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Home My WebLink AboutBuilding Permit #239 - 34 OLD VILLAGE LANE 10/3/2008 OORTil '9 BUILDING PERMIT o "aD , 4, < 6*6 0 TOWN OF NORTH ANDOVER O APPLICATION FOR PLAN EXAMINATION 3 �D ey 4 w . Permit NO: Date Received li gDRATlD �SSACHU`�� Date Issued: u"� O IMPORTANT: Applicant must complete all items on this page LOCATIONC. f Prin(� PROPERTY OWNER I-R�1` Print MAP NO: n_PARCEL:-16_ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial epair, replace Assessory Bldg Others: Demiti Other Septic Well Floodplain Wetlands Watershed District Water/Sewer ESCRIPTION OF WORK TO E PREFORMED: P4J^eo e� s- tnait- h,l,,j ke -Identification Ple�a Type or print Clearly) OWNER: Name: o , Phone: cc Address: Oi d V 1 I r' L-nf� Ivp _ nrd`, o CONTRACTOR Name: V v 1-f4 d 3 Sk C. Phone: 'T7'9 `�4o5 (17�,5 Address: / wl t rly (`� (/ Supervisor's Construction License: 7 Exp. Date: c7' 1 Z-'C 1 / 0 Home ImprovementLicense: 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: $ �0 FEE: $ g o � Check No.: J J Receipt No.: NOTE: Persons contracting h un gi ered tractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracto Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street fiire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 h I 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) i ❑ 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:INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 i i Massachusetts- Ula►rtmenmen- t_-_ j e� or Public Sarety Board or Buildin" Re•T Construction Supervisor and Standards License License: CS 75914 Restricted to: 00 j BRIAN M DIAS 7 SIR ISAAC WAY HUDSON, NH 03051 Expiration: 9/28/2010 ('ummisiunrr Tr#: 2958 I Restricted to: 00 00- Unrestricted 1G 1 2 Family Homes Failure to possess a current edition of the Massachusetts State.Building Code _ is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS I i aauotssiucmoD ZZ610 VN',12ff18M31NJ ab 31aaIW 991 SMOad31N a 13VHDIlN 00 :UO!Pw§aa;; £1541 #�l 600Z/£1/9 uot; tdx1, a 696K0-:0,1ePLPAS 10EL4 SD :8sua311 esueoll loswadng uol;onj;suo sp.n.pue;S put suoi;eingag fluiplina jo paso .. q�pYlZ�J�l0D7Y)A/'�O ��namaio2uru�oGt. a�� .OSHA 00165669 U.S.Department of tabor Occupational Safety and Health Administration Michael'D.Meadows has.successfully cgmpleted a 10-hour Occupational Safety and Health Tmining.Course in nstru ion Safe &Health Jat uary'h1a,2008 - - miner), (Date) 17- lie i�anvr�zoozulea� o�,/�aeaac�ivaelta �': Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:-,-157470 Expirat-dn 'k0/462009Tr# ,259864 Type Pn�ate Corporation MEADOWS CON U-RUCTION' MICHAEL MEADOWS% 66= 188 middle Road.Vied.MA 01922 978 4%4735 Fax;978 498-1700 Meadows Cell: 878 815 7148 • n I Str' uction Co. ANW FIRM From; Michael Meadows F= q 'Y- lv p'°°"w ofte: October 1,2008 Re: 3y old u Z) Cpp o� Co-r-� o S. c�_ W�_ 40 rRDmO h1� .- K� VO/TO 39Gd SMOCIV3W 0OLT6608L6 LE:ZO 800Z/T0/0T FP"Wlz6h;6f=Tl'0'NA RD - . CERTIFICATE OF LIABILITY INSURANCE oATn:4r, "orl iM18URANCE0 Far 7GROUPTH13q'eR �yZ00ftRY ROAD ONLY"TT C0 YE as HUED AS A—.-TTKR OF.INFORMATION AY.' hp R loom UPON-rim CERflF CA QUINCr MA OYl7�` 79 ALTER THE C tms �DOES� • EXTEnuO� ' 110MERs AFFOMFIG COVERAGE NAIL at CoNstnud noN COMPANY,LLC rNBURER n M�nniC�9p l tstOAn.e Cc >iny $160 Rps2 :!"SURER Safair Ins�neoCompnn r� -T•�— 42 11"SURER C RJkCEB WSURERf: itrlrn �IAvt ae t, ANY Reauet ,T�RAt.OR COHWnON OF ANr u60 YA lig qac . MAY PERTABI,' {g AreuRANc,E�AF CONTRACT OR prHoe�CunreM►'w+TH RE '90 TOME ICY pLfl rcA 'llp ANDMG ?�CIEi.AGM9fAiEt FO MAY eY nx PCR.�GtFs oEseRR�p _ :j--`1 8$►90Me1 NRv"A1C RiEN.Rt'3'MtD VY PM17 CL�gS BVBJECr rA Kt TI F. F l� F(CUMM4�Mpty g oq O OR' f TYPEOr.WStlRAH4C. w_ Q0�10RtQN0 OF SUCH I ERAL ,K Y 4(11YBER ++.c vy $ OAT" -7 H ttMrrs .•{ COMMFR001LC�kA.L1A8LYfYj �801fI-08 13►ua 09Vt8/p9 . A i., `` I�y CWe�sMAofi J oCCuu tr0R A0��000 l 6tFD.BMW06yonePy,�y tb i t ALAW 3ADYNAa(V y 11000 q iRLGQiATE�♦N!'C.APPLdp PR'R; -'Jr ACOATE is '.j r0� I i per' 000 IpOUGY. 1ACT LOtf ;oRORUCT • 1 — ( ' 2702831 1 . .- .�s'c•0".!P�Atm, .'s x,000,0�oe ! .. 08/scup9 o+�+er�o SuWLE Lr��T . 1000�pp I3 1 f 8CHWUWO Aj�pd WDRY IUAV / I X Ma1W4vios i( oa�j Is i("roNADVWMAUT04 eaaaYuuuRv "_• �. IFR DAMAW I1 !j •— M6Etn. i Pa 1 � AU71D jOVMOkY-FAOA ENi f 1 ;0fl1ERTRAN FA tel Is 1 AUTO GN�v; • ' '.OtCleBluA�yq WIMLRY AGG 3 �— ��a1CtXi' �. t CLAIMS MAOp I i EACH OCC :5 i RETemoH 4�JTYTIOMIWa —�s .uc rr •fps. !#.LEAGMA60MUNT � ;S Ps°um°wwwr E.L0MFAStCARAFROYte 5` 07t4ER:_ ' •EL pG,^-Aw-mCY,Le1Gf' :s ' Cf ION Of OPFMAON&LO¢ATIONSNfef1IC..... (CILSIONS ADDED BY ENDCRB 11!!1 T/SPECIAL PRgy a RT1FfCA7>C HOLDER. ! M Kkjj" 1MGAVTtfORIY1f CANCELCA 4N S$R0.CK*OOn)AOAO SNOW An,of 111F ASM oescroeSD PoUelfS ae ?OQOX 263. UPPAT1ON OATC THEREOR, 7h2(Sltnkd fmcuawt►e bic"GAR YD MAX 19 DAYS NORFOLK,MA vYnnrcr.�='o THC CERTMATL ypLp�R"MVA TO M I Or,Q AX 19 PA Qom• T00050*AU-FaMNOuiU T10N0RLWT • 0'3 AOMM OR 6NTi M& L nY OF A%y 1W(p L"*M TNG INSURER ACORD 25(Zo01/II�' Gf*fica%8 79".. Nf1IOId j9� ACORb CORPORATION 1908 600/ Z00'd b90Z# cF:nr onnv•t..sam 00/Z0 3JGd SMOQG3W 00LT6608L6 LE:ZO 800Z/10/01 -••vv vvw vva LEW Ll�?C Liberty Mubw Gmnup *� P.O.Box 9090 Mutual. Dover,NH 03823-9090 Telephone(ti00)6S3-7893 Fax(603)-245-5330 September 11,2008 NORFOLD HOUSING AUTHORITY PO BOX 293 NORFOLK, MA 02056- RE Ctreftme of Worltera Compamatbb kmrauoe bmuredt MEADOWS CONSTRUCTION CO LLC 166 MIDDLE RD BYFIFLD, MA 01922 Policy Number WC2-31S-352433-038 Eflecbve: 9/12/2008 E:pifatirar 9/12/2009 Coverage afforded taaiez Wodcers Compensation I-awof the folloaving,tbte(s)• MA �lopees L'abili��!tL� Sole PcornietorlP r Cover eg_E(�pon Bod4Y lnlu><y By Acadenr $100,000 Bach Aceidcnt Bodily Injury by Disemc: S 300,000 FAch person i B-Uy Injury by Oisease: f 500,000 policy Litaits As of this elate,the above referenced pW;ybD1der Is inssUmd by Liberty Mutual Fire ImWanc a Co under rhe 1lC listed policy above. The insurance afforded by the hsrnd polity is subject to alt the leans,esduaions and conditions,and is not albecec by any be issued. ,tears or condition of any or other documents with respect to which this cecoificate may be issued. This certificate is issued as a mutter of infonymL on and 'and confers no t upon you,the holder. This certificate is not an insurance Policy-W does uut Amend,extent the coveragecertificate afforded by the policy listed above. If*'is policy is cancellod before the salted eapicacon dste,Liberty Mutual WX endeavor to notify you of such cancellation. � *' AUTHORMED MREMTATM t.Mrs MUTUAL OWSURMCB GROUP '�c.�b ureooros t't.tsmery savrtrtr.Qratmuvice aiaevr...Q�,.�ca iasnmc„�a�o.sea ty moseoomp.fa. cc humerk Pmduoet of Retard MEADOWS CONSMMUCTTON CO LLC CLIFFORD R LARSON INS AGCY 166 MIDDLE RD 1343 MASSACHUSETTS AVENUE SYFI M, MA 01922 ARUNGTON, MA 02476 ' 9/!1/1908 • 08/£0 39tid SMOQtf3V 60L16608L6 L£:Z6 800Z/18/01 10/01/2008 02:37 9784991700 MEADOWS PAGE 04/04 ' ... �t0MV11'0i31�.iA -61 " iNoo smoavaW uoMUCICL b al a b9B8SZ N+J "..- .' ' .. e00Z'ilr ;. j . QUA b ';iio (pea t1b 0b 1N�W311 on 3WON p► Wr3gppttsaot�gn�g4%4Ppv opj LMG 10/2/2008 9: 14 PAGE OOZ/00'L LMU Liberty Mutual Group Liberty P.O.Box 9090 mutume Dover,NH 03821-9090 Telephone(800)653-7893 Fax(603)-245-5330 October 2,2008 ROBERT BARNETI' 34 OLD VILLAGE LANE NORTH ANDOVER, MA 01845- RE: Certificate of Workers Compensation Insurance Insured: MEADOWS CONSTRUCTION CO LLC 166 MIDDLE RD BYFIELD, MA 01922 Policy Number: WC2-31S-352433-038 Effective: 9/12/2008 Expiration: 9/12/2009 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability(Limits): Sole Proprietor/Partner Coverage Election: Bodily Injury By Accident: $100,000 Each Accident Bodily Injury by Disease: $ 100,000 Each Person Bodily Injuryby Disease: $500,000 Policy Limits As of this date, the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. The insurance afforded by the listed policy is subject to all the terms,exclusions and conditions,and is not altered by any requirement,term or condition of any or other documents with respect to which this certificate may be issued. This certificate is issued as a matter of information only and confers no right upon you,the certificate holder. This certificate is not an insurance policy and does not amend,extend,or alter the coverage afforded by the policy listed above. If this policy is cancelled before the stated expiration date,Liberty Mutual VA-11 endeavor to notify you of such cancellation. X—M(ro f a;�„ IZ AUTHORIZED REPRESENTATIVE LIBERTY MUTUAL INSURANCE GROUP This Cerr ficate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those companies. cc: Insured: Producer of Record MEADOWS CONSTRUCTION CO LLC CLIFFORD R LARSON INS AGCY 166 MIDDLE RD 1343 MASSACHUSETTS AVENUE BYFIELD, MA 01922 ARLINGTON, MA 02476 10/2/2008 The Commonwealth of Massachusetts 1 Department of Industrial Accidents r' F,t. %�l Office of Investigations 600 Washington Street Boston, MA 02111 f 3 www.inas sg . ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumhers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7'S Address: e-Z;a/d/I'-- f`8 City/State/Zip: i Ma ', 4 2-Z Phone#:_..9,7F �S �� Are you an employer?Check the appropriate box: Type of project(required): 1.011"am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 E] New construction ti 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. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised.their 10:0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No.workers' comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other +Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they arc doing all work at-ad then hire outside contractors must submii a new arndavir 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: Policy#or Self-ins. Lic.#: 1,tJC Z �j f�' j � �Sj Expiration Dater Job Site Address;3� iQ �. V-11c, an e. 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 cqrVyy under.the pains and pena;1 s of perjury that the information provided above is true and correct -2- Sic-mature: FL Date: Q7 Phone#: Official use only. Do not write inn this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have _ employees,a policy is required. Be advised that this affidavit 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 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/iicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/iicense 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 fiiture permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should.you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26=05 Fax#617-727-7749 www.mass.gov/dia NORTH Town of -_ y �, o jY dover, Mass.,�� 3 0 T O LAKE �, T COCMICKEWICK 7 RATED PPS\ �y BOARD OF HEALTH Food/Kitchen PERMIT T D ., Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... ..................... . ....................................................... ... .................. ..................................... Foundation has permission to erect....................................... buildings on .... ...:..:.. .� ::.. /.�. .4 ......�. Rough to be occupied as } � Chimney provided that the person accepting his permit shall in every re i 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 STS Rough ..... ...... .............................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. r Meadows Construction Company f.f—C. Established in 1978 Site Work •Construction Management• General Contractor•Home Repairs PROPOSAL Name Bob Barnett Address 34 Old Village Lane North Andover,MA Date: 10/2/08 Job Location Same as above • The following Proposal is for the roof installation for the property located at the above address. We are a certifiedMaster Elite GAF Installer. We are also certified to do Rubber Roofs with RPI and Firestone. The following paragraphs describe the work that will be performed. Installation Procedure . • Strip existing roof on the entire house • Install an 8 inch drip edge,white • Install ice and water on all leading edges and valleys and transitions • Install new vent pipe flanges • Inspect decking for any rotten or damaged areas/Price includes 5 sheets of 1/2,,plywood • Install 15 pound felt paper • Install new GAF T-30 shingles,Pewter Gray • Install new Cobra ridge vent system • Remove all Debris Cost for Labor and Material for Roof: $ 7,500.00 Payment Terms: Upon Completeion Warranty: Meadows Construction Co.LLC guarantees all work performed for a period of one year. If any problems occur we will cover the cost of all labor and material to correct the problem and meet the customer's satisfaction. b-162-- Auth na re Date Date 166 MiddleRoad .• Byfield,MA 01922 Phone: (978) 465-4735 • Fax: (978) 499-1700 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 3 9 00 l �U (-,-j is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: Q�(�c ( . ocation of Facility) , ature of e t Applicant Date r� \ The Commonwealth of Massachusetts I I Department of Industria[Accidents K; Office of Investigations � iN•.. 600 Washington Street \ UMq r Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual): /y eAd o W s Address: ) to(- nt-)31 Y ve, City/State/Zip: Ne L-.ly u!U 01� Phone#: R 7'S (a ti 7 3 5 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with -5 4. ❑ I am a general contractor and I 6. ❑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. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9 ❑ Building addition [No workers'comp. insurance 5. ❑ We area corporation and its required.] officers have exercised.their 10.[] Electrical repairs or additions 3.❑ I an a homeowner doing all work right of exemption per MGL 1 I. Plum p p ❑ ng repairs or additions myself. [No workers' comp. c. 1.52, §1(4), and we have no 12. oof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other +Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ,Homeowners who submit,this affidavit indicating they are,doing nil 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 ofthe 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: `l '0 0-e/ � 41-1 L/1-�,4 Policy#or Self-ins. Lic.#:—W C 2 - 3 / S - 3S Z<( -3 Expiration Date:— p . Job Site Address: 3 y ole) �t�� L-N Ci /State n �� —City/State/Zip:/Zi p: !V 4NJOUe2 Vit a. 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 enalties of perjury that the information provided above is true and correct Sigrtature: Date: 0O Phone 9: '17 f 4f%.S -47'325 - `- Official use only. Do not write inthis 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. 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 apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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/iicense 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. 4 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26=05 www.mass.gov/dia Location No. .3 Date 140QT1y TOWN OF NORTH ANDOVER F 9 � Certificate of Occupancy $ ;'s'„�,µ;s•`� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I �- 2x566 " '� Building Inspector