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HomeMy WebLinkAboutBuilding Permit #119-2017 - 326 FOREST STREET 8/8/2016 9 �p /� /�p •-�� �j h /�.�. NORT#I 1r'�/ 1"( ' /�V�C NVQ a •� + r Y o �t�eo ,6q/{ BUILDING PERMIT c? bd::,• ,..,.,•', °o� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION41 n � Permit NO: Date Received 7 lit Ab 02� �9SSA Date Issued: PJ /� CHuS���y MPORTANT: Applicant must cop Tete all items on this page a } LOCATION' 3z& rI .=s� Print PROPERTY OWNER Print MAP NO: P&A PARCEL:{ 'ZONING DISTRICT: t 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 0 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other o Septic f Well Floodplain 0 Wetland's Q Watershed District Water/Sewer R� 14 f dee-I., oecc I NA Identification Please Type or Print Clearly) OWNER: Name: Phone: (b11 � ?9e/- o 9--72. Address: CONTRACTOR Name: Phone: 791-$ 1 q-9�W,01 Address: ate- Ct: M4a Supervisor's Construction License: Exp. Date: ,? 4 Home Improvement License: Exp. Date: -7ti ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1-'l-L&0 , FEE: $ Check No.: -5-751F Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acces the ranty fund n 5Signature of Agent/Ow � '. rgnature of contra Location No. ) Date • - TOWN OF NORTH ANDOVER � kb Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $_ � TOTAL $ Check# I� `wilding Inspector f l , �"'4 r ✓ I I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ l 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 ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF a U FORM PLANNING & DEVELOPMENT Reviewed OnII G Signature_A COMMENTSI'v 14 PLAW IJ 1 X06 CONSERVATION Reviewed on to Signature COMMENTS HEALTH Reviewed on Signature W- A Ir COMMENT I ' Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: w FIREDEPAR�TMEN;T Temmster:ontsite �yes pDuo _ »� LocatedOsgood Street Located,�af' 124�Ma""iri�Sti:eet. �� . � �,�p < � FiretDepartrnentagnature/dafe _ 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) 1 22 r ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r` 1 1 Building Department I The following f the required forms to be filled out for the appropriate permit to be obtained. I 9 is a list o q i 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks i Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Co of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I New Construction (Single and Two Family) � Building Permit Application 6 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit i 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 m ust be submitted with the building application Doc:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ TanningfMassage/Body Art ❑ Swknm.mg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. VK Pennan.ent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING (OU DEVELOPMENT Reviewed On 'It Signature_�� "Y COMMENTS P 4 PIW IJ)0.1 CONSERVATION Reviewed on to Signature COMMENTS HEALTH Reviewed on Signature / i COMMENT k 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: F�IREDEPARTMENT u Located 384 Osgood Street F •� t Teem D ter r t d at 1T ` -p. MOS e on ;LocaT- rFireDepartimeiit�signature/date COMMENTS: � NORT1y '9 Town of Andover O so6 h y ver, Mass,L^011 A- coc«1c«ekkwsk 8 . 246 w�c« �1' 7,4 ADR�TED S u BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System t THIS CERTIFIES THAT Wid 1 . . BUILDING INSPECTOR ........... ... . ................. ........................................ Zr ✓.. s - ,..,,. Foundation has permission to erect .......................... buildings on ..... .................. .................. Rough . � i gay Ank-0. .to be occupied as ..?,r.��. t. ..�rt ...... .....: .... . . Chimney provided that the person accepting this permit shal�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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSk Rough Service .... ..... .. ......... ........ Final BUIL INSP TOR 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. Pr avviia1 Page No. of Pages HOVASSE CONSTRUCTION 16 Edgemere Ave. BURLINGTON, MA 01803 (617) 272-1252 PROPOSAL SIJIBMT�TED TO PHONE DATE IW_7--7q4- L)q7-7- -7/j/11. STREET J013 NAME CITY, STATE AND ZIP CODE— JOB LOCATION 4274'amur ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ........................................................ ................................................... ..................................................................................................... .......................... ............. ............... Cie ............. ....&. 4,e_�o........... .. ...... ...... ......... ................ L 1h , ,- , _ -.. _ _.................................................... .............................. .................................................... ................................................................................. .................. .............................................................................. ,;_Vr............................................. ........................... .......................................... .................. ......................................................................................................................................................... ............... ..... ...... .. .. . ........ ......... .......... ............................................................................ ................................................... -11111-1111.1-11-1-11.............................................. ........................................................................ 11.11-11-........................................................................................ .................... ...................................................".., 11 ............­­­­.................... ................................................................ ..........I..................11 1—................... .........................................................11.111.1"..,.............. 1.111.111.1-11-111.1'..-.............................................. 1-1-11'..,............................................­­..­.­.­­ 1.11-111111.1............................................... .............I................... ............................................................... ....................... ...........................................1.111.111.111.111.�"..�11.11,�,,�.........................................................I.I.I.."..",..".�1.1'..."..".."..",.",�...................... Or propofir hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: —rt�-7,_L_ dollars ($ Payment to t*made as follows: A1,6__4- C5 ci .j All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifica- Authorized tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. Araptatta of Proposal—The above prices, specifications d t�r 0 and conditions are satisfa Signature ory and are hereby accepted. You are authorized — to do the work as specifi Payment will b male as outlined above. Ac e [rDateof Acceptance: I Signature MqAiPVx PRODUCT 118-3 ,Nees®Inc,&OW Mass.01471.To Ode,PHONE TOLL FREE I+8DO 225 6380 4 fthAojf, 444 CIO cy 3/q .1 14 C, 4-a `(vc q pF- ps AV ell Ina,-i' ,pp�yp qq r E t ii Ir r L c � Ab e North Andover " June 7, 2014. • 1 tip, �` a - F -, ^�� �e ,.f .ka`",'• �. " +d \ v - �, I a y i.. b aux \�• s,F" !_ /ll 1 Ilk UV � .V 41 v I �a Xk.� Jy'.»V - � l "`�� Mb,.�.°` f 'w W''A. ��'3•. l-t,}`. sl yl-U Lr IA �§a� exa.�i'3 5e ., 5 ,I,, � ,;' *� R am x m r 1, .. � �„ k. "" �ftr t�{ tai �'" A%' • a'%P.` $'�� r#m,. ,a.,;YR'�r VV ��+.�r1, �hA� /a ,K:!o'�• ���1 , '. {.•'�`,•_• �; r" ,� `'� :^z�gy�— `u9 gid iF, c 'I`+}�it`-. s 'AG'�>s�„_ 'dY4 , p,. � .p �� $ ,� . ��f^--`�4`8 �`n✓P 3' ' t � i. r. SIX— ' +d n �,✓�,'u-1. �� ,`f y �' N ,iT+iJ l M K �W- L"f `� �u y` ;�'`+vy" ' kms • s t 3i 1 x> ` rF 1 ` ,; ) ,� 9 a+w lr�•{�.1.4 aK. •a `w ^ ;, ��:-. : � � t�. F ,S',poc.•"'a r,F�'' 3-�Y�,�{j�w '�� "' �,�R`'�+' c>t a�' `$'' K�.yS&1 f T k!! e ,p?. k 1 K:', f 't .. ✓- �,1y.1r�• t +."ii `S 4iw� - �'� eY 5 $�°•€+- apt MA 4;17 v *� � �E� ♦ � K� d� i ``� r`'r 4 � v �� Y`y 'at?w gg�� �'�'+�•✓ +f, `�s�, �'�'.'r. 6 1 x `�+, ,. _ 4 • ti T't IVA,Ac f y;• ,F ice. �pW MVPC 80 Interstates VAORTH Roads C.Easements 6 Parcels 0 to 41 V=114 ft .. .. •- •• •. North Andover MIMAP June 7, 2016 106.A-0072 ,t 106.A-0242 n 106.A-0247 106.A-0241 106.A-0240 106.A-0038 106.A-0219. 106.A-0244 #65 #2303Lti.'.::_ N #25 G #48 106.A-023 106.A-0225 to 0 O 106.A-0224 #87 d r` 106`A-0078` 106.A-0261 \\..... r #59 rn #66 #247 106.A-0221 106.A-0267 106.A-0®3,9 `� �. 90' 106.A-0262 #93 SI #72 #255 106.A-0222 106.A-0223 106.A-0079 #67 _ 106.A-0263 t #263 / t.r;;.:.. ::'-':::"aaltt.•`-•..X31, _.. :.: __ .:. tib•:c::::__.. .:.. 106.A-0080 p ....:- :'106.A-0 1j t' :::'::':' i;-�':_ 110'6A 026:0:•:c:__'="t:.":•:.'i`_.•- •:.':. 106.A-0011 alcr.: ':::. -.�:_- .:.::::5alu'y_:Valu• ':::=. ,y. 106.A-0013 106.A-0082 #306 :-"•' yy. Ur #295 .._' . •.•`L•..vJ[r•... ,I,'.•:•I4.:�tltr.:y:'.'` :.yp•.:•aUc`:y�, -- .... 106.A-0014 ??106rAv0.315_.'a�) : _.. � #328 -:.':uJL.:•.i:�_=-� '.i:'r::•'• .�::__• :::::... :.:" .i: Ak #326 106.A-0083 #327 01\ S� S : ....:. .. ..:. flu.' .. > S�cr #340 . .... f: lcr .:.::'.,: :i 106.A-014 �°!` -`�-�-:_"•-.: . _.:-btu.'`:,::_ i 106.A-0193. .7 _= T J,= "a 106.A-0192,;:�:: -_,., .. 106.A-0218 �, #350 #360 106.A-0140 106.A-0015 #333 #335 106.A-0012 #28 106.A-0149 106.A-0217 #370 106.A-0034 M MVPC Bo Zoning Overlay Zoning r}.Municipal Boundary [3Adult Entertainment Distdc Businer s 1 District [J Machine Shop Village Ove 13 Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Rail Line 0 Watershed Protection Dist C Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates 0 Historic Mill Area 0Businei s 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of _1 ©Medical Marijuana O GeneraBusiness District Of roc 9� North Andover.Additional data provided by the Executive Office of SR ©Downtown Overlay District G Planne I Commercial Dev Environmental Affairs/MassGIS..The information depicted on this map is 6 Roads 0 Historic District $$Corrido Development Dist �.� e OL for planning purposes only.It may not be adequate for legal boundary (�Osgood Smart Growth(40 R Corrido Development Dist O - avil to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER r Easements d Hydrographic Features a Corrido Development Dist f 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Industri 11 District x THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ❑Parcels -Streams L' Industri 12 District IF_ a OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Wetlands G Industri 13 District •o �� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 6 Industri ISD District • ' O Exempt Lands Reside ice 1 District '�7 °+�„�o•�`t.(�1 THIS INFORMATION Reside ce 2 District SSACHUS� ^.R-ide ce 3 District ll dei ice 4 District 1"=191 ftde ce 5 District ad y.de ce 6 District 7���.ge esidential District North Andover MIMAP June 7, 2016 aUu•":•."•._..•'.`.=.: :'. 60 SUNSET ROCK RD --"' 106.A-0224 ATSUGARCANE L .:•Flu..:__.•:'. ._.....�tlu •_-_ _...' :::_::'atilt.•.::__ ...... till .._. " r 106.A-0261 M 59 SUNSET ROCK RD O 66 SUNSET ROCK RD 106.A-0221 10 106.A-0267 9p` 106.A-0262 72 SUNSET ROCK RD 106.A-0222 106.A-0223 67 SUNSET ROCK RD 106.A-0263 99 SUGARCANE LIN -: - 106.A-0225 j .=-:•-' Ju :._-' I e< .106 A 0260: _ 106.A- 81 • - I ✓6 I}, :•.p.•- :':":::"Valu..•y:•��•:-::::"�Jlt.:.,y..:y3�tt,::`.':::'•CUs•:`.:. 1,•._..:::_. •-•• f;�:•:.:::_. ._.. I,:.. ::_:':'�alu.:::__�, 1 '` ::-_Vii:::__••' ::: ':r_=.::. ?......:: _•::_._. _: _.. _;: p .a<. �1i•: ':::? alts.,i,.-- .: ::': y:-- _::. 106.A-0011 t` 106.A-0013 ! -'-..1; I: .:_ 306 FOREST ST 106A-0�2 _c s // �t �• _.:::_.'�•°=:_:_••:�'..:::::.�•_..• 1,-:..:,,3,1u ';•'.�;...{r..l, . :::- ---- 106.A-0014 106.A-0014 i,. :::=. .,i,_ .:.:::::. •,i._ .i 328 FOREST ST ", .:.: r__';l; .:.•=:';G t, :1'06'.A702'15;-:':*'.'. ' :_:.::_... \326 FOREST ST :_ ::...? :' Yalu '`';` -•:.:: _.. ': :.::-=- ....:"�.� •_..:_� .....�... .:. 106.A-0083 190 ..•.....__.:`.talar.:: ': :-::. : :.:..flu • .I ... lf, ,• 41, 340 FOREST ST ;::Flu.._ ':-==:_: Ju ._: •:':":__...: 6�Pi=0192`.::...•:';. 106.A-0218 106.A-0193 10 Iii �•.-:....•_,•... ...::ally`.::.. 106.A-014 106.A-0015 S ;;•• MVPC Bo Municipal Boundary Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Rail Line Meters Data Sources:The data for this map was produced by Merrimack ORT Valley Planning Commission(MVPC)using data provided by the Toof Interstates N N wn —I Of,t�♦p r♦'q�. North Andover.Additional data provided by the Executive Office of —SR ♦ ♦♦O Environmental Affairs/MassGIS.The information depicted on this map is Roads 3' e _ OL for planning purposes only.It may not be adequate for legal boundary O -- M definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER t r Easements ~ p MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels # r► THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY • i ^ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Trails �► o q i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF O Hydrographic Features '� o♦�r�o«�`�ej THIS INFORMATION —Streams 1SSACli Wetlands 13 Exempt Lands 1"=135 ft «�` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 I www.mass.g ov/dia Workers Compensation on Insurance Affidavit: B it ders/Contractors/Electr>c>ans/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i7;�J/1:�Si_ �� � J 4z Address: City/State/Zip: ; '01223 Phone #: 7_1 D- -71 g5 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 15' _ 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.1 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 40AP-b ` S Policy#or Self-ins. Lic.#: �(off 5_-4 7- Expiration Date: 1Z(( 1,;-1J1, Job Site Address: �2 o� � 5� City/State/Zip: A� i4„,do,/G,,- jq pJ W!5' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under the pains and penalties ofperjury that the information provided above is true and correct. Si nature: Date: 7-3 / Phone#: Z70 - 79 c� Official use only. Do not write in this area,to be completed by city or town officiaC 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#: i 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." I 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 returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia ' V XIC tU077?19;?1 r7?.L(/CCI1,11?P�U( :1f7'CJLLl4CI.f Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR i 1 Registration ;� 122054 Type: E + Expiration 711:5/2018 DBA HOVASSE CONSTRUCTION—NC =` RICHARD HOVASk r' 12 COLBURN STs* �•`�? BURLINGTON,MA 01803 Undersecretary . I • Massachusetts Department of Public Safety Board of Building Regulations and Standards,V — -- I License: CS-063351 Construction Supervisor 1, l rt rt 'f E RICHARD E HOVASSE 12 COLBURN ST?- 14 BURLINGTON MA 01 ` 1s 11� F t YY If to! ,nn Expiration: i Commissioner 07/30/2017 SUMMARY OF VERTS BUILDING TIES SEWER 0 FDTN. 94.47 6'OFF � LDG. CORNER A B C D NOTEs" THIS PLAN & CERTIFICATION 7NorSEPTIC TANK IN _.97,0: SEPTIC TANK OUT 38.0 24.7A WARRANTY OF THE SUBSURFACE DISPSEPTIC TANK OUT 96.81 PUMP TANK OUT 40.3 34.4 - — SYSTEM. IT IS A RECORD OF THE LOCA PUMP TANK IN 96.74 DIST. BOX 23.7 35.8 — — AND ELEVATION OF THE-.EXISTING SYSTEM DIST. BOX IN 98.77 COMPONENTS. DIST. BOX OUT 98.59 INV. IN CHAMBER 98.50 "1 HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL; BOTT. CHAMBER 98.22 EXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS-BUILT SUBSTANTIALLY AGREE WITH THE APPROVED PLAN AND HAVE DETERMINED THAT THE BREAK OUT ELEVATIONS, IF APPLICABLE, HAVE BEEN MET." APPROVED DESIGNS PLANS. . I SIGNATURE OF DESIGNER DATE i �Ir rs9 ,TOW MAP 1OBEI TOWN LOT 13 , i (1.5 AC.) _. N/F MILLER ILL r BIELIK �, - ox � 1 ••.' QM.TFa i �Q4U VENT ftp ;;.-, �;; INSP. J �.aPORT 20 1 00 GAL. pv TIC TANr +� Wo GA� 40 PUMP TANK D-80X N r `..a- g4.72�,„ 11930' -� .,..- — LEACH FIELD ST RW W/40 INFILTRATOR CHAMBERS �H OF Mass . VIADIMIR L. oyG� g NEMCHENOK u' m ' �,. ... AS BUILT PLAN L oG�� q OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, MASS./326 FOREST STREET H AS PREPARED FOR MARK BIONDI TM: 106A w 8-18-14 TL: 13 �11 Ell cu SCALE: I"=40' 0 20 40 so MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, .MASSACHUSETTS 01810 w