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HomeMy WebLinkAboutBuilding Permit #442 - 412 MASSACHUSETTS AVENUE 12/12/2007 RTF�NO BUILDING PERMIT 0.4 "O TOWN OF NORTH ANDOVER or `.� `-~ °0 APPLICATION FOR PLAN EXAMINATION Permit Nb: Date Received �DRATED �SgACHUgE� Date Issued: �-" L IMPORTANT: Applicant must complete all items on this page LOCATION :/ ... , V (9- Print PROPERTY°OWNER 6'6'x,/d /*,011: Rrint MAP NO #ARCEL O,l ZONING DISTRICT:-Historic District yes. no Machine Shop Village,e yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building XOne family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic W6II Floodplain Wetlands Watershed.District WalterlSewer. DESCRIPTION OF WORK TO BE PREFORMED: LJ r Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Svs>�1 � � honeP 603 Address:. 5011 l s• d t� C� �' l2> Supe ndsor's.Construction License. �._S �'' / Exp. Date: ' 0 Horne-Improverhent License: . Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ,SC.$J, FEE: $ q X Check Receipt No.: NOTE: Persons contracting with unreErister contractors do not have access to the uaranty fund ignattare of wAgent/Owner Sgnature OT bontractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans I A 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS t 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 Located at 384 Osgood Street FIRE DEPARTMENT Temp Dumpsfer on site yes ':no `- Located at 'I24,Map Street Fire:Department sionaturefdate. 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 j 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 2007 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 .o Building Permit Application Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses X Copy of Contract 'a''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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location Z//O? Ave, No. '- Date NORTh TOWN OF NORTH ANDOVER BOG F p " Certificate of Occupancy $ Building/Frame Permit Fee $ 13( s�cHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 200 `/ s _ Building Inspector w T CONTRACTOR AGREEMENT THIS AGREEMENT made this 28th day of November, 2007, by and between Bostonian Woodworking Inc.,hereinafter called the Contractor,and Gerald and Regina Kean, hereinafter called the Owner. The Contractor and the Owner for the consideration named herein agree as follows: ARTICLE 1.SCOPE OF THE WORK The Contractor shall furnish all the materials and perform all of the work shown on the drawings and/or described in the specifications entitled Exhibit A, as annexed hereto as it pertains to work to be performed on property located at: 412 Mass Ave. North Andover,MA. ARTICLE 2. TIME OF COMPLETION The work to be performed under this Contract shall be commenced on or before November 28,2007, and shall be substantially completed on or before January 9, 2008. Time is of the essence. The Owner is responsible for ensuring unobstructed access to the job site during.the.time£or oompletion.. .Delays caused by the Owner or other trades may impact the time of completion. If any such delays exist, Contractor is relieved of its obligation to complete the work on the date set forth above. ARTICLE 3. THE-CONTRACT PRICE The Owner shall pay the Contractor for the material and labor to be performed under the Contract the sum of thirty thousand and four hundred Dollars ($30,400.00 ), subject to additions and deductions pursuant to authorized change orders. ARTICLE 4. PROGRESS PAYMENTS Payments of the Contract price shall be paid in the manner following: $ 9,000.00 to start production of cabinets. $ 2,000.00 after demolition and rough framing is complete and window is installed. $ 7,000.00after all the mechanicals are"roughed in" $2,000.00 upon completion of the sheetrock $ 6,450.00 after the cabinets are installed and the trim is completed. $ 2,000:00 when mechanicals are finished and appliances are installed. $ 1,950.00 upon completion of the project ARTICLE 5. GENERAL PROVISIONS 1. All work shall be completed in a workmanship like manner and in compliance with all building codes and other applicable laws. 2. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 4. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 5.All change orders shall be in writing and signed by both Owner and Contractor. Contractor will not perform change order work in advance of receiving a fully executed change-order. -6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Owner shall� obtain all permits necessary for the work to be / performed. Ta'J ton 8. Contractor agrees to remove all debris and leave the premises in broom clean condition. 9. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. Any invoice amount more than 30 days past due will accrue interest at six percent. 10.-Contractor shall not be liable for any delay due to-circumstances beyond its control including strikes, casualty or general unavailability of materials. 11. Contractor warrants all work for a period of 12 months following completion. ARTICLE 6. OTHER TERMS Owner has elected to remove and reuse existing fixtures and appliances. Owner herby releases contractor£otm any claims Including damage caused during removal, installation or storage. Contractor s all move appliances for storage or use on the premises by owner. 6T 1 Signed this day of XC4Vv X/' , 20 V ❑Owner❑❑ ❑Contractor 11/28/07 Exhibit A Walls and Wall Surfaces Remove and replace all ceiling sheetrock with new 1/2 sheetrock Remove existing bathroom walls and frame a new partition wail for the bathroom Patch or replace existing sheetrock walls as needed per Bostonian Woodworking Inc. Frame-and sheetrock a new wail in-the closet-of-the downstairs bedroom-to leave 20"of closet space in-the bedroom side and maximize the space for the recessed fridge and cabinets on the opposite side. Frame and-sheetrock a wall between the washer/dryer and the shower A new Harvey vinyl replacement window will be installed in the kitchen (performed by BWI) Floors Kitchen and bathroom floors will be removed to the sub floors and replaced with a new underlayment to be determined to achieve a smooth transition to the existing hardwood. Labor only will be provided to install and grout ceramic tile,materials to be supplied by Kean. This does not include any necessary repairs needed to the existing sub floor. All repairs will be made at an additional cost for time and materials. (demo by BWI,installation by other sub contractor or BWI) Plumbing Install and supply a new shower enclosure without a shower door. Install but not supply the following:Toilet,bathroom sink,bathroom faucet,kitchen sink,kitchen faucet, garbage disposal,dishwasher,water line for the fridge,washer hookup,shower valve. Relocate the steam-radiator in the bathroom to achieve more-room for the toilet. Fixing the plumbing in the ceiling of the existing bathroom to allow the ceiling to be raised will be an extra charge-of-straight time and material. Vents for the dryer and the ceiling vent will be provided and installed out of the exterior wall using white plastic units. (performed by other-Empire) Electrical Install and supply all switches and outlets as necessaryper state electrical p code requirements. Install an d supply six basic-light cans in the kitchen ceiling,more cans can be added if requested q sted at an additional charge of$150 each. Install but mot supply the vent/light unit and a light over the vanity-in the bathroom. Provide a outlet for the fridge,range,dishwasher,washer,dryer,and microwave. Additional-switches and outlets can be-provided at additional costs. A light will also be provided in the shower. (performed d by-other) Trim and woodwork All casing and doors will be provided to best match the existing trim. A new interior door(2-6")will provided and installed in the bathroom with new trim. The kitchen window will also receive new trim,all existing doors and windows will not receive new trim unless additional charges are incurred. New baseboard will be provided and installed in the kitchen and the bathroom. The beam in the kitchen will be re-trimmed(to stay as narrow as possible)with new paint grade materials, please note the sheetrock and crown molding on the family room side will not be repaired as requested by Kean Crown molding will be installed around the entire kitchen to match the cabinetry. ' k (performed by BWI) Cabinets Cabinets will be provided and installed as per layout. Door color and style will match the sample provided. Cabinets will be full access(frameless)constructed of maple plywood with a natural interior finish. Drawers-will be solid maple with dovetailsandlravel on Blum-full extension slides-with a-soft close. Doors will use Blum hinges and utilize a soft close feature. Extras for the butch are to be included: glass prarie style doors with beadboard-on the cabinet backs and finish the interior of the cabinet as the exterior.and add beadboard backsplash,3 bun feet will be -added to the bottom of the hutchforno additional-charge. Pantry to include a pullout unit on the bottom half to be accessed by both sides of the cabinet,approximate height-of thepullout unitis.5feet tall. Back side of the peninsula facing the family room to be finished with a beadboard back. The peninsula will have an operable door across from the pantry on the comer cabinet for access and false doors on the back of the end cabinet across from the fridge. (the end cabinet size will be determined after all the cabinets are installed(24-30inches)as per discussion) Kitchen and bath counters are to be supplied and installed by Kean unless another agreement is made. Bathroom vanity to be built and installed to match kitchen cabinetry. The cabinet will have a 3 drawer bank on the right side a door on the left side. The size of the cabinet will be determined after the bathroom wall has been framed and the interior door installed to maximize the size of the cabinet and still allow-the door to swing. A matching cabinet in-the corner above the washer/dryer will be provided. A laminated countertop will be made to fit over the washer/dryer with a 4 inch matching backsplash,-Kean to choose from Wilsonart color samples provided by BWI Contractor will install-but supply handles for the cabinetry. (performed by BWI) e ' ., ` r-111 — TPI 2036 Q;.;^; 1 ? a , W i " _J_ m �. 0 r a M a 1, x M" A C. W 2134 L W 3018 W 1934 R CW 2434 L" =i g B21LB09 i ..- O Co w . o �3 a" AM Co M _ M. 6 1r 5 B3D ." BB 36 L. M iA p ne� (k(k W� �xn r: s a1K TC.2388 j' 7 6 . W 3618-24 4 All dimensions size designations given are 2/1 MA is an original design and must not be Designed: 10/18/2007 subject to verification on job site and TECHNO'ocies�I released or copied unless applicable fee has Printed: 11/28/2007 adjustment to It job conditions. been paid or job order placed. kean All(no dims) Drawing#: 1 T Board of Building Regulatiofis and Standards Construction Supervisor License License: CS 82864 Birthdate: 8/10/1972 Expiration $/10/2008 Tr# 2713 Res`ncfion:`:06 E- - TODD M SHILMANV a` 30 BAYSIDE RD '<:.;_•�:.Y: 1':; GREENLAND,NH 03840 Commissioner KORrp TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 41 ° ,. . 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 s�c►as f Gerald A.Brawn Telephone(978)688-9545 Inspectpr of Buildings Fax (978)688-9542 Vs HOMEOWNER LICENSE EXEMPTION Please wint DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER G�\3 ���.� ��8s.�403 Name Home Phone Worm Phone PRESENT MAILING ADDRESS 40. (�1�ssGc�►� 5 ��p_ Nam -e- MA o�g5 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsriUq for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that Wshe understands the Tawe of North Andover Building Departwnt minimum inspection procedures and regm nments and that he/she will comply with saidP rocedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Foam Homeowners Eamon BOARD OF \PPEALS638-95{1 CONSERV.vri?t633-9530 1TE.\1.:1'1i698-95.30 PL.L\ViN'G(88-9535 12/21/2007 08:51 FAX DATE IrMloa+r"Yl AD=. CERTIFICATE OF LIABILITY INSURANCE 12n1/2007 PRODYCER 603)772-4781 FAX (603)772-3246 THi3 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION C ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Fay Insurance Group - Exeter HOLDER.-HIS CERTIFICATE DOES NOT AMEND,EXTEND OR 64 Portsmouth Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 1030 INSURERS AFFORDING COVERAGE NAIC S Exeter, NH 03933 INSURERA: National Grange Mutual 14798 INSURCO-11oston an Woo wor i ng 30 Bayside Road INSURERS' Concord General Mutual Ins CO 20612 Greenland. NH 03840 INsL+RERc: The Travelers Iffdemnity Co. INSURER D: INSURER E: E THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PGRTAIN,TMG INSURANCE AFFORDED BY TILE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R ME OF INSURANCE POLICY NUMBER Al I TE L T i E CY RRATI 1 LIMITS GENERAL LIABILITY MP063845 06/05/2007 06/05/2008 ;AcmOcc0RENCE i 1 000.0001 DAMAGE TO RENTED f 500 ,0001 X COMMERCIAL GENERAL LIABILITY mega e,r CLAIMS MADE �OCCUR MED EXP NAY me parson) S LO A PERSONAL&ADV INJURY f 1,000, "NFRAL AGOREOAIT t 2,000,000 GENL AGGREGATE LIIMII.T APPLIES PER: PRODUCTS-COMPIOP AGO S 2,000, NO POLICY M LOC AUTOMOBILELIABILRY C646053-3 06/18/2007 06/18/2008 COMBINED SINGLE LIMIT = ANY AUTO cE•°�identj 300,000 ALL OWNED AUTOS BODILY INJURY S X SCHEDULED AUTOS (Per pwan) B X HIRED AUTOS BODILY INJURY (Perbabdenq = X NON-OWNED AUTOS PROPERTYOAMAOF f (Per om Mend GARAGE LIABILITY AUTO ONLY,EA ACCIDENT S F I ANY AUTO OTHER THAN FA ACC = AUTO ONLY: AGO S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE f OCCUR pCLAIMS MADE AGGREGATE s DEDUCTIBLE f RETENTION S f WORKERSCOMPENSATIONAND GKI188077871907 02/20/2007 01/20/2009 1TOC. A O TH EMPLOYERS'LIABILITY E.L.EACH ACCIDENT IS 100,0001 ANY PROPRIETORMARTNEWEXECUTNE OFFICERMIEMBER EXCLUDED? EL.DISEASE•EA EMPLOV!j 1 100 0 b��yyeess.dea,.rbeunder SPECIAL PROVISIONS eelaw E.L.DISEASE•POLICY LIMIT I i 500 00 OTHER 0lECRIPTION OC OPERATIONS!LOCATIONS I VEWICLES/EXCLUSION&AMU BY ENDORSEMENT I SPECIAL PROVISIONS Interior Carpentry CERTIFICATE HOLDER TION SHOULD ANY OF THE ABOVE DESCRIEED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE mumu INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Gerald Kean BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 412 Ma SS. ,Avenue of ANY awn UPON THE INSURER,IT&AGENTS OR REPRESENTATIVES. N. Andover, MA 01945 AUTHOFaEDREPREEENTATNE Gar Rohr, [I[ ACORD 25(2001106) FAIT: (978)699-9542 WORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 1Gn VV (f- Address: Address: 30 Qay,S-,' _ City/State/Zip: &rfr,j 1,wJ A44 11 `fy Phone.#: 615 �3`"' `�91 Are,you an employer?Check the appropriate box: Type of project re uired ' 4. I am a general contractor and I p ( q ) 1.❑ I am a employer with_ '. ❑ employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I 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' 9. Buildingaddition [No workers' comp.insurance comp. insurance.$ ❑ 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 employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: Policy#or Self-ins. Lic.#: G,���GO U 77 0 7 j 96 7 Expiration Date: v V 20 OC6 Job Site Address: �fj' -N14Js ✓ City/State/Zip: % • A,Jv<7— 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 and r the pains and penalties ofperjury that the information provided above is true and correct Sipnature: -/ .� Date: �Z L I �' -7 _ Phone#: �03 2_;Y y'2'1 Z Official.use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.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"ever 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 co ,. mmonwealth for an ` g Y ; 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 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. # 617-7274300 ext 406 or 1-877-NlASSAFE Revised 11,22-06 Fax# 617-727-7749 www.mass..gov/dia WORTH Town of Andover No. o dover, massJdAl-VI-_.� GOC MIC ME WICK y1. 0RATED P? C7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.....(,77G.r.1..a......... ..it On.......... Foundation has permission to erect............... ........................ buildings on ...(IJ491.....P& ....A. ............................. Rough to be occupied as.... Chimney permitshall in every respect conform to the terms of the application on file in Final provided that the peii�i X�a�/ 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 l�3 - PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU<0aNj TS ....4le Rough Service ........... ................................... BUILDINGi-...-...." 1 MP-E-M R 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.