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Home My WebLink AboutBuilding Permit #31 - 524 REA STREET 7/14/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: C` Date Received Date Issued: ? :/T O l IMPORTANT:Applicant must complete all items on this page LOCATION PrintWOL4 PROPERTY OWNER AJ 1 7 -^+ Print MAP NO: _5,Y PARCELZONiNG DISTRICT: Historic Districtyes Cry' Machine Shop Village yes M TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building i-,Tne family vAddition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other i tteptic Well Floodplain Wetlands Watershed District I—JWater/Sewer ®rnL h cz— ,e-0d DW4 10 k 4GTAJE CRIPTION OF WORK TO�BE PREFORMED: Identification Please Type or Print Clearly) /' OWNER: Name: V� � A�/ GUD[ -= PhoneCL?78) Address: 6-A4 )" Sr. OA77f &100 VW.. �fOmN CONTRACTOR Name: Address: Supervisor's Construction License: Exp. Date: Home Improvement 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: $ g2 4, 3 25- FEE: $ 0?qf qv Check No.: e-) Receipt No.: 93:ao- NOTE: Persons contracting 'hWpregi eyed ontractors do not have access to the guaranty fund _ - - _ _ _-.- ignature of Agent/Owner Signature of contractor Plans Submitted P s Waive 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 . r p ; CONSERVATION Reviewed on lb Signature ~.` COMMENTS ( /.�(C _ r PP c EALTH Reviewed on Signature 1 COMMENTS _+tk�-� rj �,.,�E=Y-`�- Gs-� tc_T��d'^- � jq- C— G'��Dl�'L�c� Zc;iing Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes P>dnning 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 ` i7l Fire Department signature/date� r ` ,- = -key 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 I ❑ Notified for pickup - Date ............_----._._................._....__..._....................................._..._........_...............__._.._...._..........._..... Doc:.Building Permit Revised 2008 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) ❑ 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: Doc.Building Permit Revised 2008 Location.." Y 1&4 S7_ No. Date ` O s NORTH TOWN OF NORTH ANDOVER 3? ' OL • � ; . Certificate of Occupancy $ 'SscMustBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ • TOTAL $ Check # .� 2LG � � Building Inspector gym- Vl 4fr.� r Y 5 y R 1, rY i' a:..a...,hvi a:w„4..:iw.�p -' �✓S �C `J �. t� e��r t.� � Iv � a<c.•n:H.n „�w ;�h.n. �.� ''k.;�t,,,,. ��,1� .� -�' t ; • T `-"n-kt;.�i nw,•.yo-. ..w.. r � f i.eiM•d9::>nt•d3 e7weT.,r y �k ••,.w n_..• - « '� w� a � E 1Zx12 r S 4 � �a P-EA. I!ST ORTH own oft 4Andover `31 = 0 r LA.K E z dover, Mas, HI _K 0RATED BOARD OF HEALTH Food/Kitchen PERWT T Septic System 6//�)4 BUILDING INSPECTOR THIS CERTIFIES THAT...............6................ d/ Foundation has permission to erect........................................ buildings on ..... Rough to be occupied as.........................................................W... ..................................... Chimney _i,Pf�� ..k........ provided that the person accepting this permit shall in every respect conform t4-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 UNLESS CONSTRUCTION TARTS ELECTRICAL INSPECTOR Rough Service ............................. ................ .... ........... .................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. 5 5 lu PRU HOWE DOHERTY E E 01 Ile 0. ii 7 -,P CP V 14 .......... /oz o r 1,=z-4.,,v eAV 2r, /-4/ r A'ettre-le ,IVO 04.1 At Iwo VJq alp- AN S s�o �Go do�` N �F X00 sy O,y 11OJ, `' � LOT D ,�'• AREA=43,733 S.F. =1.00 AC. j PROPOSED DECK N 39 co l9, .5ro -j�d ? to 2 STORY W.F.D. j 32' #524 N bc N63'18'06"W 136.96' 0v� REA STREET A=5500544" (PUBLIC - 50' WIDE) L_24.04' C7J �G QJ 0 PLAN OF LAND IN NORTH ANDOVER, MASSACHUSETTS DRAWN FOR DANIELLE WOLF 0 524 REA STREET NORTH ANDOVER, MA "I HEREBY CERTIFY THAT THE BUILDING IS LOCATED ON THE LOT AS SCALE: 1"=20' DATE: JULY 17, 2009 j t L 1 0 20 40 80 120 sewc� 0 . 7117109 MERRIMACK ENGINEERING SERVICES 66 PARK STREET STEPHEN 0., NS I, R.L.S. DA TE ANDOVER, MASSACHUSETTS 01810 2683 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. L) �C Application by the undersigned is hereby made to connect with the town sewer main in Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. z Street orubdivision lot no 50�V Owner Address Contractor Addrr s�JG Applicant's Signature h, PERMIT TO CONNECT 171TH SEWER MAIN f The Division of Public Works hereby grants permission to to make a connection with the sewer main at :54,AgtmdfStreet subject to the rules and regulations of the Division of Public Works.. ivi n of Public Works By Inspected by Date See back for rules and regulations PROPOSAL Homes and Demolition PROPOSAL SUBMITTED TO: W RK TO BE PERFORMED AT: NAME NAME ADDRESS-51k4 I pC��/� ADDRESS PHONE NO. �'( �`(�- �j�I - tJ�7`� PHONE NO. We hereby propose to furnish the materials and perform the labor necessary for the completion of 1 � Sur l t L 'ti 1; F T. 1 `' 1 fir . " - i o (0 ooctt)✓" nOr I)A or (ai1i` i w, IOf C60V, r 0 tV1` � �iC . �; f� i tie IY�r11 All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for a_bove wor and com(�leted in a substantial workma��i manner for the sum of Q ^I ("Ind i' ; ( L`j ( � U Dollars($ ) with payments to be made as follows. �3 q 10, 00 (� Ltj D-v Respectfully submitted Per Any alteration or deviation from above specifications NOTE -This proposal--Tay be withdrawn by us involving extra costs will be executed only upon written if not accepted Within— L days. order, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date /,/ o Signature DOYLE LUMBER CO. Customer Copy 43 RIVER RD - ANDOVER MA 01810 www.doylelumber.com INVOICE (978) 688-4099 FAX {978} 683-6376 THIS COPY MUST REMAIN AT MERCHANT AT ALL TIMES! Page: 1 Invoice: 10191478 Special Time: 11:50:38 Instructions Ship Date: 07/06/09 Invoice Date: 07/06/09 Sale rep#: 0519 Leo Whitman Acct rep code: 23 Due Date: 08/31/09 REPRINT Sold To: FRANK VANCOPPENOLLE ship To: WOLFE 34 AZARIAN ROAD (978)697-4835 524 REA ST SALEM, NH 03079-2758 N.ANDOVER Customer#: 624700 00002 Customer PO: Order By: 2%1 OTH/l EOM popimg02 T 11 LN ORDER SHIP I L U/M ITEM# DESCRIPTION Alt Price/Uom PRICE EXTENSION 1� 9.00 9.00 L EA 468PT 4x 6x 8 #2 MCQ/MCA PRESSURE TREATED 10.5800 EA 10.5800 95.22 2 31 6.00 6.00 L EA 21012S 2x10x12 KD SPF#2 BTR 8.0900 EA 8.0900 48.54 41 3.00 3.00 i L EA 12CDF 1/2 48 CDX FIR PLYWOOD 13.7400 EA 13.74001 41.22 5 1.00 1.00 L EA 21212S 2x12x12 KD SPF#2 BTR 11.7400 EA 11.7400 11.74 6 20.00 20.00 L EA 21010S 2x10x10 KD SPF#2 BTR 6.9500 EA 6.9500 139.00 7: 10.00 10.00 L EA 268S 2x 6x 8 KD SPF#2 BTR 3.0500 EA 3.0500' 30.50 ei 8.00 8.00 L EA 58CDF 5/8 48 CDX FIR/SPRUCE PLYWOOD 18.4600 EA 18.46001 147.68 91 20.00 20.00 L EA 248S 2x 4x 8 KD SPF#2 BTR 1.9700 EA 1.9700 39.40 10 120.00 120.00 L LF 13FT 1x3 KD SPF STRAPPING 0.1100 LF 0.1100 13.20 11' 10/12 12' 48.00 48.00 L LF 18PPT 1x8 PRIMED KNOTTY PINE 1.6100 LF 1.6100: 77.28 13 4/12 1 141 24.00 24.00 L LF 15PPT 1x5 PRIMED KNOTTY PINE 1.0000 LF 1.0000 24.00 151 2/12 16 24.00 24.00 L LF 16PPT 1x6 PRIMED KNOTTY PINE 1.2000 LF 1.2000 28.80 17 2/12 181 3.00 3.00 L EA V201 W #201 8'VENT DOUBLE FLANGE WHITE 4.8100 EA 4.8100 14.43 19; 8.00 8.00 L BDL ICWW IKO CAMBRIDGE WEATHERED WOOD 30YR 31.0100 BDL 31.0100 248.08 20'; 1.00 1.00 L BDL IMWW IKO MARATHON WEATHERD WOOD 30YR 29.3400 BDL 29.3400 29.34 21' 6.00 6.00 L EA 8WADE 8"WHITE ALUM DRIP EDGE STD 6.6900 EA 6.6900 40.14 zz! 1.00 1.00 P EA SF PKG(100)5x7 STEPFLASHING 13.0500 EA 13.0500 13.05 23 1.00 1.00 L ROLL IICE IKO ARMOURGARD ICE/WATER 3X65 63.5500 ROLL 63.5500 63.55 24 1.00 1.00 L ROLL 15F 15# FELT PAPER 432sf 21.5100 ROLL 21.5100' 21.51 25 i I FILLED BY CHECKED BY DATE SHIPPED DRIVER Sales total $1126.68 SHIP VIA RECEIVED COMPLETE AND IN GOOD CONDITION Taxable 1126.68 Non-taxable 0.00 Sales tax 56.33 X Tax# TBF: 748 TOTAL $1183.01 1 - Customer Copy * 0 0 5 L D B 0 0 1 3 S 0 I U K 5 DOYLE LUMBER CO. Customer Copy 43 RIVER RD - ANDOVER MA 01810 www.doylelumber.com INVOICE {978} 688-4099 FAX {978} 683-6376 THIS COPY MUST REMAIN AT MERCHANT AT ALL TIMES! Page: 1 Invoice: 10190913 Special Time: 07:02:26 Instructions Ship Date: 06/30/09 Invoice Date: 07/01/09 Sale rep#: 69 Bob Veins Acct rep code: 23 Due Date: 08/31/09 REPRINT Sold To: FRANK VANCOPPENOLLE Ship To: WOLFE 34 AZARIAN ROAD (978)697-4835 524 REA ST SALEM,NH 03079-2758 N.ANDOVER Customer#: 624700 00002 Customer PO: Order By: 2%10TH/1 EOM pop1mg02 T 58 LN ORDER SHIPI L U/M i ITEM# DESCRIPTION IAlt Price/Uom ! PRICE EXTENSION 1 45.00 45.00 L EA 21012PT 2x1 Ox12 #1 MCQ/MCA PRESSURE TREATED 12.4000 EA 12.4000 558.00 21 12.00 12.00 L EA 248S 2x 4x 8 KD SPF#2 BTR 1.9700 EA 1.9700 23.64 31 65.00 65.00 L EA 54612TTR 5/4x6x12 REDWOOD TIMBERTECH SO EDGE 33.6400 EA 33.6400 2186.60 4 2.00 2.00 P EA 13R25 REDWOOD 2-1/2 SPLITSTOP 1200ct 101.4300 EA 101.4300 202.86 APROX=345sf 5 2.00 2.00 L EA 1220YF 12x20 YORK FLASHING 38.5300 EA 38.5300 77.06 6 8.00 8.00 L EA 448PT 4x 4x 8 #1 MCQ/MCA PRESSURE TREATED 7.9300 EA 7.9300 63.44 20.00 20.00 L EA 21 OH LUS21OZ 2x10 SGL JOIST HANGER ZINC 1.1000 EA 1.1000 22.00 8 2.00 2.00 L EA 2102H LUS2102Z 2x10 DBL JOIST HANGER ZINC 2.4200 EA 2.4200 4.84 9 36.00 36.00 P LF CSF48L SCREEN 48" BLACK FIBERGLASS LF 1.1300 LF 1.1300 40.68 10 1.00 1.00 P EA PS12G 12d SM GALV PLASTIC FH STICK 4000 78.5100 EA 78.5100 78.51 BOST/DUO/HITACHI/MAKITA/PASLODE/PC/SENCO 11. 12, DEL WED AM EARLY 13' BOOM 21 SEE SIMPSON FASTNER GUIDE I I i I FILLED BY CHECKED BY DATE SHIPPED DRIVER Sales total $3257.63 SHIP VIA RECEIVED COMPLETE AND IN GOOD CONDITION Taxable 3257.63 Non-taxable 0.00 Sales tax 162.88 X Tax# TBF: 1049 TOTAL $3420.51 1 - Customer Copy 11111111111111111111111111111111 IN 11111111111 Ill 1111111111111 * 0 0 5 L 0 0 0 0 1 0 0 C 0 L 4 T � t%OR10RTM q 3�-T � — p � �°•tip SSACHUs�tty CONSERVATION DEPARTMENT Community Development Division June 6,2007 Ms. Danielle Wolf 524 Rea Street North Andover,MA 01845 RE: SITE INSPECTION- 524 Rea Street,North Andover,MA Dear Ms.Wolf, It was nice meeting you yesterday to discuss the possibility of constructing an in-ground pool at the above-referenced property. The intent of the meeting was to determine if the proposed work would require the necessary permit from the North Andover Conservation Commission. Based on our discussion,it is my understanding that you would like to place the pool in close proximity the existing deck.As you know,Mosquito Brook traverses from south to north along the rear property line. There is also a fringe of Bordering Vegetated Wetlands (BVW) that flanks the bank of the brook. Measurements taken from the resource areas to the approximate location of the proposed pool confirmed that the work would be outside of the 100'Buffer Zone associated to the BVW and the 200' Riverfront esource Area associated to Mosquito Brook. Therefore, this proposal would not redwre a permit fro the North Andover Conservation Commission. As you are aware,you will need to obtain a sewer tie-in permit from Tim Willett, Superintendent of Water and Sewer in order to connect to municipal sewer.You may also want to notify the Health Department that you will be connecting to sewer, as they will need to sign off on the building permit application. I trust this information is sufficient from your needs. Should you have any additional questions or comments,please do not hesitate to contact the undersigned at your earliest convenience. Respectfully, NORTH ANDOVER CONSERVATION DEPARTMENT Pamela A. Merrill _ Conservation Associate 1600 Osgood Street,Building 20,Suite 2-36,North Andover,Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web:http://www.townofnorthandover.com/Pages/NAndoverMA_Conservation/index ! 00ftTM TOWN OF NORTH ANDOVER •` °� OFFICE OF p BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 s,°►a►s Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: Number. Street Address MapJLot HOMEOWNER 9V HA J -/ b A-A)/'EU1 F LOOLF Name Home Phone Work Phone PRESENT MAMING ADDRESS &v;q p)E 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 Persons)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 responsibility for compliances with the State Building Code and other Applicable codes,by-laws,niles and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Departmeut minrmum inspection Procedures and requirements and that he/she will comply with said proms and requirements. HOMEOWNERS SIGNATURE 71 A APPROVAL OF BUILDING OFFICIAL Reused 10.2005 Form Homaowam F.=mption ROARDOF \PPF:\I.S(R9-9511 CONSER\'.1'11ON(,,y 9530 . -N! .9530 PIA�IING(.ug_c 515 The Commonwealth of Massachusetts j 1 DePartmerzt of Industrial Accidents �_. Qjf1ce of Investigations 600 ITashington Street Xlel Boston, MA 02111 www-mass.gov/dia . Workers, Compensation Insurance Affidavit: Builders/Contractors/Eiectncians/Piambers A licant Information Please Print L&-gbl NaIIIe(BusinessJOWiration/Individual):_ Address: 5�q REA QST. _ CitylState%Z,ip: AJ - �� `� -7� d�J�' oL- F2.03 Yuman employer?Cheek.the appropriate box: I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(fun and/or part-time).* have hired the sub-contractors 6' ❑Now construction I am.a.sole proprietor or partner- listed ors,the attached sheet i 7. ❑Remodeling ship and have no employees'. These su}i- tors have workingfor mein 8. Q Demolition . any opacity. workers' comp.insurance. [No workers comp. insurance . 5. 9. ❑Building addition P ❑ We are a corporation and its required.) officers have extncised their 1Q.❑Electrical repairs or additions 3 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbin myself [No-workers'comp. c grepairsoraddititms 2, §1(4),'and-we have no 12.Q Roof repairs insurance required.]t .employees. [No workers' comP. insurance required_j 13.❑.Other `A,,y appiicam flan blacks boZ#I most also fill out the section Wow showing their workers'compensation policy information. t Fiomeawners who submit this eflidavit indicating they ars doing all WM*and then hire outside contractors must submit a new afndavit indiostiq such. -- 4Corttractors that cheek this box mIMMkOhed as ad sl'a,_show' the name of the sols-comractors and tieeir workzrs'cernp.pal,�;ir nsuranceorfomsstian. lam an empfover brat ispro g:workers'compensadori i infornzWo2 I 'M emplayem Below is Use Policy andjob site . Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Bate: Job Site Address: Cityl3tato/Zip: Attach a copy of the workers'compensation Policy declaration page(showing the Failure to policy number and expiration date]. secure coverage as required under Section 25A of MGL C. 152 can lead to,the imposition of criminal penalties of a fine up to$1,5DUD 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 acrd penalties of perjury that the ut ormation roviafed above is f p Si &Ue and eorrect tta�e:. Date' 7 Phone#: �� ai 5 Of]`iris!use only. Do not write in this area,m be complete d by nJs or town or1a[ City or Towns Permit/License# Issuing Autbori{y(cirvie one I. Board of Health 2. Buiiding Department 3.City/Town Clerk 4. Electrical Inspector 5. 3ctor6 Otber Contact Person: Phone#: 1 Information a nd Instructions Massachusetts General Laws chapter l 52 requires all emp 3 oyers 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'fbmgDing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,lir the r=iver ertnrstee of an individual,partnership,associatiorn or other legal entity,employing employees.'However the owner•of a dwelling house having not more than three apazrtrnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair wdrk 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 license or permit to operate a business or lco construct building in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required." Additionally, MOL chapter I52,§25C(7)states"Neither tiro 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 comps=tely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es):mind phone number(s)along with their certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,arc not requiredito carry workers'co-Tnpensation insurance. lfan 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.. Aliso 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,natthe Department of industrial Accidents. Should you have any.questions regal-ding the law or if you are required to obtain a workers' compensation policy,please-can the Department at the number listed below. Self.-insured companies should enter their self insurance.karst number on the*appropfiate 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 A-iII be used as a reference number. In addition,an applicant that must submit multiple permit/liconse 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.officisily stamped or marked by the city or town may be provided to the appiicart as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must befilled out each year.When 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 parson is NOT.mquired 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 Departruent's address,telephone and fax number. The Commonwcalth of Massachusem Department of F-ndustriai Aacideats Office of LnvestEigations 600 wash ngton Street Basion, IIIA 02111 TeL 4 617-727-4900 ext 406 or I-877-MASSAFE Fax##617-727-774 Revised 5-26-45 www.mass.gov/dia v' i The Commonwealth Of Massachusetts Department of Fire Services Office of the State Fire Marshal P.O.Box 1025 Slate Road,Stow,MA 01775 PERMIT Date: 7— 7 -may North Andover Permit No (City of Town) (if Applicable) Aig Safe Num er In accordance with the provisions of M:G114$Chapter__]_Q_as provided iu section S 7 7 CMR 34 Start Date ./ This Pcrn�t is granted to: / �7i1: //r ." 7�Xn /.(/0,—/ F Full name of person,Firm or Corporation Pennissionto locate dumpster for construction/renovation/demolition of building. Comments: dumpster must be 25 ' from structure if unable to place with required Restrictions: clearance dumpster must be covered with plywood or tarp end of work -day at ( ive location by street and no.,or describe in such er s to qvitd adequate idcntiftcatioa of location) Fee Paid 50.00 Fire Chief This Permit will cxoire-�� (Signature of offical granting permit) Ofz"tcal granting pemlit (Title) N° FD 6638 Date .....7:...7.�".f-�.✓��,. OF NORTH q� TOWN OF NORTH ANDOVER n o RECEIPT SSACHUS This certifies that . ..................................... u haspaid...... v......................................................................... for ...... .. ./ •-. G. ?. ..................I............. Received by . .. . ...... ......................... Department .......... .?../�............................................................ WHITE: Applicant CANARY:Department PINK:Treasurer i Bird's Eye View of 524 Rea St,North Andover, MA 01845 - Zillow#birds-eye-view Page 1 of 1 ....... - ......... US Massachusetts North Andover 03845 Views: 256 -...............-... ; 4 beds, 3.5 baths,3,622 sq ft Make Me Move®Price: $829,000 My Estimate Create i Monthly Payment: $3,644 edit i 4 ;yYY = , r� Not for for government use Not for government use What is Bird's Eye View? http://www.zillow.com/homedetails/birds-eye-view-map/56102703_zpid/ 7/14/2009