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HomeMy WebLinkAboutBuilding Permit #119 - 83 ACADEMY ROAD 8/14/2008 BUILDING PERMIT 0* NORTH ttttt O..h 611 tiO TOWN OF NORTH ANDOVER o? 4,, 00 APPLICATION FOR PLAN EXAMINATION Permit NO:4� Date Received ��ssgc►+us�� Date Issued: - C IMPORTANT:Applicant must complete all items on this page LOCATION aJA-Ct� . c� LPrint PROPERTY OWNER iGttl+t7Tt=fit= iS J Print MAP NO: 10 PARCEL: 09'i ZONING DISTRICT: Historic District es no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial 'repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer ESCRIPTIONLOF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: I flA-Ir, `/ <�I- r✓aJS Phone: 4 Address: 9 (Z'Tctrtt�u CONTRACTOR Name:-,0rJW,o,yo Phone: ?7d -6f,2 -.2;Z7 9 Address: 1Y 41,A6,?A0 S`7`. A10, Supervisor's Construction License: G5 7rgF7 Exp. 'Date: 3,/74 Id Home Improvement License: Py )10 Exp. Date: Ca I F `Al ARCHITECT/ENGINEER Phone: Address: Reg. No. !i FEE SCHEDULE.BULD/NG PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Z- ©UC' FEE: $_ 19�2 Check No.: 3s, Receipt No.: l �" NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/O�rner -Signature of contract Location No. Date l ,.aR•h TOWN OF NORTH ANDOVER O? • • 0 Certificate of Occupancy $ —; Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # \`tom ---•'_._....- 2 i i 7 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans ,,=01 EWERAGE DISPOSAL e 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster ori site ye!Vxano Locatd at 124 Main Street Fire eDepartment signature/date c�-1� C COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 __ I Building Department i The followingis a list of the required forms to be filled out for the q 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 u 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 u 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 j must be submitted with the building application I Dor.INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 I I i Revised 2.2008 { /ce axnmamu,ea a ✓�rakuze��edet6 or registration valid for individul use only License Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Y' Board of Building Regulations and Standards Registration: 143109 One Ashburton Place Rm 1301 4 Expiration: 6/18/2010 Tr# 268353 Boston,Ma.02108 Type: Private Corporation DESMOND CONST.INC. j MATTHEW DESMOND` _'" 19 UPLAND ST ��'G"" ` Not valitw hout signature N.ANDOVER,MA 01845 Administrator N-lassachusetis- Depat-tmtnt of Public S:tfeo IM Board of Buildina Regsulztti(ms.inti Standards Construction Supervisor License License: CS 72487 �. .,- Restricted to: 00 MATTHEW F DESMOND 19 UPLAND ST N ANDOVER, MA 01845 �i--G-- -� - Expiration: 3/22/2010 ti,uttniitiui+aef Tr#: 26743 L �e PROPOSAL Desmond Construction, Inc. P.O. Sox 41 North Andover,MA.01848 (978)682-2279 Date: 8/5/08 Page 1 of 2 TO: Job Site: Kathy Stevens same 83 Academy Road North Andover, MA 01845 978-683-5522 DESCRIPTION TOTAL LAT N MHIG Remove all existing clap board, comer board and window trim.All debris to be removed from site in construction dum ster. Install Tyvek house wrap over existing sheathing.Window trim and comer board to be 4" x 8"primed board. Install primed,fin er jointed cedar clap board,4-4 1/2"reveal, using stainless steel siding nails for paint coverage. No window sill r ac ment Remove partial utters as discussed Remove all window shutters MI-painting b others rareas found to be rotted and in need of air to be additional cost.Time and Material. Uoor trim to be additional. TOTAL #82,000.00 152,000.00 Desmond Construction, Inc. Date: 86108 Page 1 of 2 TO: Job Site: Kathy Stevens same 83 Academy Road North Andover, MA 01845 978-683-5522 y` All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specifications submitted for above wont and completed in a substantial workmanlike manner for the sum of: $62,000.00 ' with payments to be made as follows: 25%upon signing $13,1000.00 25%upon start of project $13,400.00 Remaining per job progress $26,000.00 An interest charge of 1.5%per month will to applied to any balance due 30 days after completion of this project. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over an above the estimate.All agreements contingent upon strikes, accidents or delays beyond our control.Owner to carry fire,tomado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on the above work to be taken out by DCI. Respectfully submitted Per Desmond Construction, Inc_ NOTE: This proposal may be withdrawn by us if not accepted with days. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specili . Payment will me made as outlined above. Signature: 0 Date: Signature: per. ON The Commonwealth of Massachusetts �� Department of Industrial Accidents Office of Investigations ;l�•'-' 600 Washington Street Boston, MA 02111 www.rrtass.b'ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Legibly Name(Business/Organization/individual): ee..rojelV.7 'CjA/V 1-,4 Z,e.Y-o_1 Address: / 4//C4,✓? ST City/State/Zip:J(/D 4.Npa4ltr, k.44, O/Pyd' Phone 6,F-,,2-ZX 7 AA you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. # 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[:1 Electrical repairs or additions 3.❑ 1 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' comp.insurance required.] 13.0 Other r:A.,va et o�eA;.•• *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 'Homeowners wlio submit.!i is affil indicating they arc uoiiig ail 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P I it. 1A1✓'raA )_,✓f, Policy#or Self-ins. Lic.#: /9 WG '70/9s Expiration Date: F,3j16r Job Site Address: Y i 4CADc'.> o, City/State/Zip: A/v.4A poyj�„ M# plgti-t' 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.t&pains andpenalties ofperjury that the information provided above is true and correct Sianature• Date: 6 /1/0`p Phone#: _207% 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-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 polity information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia TH o" o 6 Andover �_ - ..,T No. 9 yo dover, Mass., - L A K 1�40CK 'OCHICHEWIC C "?ATED S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ............. ............................................. . .......................... Foundation ......... ............................ buildings on.....�7 has permission to erect ........... . ..................... Rough to be occupied as.... ... ...... Chimney ........ ........71.. ....................................... ............................. . .... Final provided that the person acc. tj g this permit shall every respect conform to the terms of the application an file in" this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU STARTS ELECTRICAL INSPECTOR Rough Service .......... ......... ................................................................................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy BuildiAg,, GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ACORD� CERTIFICATE OF LIABILITY INSURANCE 8/6/2008 PRODUCER (978)372-2790 FAX: (978)373-2281 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION William C. Sullivan Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 487 Groveland Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Commerce Insurance 34754 Desmond Construction, Inc. INSURER B:AIM Mutual Insurance 33758 19 Upland Street INSURER C: INSURER D: North Andover MA 01845 INSURER E: OVERAGES 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 BEE 4 REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY MPDD TION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED REMI E a occurrence) $ 50,000 A CLAIMS MADE OCCUR ZS1282 7�7�2008 7�7�2009 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADVI RY $ GENERAL AGGREGATE $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S X POLICY PECT RO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ A ALL OWNED AUTOS T90224 912/2007 912/2008 BODILY INJURY X SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA A $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCQI $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU-TORY I WITS OH- ETR LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? AWC7019598 8/23/2007 8/23/2008 100,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE$ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Construction CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of North Andover EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL North Andover, MA 01845 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSEtNO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGEA OR REPR ENT S. AUTHORIZED P NT THE :��y ACORD 25(2001/08) ©A ORD CORPORATION 1988 INS025(0100).08a Page 1 of 2 Date...?.- TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS us This certifies that ...At`� ................ . ......L ................... .............................. has permission to perform -.-0.......... ......................... .. ................... wiring in the building of_::-.5�- ................................................... at...... North Andover Mass. Fee..?'? Lic.No ........ . ...................... P ELE RAL�S�Z R I/- Check # 7675 Commonwealth of Massachusetts Official Use Only, a it No. �� N Department of Fire Services Perm6.. Occupancy and Fee Checked';i9i r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: '3 �1 p -7 City or Town of: NORTH ANDOVER To the Insp etor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 , 8�=4 yt, t J . Owner or Tenant �L( 5 'iV� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0�No ❑ (Check Appropriate Box) Purpose of Buildings t tJ��J j1�_ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,tJ y-lfl'GC� �t �.t �� yl�o A,— Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Tota ` Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA Above n- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices y No.of Ranges No. of Air Cond. Tonal No. of Alerting Devices No.of Waste Disposers eat ump Number ons o.of elf-Contained Totals: I I Detection/Alerting Devices 1 No.of Dishwashers Space/Area Heating KW Local❑ municipal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems: No.of Devices or Equivalent No. o Water KW No.of o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecom f Devices or ging: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 147ires. Estimated Value f Electrical Work: ,`� (When required by municipal policy.) 1 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 is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE E BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: &k"LA-r- �t.�r��Lcs(-�_ 5'�vt,✓t LIC. NO.:M.C'�If. Licensee:/l� -C�f ,,i,4-� Signature LIC. NO.62-77) &O'C — (If applicale, en er -exempt"in the license number line.) Bus.Tel. No.: 3frZzv Address: t,",S60— S K� Alt.Tel. *Per M.G.L c. 147,s.57-61,s curity work requires Department of Public Safety "S" License: Lic.No. 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. Own nt PERMIT FEE: $�Q Signaturetura Telephone No. � i ,� o� �� .� ff k t' I i I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 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 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[:] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 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 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 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 1 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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#: 08/13/2008 14:28 FAX 978 685 3900 CARLSON-GMAC 001/001 .-qua I'j vo va.Uop }Levens 978-683-5522 p.2 i TO: Mr. Matt Desmond,Contractor Kathy Stevens, Home Owner FAX: 978-682-2279 RC:Proposed Repairs to House at 83 Academy Rd. The proposed repairs are replacement of the wood clapboards with new preprimed wood clapboards,the wood trim around the windows with similar wood trim including the Darner ornamentation,and the wood corner trim with similar woad trian. ' �repairs,are regular maintenance. herefore, they do not require review by the Historic District Commission. August l� 2048 George Srhruender, Chair / Historic District Comrnissim North Andover HISTORIC DISTRICT COMMISSION Town of North Andover, Massachusetts APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for the issuance of a CERTIFICATE OF APPROPRIATENESS under Chapter 40C for proposed work as described below and on plans, drawings, or photographs accompanying this application. CHECK CATEGORIES THAT APPLY: 1. Exterior building construction: ( ) New Building ( ) Addition O Alteration Type of Building ( ) Home gA+A, ( ) Garage Commercial Other 2. Demolition or Removal of: 3. Signs or Billboards ( ) New Signs ( ) Existing Sign O Other 4. Structure: ( ) Fence O Wall O Other TYPE OR PRINT LEGIBLY Address of Proposed Work: r7 4CA&,ff%j Date: Owner:4-:, I( i ; -i% C- St c-4- KTelephone# Home Address(f different from above): Agent or Contractor. 4e,fH&r? Telephone# .r'a1-.r'>3-72s�P Address: d I6 Ari /—f - Nd, A.✓ay✓re" 10&f4. Assessors Map#: Assessors Lot#: Detailed Description of Proposed Work: Give all particulars of work to be done(see#8 below),including materials to be used,if specifications do not accompany plans. In case of signs,give locations of e)asting signs and proposed locations of new signs. (Attached additional sheet if necessary.) ;2126de" Siy,.✓G A,, 2250ir, Owner(Agent,Contractor) DO NOT WRITE BELOW THIS LINE Received for hlsboric district commission: Time: Date: By: Application No: THIS APPLICATION FOR CERTRIFICATE OF APPROPRIATENESS: ( ) APPROVED O Disapproved Reason for Disapproval: ( )NO CERTRWATE OF APPROPRIATENESS REQUIRED A CERTIFICATE OF APPROPRIATENESS IS FOR WORK DESCRIBED IN THE APPLICATION ABOVE AND ATTACHED DOCUMENTS SECRETARY: Chairman: Members