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Building Permit #646 - 657 FOREST STREET 4/23/2010
Permit NO: y Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 1 IMPORTANT: Applicant must complete all items on this page f. LOCATION Print PROPERTY OWNER Print MAP 210 - PARCEL: �1_ ZONING DISTRICT: Historic District yes no Lachine Shop Village . yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne TaftfV Addition wo or more family Industrial Alteration No. of units: Commercial Re air, replacement Assessory Bldg Others: Demoi ion z Other TIC Floodplain Wetlands Watersbed District Water/Sewer OF WORK TO BE PREFORMED: C>A,o W�- no � P A Identification Please Type or Print Clearly) OWNER: Name: 6-oo 0 //Qes-A/%)210- Phone: 2Y-5-5�-7�-k ArlrirPcc- CONTRACTOR Name: % j C' . A Phone.- Address:'`" Supervisor's Construction License:, Exp. Date: Home Improvement Licenser Exp. Date: ARCHITECT/ENGINEER Phone: e Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BA E ON $125.00 PER S.F. Total Project Cost: $ / C C FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t :e guaranty fund T �a. Location ro /I— No. Date ,AORTN TOWN OF NORTH ANDOVER AL Certificate of occupancy $ Building/Frame Permit Fee $ C Foundation Permit Fee $ Other Permit Fee $ TOTAL A'> $ Check # 22963- Bui(ding Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools , Wel 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 PLANNING & DEVELOPMENT COMMENTS NSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on 4112, Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: h Conservation Decision: Water &Sewer Co DPW Town�nginek n Comments Comments j v Located 384 Osgood Street FIRE DEPAR%MENT I -:Temp Dumpster on 'si# yes _ no Located at 124 M66 S#reet ; Fire Department signatureldate COMMENTS A Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 No 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: Building Permit Revised 2008 O z u O 0 E C L Z CD Q O H O � C C � p o ca O �O '9 m co CD �3 00 C L O a o cc� c VC J•O O. O CD CA C Z tsO CL C.3 CIO R C c _c CL. H 0 LU 0 U) LLIN W LLI C9 LLIW N w° co V) ° U w° v U w � p w ao' w oo� U w ao' cn w x p w z w rA o cn cn u O 0 E C L Z CD Q O H O � C C � p o ca O �O '9 m co CD �3 00 C L O a o cc� c VC J•O O. O CD CA C Z tsO CL C.3 CIO R C c _c CL. H 0 LU 0 U) LLIN W LLI C9 LLIW N :co o o C N O_ C ' � O Chi V •dam CL. c �C O • L E Q m c ID g CL. o m v L to y : O y . m t ti co �` c m •,yv • •g E H •p Amo 3 CD fl.C� a. m Le m ; L z o cm CD's Q fid• ;mo: 02 o m V H Occ V ZIP Z O Co «: coo m ym� o a = m m:S 30 N H � y o m W C Wrest s C •H � d= c Z m E �� �•H Qo Q V2 CL ce m- O� Ni- h C 2 F- Z ` 0 G. w m S; u O 0 E C L Z CD Q O H O � C C � p o ca O �O '9 m co CD �3 00 C L O a o cc� c VC J•O O. 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' �� � ,k.. f' ,yy` �*� { +'C,: ' �• a v , � '',' q 'w'' x ` r' . `{`a {�t ' ` ��• Of r �s,�'1+'►1..� � +�'ne,. r y'1 �' g�?'d� lni4� 4.,LC. 'rte _ ..:c � ,. IL l+ - `-•�1F�. sc���� � ,: ! "-rr r t� y � "�t� , "ae. � Y'•"' i ; T lrt� � '�� `� ��.s<w1��J�� J y� �`'' � .may t Y Y '� t'f ;,�7 ,'i.•t1. r,�. A f v.� �, � " Y� _Ayy' .(/, t.�3•i,• . r �•��'r• a c �' `.S •F." b�� . `' ��'1 •..` 1 k _ vka;k MAR/23/2010/TUE 10:22 FAX No. 9786881875 P.002 Krom:JAY-MOR ENTERPRISES, INC 603 635 9024 03/23/2010 09:46 Town of North Andover Building Department 1600 Osgood Street Bldg 20, Suite 2-36 North Andover MA 01 B45 'Tel: 970-688-9545 Fax: 978.688.9542 DEMOLITION OF BUILDING AFFIDAVIT DATE /O FaSkI;�+I+Y�ItItYa OWNER'S NAM & DDRESS 'fit 3a o LOCATION OF PROPERTY TO DEMOLISH_ /051 Fare,S- - (51. A, lln, + )er_ P4 C1lrSORIPTION CON CT 'S N ME & ADDRESS r i7 : 4. PD ✓.�oX /ri_S~ �lfia.m. /!�f Gt3d?� DEPARTMENT SION-OFFS DEPT. OF PUBLIC W KS - W R' /� p SEWER:' GAS �_ -f'7l 54 ELECTRIC TAXES POLICE FIRE - --- 9=RMIN TOR 2 j eet S --e DIG SAFE NUMBER Ol b �zq;w auung 0 mourn Affidavit BLDG. INSPECTOR Ap r, 12. 2010 8: 49AK I ium•4ni-mvil EIVIL1,1 w.)ES, INC MAR/23/2010/TUE 10:22 No, 1105 P, 1 603 635 9024 04/09/2010 09:05 A7/j P.0„"IV02 PAX No. 9786881876 P.002 rron:JAY-MOH ENTERPRISES, INC. 603 635 9024 Town -of North Andover Building Department 1600 099aod Street Bldg 20, Suite 2.36 North Andover MA 01845 Tel: 9784BB-OUS Fax: 978488.9 A2 DGMOLMON_OF BUILIN G AFFIDAVI'� 03/2312010 09:46 #413 P.0021002 a r_ • • •,• �^ •- iJ� =tea a�� �� �/ I _-1 DEPAR1 EW 1 asph(2_1 FIRE— _-- DIG SAFE NUMBER lea n - WUpo Froc National Grid From:JAY-MOR ENTERPRISES, INC Y,AR/23/2010/TUE 10:22 From:JAY-AOR ENTERPRISES, INC 17815221067 603 635 9024 04/09/2010 09:44 04/0912010 09:03 #112 P.002/002 #472 P.002/002 FAX No, 9786881875 F. 002 603 635 9024 0312312010 09:48 #413 P.0021002 'Town -of North Andover Building Department 1600 Osgood Street Bldg 20, Suite 2.36 North Andover MA 01645 Tel:978-666 Fax: 976-688.9542 gSMO+ MON OF BUILDiy NAFFIDAVIT ,Q prw'.r4 `( l' 11 C &QQjNNSPgQTOR Bumnp DMOMI a AibdM t?Is CP Af Ric✓ pORTH tLeO �6 6ti0 1 4 � Oq cxminiwlc• _ �• CONSERVATION DEPARTMENT Community Development Division MEMORANDUM DATE: April 15, 2010 TO: Gerald Brown, Inspector of Buildings FROM: Jennifer Hughes, Conservation Administrator SUBJECT: 657 Forest Street - Demolition Permit The owner of 657 Forest Street is currently seeking a permit from the North Andover Conservation Commission (NACC) for the demolition of an existing house and construction of a new house with associated driveway, grading, and appurtenances. Normally, no work may proceed on a project prior to the closing of the public hearing and the issuance of a positive Order of Conditions (OOC). However, because the existing structure is located in the outer portions of the buffer zone and no excavation is proposed, the Conservation Department, with the approval of the NACC Chairman, has signed the attached Demolition Permit. The following conditions must be observed: Erosion controls shall be placed between the demolition and wetland resource areas and shall remain in place until all the demolition and clean up work is complete. Erosion controls shall be within the existing lawn area. No excavation of the foundation or soils may occur. All demolition debris shall be removed from the site and disposed of in compliance with state and local laws. Please do not hesitate to contact me if you need further information. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9530 Fax 918.688.9542 Web www.townofnorthandover.com ELIMINATOR PEST CONTROL INC. 22 ALAN DALE ROAD MEDFORD, MA 02155 Jay -Mor Enterprises Fax 1-603-635-9024 Post Office Box 195 Pelham, NH 03076 Email: Jaymorent@comcast.net Invoice # 1994 Rodent Control Services performed for mice and rats at:657 Forest St. North Andover, MA. Date: 4/8/2010 Serviced by: Joe Testa Pest Control License # 16627 Integrated Pest Management for mice and rats. No problems were found at inspection. Service $65.00 Amount Owed $65.00 Thank you ON, TARGET. Jtility Services Date/Time, 4/13/2010 12:36:32 PM To: TRACY Locsft 5eitnces o� rrpxss 04345 enue www.ontargetservices.com , Mainete1800-598-0628 fax 207-588 302 email: scmuiug@ontugetwvims.com Company : JAY MOR ENTERPRISES INC Tel.: (603)-635-2035 ext. Fax: (603)-635-9024 ext. This message is being sent in response to your request for underground cable location. The following represents a list of responses for the indicated member. These reponses only pertain to the specific member. Ticket # : 20101604765 Place : NORTH ANDOVER, MASSACHUSETTS Address'. 657, FOREST ST 1- COMCAST CABLE -GREATER BOSTON -NORTH Ticket Screened on 04!1312010 This ticket is clear of conflict and has been screened by On Target Utility Services If there are questions regarding this transmission or if you arrive at the site and have a question aboutthe markings, please call 1-800-598-0628, extension 3347, during normal business hours, Monday- Friday between 7:00 and 4:30 Zimbra: jaymorent@comcast.net SmartZone Communications Center Collaboration Suite No Locate Notification From: OneCall@spectraenergy.com To: JAYMORENT@COMCAST.NET Page 1 of 1 jaymorent@comcast.net Thursday, March 18, 2010 7:41:44 AM Spectra Energy Transmission has received notice 20101204522 from the State One -Call Agency that you are planning an excavation that the agency has reason to believe is in the vicinity of a Spectra Energy Transmission pipeline. Spectra Energy Transmission's operating pipelines include Texas Eastern Transmission, LP; East Tennessee Natural Gas Company; Algonquin Gas Transmission Company; and Maritimes and Northeast Pipeline. The location of the excavation is reported to be at or near 657 FOREST ST, near the intersection of SCOTT CIR , in NORTH ANDOVER , county. Based upon the information provided about your planned excavation, no Spectra Energy Transmission pipelines or any of its other assets will be affected by your work. Therefore, Spectra Energy Transmission does not plan to mark the approximate location of any of its pipeline(s). Should you feel that a Spectra Energy Transmission pipeline or any other company assets will in fact be affected by your excavation or if the location provided to Spectra Energy Transmission changes or you now believe the description to be inaccurate, please contact Spectra Energy Transmission at 713-627-6306. 04/21/2010 11:05 9786888476 HEALTH PAGE 02/02 6 OCL 4r I� \�A_ tONNCitwn�w _ A• CONSERVATION DEPARTMENT [ommunity Development Division MEMORANDUM DATE: April 15, 2010 TO: Gerald Brown, inspector of Buildings FROM: jennifer Hughes, Conservation Administrator SUBJECT: 657 Forest Street - Demolition Permit The owner of 657 Forest Street is currently seeking a permit from the North Andover Conservation Commission (NACC) for the demolition of an wdstiung house and construction of a new house with associated driveway, grading, and appurtenances. Normally, no work may proceed on a project prior to the closing of the public hearing and the issuance of a positive Order of Conditions (OOC). However, because the existing stricture is located in the outer portions of the buffer zone and no excavation is proposed, the Conservation Department, with the approval of the NACC Chairman, has signed the attached Demolition Permit. The following conditions must be observed;- Erosion bserved: Erosion controls shall. be placed between the demolition and wedand resource areas and shall remain in place until all the demolition and clean up work is complete. Erosion controls shall be within the existing lawn area. No excavation of the foundation or soils may occur. All demolition debris shall be removed from the site and disposed of in compliance with state and local .laws. Please do not hesitate to contact we if you need further information. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9530 Fox 978.688.9542 Web www.iownofnorthandover.com Massachusetts - Department (rt' Public Safetc Board of Building Regulations and Standards Construction Supervisor License License: CS 81490 Restricted to: 00 ROBERT MORGAN ZERO ROMANS ROAD WINDHAM, NH 03087 11 Ial Expiration: 5/2/2010 ( numis.i nrcr Tr#: 29610 Page 1 of 1 Brown, Gerald From: david.n.tremblay@gmail.com on behalf of Linda E Tremblay [linda.e.tremblay@gmail.com] Sent: Monday, April 12, 2010 9:27 PM To: George Haseltine Cc: Brown, Gerald; kathleenszyska Subject: 657 Forest St Hi George, At the NA Historical Commission meeting on April 12, 2001, it was voted that 657 Forest St, North Andover, NIA is not a historically significant structure per the Town's Demolition Delay bylaw (Chapter 82). There will be no delay period, and your demolition application has been signed off. It will be returned to you in tomorrow's mail. Regards, Linda Tremblay NA Historical Commission 4/13/2010 Town of North Andover Building Department 1600 Osgood Street North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 DEMOLITION OF BUILDING AFFIDAVIT OWNER'S NAME & ADDRESS 6-fOr -,,� aje / �7,? C r..tkORTh-%*% Da OL ?, e" O LwK! ,� COCNIC NlWKM � �% HVS�'t LOCATION OF PROPERTY TO DEMOLISH /05 % FJr6,S 7- %i. 1�4 DESCRIPTION �[C�/1� ,iru�-L6sycDAe- A-_ L_/ Mo CONTRACTOR'S NAME & ADDRESS/-/YDO DEPARTMENT SIGN -OFFS DEPT. OF PUBLIC WORKS - WATER: SEWER: V106PT OF CONSERVATION `,_ol:b� HEALTH DEPT: Septic Well �aalo HISTORIC COMMISSION GAS ELECTRIC TELEPHONE CABLE TAXES POLICE FIRE EXTERMINATOR DUMPSTER - ON/OFF STREET DIG SAFE NUMBER DATE REC'D Doc.form demolition of building affidavit BLDG. INSPECTOR 'r� D 'ARTMENT OF UB.LIC SAFETY Hoisting Engineer License ° - Number: HE 074706 Expires: 05/02/2010 Tr. no: 25718 1.4 Restricted 18.2A ROBERT J MORGAN, ZERO ROMANS ROAD G— WINDHAM, NH 03087 Commissioner 11 Massachusetts - Dcpartnicnt (it' Public SafetN Board of Building Regulations and Standards # VConstruction Supervisor License f License: CS 81490 Restricted to: 00 t ROBERT J MORGAN ZERO ROMANS ROAD WINDHAM, NH 03087 ( �nnmissioncr Expiration: 5/2/2010 Tr#: 29610 Certificate Of Training T9Z.ENCNING/SN0WJXG/EXCAVATION SATE2 Y •rre—fi—k.[-„-.,da,� P00E9(•T 7H09LGAT' i 3AT-%09(. Ewnq("JSES coo.ma.,�ray�omp�d,�l�.X.9�MvrEa:H nil. z ,r�h��sFo�rr���„l�or, Safra• �o�,u o� l� opormse,ryrr6no>„ � osxa rcgoreing,f anep.oyrr Trrnahi B, sla+n�g, ueZ.�<.vnlmnS�ryu arG w ahUNra / b/jvey\I Wfmrrv, l�arrw ro. TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units ... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: `IJ-e.rYI6114 on Est. Cost Address of Work („59 Gr--aS+ ,_q. %a,����trel, Owner Name: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Permit No. Job under $1,000 Date Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND UNER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: ane- Date Contracto Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name f I www mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual):--\A Address: ' b e3bX AS- City/State/Zip: SCity/State/Zip: k1�vY\ .n (o Phone #:-W3-(o�S-a\6 u an employer? Check the appropriate box: AZO/I The Commonwealth of Massachusetts sr 1 Department of Industrial Accidents Office of Investigations .' \U4,, 600 Washington Street Boston, MA 02111 f I www mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual):--\A Address: ' b e3bX AS- City/State/Zip: SCity/State/Zip: k1�vY\ .n (o Phone #:-W3-(o�S-a\6 u an employer? Check the appropriate box: AZO/I Type of project (required): Iam a employer with r_ 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. $ �• Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition workingfor mein an act y capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.[] 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 bo)C#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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company X11 / 1 B Policy # or Self -ins. Lie. Expiration Date: ��'Jcq(0 I JC) Job Site Address: f w64,9- n : Lit, rot 1C' _ ri A City/State/Zip: )U , lggr.16 � . 144 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 DCA for insurance coverage verification. I do hereby erlfy under the nd penalties of perjury that lite information provided above is true and correct Si ature G Date: 7 13 116 teo3 f-IoAS_o18"3 use only. Do not write inthis 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 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. # 617-72.74900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia ��D- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 4/13/2010 PRODUCER ACORN INSURANCE 25 Old Lawrence Rd Pelham, NE 03076 (603) 635-7399 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE MAIC# INSURED Jay -Mor Enterprises PO BOX 195 PELHAM, , NE 03076 603 635-2035 INSURER A: Burlington Insurance INSURER B: Princeton Excess INSURER c Cozwfterce & Industry INSURER D: ESSeX Insurance INSURER E COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. Im UPD WDIL I C POLK Y NUMBER POLICY EFFECTIVE DATE MMIDDNY POLICY EXPIRATION A LIMITS REPRESENTATIVES. r) ° AUTHORIZED REPRESENT -i�- GENERAL LIABILITY f EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PRnjSES oecurence $ 50,000 CLAIMSMADE W OCCUR MED EXP (Any one person) $ 5,000 A X EGL0023632 2/18/2010 2/18/2011 &ADV INJURY $ 1,000,000 -PERSONAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY MWT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED ALTOS (Per ASO") BODILY INJURY $ HIRED AUTOS NON•OWNEDAUTOS (Per— PROPERTY DAMAGE S (Per aocident) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTOONLY: AGG S EXCESSIUMBRELLALIABILITY EACH OCCURRENCE $ 5,000,000 X OCCUR II CLAIMSMADE AGGREGATE S 5,000,000 66A3FF000053500 2/19/2010 2/18/2011 S S B DEDUCTIBLE 5 RETENTION S WORKERSCOMPENSATKNIAND I TORY UMTS ER EMPLOYERS'UABILITY WC006788024 5/26/2009 5/26/2010 E.L. EACH ACCIDENT $ 1,000,000 C ANY PROPRIETORmnRTrER1EXECtmvE OFFICERNAEMER EXCLUDED? E.L. DISEASE - EA EMPLOYEES 1,000,000 R yes. describe under SPECIAL PROVISIONS below E.L. DISEASE - POUCY LIMIT $ 1,000,000 OTHER r , 00 e g poll D Pollution 10CPLCO0711 2/18/2010 2/18/2011 $2,000,000 gen aggregate Liability DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS Demolition of 657 Forest St No Andover MA Additional insured applies CFRTWICATF mLnFR CANCELLATION ACORD25 (2001108) © ACORD CORPORATION 1988 T -d STSEGE9609 SaDIJ40 SUI d0T=E0 01 61 idd SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATICt DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL10 DAYS WRITTEN George Haseltine 32 R Old Point Rd NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL Newbury MA 01951 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. r) ° AUTHORIZED REPRESENT -i�- f ACORD25 (2001108) © ACORD CORPORATION 1988 T -d STSEGE9609 SaDIJ40 SUI d0T=E0 01 61 idd Massachusetts Department of Environmental Protection L71 Bureau of Waste Prevention . Air Quality BWP AQ 06 Notification Prior to Construction or Demolition 100103752 Decal Number Important: A. Applicability When filling out Pp y forms on the computer, use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building, or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor - not use the return (DEP), Bureau of Waste Prevention - Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09 (2) ten (10) days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. B. General Project Description 1. a. is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied Instructions residence of four units or less? ❑ Yes ❑✓ No 1. All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order to comply with the 2 Facility Information: Department of RESIDENCE Environmental Protection a. Name notification 1657 FOREST ST. requirements of b. Address 310 CMR 7.09 North Andover MA I 01845 c. Citv/Town State Zip Code f. Tele hone Number area code and extension . E-mail Address (optional) 3600 2 h. Size of Facility in Square Feet i. Number of Floors j. Was the facility built prior to 1980? ❑✓ Yes ❑ No k. Describe the current or prior use of the facility: VACANT RESIDENCE _ I. Is the facility a residential facility? ❑✓ Yes ❑ No m. If yes, how many units? Number of Units 3. Facility Owner: =N GEORGE HASELTINE �O a. Name 10 132 R OLD POINT ROAD b. Address NORTH ANDOVER mA 101845 �O c. City/Town d. State e, Zip Code �° f. Telephone Number (area code and extension) E-mail Address (optional) _a GEORGE HASELTINE �Q h. Onsite Manager Name ag06.doc • 10/02 BWP AQ 06 • Page 1 of 3 L71 General Statement: If asbestos is found during a Construction or Demolition operation, all responsible parties must comply with 310 CMR 7.00, 7.09, 7.15, and Chapter 21 E of the General Laws of the Commonwealth This would include, but would not be limited to, filing an asbestos removal notification with the Department and/or a notice of release/threat of release of a hazardous substance to the Department, if applicable. Massachusetts Department of Environmental Protection Bureau of Waste Prevention - Air Quality 1100103752 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition B. General Project Description (cont.) 4. General Contractor: JAY -MOR ENTERPRISES INC PO BOX 195 PELHAM NH c. Cit /Town d. State 6036352183 ROBERT MORGAN h. On-site Manager Name C. General Construction or Demolition Description Construction or demolition contractor: JJAY-MOR ENTERPRISES INC a. Name PO BOX 195 b. Address NH d. State 83 ROBERT MORGAN 2. On -Site Supervisor: ROBERT MORGAN On -Site Supervisor Name 3. Is the entire facility to be demolished? 0 Yes ❑ No 4. Describe the area(s) to be demolished: ENTIRE STRUCTURE 5. If this is a construction project, describe the building(s) or addition(s) to be constructed: NA ag06.doc - 10/02 BWP AQ 06 - Page 2 of 3 Lll�Massachusetts Department of Environmental Protection Bureau of Waste Prevention . Air Quality BWP AQ 06 Notification Prior to Construction or Demolition 100103752 Decal Number C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project, were the structure(s) surveyed for the presence of asbestos containing material (ACM)? ❑✓ Yes ❑ No If yes, who conducted the survey? EMSL ANALYTICAL b. Survevor Name AA000188 c. Division of Occupational Safety Certification Number 7. Construction or Demolition: 4/19/2010 5/19/2010 a. Start Date (mm/dd/yyyy) b. End Date (mm/dd/yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: ❑ seeding ❑ paving b. If other, please specify: ❑✓ wetting ❑ shrouding ❑ covering ❑ other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? INA a. Name of DEP Official NA b. Title C. D. Certification I certify that I have examined the above and that to the best of my knowledge it is true and complete The signature below subjects the signer to the general statutes regarding a false and misleading statement(s). JAMES R.MORGAN a. Print Name James R. MOraan IJAY-MOR ENTERPRISES INC 4/2/2010 e. Date (mr ag06.doc • 10/02 BWP AQ 06 • Page 3 of 3 eDEP - MassDEP's OnlineFiling System Page 1 of 1 MassDEP Home I Contact i Feedback I Tour i Privacy Policy MassDEP's Online Filing System My eDEP I Forms c* My Profile I* Help Receipt Forms Signature Payment Receipt Summary/Receipt print receipt Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select "My eDEP" to see a list of your transactions. DEP Transaction ID: 297834 Date and Time Submitted: 4/2/2010 3:45:55 PM Other Email: Form Name: AQ 06 - Construction/Demolition Notification Payment Information DEP code: 44455 Date: 4/2/2010 3:45:48 PM Amount ($): 85 Payment Detail: MORGAN LAURIE--AccountType -- AccountNumber ***"7254 Confirmation N umber: Contractor Contractor Number Name Address, , Supervisor Project Monitor Lab Usemame:JAYMOR Nickname: JAYMOREDEP My eDEP MassDEP Home I Contact I Feedback I Tour I Privacy Policy MassDEP's Online Filing System ver.9.3.7.0© 2010 MassDEP IM Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. I! INSTRUCTIONS 1. All sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 7.15 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 Commonwealth of Massachusetts 100103750 Asbestos Notification Form ANF -001 Decal Number A. Asbestos Abatement Description a. Is this facility fee exempt - city, , town, district, municipal housing authority, owner -occupied rpsiripnrp of four units nr 1pss9 171 Yps n Nn b. Provide blanket decal number if applicable: 2. Facility Location: RESIDENCE a. Name of Facility North Andover MA c. City/Town d. State 3. Worksite Location: Blanket Decal Number 657 FOREST ST. b. Street Address 01845 e. Zip Code f. Telephone Number THROUGHOUT a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room 4. Is the facility occupied? ❑ Yes ❑✓ No 5. Asbestos Contractor: JAY -MOR ENTERPRISE a. Name PELHAM 1 03076 c. Ci /Town d. Zip Code AC000696 f. DOS License Number (GEORGE HASELTINE I ROBERT J. MORGAN 6' a. Name of On -Site Su ervis ED MORGAN 7' a. Name of Project Monitor $ EMSL ANALYTICAL a. Name of Asbestos Analvti4 9. 4/17/2010 a. Project S1 7-3PM c. Work hour 10. a. What type of project is this? ❑✓ Demolition ❑ Renovation ❑ Repair ❑ Other, please specify: 11. a. Check abatement procedures: [I Glove bag ❑✓ Enclosure ❑ Cleanup ❑✓ Full containment Encapsulation ❑✓ Disposal only ❑ Other, specify: 215 GAGE HILL RD POB 196 b. Address 6036352183 e. Telephone Number g. Contract Type: ❑✓ Written ❑ Verbal 6037858768 b. E nd Date mm/ dd/ SATURDAY d. Work hours Sat -Sun. b. Describe b. Describe 12. Is the job being conducted: ❑✓ Indoors? ❑✓ Outdoors? anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 A. Asbestos Abatement Description (cont.) 100103750 —� Decal Number 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 8 1150 a. Total pipes or ducts linear ftotal otner su aces square c. Boiler, breaching, duct, tank I INA surface coatings Lin. ft. e. Corrugated or layered paper St. pipe insulation Lin. ft. I� Sq. ft. h. Transite board, wall board g. Spray -on fireproofing Lin. ft. Lin. ft. i. Cloths, woven fabrics Lin 18 150 k. Thermal, solid core pipe Lin. ft. insulation Lin. ft. 14. Describe the decontamination system(s) to be used:. 3 CHAMBER DECON I. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (a): IWET REMOVAL. EMIL POLY. COVER THE CRITICALS I 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: INA I INA a. Name of DEP Official d. Insulating cement Lin I I St. f. Trowel/Sprayer coatings — — Lin. ft. I� Sq. ft. h. Transite board, wall board 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A–F apply to this project? ❑ Yes ❑✓ No B. Facility Description Lin. ft. VACANT RESIDENCE 1. Current or prior use of facility: 18 150 j. Other, please specify: Lin. ft. Sq. ft. FLASHING&LINO b. Address NEWBURY 14. Describe the decontamination system(s) to be used:. 3 CHAMBER DECON I. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (a): IWET REMOVAL. EMIL POLY. COVER THE CRITICALS I 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: INA I INA a. Name of DEP Official b. Title c. Date (mm/dd/ ) of Authorization d. DEP Waiver # e. Name of DOS Official f. DOS Official Title g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver # 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A–F apply to this project? ❑ Yes ❑✓ No B. Facility Description VACANT RESIDENCE 1. Current or prior use of facility: 2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No GEORGE HASELTINE 32 R OLD POINT ROAD 3' a. Facility Owner Name b. Address NEWBURY 01951 603-785-8768 c. Ci /Town d. Zip Code e. Telephone Number area code and extension GEORGE HASELTINE 1 132 R OLD POINT ROAD 4' a. Name of FacilityOwner's On -Site Manager b. On -Site Manager Address NEWBURY 1 101951 603-785-8768 c. Citv/Town d. ZiD Code e. Telephone Number (area code and extension) anf001 ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 Note: Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 B. Facility Description (cont.) JAY -MOR ENTERPRISES INC 5' a. Name of General Contractor PELHAM 03076 c. Ci /Town d. Zip Code COMMERCE & INDUSTRY f. Contractor's Worker's Comp. Insurer 6. What is the size of this facility? 100103750 Ll Decal Number PO BOX 195 b. Authorized Signature b. Address 14/2/20110 6036352183 d. Date mm/d e. Telephone Number area code and extension WCO06788O24 J 15/26/2010 q. Policv Number h. Exp. Date mm/dd/ 3600 2 a. Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos -containing material from site to temporary storage site (if necessary): JAY -MOR ENTERPRISES INC a. Name of Transporter PELHAM 03076 c. City/Town d. Zip Code 2. Transporter of asbestos -containing waste material a. Name of Transporter c. Ci /Town d. Zip Code 3. a. Refuse Transfer Station and Owner c. Ci /Town d. Zip Code 4. ITURNIKEY LANDFILL (WASTE MGT NH) 7 ROCHESTER NECK ROAD c. Final Disposal Site Address NH 103839 e. State f. Zip Code D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. PO BOX 195 b. Address 6036352183 e. Telephone Number from removal/temporary site to final disposal site: b. Address e. Telephone Number b. Address g. Telephone Number JAMES R. M liames R. Morgan a. Name b. Authorized Signature PRESIDENT 1 14/2/20110 c. Position/Title d. Date mm/d 6036352183 JAY -MOR ENTERPRISES e. Telephone Number f. Representing PO BOX 195 a. Address PELHAM I 03076 h. City/Town i. Zip Code anf001 ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 eDEP - MassDEP's OnlineFiling System r MassDEP's Online Filing System My eDEP I Forms d My Profile K* Help Receipt Page 1 of 1 MassDEP Home i Contact I Feedback i Tour I Privacy Policy Usemame:JAYMOR Nickname: JAYMOREDEP cm Forms Sianature Payment Receipt Summary/Receipt print receipt Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select "My eDEP" to see a list of your transactions. DEP Transaction ID: 297821 Date and Time Submitted: 4/2/2010 3:40:18 PM Other Email: Form Name: AQ 04 - Asbestos Removal Notification Form ANF -001 Payment Information DEP code: 44454 Date: 4/2/2010 3:40:08 PM Amount ($): 85 Billing Info: MORGAN LAURIE--AccountType -- AccountNumber ****7254 ConfirmationNumber: Contractor Contractor Number: AC000696 Name: JAY -MOR ENTERPRISE Address: 215 GAGE HILL RD POB 196, PELHAM, NH 03076 6036352183 Supervisor ROBERT J. MORGAN Project Monitor Lab Location THROUGHOUT Project Start Date 4/17/2010 My eDEP MassDEP Home I Contact I Feedback I Tour I Privacy Policy MassDEP's Online Filing System ver.9.3.7.0© 2010 MassDEP V 4 .r Page 1 of 1 Brown, Gerald From: david.n.tremblay@gmail.com on behalf of Linda E Tremblay [linda.e.tremblay@gmail.com] Sent: Monday, April 12, 2010 9:27 PM To: George Haseltine Cc: Brown, Gerald; kathleenszyska Subject: 657 Forest St Hi George, At the NA Historical Commission meeting on April 12, 2001, it was voted that 657 Forest St, North Andover, MA is not a historically significant structure per the Town's Demolition Delay bylaw (Chapter 82). There will be no delay period, and your demolition application has been signed off. It will be returned to you in tomorrow's mail. Regards, Linda Tremblay NA Historical Commission 4/13/2010 Town of North Andover Building Department 1600 Osgood Street North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 DEMOLITION OF BUILDING AFFIDAVIT OWNER'S NAME & ADDRESS 6-foC-,,� µORT11 q 46 O o O 19�A C0CNIC"11WK84 `y ORATED SPP '9SSAC HUS�� LOCATION OF PROPERTY TO DEMOLISH bf 1 `%. %l-ade(Jer . 1-l4 DESCRIPTION. J odj-� ,Ami-e_ S \ 14 --car- /ala/ /" -rte- D1 -7 S -es DEPARTMENT SIGN -OFFS DEPT. OF PUBLIC WORKS - WATER: SEWER: DEPT OF CONSERVATION HISTORIC COMMISSION GAS ELECTRIC TELEPHONE CABLE TAXES POLICE FIRE EXTERMINATOR DUMPSTER - ON/OFF STREET DIG SAFE NUMBER DATE REC'D Doc.form demolition of building affidavit HEALTH DEPT: Septic Well BLDG. INSPECTOR