permit# �C, 3 �_9 y Type of Occupancy A-mount New Renovation Replacemen'? Plans Submitted Yes No 'FIXTURES � x H W� En a H . O O cc L W CCn nCn x a' • z a C SLRESNE BASUVEW M lJO I M Rpm ( I MH-" 4M HDM M IL" 6II3 HDM 7MHDM M FI-CM (Print or type) / L Check one: Certificate Installing Company Name q11074-Rd E RIL hW— ❑ Corp. Address 9L'5- LA/Wc- S7' Partner. Al vr-!L NI t1- A?'qL- 0r8� usmess Telephone Finn/Co. Name of Licensed Plumber: ) [� 9�k Jj f Insurance Coverage: Indicate the type of insurance 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 three insurance Signature Owner Agent F I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa se State P mbing Code an Chapte 142 of the General Laws. By: nature 01 UctnseGum er Title Type of Plumbing License 187y City/Town icense Numner Master ❑ Journeyman APPROVED(OFFICE USE ONLY The Commonwealth of Massachusetts kj 11 Department of Industrial Accidents Office of Investigations izit'4 600 Washing ton Street ti Boston, MA 4.2111 c www_massgov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Eiectricians/Plumbers kripficant Iaformation. Please Print Le--ibE BIIle (Business/prgsttization/Endividual}; 57 , Address: a 5 Lek ST. City/State/Zip:1V4v&2ff141- f!1?c., OiP �. Phone `)a 3 6a °7c-)/$ . Are you an employer?Check the appropriate box: 1.01 .❑ I am a employer with * 4. ❑ I am a general contractor and I Type New constructionof (required): employees(full and/or part-time). have bred the sub-eontmaors I am.a-sole proprietor or partner- listed on the attached sheet.2 7• ❑Remodeling ship and have no employees hese sub-contractors have working for me in any capacity, workers' comp.insurance, g Q BuildingDemolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9 Building addition required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing Myself[No-workers'comp. c. ISZ §1(4),and we have no g repairs or additions insurance required.]t .employees. [No workers' 12.❑Roof repairs comp, insurance required_] 11❑Other `Airy applicant limo checks bo>•}(must also Elul out the Homeowners who submit this affidavit indsection below showing their workers'compensation policy information. t icating they am doing all work and then hire outside contractors must submit a new affidavit indi ;Contractotr that check this box must attacked an additions:sheat st-,owir catiog such. Ehe risme of the sub-caonactors and their workers'temp.palm infomnstiorc. I am an employer than is pronrfMg:workers'compensation er�suranre information, for my ePloye= Below is the pout y ana'job sift . Insurance Company Name: ' L 14TH p5(,y,P�gAIG� Policy#or Self-ins.Lie.# / 9 Expiration Date- 9L I O - /D Job Site Address: 5 f,� 11�T . City/Statea fyd 4adla t 8y5 Attach a copy of the workers' com nsati P� MFS d pe policy declar'atioo page(showing the ure policy somber and expiration datej. Failure to seccoverage 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DlA for insurance coverage verification. I do hereby certify unde�andpenaWm ojperjary that the information provided above Si tore: - A is true and tarred Date: S G - Phone#: q - �/ Of Jcial use only. Do not write in this area,to be completed by city or town offu iaL City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Tovvn Clerk 4. Electrical Inspector S.plumbing inspector 6.Other Contact Person; Phone#: Information a end Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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 mom of the'foreping engaged in a joint enberprise,and includirag the legal representatives of a deceased employer,or the receiver ortnistee of an individual,partnership,association or other legal minty,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 bo deemed to be an employer." MGL chapter 152,525C(6)also states that"every state or-local licensing agency shall withhold the issuance or renewal of license or permit to operate a baseness or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidenee.of compliance with the insurance coverage required" Additionally, MGL chapter 152,§25C(7)states"Neither t3he commonwealth nor any of its political subdivisions shall enter irrto any contract for the perfarmarice of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cantsacting authority," Applicants Please fill out the workers'compensation•affidavit compie✓tely,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 certificates)of l 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 koe sure to sign and date the affidavit The affidavit should be rehrrned to the city or town that the.application for.the permit or license is being requested.,notthe 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 numberlisted below, Self-m-sured mrrepaniess should ent-_their self insurance-liemse 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 wiII 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of lndmtrial Accidents Office of Investfisations 600 Washington Street Boston, MA 02111 TeL 9 617-727-4900 ext 406 or 1-8.77-NIASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia