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HomeMy WebLinkAboutBuilding Permit #430 - 59 COURT STREET 12/14/2007 BUILDING PERMIT opt"°RT"qti TOWN OF NORTH ANDOVER 3� 4`"' ♦ ib ° C �.- APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Z' 74p�R4TlD �SSACHl1SF�'(� Date Issued: 0 IMPORTANT:Applicant must complete all items on this page 44flCAT101 rT yyy r�I n /y x k (y`�rrI�Tl3 ri��l 4 � O� R?J Y 0 }!i��4 t� V�.x V' '�/c . sett �a'` say ��'���� <-� -� . ✓r it R k �?+" x - } .�,��tRt�`. �. `� i 1 Y=...1t�11r ,: l ,P 10 `� PA CE ZOI aNG� R1�CT fl t' fs orac��str c# L TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Z Commercial epair, replacement Assessory Bldg Others: Demolition Other Sep#ic'�__ 1ll�lell 7 �o�dpla�t� r etlat�zls u qpi, rstaed District r` 7 DESCRIPTION OF WORK TO BE PREFORMED: Iz P+2 .- 1 #Qr ��'x c 7 ; j Identification Please Type or Print Clearly) OWNER: Name: J'oe 4 Mart« v►hq— Lac,- 15 Phone: 1751 7 7&�3 Address: `I C' +--f- S�-- 1v o r f k kPi d o vor Mil d s ur n t f ,� C© lTRAGTORNareu # - a phone �� k lam? ' AtltreSs1} .�« +�wJ, eC / t# 1 ��ata, e {3��:,. �� 1, y r # f 5 � Y s Supen�aso�-'s Consl�actio� Acense �` Y p bate 5 "� � a 3 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: $ 200, O c' U FEE: $ 7 Check No.: �71 2 S— Receipt No.: ". JP6 Z. NOTE: Persons contracting with unregistered c tractors do not have access to the guaranty fund Signa at!ire of Agern .::wner ` = Signature of contractor Location No. Date 62 NORT►, TOWN OF NORTH ANDOVER 0 n Certificate of Occupancy. $ Nus<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # yy2s' a' 20862 Builbing inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS14111"G too 'fi ,"se4 c..tk DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes � Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/si n ature 8 Date Driveway Permit Located at 384 Osgood Street :FIRE DEPARTMENT -'Temp Dumpster ora site des no Located at 124 Main Street :Fare Departrnerat s�gnature1date r 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use I I 0 Notified for pickup - Date Doc.Building Permit Revised 2007 I 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 U 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 tAORTH ONNM of Andover 0 No. 0 dover, COC Cp(\"*I* C of�ATE D DoBOARD OF HEALTH 0"" Food/Kitchen PERMIT T Septic System[o r, THIS CERTIFIES THAT...... ..... . BUILDING INSPECTOR ................................................................................................................................ 02 " 4 11 Foundation has permission to erect........... �.O.� ^... .. buildin gs on..6'. ..... ....... ......................... Rough to be Occupied as................. ...... .. Chimney 1671.......... 'i terms of the application on file in provided that the person accepting his permit shall in every respec conform t 14............................................... ..... .. 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 q 0 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIO TARTS ELECTRICAL INSPECTOR Rough ............ .......... ..... Service BUILD Final OCCUParw-y 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. IL SEE REVERSE SIDE Smoke Det. s Herb Jones Architectural CAD-Design Computer Drafting Service 39 Harvard Ave Methuen,MA 01844 Phone=1-978-689-9332 Cell=1-978-886-3646 haicabinet ftomcast.net / As of 10-24-07 co 0 D \ 00 co N V7 Drawing Legend o 0 06 06 a e E-1 - Right Side Elevation - Pictorial View C rl rl E-2 - Rear Elevation - Pictorial View 0 ❑ P-1 - Over All Plan - Pictorial View x ❑ P-2 - Framing Plan View D-1 - Details of Steel Columns for Main Herb Jones Deck Supports Architectural CAD - Design � Computer Drafting Service N o 6 39 Harvard Ave. ") � a) Methuen Ma. 01844 - 1515 N U) , Tel. 1-978-689-9332 c Cell. 1-978-886-3646 v Q W �-- hajcabinet@comcast.net & "' Z a Building Permit Drawinas Clients Name: Job Location : Scale: Y<-=V-o„ Mr. & Mrs. Joe LevisDace` 59 Court Street 59 Court Street 10-12-07 No. Andover, Ma. 01844 No. Andover, Ma. ,O 1845 Revisions:10-24-07 Tel. 1-978-687-2783 Cell 1-978-815-5635 Sheet# Cover Sheet 24"x36" Herb Jones Architectural CAD-Design --i Computer Drafting Service ' I 1 39 Harvard Ave I I Methuen,MA 01844 I 1 Phone=1-978-689-9332 Cell=1-978-886-3646 1 I haicabinetRcomcast.net p------ f------j 11 II II II I I I I I I I I til II II II I 'I 1 1 I I I I I i 00 M I L___J 1 1 L___J 1 t------� t------� N to t\ t1) L- -----------------------------------------------------------------------------------------\ J T- -Z- z 00i i I 00 00 1 ---T----------�--F--I --�r-- -------------- -------------------T--- _--___ II II Ir------ ll 11 11 II II 1� ll 11 II I r=_____ I I I I I I I I 11 11 I I 11 I I 11 I I I I I I I II- I I 11 It II II II II II II II II 11 II I 111 111 I I I � i I I I I 11 j l I j 11 I I I I 11 11 11 11 11 I III III I I I �--� I I IL_JI II I1 IL_JI IL_JI 14-_----4I IL_JI I Iil Ii1 1 1 ; SEE DETAILS ON SHEMf#D-I Ir--ijK"A :r1: Ir------ll Ir-11 1 III 11 I I I 0 V 1 i i i i I i i i i i I l i i i i i i i1 i i�i i i I Fa STEEL DECK SUPPOI2f POST x I I I I I I 11 I I 11 I I 11 I I 1 ill III I I I & PLATE DETAILS I I II II II II II II I I I IL_JI iI•---------1i IL-JI I ALL P05T, HANDRAILS, AND SPINDLMS TO 1 1 DM WHITE PLA511C PIN15H W ALUMINUM SEE DETAILS ON SNEET#t?-1REINFORCED, rYM AND STYLE f0 DE CH05EN POP 51MEL DECK SUPPORT P05T -- DY11f OWNER OR CONTWTOP & PLATE DMf&5 I I 1 �� i 1 II T____________�.__� . r-7 ---------� _ ---------T-- 1 I �r-�i rr=====____� �r-nl -1�-1 r1--- -- C-_ Ir�-r11 rr=====-'1 Ir--i I U5E �8"NUf5&DOLTSTO%CUM L0 �� 1i ii ii li 11 i LMGS TO LANCING C4-PLACES) I I I I II II I I II I I I I I II II I I (l II 1 I I II II II II 11 11 II 1 11 11 I I II II II II II II I 00 I I IL_JI jI Ij IL_Jj IL_J II 11 L_J jL_JI L_JI IC==-======�1Ir--+ IG======al r-� l i I I i 2n"X 10" RTED LANDING TO K SUPPODY I I II 11 II 11 tt II ' I II 11 ' 1 II II 11 11 I' II I /�� I I I I 11 I I I I t 1 I I I I 1 I I I I I 1 I I 1 i t 11 t l 11 I 4 X 4n P05T NOTCHED & 001,1Wf0 LANDING y/ WITH 9055 BRACING (4-PLACES) Cd I I IL_JI I� _ji IL_JI IL_JI IL J) tL_J IL_J IL_ _JI IL JI I }� L__�L L__ 1— (AACJ`` I I I 0 W '16^— I 0 --L----------- -- -- --------------- 2"X 611 POR SWAY�WACING I&G O -- ---- J i SUPPORT (TT,AS SHOWN) � L---------J I y"x 411X 4"SUPPORT P05f WITH i WELDED PLATES A5 SHOWN DOLTMD d i USE ADA44 POST RASE ' cLL O TO DMCK FRAMEWORK AL50 A5 J i CONNECTORS C 4-PLACES) G Z SHOWN TYPICAL (3)-PLACES Bulldlna Permlt Drewtrma Scale: O SUPPO"r 4"X 4"P05f WITH 12"DIA, SUPPOKi 4"X 4"P05T WITH 12"DIA, Date: SONATI�3M & DIG-FOOTS AS SHOWN � ) � 10-10-07 LOCATED JUST UNDER NEW PAHO _ } _-- -_ _) 50NATUDM & DIG-FOOf5 A5 SHOWN CONCRETE SLAD -- - - LOCATED A5 SHOWN Revisions: 10-24-07 Right Side Elevation - Pictorial View sheet (Looking West) Scale+XV= V-0' E- 1 24"x36" Drawing Printed Out Of Scale Herb Jones Architectural CAD-Design Computer Drafting Service 39 Harvard Ave r-------- --- Methuen,MA 01844 i ------------ Phone=1-978-689-9332 I Cell=1-978-886-3646 I I haicabinetAcomcast.net OUSW OF �45TTN6 NOUS I OMO M f---------------- — ----T--------- N L?I t` I I 00 --1 ' z 00 1 j 06 C6 I I C� ' I Q 1 � 1 � C U x � I I I I 1 I I I I � I 211X 12' 12�GK J015T I � r---------- ir------- U I I i II ALL P05T, HANRAL5, AW 5PIWL�5 TO CO Pe WN9 FLA5VC FIN15H W ALUMINUM .N O ' ITIINpOP02, MANt7 5m^ TO M CH05�N 1 i 1 i PY TNS OWW R Ott CONVACfR (D u5� 3/g" mars&i3aT5 TO 5�cwf L�65 TO LANDING (4-FLACp5) , _ OZZZ O 2"X 10'LAN171NG ; �,__ -_____ 7) O I O L + 2"X 6" CP055 13FACIN6 ___________ 0 C FR SWAY 13WINCA & ��-'? �-'� � V Q 5UppoI,-r me,A5 9-IOWN) O Yu Lo Z Bulldlna PennR Drawlnns Scale: Date: Y4.. 0 _1�-0" 10-10-07 Revisions: 10-24-07 Rear Elevation - Pictorial View (Looking South) Scale+Y/4° = V-0° Sheet# E-2 6x36" Drawing Printed Out Of Scale r Herb Jones Architectural CAD-Design Computer Drafting Service 39 Harvard Ave Methuen,MA 01844 Phone=1-978-689-9332 Cell=1-978-886-3646 h aicabinetAcomcast,net OUTLINE OF N511N6 co to 00 co N L? 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All f'raminq Materials to be Pressure Treated Stock Revisions: Unless Otherwise Spedfled, 10-24-07ons: Scale+3/a°= 1'-0" Sheet# P-2 24"x36" Drawing Printed Out Of Scale Herb Jones Architectural CAD-Design Computer Drafting Service 2' 39 Harvard Ave 60 61 Methuen,MA 01844 O II l 0 II Phone=1-978-689-9332 2 11 Cell=1-978-886-3646 r01'PLM haicabinetA,,comcast.net y"X 4"X 9"5SEL P05-ry M to MM?r0 r0P MAS Ye PLAS Wc=9 r0 00 M r0P FLM & P05r 2" t` %.0 Typical - Single Top-Plate Detail 00 � 00 00 00 z � � U y"X 4"X 4"5Sf L P05r S W1 l,1 P r0 r0P PLAT v � � a 0 U 3' "1 ,211211 C D %"PLAiE W1 L 7�7 „4"TNI Typical 611 roP PLM Center Post /,''X 4''X9"5rEf`.L POST LIDL W lan r0 rOP PLArE 00 TO rOP I'LAr� & P05r Typical - Double T_ Top-Plate Detail N N � U) > CO) O z � 06Q O � Y°x4"xasr��L Pcsr �Iz (� w Ltr7 ro TOP PLAfE V 8 II V U.11 O o 2 Lr) Z W a 81 1 - 1uliding Permit Drawlnas III Scale: Y4"=V-o" art /r_ x Date: I�T1Cal 10-10-07 Typical - Single Revisions: _ P End Post g 10-24-07 Base - Plate Detail Sheet# D- 1 24"x36" Drawing Printed Out Of Scale AAo" /,-"RG'PHR.-z, FoR S C RAX ' Q• S roVV.ZRS 19S ocJRTBs Z�c A-C. .LA/vv SURVRyoR.S �• � S.�PT,L=/y�FR 2D d � MFTKVE/.i/ MASS . . c ~7i�.. ti UUKGL a M . f RIO'Ai? -4 JV! No 24052 s -- q� a p QEF J9 O 's a 0 t a 0 N Lq N �� 2g 9,3 4C N l a � .r"x/s T'/N f O I--- -r- � DE c I< Ck i 2 w Q i h to 4lu � 1 Qp r Ro / Qa. 2/ T PA R K ¢ O,S G o o P S TS O dJ r �ocvs SNOY�/N [3� �Nc .1.or l3 ,s rio v✓ni on/ /��R 7'r� ,�s s�x R�C �s 7 P y I r 91te -P Board of Building Regulati ns and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement,'.CoAtractor Registration j . 1 Registration: 103772 Type: Individual j' f` Expiration: 7/9/2008 JOSEPH G. LEVIS JOSEPH LEVIS 160 PLEASANT STREET NORTH ANDOVER, MA 01845 Update Address and return card.Mark reason for change. DPS-CAI is 50M-05/06-PC8490 Address Renewal Employment ❑ Lost Card 0/:e >�aam�noouaeal!/ o�✓��aadadcuaeaa Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of BuildingRegulations and Standards Registration:-.103772lug g Exp1ratlo. :=7----19j' One Ashburton Place Rm 1301 ,, Boston,Ma.02108 j-Type:i-andividual JOSEPH G. LEVIS , JOSEPH LEVIS („ Sj 160 PLEASANT STREET __ NORTH ANDOVER,MA 01845 Deputy Administrator Not valid w' 10 gnature T� P ea Board of Building Regulatio s and Standards Construction Supervisor License License CS 30651 Exp ration; 1/7/2010 Tr# 11968 ;Restriction 00('� JOSEPH G LEVIS 't r 160 PLEASANT STS` N ANDOVER,MA 01845 Commissioner I TOWN OF NORTH ANDOVER i OFFICE OF . BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 ss�c � Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax '(978)688-9542 HOMEOWNER LICENSE EXEMPTION Please wi t DATE: /,Z- JOB LOCATION:_ 9 C v v r S� Number Street Address Map✓Lot HOMEOWNER Z-0.P 1'1 y r to n w LP V S Name Home Phone Work Phone PRESENT MAILING ADDRESS S—I Par, 4 IA ndcJt,of — O 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 responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and and that he/she will comply with said procedures and requi:rements. HOMEOWNERS SIGNATURE (De APPROVAL OF BURRING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF \PPE:U-S 61"-9541 CONSERI'XF10\638-9530 IIE.1LT11 698-95.30 PL.1\VING 6S8-9535 OP ID DATE(MMtDDmm � VIS �Q. CERTIFICATE E OF LIABILITY ltie S ��� r.Ezs 1 10/25/07 PRODUCERTHIS CERTIFICATE:18 ISSUE i)AS A MATTER OF INFORMATION ONLY AND CONFERS NO R13HTS UPON THE CERTIFICATE: HOLDER.THIS CERTIFICATI: DOES NOT AMEND,EXTEND OR Michaud, Rowe And Rusaak Ins. ALTER THE COVERAGE AFI ORDED BY THE POLICIES BE=LOW, 198 Massachusetts Ave North Andover mA 01845 INSURERS AFFORDING COVE RAGE NAIC# Phoue: 978 668 8829 Fax:97B 557 2130 J 024 IPL.,URID INSURER A: Prefec=d Hatuaa In,i,Q— Co- 15 INSURER B: Guard InsuraZ Levis CozEapan.ies Inc. INsuREFLG: Safety Insura .ce Company 33618 JOSeph Lewis INSURER D: 150 Fleasatlt Street North ,Andover MA 01845 INSURER E; COVERAGES RED NAMED ABOVE FOR THE POLICY THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSU70 WHICH THIS :IOD INDICATED.:'ERTIFICAT E MAY ($SBE 3SUED OR WSTANpING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT S MAY PERTAIN,THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HERRN IS SUBmCT TO ALL THE TERMS,EXCI IJSIONS AND CONDITIONS OF SUCH EOXIES.A03R'EGATE UNNTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAUS, N LIMITS POLiL�EFF 'P�Ii1�P�Xp11fA'� TYPE OF INSURANCE 1 POEJCY NUMBER DATE MNllDD/YY DANE MNUD[� LTRINSR EA ;HOCCURFcE1VCE S 1000000 GENERAL LLAMUTY - s 50000 A �[ COMyI3iCIALGENERAL LIABILITY CPP0100589059 10/26/07 10/26/08 p :MISES(E�xcurence) CLAIMS MACE OCCUR MI I:ECP(Any one perwn) S5000 _ PE LSONALBADV INJURY i11000000 — GI 4ERALAGGREGATE s 2000000 PI mucro-COMP.'OPAGG Is 1000000 GENL AGGREGATE UMIT APPLIES PEP: I - X POLICY I AUTUMOBELE I,IAf3iLETY `G,E'M81NF1.SINGL=LIMIT ' �ANY AUTO 821254 01/01/07 i 01/01/08 L e'` °"� A:LCNJNEDALTJS I I I a.oILrN�r RY l$500000 II(F, pereon) XSCHEDULED AUTOS :`` HIRED AUTO i B OILY INJURY Q::r acci06fT:) js 550000C :Fl NON-"Wv:-:D AUTOS I I I r;CP-fYDAMAGE $250000 I _i I i (I xoccdant] A.rm ONLY-EA A=DENT IS GARAGE LIABILITY AN EA ACC 15 ANY AUTO I t MC ON Y; _II � AGG S i tCF!=-URRENCE EXCESS)UMBRELLA UABIUTY 5 S _ OCCUR �CLAIMS MAOI 1 E iGREGATE S I i DEDJCFi31-E S RETENTION S _- I WORKERS COMPENSATION AND ORY{.IMI a JZ EMPLOYERS'LIABILITY , LEyJC$03fi25 i 02/27/07 i 02/27/08 L.SACHACC,DENT S100000 8 ANY PROPRIA OZPA4 NE2 �:LmVE r DIS�asE.EA=_nrflLovE 5 100000 0FP7CERlM1IFMBER ECCLUCED7 "YES dezoribe under L DISEASE-POLICY LIMIT S 500 Q 0 0 1EOIAL PROVOONS Se!Cw OTHER I I OINS DESCRIPTION OF OPERATIONS!LOCATIONS I'VEHLCLES I EXCLUSIONS ADDED I3Y EWORS ! ECIpL PPOVts+ Residential Construction and F,=0deling, p£fice Bldg gpmndeling- CANCELLATION CERTIFICATE HOLDER NQRTHI3 SHOULD ANY OF THE ABOVE OESCRIE!D PVLICiES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURE I WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDEF NAMED TO THE LEFT,BUT FAILURE TO DO So SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABIUTI 3F ANY KIND UPON THE INSURER,ITS AGENTS OR 384 Osgood street REPRESENTATIVES. North Andover MA 01845 AUTHOR NTATI ' �ACORQ CORPORATION ACORD 25(2001108) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,MA 02111 S www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Le v-k-s Lr, m go vt t -S Address: /(. a Plea S+ City/State/Zip: �Ja r 11 d a o--- l''l Phone.#: q -7 G cr 7 -2 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• � . 9. Q]-Bailding addition [No workers'comp.insurance comp. insurance. re uired.] 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions d i h ffi ocers have exercised their 11.❑Plumbing re 3. am a homeowner doing all work gairs or additions P 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. (Contractors 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. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: _ Phone k 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 i 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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 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 Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #6.17-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gou/dia