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HomeMy WebLinkAboutBuilding Permit #599 - 50 BRIDLE PATH 3/14/2007 NORTI� BUILDING PERMIT of�•�.o bq"o TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION Permit NO: �f Date Received`2 '1 ��SSgCHus���h Date Issued: - ( l IMPORTANT Applicant must complete all items on this page m.,,b..* � r$IIt tY,r s .s MAF?�l 3 PR .lL � I1 1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building >tOne family ❑Addition ❑Two or more family [I Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other { Sept►cell� t ,llahs7 � U/1/etla�� aters� [?7 (CtP , g 1telaf:1N .k. Y DESCRIPTION OF WORK TO BE PREFORMED:FE XDPEL =2 BA WR00� f (�nl. 2nd A7 Ooit - A)EhJ �LGUK/AI(r- Ahlo Identification Please Type or Print Clearly) t OWNER: Name: P Nom/ .C. Phone: A) OWNER: Address: CONTRAST©R Address' y , 77— uPprv�so' csnstctiaer� a HomMpra emet� 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: $ -//a 6aLAIFEE: $ Check No.: ('p s3 ( Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location 50 �7O t r Py Y k No. � r�• � Date 't 0, 40RTN 1� TOWN OF NORTH ANDOVER a i " Certificate of Occupancy $ •o �►�s ACHU V Building/Frame Permit Fee $ Z' s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 6 1-3/ 24041 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 I DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,eta ❑ Permanent Dumpster on Site ❑ e 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 DEPAR WW1 NTIremp 7ur 1ps er or��slte esu nv E chis.atq z, �f l6h Street Frre IJtoe p. I'��EIT[ sibnatuyemtt�. b P z �A e'�. .n r y'- „sem COMMENTS ` n* 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) I �I ❑ 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract " o Floor Plan Or Proposed Interior Work — ❑ Engineering Affidavits for Engineered products 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 o 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 New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan o 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 o Engineering Affidavits for Engineered products 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 .. I l DMConstrucdon Building with the QI)ALITY and Character of yesteryear. 44 Addison Ave Ext. Methuen, MA 01844 (978)685-3037 Estimate Submitted To: Peter O'Neill 50 Bridle Path N.Andover,MA We hereby purpose to fiunish the materials indicated and perform the labor necessary for the completion of 2nd Floor Renovations(See specifications and drawings) All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specifications submitted for above work and completion in a substantial workmanlike manner in the sum of One hundred twelve thousand six hundred seventy-five dollars-$112,675.00 Payments to be made as follows: Initial payment$15000.00 Remaining payments as work progresses. Respectfully submitted:Darren Martino Any alteration or deviation from the above specifications i volving extra costs will be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon accidents,or delays beyond our control. Note-This proposal may be withdrawn if not accepted within 10 days. Proposal Date 2/23/07 ACCEPTANCE OF PROPOSAL The above prices,specifications,and conditions sfactory and are h �by accepted. You are authorized do the work as specified. a en will be made outlined above. Date: �� / Signature O'NEILL RESIDENCE Specifications Sheet Scope of work: Interior renovations and home improvements including new master bath,full bath, and bedroom configuration on 2dfloor.lour. Reconfiguration of layout according to submitted drawings. Permits The following permits are included as part of this contract. Building, electrical, and plumbing. Any other permitting required would incur extra cost. Drawings Provide drawings as required by the Town of N. Andover for permitting. Demolition The existing master bath and full bath will be completely gutted All flooring,drywall, and fixtures will be removed. Demolition of the remaining 2"d floor will take place as necessary for completion of the submitted drawings- Debris rawingsDebris Removal DM Construction is responsible for the removal of all debris generated. A container will be placed on site to ensure a clean work site. The container is for debris generated by DM Construction only, it is not intended for homeowner use. All material put in a container must first be approved by DM Construction. Framing 2"d floor walls will be framed according to submitted drawings. Any alteration from the submitted plan could incur extra cost. Insulation New insulation will be installed where removed or deemed necessary. Drywall New blue-board will be installed on all newly framed walls. 318"blue Board will be installed over all 2"d floor ceilings. A plaster skim coat will be applied to all new blue board All ceilings on the 2"d floor will receive a smooth finish. Windows New windows will be installed per submitted drawings. The cost of the windows is covered under an allowance. Siding Siding will be stripped off as deemed necessary for the installation of the new window units. New siding, matching existing conditions, will be installed as deemed necessary O'NEILL RESIDENCE Specifications Sheet Finish New door units 6 panel, solid core, smooth finish, masonite w/brass hinges and hardware. Baseboard New baseboard to match existing conditions. Crown molding 3 %"Crown molding installed in the master bedroom and master bath. Window trim New windows to be trimmed to match existing conditions. Whirl pool face A raised panel whirlpool face will be built from paint grade materials. Attic pull down A new attic pulldown will be installed and cased. Painting Exterior All newly installed siding and trim will be painted to match existing color. Interior Ceilings All 2"d floor ceilings will be primed and painted white. Walls All 2"d floor walls will be painted. Newly plastered walls to be primed. Paint walls in 2"d floor hallway, stairwell, and foyer. Trim-All newly installed trim to be primed and receive two coats of finish. Existing trim 2"d floor trim will receive one coat offinish. Central air Existing registers will be relocated as necessary according to new layout. Existing damaged flex in attic will be replaced. The main trunk will be reinsulated Central vacuum Central vacuum outlets and piping will be rerouted and relocated as deemed necessary. Cabinetry DM Construction will install all vanities, toilet toppers, linen cabinets, etc. The cost of these items is covered under an allowance. O'NEILL RESIDENCE Specifications Sheet Tile/Marble Installation Full Bath A stone,floor will be installed. Master Bath The shower walls,floor, and ceiling will have stone installed A custom bench will be constructed in the shower. A stone floor will be installed. A water proof membrane will be installed to the entire master bath floor. The membrane will protect against water from the shower area. The membrane is not intended to protect against large amounts of water. The cost of all tile/marble/stone is covered under an allowance. Standard setting installation included. Arty patterns, designs, or feature strips could incur extra cost. Plumbing Full Bath Demolition of existing fixtures, water and drain lines as necessary. Provisions for new 5'fiberglass tub/shower unit, 3 z3'fiberglass shower unit, toilet, and 2 sinks. If either of the fiberglass shower units are change to a custom unit this will incur extra cost. Master Bath Demolition of existing fixtures, water and drain lines as necessary. Provisions for a toilet, 2 sinks, whirl pool(air tub), and custom shower. Custom shower comprised of a copper pan base, two independent main shower heads on opposing sides with two separate thermostatic valves and volume controls, one hand shower with volume control,four body sprays with a volume control for all four. Custom Shower Summary shower heads(2) hand showers(1) thermostatic valves(2) volume controls(4) body sprays(4).) copper pan(1) All fixtures including toilets, sinks,faucets, whirlpools, thermostatic valves, volume controls, shower heads, body sprays, copper pans, shower doors, accessories, etc are covered under an allowance. Heating Demolition of all existing 2"d floor baseboard heat. Installation of new baseboard heat and toe kick heaters as necessary for entire 2"dfloor. Installation of 2 new thermostats. Installation of isolation ball valves on boiler. Existing zones will remain as is. This estimate does not include any new zones valves or any other components to the boiler. O'NEILL RESIDENCE Specifications Sheet Electrical Demolition of existing wiring and fixtures as necessaryfor new layout. Installation of new receptacles, switches, and GFI receptacles as required Relocate existing phone, cable, and t-stat wires as necessary. Installation of fire protection equipment(smoke detectors and CO2 detectors as required to meet code on the 2"d floor only. If the inspector requires the remainder of the house to be upgraded, this will incur extra cost. Full Bath Provisions for and installation of a vanity light.(Homeowner purchase) Provisions for and installation of an exhaust fan(Allowance) Recess lighting(Allowance) Master Bath Provisions for and installation of two vanity lights(Homeowner purchase) Provision for and installation of two exhaust fans.(Allowance) Provisions for concealed rope lighting in crown molding(Allowance) Recess lighting(Allowance) Wiring as necessaryfor whirl pool. Wiring for toe kick heater if necessary. Master Bedroom Provisions for concealed rope lighting in crown molding(Allowance) Provisions for and installation of a ceiling fixture(Homeowner purchase) Provide and install fluorescent light fixture in walk in closet. Secondary Bedrooms Provisions for and installation of a ceiling fixture(Homeowner purchase) Provide and install fluorescent strip lighting in closets. Miscellaneous Items Installation of durarock underlayment to bathroom floors. Installation of water proof membrane for master bath floor. Installation of a custom copper pan for master bath custom shower(Allowance) Installation of dense shield wall board in custom shower. Construction of and water proofing of a bench in master bath shower. For an additional$825.00 the existing air handler and main trunk can be relocated to the rear of the attic. OWEILL RESIDENCE I Allowances The following allowances are included in this estimate. The allowances exist to cover the purchase of materials only, unless otherwise specified. Any amount in excess of an allowance will incur extra cost. Any amount less than an allowance will warrant a credit. Upon completion of the project any extra costs or credits will be issued. Lighting Fixtures-$I 500.00 This allowance includes all light fixtures, specialty switches,(dimmers, timers, low voltage, etc.)and recess lighting. The labor cost for the installation of recess lights, low voltage lighting, or any other accent lighting is covered under this allowance. Example: 5"Recess light w/air lock sealed baffle, white trim, halogen bulb, and dimmer-$150 complete Plumbing Ffttures-$12000.00 This allowance covers the cost of all toilets,faucets, sinks, tub and shower units, copper pans, shower valves, shower heads, volume controls, body sprays, thermostatic valves, etc. Cabinetry-$3000.00 This allowance covers the cost of all vanities, toilet toppers, linen cabinets, etc. and their associated hardware. Countertops-$5000.00 This allowance covers the cost of all solid slabs of stone and their associated template and installation costs.(Countertops-whirl pool deck bench in custom shower) Tile/Marble-$6000.00 This allowance covers the cost of all tile, granite, marble, or any other type of stone to be used on the floors, walls, or ceiling in the bathrooms. Also included in this allowance is the grout and any enhancers or sealers. Windows-$3000.00 This allowance covers the cost of all windows, grills, screens, hardware, extension jambs, and specialty trim. Flooring-$4000.00 This allowance covers the cost and installation of carpeting in each of the three upstairs bedrooms and closets. Also covered is the refinishing of the hardwood flooring in the upstairs hallway and stairs. Shelving-$2000.00 This allowance covers the cost and installation of shelving and custom built-ins for all 2"d floor closets. O'NEILL RESIDENCE Miscellaneous Accessories-The purchase and delivery of all accessories(toilet paper holders, towel rings/bars, robe hooks, etc) is the responsibility of the homeowner. Dm Construction will install these items provided they are made available in a timely fashion before completion of the project. Mirrors Mirrors and their installation are not included in this estimate. If any are desired they can be provided at additional cost. Change Orders Any changes from the existing plans or increased scope of work involving extra costs will become and extra charge over and above the contract price. Change order agreements must be signed before any work commences. Note: Due to the nature of wood and the drastic temperature and humidity changes in our region,you may notice the movement and shrinking of interior and exterior trim. This is typical of the region and is not due to defective product or installation. The following schedule will be adhered to, unless circumstances beyond our control arise: Time frame for completion: From date demolition begins to project completion 10-12 weeks All work to be done Monday-Friday between the hours of 7:00am-6:00pm. If deemed necessary to work any other times, homeowner will be consulted first MEMBER OF THE BETTER BUSINESS BUREAU HOME IMPROVEMENT CONTRACTOR: 124961 CONSTRUC77ONSUPERVISOR LICENSE:CS 066342 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR t Number:CS 066342 Birthdatec 08/1511971 f Expires:08/1512007 Tr.no: 2502.0 Restricted: 00 DARREN MARTINO C 44 ADDISON AVE EXT METHUEN, MA 01844 Commissioner �,, ��e T�an�nnarxruealC� a�✓��avxcc�ri.ra./a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 124961 Expiration: 9/17/2007 Type: Individual DARREN MARTINO Darren MARTINO 44 ADDISON AVE.EXT. METHUEN,MA 01844 Administrator W-1C-dou 113:5( Lht*UX 1NbUK#cE K*.NLY 181 598 PAGE1 I DATE(e1MIODlYY) ACORD- CERTIFICATE OF LIABILITY INSURANCE 03112MI PRODUCER Lennox b"Umnce ms CERTIwATE IS ISSUED AS A RATTER OF IWOMATWN 553$seem St ONLY AND CONFERS NO RIIG iT S LIQ THE C:ERTO ICATE HOLDER.THIS CERTWICATE DOES NOT ADDEND,EXTEND OR LynnfeW.MA 01940 LTER THE COVERAGE AFF. _ Y CIES BELOW. (781)598-7132 T INSURERS AFFORDING COVERAGE_ NAIC E INsuRm Darren Martino INSURER A: PENN AMERICA INSURER 9: 44 Adelson Avenue Ext RNSURER C: Methuen,MA 01844- INSUR m a INSURER E: COVERAM INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. A onftiTH5rANm ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AMY BE ISSUED OR J MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SMOYVN MAY HAVE BEEN REDUCED BY PAID CLAW. LTR NOW TYPE OF INSURANCE POLICY NUMBER Y�EIM[ILAXYyITI. LAOIS AEIERAL.LIABB.ITY I EACH OCCURRENCE { 300,000 [�CMIMERCIAL GENERAL tULBHJIY DAMAGE TO RENTED PAC6519799 = 08x08106 i 08x08x07 PR s ma MED EXP(Any pornm Un CLAIMS MADE 9OCCUR A U i PERSONAL L:ADV RUURY 600.000 ❑ GENEERALAGGREGATE 60(),000 GElfL AGGREGATE LST APPLIES PER- Cl ER ! PRODUCTS-COINPiOP AGG _ ❑POLICY ❑PROJECT Cl LOC ! = AUTOMOBILE UABOJTY 1 COMBINED SINGLE LIMIT IU ANYAUTO e>OcdUEn ' (G ALL OWNED AUTOS I BODILY INJURY B ( 1 i f SCHEDULED AUTDS (Per PLuypnj ! ,lj HIREDAUTOS BODILYINJURY j❑ NONOWNEDAUTOS jPer�pMenp - UPROPERTY DAMAGE - -- n ' (pawaft" GARAGE LIABILITY AUTO ONLY-EA ACCIDENT c , n n ANY AUTO OTHER THAN EAACC ( I 1 AUTO ONLY: ACG f EXC-3 LIABILITY I EACH OCCURRENCE D U ( I OCCUR I I CLAW MADE +AGGREGATE ^- n DEDUCTIBLE U RETENTION I _— WOMM COMPRWATION AlmWC STA -I 0TH, EMPLOYERS•UMILITY i TORY t —' [7t E ANYPROPRJETORiPARTNERiEXECUTWE EL EACHACCIDFJ+It — OFFlCFJZ/NIEIIBER EXCLUDED? ;EL DISEASE-EA EMPLOYEE lyes.descMDUndIN SPECIAL PROVISIONS bel w I _i EL OISEASE-POLICY UYRT I OTHER , F i DESCRIPTION OF OPERATIONS)LOCATION$!VEHICLES J EILCLUBION6 ADDED BY ENDORSEMENT/SPECIAL PROVISIONS I i CERTIFICATE HOLDER CANCELLATION SHOULD ANY'OF 71HE ABOVE DESCRmw POLICIES LRE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL.&WEAYOR TO BAL PETERO'NIEL DAYSVVMTTEMMD7WETOTHEeUMFICAYGIIMDERKAAMDTO 50 BRIDAL PATH THE LEFT.BUT FAILURE TO 00 SO SMALL INO OBLIGATION OR LJABLlTY NORTH ANDOVER,MA 01810 OF ANY Nam UPON THE INSURER.ITS AGENTS OR REPREM11TATIVEL L I - -- AUT REPRESENTATIVE t . ACOR (O 25 MMG) I T C ACORD COIWORATION 18Bi The Commonwealth of Massachusetts Department of Industrial Accidents �K Office of Investigations 600 Washington Street i i r'ti Boston,MA 02111 ♦ a it•i www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Leeibly Name(Business/Organization/Individual): /l.� /I IA'V7/A-14 Address: q Y ADD Isonj me &T City/State/Zip: MEWj O Ol f q# Phone#: Q_/�-fQ& 3?60 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2l am a sole proprietor or partner- listed on the attached sheet.t 7. RrRemodeling 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.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions 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 box#I 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 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.#: Expiration Date: Job Site Address: ?SD Zapu, ea-Tou City/State/Zip: /J' 41) /YY� 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 cerci under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phon / Oficial 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"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 permitllicense 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 60.0 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 r � NORTfy � Town of over No. over, Mass., 3 • �' 4D 1-7 COCKICMEWICK RATED Pp 4 �� BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................ .At�.......... .,001J.J. ........... ............................... Foundation has permission to erect..................�„�..........--.--. buildin on....... 0...... 1n. ........... .. .. . .......... Rough op to be occupied as..A .. ........r�v0iit........ ... ............ ...............��......�4... ... ..5..�........ot Chimney ... provided that the person accepting this permit shall in every respect 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 I�rj Z Final PERMEXPIRES IN 6 MONTHS IT UNLESS CONS O TARTS ELECTRICAL INSPECTOR 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.