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HomeMy WebLinkAboutBuilding Permit #477-16 - 80 CHICKERING ROAD 10/14/2015ED BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION • �.csilllci; LOCATION 0O PROPERTY OWNER MAP V& _PARCEL: icant must Date Received all items on this //— 21/ M261 Print 100 Ye Structure yes ZONING DISTRICT: Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential _ ❑ New Building ❑ One family El Two or more family [I Industrial ❑ Addition El Alteration No. of units: ❑Commercial El Others: 0 Repair, replacement ElAssessory Bldg ❑ DemolitionElOther - - - _ p Septic . ❑ 1Nell -- ❑ Floodplain 0^Wetlantls. r ❑ Watershed'District ❑ 1Nate�ISewer_ vo,Cer•o1D-nr1n1 �_. __. y _� _ _ --- ru Wr1RK Tn RF PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: - Contractor Name: Email: Address Supervisors 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: $ J���v FEE: $ Check No.: �� Receipt No.: �� �� NOTE: Persons contracting with unregistered contractors do not have access to the Juaranty fun Location W- %-.1-1-f -9-0 f No. Date /� ..— / j I IV/ I -/' / / Check # —333--A-� TOWN OF NORTH ANDOVER A r Certificate of Occupancy $ , Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector LocaiiongC�T '� 1� vr No. !oJ?� Date ,.ORTq TOWN OF NORTH ANDOVER Of�t�o ,�1ti0 9 Certificate of Occupancy $ ,�SSACNUSE� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #o1 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanuing/Massage/Body.A,rt ❑ SwunmiugPools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS ,HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Suer Connection/signature � pate Drivewav Permit DPW Town Engineer: gignaiure: FIREIDEPART Located 384 Osgood Street �� IMEN,I-�� TbM'piDumpst .ran site ) es ` Located�at}1F249Maiii�St�eet �' `' Y.- FiretDepar#ment signature/date 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 ®ANGER ZONE LITERATURE. yes MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine Ef Doc.Buildin,; Penuit Revised 2014 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 4 Floor Plan Or Proposed Interior Work � Engineering Affidavits for Engineered products TOTE: 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/Cross Section/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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) j- Building Permit Application 46 Certified Proposed Plot Plan 46 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 2012 IECC Energy code Engineering Affidavits for Engineered products TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 w 0 3 0 H E J w LL. 0 t u y \ O LL +cu N U CL In a Z z Z m C O N "O LL L � d' Nz C U LL O0 d H Z Z G C L to 7 of LL 0 d H Z U LLI L OLO 7 K V i(a In LL XZ O V a Z C7 L CLO K LL LLI G °C Q W 0 LLI a' m O ++Y a) N Ul N O (A 0 I O V Z E Z U U) W > a U) U) Z o W O U CO �w a z_ m G a� O N d t O z O Q J O O W :a c� •z 0 •m ti Al rE e w N a w z PYRAMID CONSTRUCTION 508 Lowell Street • Methuen, MA 01844 • (978) 852-8518 phone • (978) 794-1961 fax JOB PROPOSAL Proposal Submitted to: Harrisons Roast Beef / Mike McMains Date: October 7, 2015 Job Name: Harrisons Loading Dock Job Description: Rebuild damaged loading dock, 8'x 14' as discussed,lnstall metal safety rail on 2 sides, and 5/4 decking to be painted with non slip material. We hereby propose to furnish labor for the sum of: $ 5,000.00 Payment to be made as follows: 100% materials and 50% labor cost due upon approval of proposal. Remainder of labor cost due upon completion All work will be completed in a timely, professional manner consistent with standard practices. Any deviation or alteration of the above proposal involving additional charges will be executed upon written request only. Any such charges will be in addition to this proposal. All agreements are contingent upon the absence of accidents, strikes or other delays beyond our control. The owner is to carry fire and other necessary insurance. All employees of Pyramid Construction are fully covered by Workman's Compensation insurance. This, pro a may be withdrawn if not accepted within 30 days. Authorized Signature: Acceptance of Proposal The above prices and -conditions aresatisfactory.and are.bireby accepted. Pyramid Construction is authorized to do the work specified above. Payment will be made as outlined above. Signature:_.( ,�`'`� Date of Acceptance: la /S` ]AM L J i ]AM J, ® CERTIFICATE OF LIABILITY INSURANCE AD DATE`MM/°°'"'"' 10/14/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Hasbany & Regan Insurance AgenPHONE CONTANAME: Eric Jansen (978) 685-3188 FAx No: (978) 685-9460 254 Pleasant Street Methuen, MA 01844 ADDRESS: eric@hasbany.com INSURERS) AFFORDING COVERAGE NAIC ft INSURER A:Capitol Specialty Insur EACH OCCURRENCE $ 1,000,000 INSURED INSURERS: Progressive INSURER C: American Zurich Insurance Peter Budish INSURER D: Pyramid Construction, LLC INSURER E: 508 Lowell St INSURER F: Methuen, MA 01844 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVID POLICY NUMBER POLICY EFF (MM/DD/Y POLICY EXP MMIDDIYYYY LIMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR y CS01357938- 8/16/15 8/16/16 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTEDPRE n $ 100,000 MED EXP (Arryone person) $ 5 000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRO LOC X POLICY JECT PRODUCTS - COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANYAUTO ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS 07736803-4 12/2/14 12/2/15 EOMBINED�SINGLELIMIT $ BODILY INJURY (Per person) $ 100.000 BODILY INJURY (Per accident) $ 300,000 PReOPPEoniRdTY DAMAGE $ 100,000 4UMBRELLAIAB EXCESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE Y / N OFFICERMIEMBER EXCLUDED? (Mandatory in NH) If yes describe under DE StRIPTIONOFOPERATIONSbelow N / A WC1-31S-379615-015 9/1/15 9/1/16 WC STATU- X OTH- 11 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 - POLICYLIM IT $ 1,000,000 E.L. DISEASE DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CFRTIFICATE HOLDER CANCELLATION U 1985-207 ORD GORPORATIUN. All rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks o CORD Phone: Fax: E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector AUTHORIZED REPRESENTATIVE Eric Jansen lee I U 1985-207 ORD GORPORATIUN. All rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks o CORD Phone: Fax: E -Mail: The Commonwealth of Massachusetts . Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, H4 02114-2017 www mass.gov/dia yYy Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/lndividual): T\ Address: slog t-6 CL�)Ir lt k City/State/Zip: n -r ft)a 0 `C LLC � \- Phone Are you an employer? Check the appropriate box: Type of project (required): 1.M I am a employer with _employees (full and/or part-time).* %. (] New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. F1 Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 E] Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ g. 13.ORoof repairs These sub contractors have employees and have workers' comp. insurance.$ j 6. [J We are a corporation and its officers have exercised their right of exemption per MGL c. 14. � Other 152, § 1(4), and we have nQ employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 state whether or not those entities have employees. If the sub-conracfors 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; Me� k kV,= -h. rk Policy # or Self -ins, Lic. #: CEPA �b i21^\ 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify un der th epaills andpenalti of pe •ury that the information provided above is true and correct. Cinnai-nra• Date: Phone #• !q ? k _ or,- 9 P �3 l Official use only. Do not write in this area, to he 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall_ enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill- out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to 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 retuned 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-insur6d 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 bottorn 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia N / rp - � -'*�o - 0,9 Date.. ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................................................. has permission to f ....................................... wiring in the building of ............... ........................................... at.?� .... ............. North Andover, Mass. Fee,�P.. ........ Lic. No. j%,E ............. iLE - ICAL - INSPECTOR - ...... .. Check #t,3 SQ_ -- 91 01 w �� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 4/ Occupancy and Fee Checked / [Rev. 1/07] Qeave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: f ( —2,1- d 9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his`or her inten^on perform the electrical work described below. Location (Street & Number) / 7 1 G " Owner or Tenant 46 �P� �' Cl 2 Owner's Address q4'r Is this permit in conjunction with a biding permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity n No. vel Yes ❑ No � (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Propos//ed Electrical Work: / AVL°12 T— -••��•aeiuu > aescrea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover ffiis in force, and has exhibited proof of same to the permit issuing oce. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) IN under th%e�ains and penalties of p ury, that the information on FIRM this application is true and complete "' @ C � LIC. Licensee: �/� Signature LIC. NO.:� �a (If applicable, enter "exempt" in the lice a number line.) Address: Jr— Q (/� smotey(/ pi© `79 Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lic. No 47 ry y /f6 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $.1 j �- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, A"-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): &U J CL 4LP__/_ Address: 5—e ate City/State/Zip: I�P_ 04 vt%/ Q, 'P§hone #: ? 7 9 " �I z�) I/Z �O Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with t — 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.) 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no .employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I0.f011ectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 1.n7 UPPH HM -GSL U11CCKS GGx Tri oils -a30 tall our me section below shOwmg their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: , Policy # or Self -ins. Lic. #:, Expiration Date: y 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. Ido hereby certi& un er the pains and enalties of per'ury that the information provided above is true and correct Signafore: Date: y 21— (9 G Phone #: - 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 � - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants , Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability.Partnerships (LLP) with no employees other than the members or partners, are not required to 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 Iicense 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 Washi gton Street Boston, AEMA. 021.11 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 mrww-maSs.gov/dia NORT1y olArso CHUS This certifies that Date c7/ f TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1.30<q4.` ....................... has permission to perform ...�� : f.' .. A'.....' . �' I............. plumbing in the buildings of . vxr . !y!!? :.`.'.................. o c l - < h �t , , ..... , North 'Andover, Mass. Fee.VU r.. Lic. No.. ��` c �.. . h. (�v�.r ....... 0. PLUMBING INSPECTO Check -3/ 7 6 4 ): FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_d0e_ Arj 4-ye,&t- MA. Date: o? Permit# 7 Y3 Building Location: �� i P�Li r1 t �� Owners Name: AiZe Ak/11,R'iv S Type of Occupancy: Commercial [Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: El] Plans Submitted: Yes ❑ No FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yest"o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy (Ir Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ of Owner or Owner's Agent �rtify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: d Title[I P umber Sig pure of Licensed Plumber Q/ City/TownD`Mr License Number: l 3 T ` `' APPROVED OFFICE USE ONLY [�1ourneyman z z rn Y O U a Z FQ- `1 Q N cn J Q U Q LU 0 N z 0 z w W Q W W WW w z cn O a lX O m W = w 0 Q F' Q z }' IY O W IY w z W w N J O Z v a FL`-, Q LL Y= z LL a YOp zQ x w w w IY Q Q N- 0 Q O >> Q Q O x Q o! cn Q ►- Q Q x 0 F - Q O SUB BSMT. BASEMENT 1 FLOOR r 2 FLOOR 3 FLOOR 4 1HFLOOR 5 FLOOR -6T"-FLOOR 7 FLOOR 8 FLOOR rI•- (('' Check One Only Certificate # Installing Company Name: JO W M1� �U/b1 f7�N9 JL'�L jeie ps /+ I'_ Address: C No# -VE cs+- " �� ( CitylTown: �tAACVrt� State: tom' L] Corporation E]Partnership Business Tel: 17t ff fd -462-07 Fax: ❑Firm/Company Name of Licensed Plumber:(G� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yest"o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy (Ir Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ of Owner or Owner's Agent �rtify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: d Title[I P umber Sig pure of Licensed Plumber Q/ City/TownD`Mr License Number: l 3 T ` `' APPROVED OFFICE USE ONLY [�1ourneyman VcV ' C14 N `«?cl i' rb � y o x•' � m v, O `. o. 14 p •� o t GC w ��� w 1 o a., •., � O �� a0 � � •�`' w � W � z � � o a. .� r U °U il *•� y Z b o o c °' °c p / a cc00 z 05 (� W `ti 4 chi '�� k U � C'•y .x � >, y W 1142 a� ti �slZ w zwinw h A o � , Location No. Date �� 1, rx N'0 Th TOWN OF NORTH ANDOVER . ~ •. OA Certificate of Occupancy $ 9 cMBuilding/Frame /Frame Permit Fee $ J�ust ^;;1 fL r, ,� foundatiorl7kAii Fee6 G is Other Permit Fee IOTAL $ Check # �p� GG r Building Inspector i° €moi �' fhti COMMONWEALTH OF MASSACHUSETTS ssb`"-TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 APPLICATION OF CERTIFICATE OF INSPECTION 2008 Date: 7 (--(Fee Fee Required (Amount) $100.00 ( ) No Fee Required Accordance with the provisions of the Massachusetts State Building code, Section 108,15, 1 hereby apply for Certificate of Inspection for the below -named premises located at the following address: Street and Number S-10 Name of Premises �Cu ��_►t� Purpose for the Premise is used. �T i�lLaAulJ�� Licenses (s) or Permit (s) Required for the Premises by Other Governmental Agencies: Contact Person Ann Higgins Telephone 978-682-8785 License or Permit Agency Certificate to be issued to Address k�v C.Rj C, [,L �Telephone Owner of Record of Building Address %-A� Z) -h w,lS (K ST rJ 11 _ i4 vJ Name of Present Holder of Certificate CtAk f 0& Name of Agency, if any SIGNATURE OF PERSONS TO WHOM CERTIFICATE TIT E IS ISSUED OR HIS`;AUTHOIRIZED AGENT ' DAT INSTRUCTIONS: 1) Make check payable to: Town of North over 2) Return this application with your check to: Building Dept., 1600 Osgood Street, BLDG 20 STE 2-36 North Andover MA 01845 PLEASE ' NOTE: Application form with accompanying FEE must be submitted for each building or structure or part thereof to be certified. 3) Application and fee must be received before the certificate will be issued. 4) The building officials shall be notified within ten (10) days of any change in the above information. CErcT7FICATE # �� EXPIRATION Application for Cl. revised 1/08 jmc / INSPECTION REPORT FORM CLASSIFICATION l PASSES INSPECTION OWNER MMkl -$-, BUILDING NAME OR NO STREET LOCATION TYPE OF OCCUPANCY - Day Care Auditori School Common Victualer's DATED Cafe Gym Apt Place of Assembly EXIT SIGN yes no LIGHTED EXIT SIGNS ye no NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STOREYS EMERGENCY LIGHTING SYSTEM dry cell wet cell operable SPRINKLER SYSTEM r _ �operablogage pressure ss.... _:. .._ -:. yes, .:.. no �. SIVIOKEFDETECTOR_� table m es . no _ . _ _.. FIRE ALARM SYSTEMexpired_date _ v ... v , __.: w y Yes ^ no ELECTRIC EQUIPMENT VIOLATIONS `i� yes no FIRE RESISTANT CURTAINS OR DRAPERIES yes no EGRESSES LAWFULLY DESIGNATED unobstructed yes no HANDICAP ELEVATOR yes no STAIRS PROPERLY RAILED S'ry� ,Q J)o no HALLS AND STAIRWAYS LIGHTED no UTILITY ROOM — CLOSETS yes no RADIATOR GUARDS �.�res-- no COMPLIES HANDICAPPED PERSONS LAWS ye no HOW HEATED NO. FIREPLACES yes no BOILER ROOM CONDITION: ROOM LOAD IF APPLICABLE INSPECTOR: BRIAN LEATHE: - i � - 0.4..___ DATE OF INSPECTION