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Building Permit #898 - 498 CHICKERING ROAD 6/14/2012
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: 911�10mmercial ❑ R!'Oair, replacement El Assessory Bldg ❑ Others: 'Demolition ❑ Other "0 Se tido �jWell� pla n�" �` ©Fl odetlands � i �,��;:;���t.� 4;� Watershed District •.. ; iter"%Sewer�;a t �`,' � , _� DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: �Uss►S P Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PER /MIST.• $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location Date Check 41" 25412 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Milding Inspector I 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 (septib tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ 3 COMMENTS �1�� /� ayie-u, a atle-d CONSERVATION Reviewed on Signature COMMENTS HEALTH' COMMENTS Reviewed S 1// y11 Z, N 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: Located 384 Osqood Street t1,24Matn�Street ;` I . #- Msd. t�` • � ��l`a Vw` f:.rt�In°,�'F+�'.��,.,��F���.. ,i��ltati�:.�,�xt � v,. C� �s, z7} i r� ���`�������r �d �`„E 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.$10041000 fine NOTES and DATA — For de ® Notified for pickup - Date Doc.Building Permit Revised 2008 use 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 DOTE: All duinpster 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 o Photo Copy of H.I.C. And C.S.L. Licenses ❑. Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass'check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products M ®TE: 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 Ir C 0 r V 0 �a c ..2 Q L N O d 7 I: • � 0 E 0.- 0 0 • T; 3 Nm > 0 _ °' (n o ,__ am >o 0 0 CCU E O o — 0 0 Q.i 0 C L cc 0 .y r O co F- i0 C = C 1- 0 N v m N _ O '0 O O W uj LL ''� N C 'Q. t O O ..+ � w uj Q V O L N O F- t . C. O (-) CL U) t U) N O a� m O C N d t O z O a J O F, O I-- 0 V W IL z C9 z 0 J m �, • N i .N •N 4 it E O O Z N 0 � C = O .— CD E .� m m Q 0 s O �+ O V � i o CL CL Q O v_ J �CL O }'CyAD++ Z W O CL UY/ cc C C CA 0 OH 0 J O o< W LU L CL Z Z Z O 0 Q Ln OZ cm Z W o Q J c 0 Q W m CE co U- 4) d W N 0 f0a Z cu o u � t = c t = t u °O° s O Y a � v Qj O LL Ln LL K U LL W LL d' N LL d' LL CO y to C 0 r V 0 �a c ..2 Q L N O d 7 I: • � 0 E 0.- 0 0 • T; 3 Nm > 0 _ °' (n o ,__ am >o 0 0 CCU E O o — 0 0 Q.i 0 C L cc 0 .y r O co F- i0 C = C 1- 0 N v m N _ O '0 O O W uj LL ''� N C 'Q. t O O ..+ � w uj Q V O L N O F- t . C. O (-) CL U) t U) N O a� m O C N d t O z O a J O F, O I-- 0 V W IL z C9 z 0 J m �, • N i .N •N 4 it E O O Z N 0 � C = O .— CD E .� m m Q 0 s O �+ O V � i o CL CL Q O v_ J �CL O }'CyAD++ Z W O CL UY/ cc C C CA 0 PARK STREET REDEVELOPMENT, LLC 231 SUTTON STREET, SUITE 1B NORTH ANDOVER, MA 01845 978-687-6200 phone 978-682-6473 fax Abutters to 498 Chickering Rd. North Andover, MA June 7, 2012 Re: ' 498 Chickering Rd., North Andover. Dear Neighbor: As you may know, Park Street Redevelopment, LLC has leased the site at 498 Chickering Road in North Andover to the Lowell Five Savings Bank, which is planning to build a branch bank at this location. The Lowell Five is planning to begin construction soon and the first step is to demolish the existing building, the former Mobil Station, which has been closed for many years. The demolition contractor, F.P. Reilly & Sons, will put measures in place to control the amount of dust created, but all demolition involves both noise and the creation of debris. The demolition will be completed within the next 30 days. If you have any questions or concerns, please call 978-687-6200 and ask for Lou Minicucci, III. I Thank you. Sincere Park Str Louis P. P Manager LPM/kp I Cc: Lowell Five Savings Bank CAMinco Fii1es\Ipmfi1es\498 Chickering Rd., N Andover\demo Itr.doc R' 6�g "Serving Andover and Vicinity Since 1947 PROPOSAL PROPOSAL SUBMITTED TO PHONE DATE Park St. Redevelopment LLC (978) 799-8947 03/15/2012 STREET I JOB NAME 213 Sutton St., IA Demolition & Removal of Gas Station, c,STATE, ZIP coDE Garage, North , & Canopy Overhang Andover, MA 01845 498 Chickering Road, North Andover AM Louis P. Minicucci, III We hereby submit specifications and estimates for: Phase 2 — Demolition and Removal of 4 Structures including Concrete 1. Call Digsafe. 2. Pull Demolition Permit. 3. Demolish and Remove Mobil Station, Canopy in Front, Small Building and Garage in Rear of Property. 4. All wood will be disposed of at a legal recycling facility. 5. Excavate out and Dispose of all Concrete at all 3 Locations including Slabs, Footings, and Foundations. Dispose of at a legal site. 6. Truck in Clean Fill, Grade and Compact all Holes to Correct Elevation. Not Included in Phase 2 1. Police or Fire Details are not included if required by the Town of North Andover 2. Any work with or disposal of contaminated material or hazardous waste 3. Any dealings with conservation if required 4. Oil Tanks 5. Flourescent Light Tubes 6. Ballasts 7. Freon Reclaim 8. Removal or Disposal of any Friable or Non -Friable Asbestos Contaminated Materials 9. Any work with buried debris 10. Sufficient Water Hookup for Dust Control if required. 206 Andover Street • Suite 11 • Andover, Massachusetts 01810 • Tel: 978-475-1237 Fax: 978-475-3102 email: fpreillyandsons@comcast.net IServing Andover and Vicinity Since 1947 Park Street Redevelopment LLC Phase 2 - Demolition of Mobil Station, Canopy & Garage March 1 S, 2012 Page 2 We propose hereby to furnish material and labor -- complete in accordance with above specifications, for the sum of $10,900.00 (PRICE GOOD FOR 45 DAYS) Options: 1. Excavate Out and Remove all Hot Top and Dispose of Off Site ...... ......... $1.,000.00 2. Remove and Dispose of Mobil Signs, 9 Light Bases and Phone Bases; Fill and Compact Holeswith Clean Fill...................................................................$1,000.00 NOTE: Any change from proposal could result in price change. Final payment is due upon completion of job. In the event that you do not make the payment, when due, you will be responsible for our costs of collection, including our reasonable attorney fees and costs. In addition, you will be charged interest on any outstanding amount at the rate of 18% per year (1.5% per month) from the date, which it is due. 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 specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature'90ji charge over and above the estimate. All agreements contingent upon strikes, accidents --� —U or delays beyond our control. Owner to cavy fire, tomado, and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. ACCEPTANCE OF PROPOSAL - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature: 206 Andover Street • Suite 11 • Andover, Massachusetts 01810 • Tel: 978-475-1237 Fax: 978-475-3102 email: fpreillyandsons@comcast.net AC40RIX CERTIFICATE OF LIABILITY INSURANCE aTE(Lva16 13 112 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTA71'VE OR PRODUCER, AND THE CERnRcATE HOLDER IMPORTANT: If the certificate holder Is an ADOMONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen Southmayd Ins Agency R 668 Main StI Suite 9 Wilmington, MA 01887 CONTACT Louise Southma d PAHONNe 978 657-0263 . (978) 657-0201 gyral ADDRF-ss: louise@tlsins.com CPP0110598560 INSURE S AFFORDING.COVERAGE NAIC0 INSURER A: Preferred Mutual EACH OCCURRENCE $ 1,000,000 INSURED INSIIRERB: St Paul Travelers WC -AR Tetreault Construction LLC 90 Elm Street Andover, MA 01810 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE N UMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIM" SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE RM W 120 Main St POLICY NUMBER PMIW ID LIMITS A GENERALLIABILITY X COMNERCWIGENERALLUIBMJTY CLAW44ADE � OOCUR �{ • � 2�iKdti/ CPP0110598560 8/18/11 8/18/12 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 LED OF ore Pasco) $ 5,000 PERSONkL&ADVIKURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREGATELMITAPPLIESPER POLICY PRO LOC PRODUCrS-OOMPIOPAGG $ 2,000,000 $ AUTOMOBILE LW RM ANYAUTO ALLOWIED SCHEDULED AUTOS AUTOS HIREDAUTOS ! NO - WNED aacddart WMTMIT$ ODDLY INJURY (Per pown) $ BODILY INJURY (Per aoddent) S P as GE $ S UMBRELLA LIAR EXCESS LIAS [7OCCUR CWMS-MAOE EACH OCCURRENCE $ AGGREGATE S DED RETENTION S H WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUME YIN OFFICERMEMBEREXCLLDED4 (Mandabyy In NH)' H�y8S, describe under DESCRIPnONOFOPERATIONSbebW N!A ORICs TO }!'OLLOW 4/27/12 6/27/13 WC STAN �- _ E.L.EACHACOOENr 100,000 E.L. DISEASE -EA EMPLOYE 100 ,000 EL. DISEASE - POLICY LIMIT I S 500,000 Oman noNOFOPERATIONSJLocmNsivmcLmimKhACORDim,AdMimARermrksSclrediie,IfmorespaceIsragdrod) Email craigtl23@verizon.net . ti CERTIFICATE HOLDER CANCELLATION Town Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St ACCORDANCE WI7H THE POLICY PROVISIONS. North Andover, MA 01845 AU7t10PRESENTs'i�; �{ • � 2�iKdti/ Loui" Southma d Mana ACORD 25 (201010 5) Phone: 01988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Fax: E -Mail: ACORV CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYI) 1 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 11/07/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT::If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,'�ubject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: 1 ; NORTH ANDOVER INSURANCE AGENCY, INC. (AIS, 10, E,): (978) 686-2266 NE jn,C, No): (978) 686i6d10 ADDRESS: cfernanadez@nafins.com M.J. FOSTER INSURANCE SERVICES MA 163 IN STREET PROUCER CUST OMER ID #Reilly, F.P. , & Sons, Inc. INSURER(S) AFFORDING COVERAGE NAIC# NORTH ANDOVER MA 01845-2508 INSURED INSURER A ACADIA INSURANCE Reilly, F.P., & Sons, Inc. INSURER B 206 Andover Street Ste 11 INSURER C INSURER D INSURER E Andover MA 01810— INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES 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 PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) LIMITS A GENERAL LIABILITY Y PA0193900-14 10/20/2011 0/20/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PAMMAGE ISES To OEa RENTED 250,000 Poccurrence $ / CLAIMS -MADE [K] OCCUR / / / / MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS - COMP/OP AGG $ 2,000,000 POLICYFXPEO LOC / / / / $ A AUTOMOBILE LIABILITY 0193901-14 0/20/2011 0/20/2012 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ X ALL OWNED AUTOS / / / / PROPERTY DAMAGE SCHEDULED AUTOS X HIRED AUTOS / / / / $ (Per accident) X I NON -OWNED AUTOS / / / / $ / / / / $ A X UMBRELLA LIAB X OCCUR A0193902 0/20/2011 0/20/2012 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 EXCESS LIAB CLAIMS -MADE / / / / DEDUCTIBLE / / / / $ RETENTION $ $ A WORKERS COMPENSATION WCA0336827 6/03/2011 06/03/2012 X WC STATU- DTH - TORY LIMITS ER AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNERIEXECUTIVE / / / / OFFICERIMEMBER EXCLUDED? ❑ N I A / / / / (Mandatory in' NH) E.L. DISEASE - EA EMPLOYE $ 500,000 if yes, describe under / / / / DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 500,000 INMRC PA0193900-14 0/20/2011 10/20/2012 �SCHED 549,200 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE* BUILDING 20, STE 2-36"' { NORTH ANDOVER MA 01845- ACORD 25 (2609109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leatbiv i I- n A Name (Business/Organization/Individual): Address: c 6w ✓ ' ��, t S� 1 i'C� City/State/Zip: /�� 6I9/ a Phone #: 7g� �%� ��o ✓ Are u an employer? Check the appropriate box: The Commonwealth of Massachusetts 1 Department of Industrial Accidents ^ AA i Office of Investigations M t ��! 4 600 Washington Street �aN pt Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leatbiv i I- n A Name (Business/Organization/Individual): Address: c 6w ✓ ' ��, t S� 1 i'C� City/State/Zip: /�� 6I9/ a Phone #: 7g� �%� ��o ✓ Are u an employer? Check the appropriate box: Type of project (required): 1. L[v I am a employer with_ 4. ❑ 1 am a general contractor and I 6. ❑ New construction , employees (full and/or part-time). * have hired the sub -contractors 7. Remodeling emo ❑ g 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ These have 8. gemolition ship and have no employees sub -contractors working for me in any capacity. [No workers' comp. insurance workers comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10. Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions I myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roof repairs insurance required.) t .employees. [No workers' 13.❑ Other comp. insurance required.) $Any applicant that checks hoz # 1 must also fill out the section below showing their workers' compensation policy information. t homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t � Ia�; (.,f'raIxe �Policy # or Self -ins. Lie. #: VJC41,33 �� Expiration Date: Job Site Address: City/State/Zip: Vy0!-_fn 42?16KY/W Attach a copy of the workers' compensation icy 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. •! ACo;flereby cercif� un er a pains and penalties of perjury that the information provided above is true and correct 1i�A it )U 11. iti �.... ll. li➢ � / Y ../ Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitfLicense # 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 cavy 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 IIndustrial 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 permitllicense 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 Offiee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFF Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia oA O r C - 1 Ca o -i i � @ x o c 7d�1R m e > m n. m3 S. i c N C) D Z m ocp p f pp y; Ci ift z r+ 5 r c, NAM fD �. � - W N � Z y 0 A et eb x � A N a Q ^ QQ CD AP r. 13. 2012 2 ; 39PM AP`02129Z.4Gp F. fl. RjaiIIy&Som 9784No. 8581 P. 1, Town'of North Andaver NORTN Building Department oEtt�ee ,e qy 7600 Osgood Street a�,� �, •� 4 Na t, Andover MA 01845 F � Tel. 978-668.8545 Fax, 978-868-9542 OEMOLI O F t3Ul� 1)I 6 Yrj 4► o " '"'"'�r'' . ss�cHtls�� DAT F-- I 1 LOCATION OF PTY TO DEMOIJS ch) sc IFT10N,?-JLJf?il I . DEPT. OF PUBLIC wOW6 -V DEPT OF CONSERVATION HISTORIC COM 23 ON f3A3 ��iG���-, ELECTRIC OFPAQ rMrwV ou+►i la -�Pq ) LI717- - S / A 9 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: �qg Ch r is that the debris resulting from this work shall be disposed of in a pr6perly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: a I N I t RoadNorth Arid aW 1,4)q d I L d l 5 U` -i a Location of Facility) a) -&+&C , U jacks e�f) 17i' of Mir Signatureermit Applicant Date r 1 ✓ Pp -t- S hv jz `fey 644'ey 4 ree LocatioA 8 0,� ju , ve d No. Date Check # 25550 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Feek --Ip $ Other Permit Fee $ TOTAL $- Buildin'g Inspector �c CD I z °c CD CD ° CD �c I 0 � o CD 0 0 A� I t... 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