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Miscellaneous - 1018 OSGOOD STREET 4/30/2018 (2)
November 15, 2011 Mr. James A. Chepulis 4 Locke Street, Apartment 3 Andover, MA 01810-4031 Mr. William Chepulis 1018 Osgood Street North Andover, MA 01845 -Re: 1018 Osgood Street, North Andover, MA 01845 Dear Sir, Please be advised that upon inspection dated .......of the structure at 1018 Osgood Street it has been deemed that the building is in unsafe condition. Section 780 CMR Mass State Building Code 5121.1 ] Unsafe Structure — Roof Failed 5121.6) Both exist blocked, porch collapsed, water pouring thru building, uninhabitable building. Please contact the Building Department so that we may begin the process to remedy this in a timely fashion. Please call 978-688-9545. Gerald Brown, Building Inspector Cc; Curt Bellavance, Director Community Development Susan Sawyer, Director, Health Department Mi/desktop/1018 Osgood St. Sk 12795 Pw255 02633 01-31-2012 a1 11234a IIASSAC M77S STATE EXCISE TAX Essex North Registry Dotes 01-31-2413 a 11:34as Ct1Ds 62 Des 2633 Fm: 41*824.00 Cons: 14WtOW.00 MASSACHUSETTS QUITCLAIM DEED I, William N. Chepulis, an unmarried individual, of 1018 Osgood Street, North Andover, County of Essex, Commonwealth of Massachusetts, for consideration paid in the sum of Four Htmdred Thousand and 001100 ($400,000.00) Dollars, grant to JFJ Holdings, LLC, a New York limited liability company; of 751 Main Street, Sanford, Maine, with quitclaim covenants, the land with the buildings thereon, situated in said North Andover, being shown on "Plan of Land in North Andover, Mass.-, as surveyed for Flora M. Greenwood" dated Dec. 1, 1950 which plan is recorded with Essex North District Registryof Deeds No. 2327. Said parcel is more particularly bounded and described: Southeasterly - 150 feet by Osgood Street; Southwesterly- 202.12 feet by land of Flora M. Greenwood, as shown on said plan; Northwesterly - 150 feet by land of the City of Lawrence as shown on said plan; and, Northeasterly- 200.90 feet by other land of said Flora K Greenwood, as shown on said plan. Said parcel contains 29,760 square feet of land, more or less, according to said plan. For my title see the Will of my late mother, Olga E. Chepulis, Essex Probate dt Family Court D ket No. 91P -2061. For Olga E. ,Chepulis' title see;ee dd_ at Essex North District Registry of ds, Book 856, Page 73, dated lune 10, 1957 and; recorded June 13, 1957. See also de*th certificate of William Chepulis, Jr. recorded herewith. v11 0 Bk 12798 Pg256 #2633'. Witness my hand this 9 / day of January, 2012. WilftN.pulis Commonwealth ofMassachusetts llssex, ss. at North Andover, MA. 'When personally appeared the above named William N. Chepulis, and, atter producing satisfactory evidence of identification, to wit, a Massachusetts Driver's License, did acknowledge the foregoing instrument to be his free act and deed this 2-4'6 day of January, 2012, before me, CHRISTOPHER A. ROMEO Pffistoph6r A. Romeo, N.P. Notary Public My Comm. Exp.: 9/17/2015 Commonwedhh of MassachusNk My Commission Expires September 17, 2013 Bk 12798 P9258 02635 01-31-2012 a 11 a34cF. MASSACHUSETTS QUITCLAIM DEED JFJ Holdings, LLC, a New York limited liability company., of 751 Main Street, Sanford, Maine, for consideration paid in the sum of One Dollar, grant to Claffua Realty Trust LX, LLC, of 280 Merrimack Street, Methuen, MA with quitclaim covenants, i I land with the buildings thereon, situated in said North =�wer, being shown on "Plan of nd in North Andover, Mass., as surveyed for Flora M. ood" dated Dec. 1, 1950 hick plan is recorded with Essex North District Registry of Deeds No. 2327. Said parcel is more particularly bounded and described: Southeasterly - 150 feet by Osgood Street; Southwesterly- 202.12 feet by land of Flora M. Greenwood, as ishown on said plan; Northwesterly - 150 feet by land of the City of Lawrence as shown on said plan; and, i Northeasterly- 200.90 feet by other land of said Flora M. Greenwood, as shown on said plan. Said parcel contains 29,760 square feet of land, more or less, according to said plan. The consideration being less than one hundred dollars, no revenue stamps are required. Por my title see deed of William N. Chepulis recorded herewith. Bk 12798 Pg259 #2635 _p + Witness my hand this 3W day of January, 2012. JFJ Holdings, LLC Mark Cafua, VIAQer Commonwealth of Massachusetts C,&/,41 dFc swA , as. Then personally appeared the above named Mark Cafua, and, after producing satisfactory evidence of identification, to wit, a Massachusetts Driver's License, did acknowledge the foregoing instrument to be his free act and deed this Wr day qf January, 2012, before me, My A i DelleChiais., Pamela From: Sawyer, Susan Sent: Wednesday, December 07, 2011 2:53 PM To: Rillahan, Deb Cc: DelleChiaie, Pamela Subject: 1018 Osgood Attachments: 1018 Osgood Street letter.doc Pam, My letter from the hearing motion is with the file in your box. Deb will use this word document to write a second letter to Mr. Chepulis. I am ok with sending them both together. If you send by email you may want to note there are 2 letters 1 is from the hearing of November 17 and the other is an extension type of letter. Anyway wait for Deb's letter and then email it to everyone, but also send the hard copies to him. thx -----Original Message ----- From: norenly@townofnorthandover.com fmailto:noreplv@townofnorthandover.coml Sent: Wednesday, December 07, 20112:28 PM To: Sawyer, Susan Subject: This E-mail was sent from "RNPOA428C" (Aficio MR 65000). Scan Date: 12.07.201114:27:58 (0500) Queries to: noreply@townofnorthandover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. A. North Andover Health Department (ommunity Development Division December 7, 2011 To Owners of Record: Property Location: William Chepulis and James Chepulis 1018 Osgood Street 1018 Osgood St. North Andover, MA 01845 North Andover, MA 01845 Board of Health On November 17, 2011, a determination was made by the Board. Pursuant to 105 CMR 410.831 (E). The Board finds that the conditions within the dwelling are such that the dwelling is unfit for human habitation and an order to secure and to vacate has been issued. A motion was made by Frank MacMillan to vacate within 2 weeks, (from the date of the hearing) Joe McCarthy seconded the motion. All were in favor. Thank you for your anticipated cooperation. cc: Curt Bellavance, Community Dev. Dir. Gerald Brown, Inspector of Buildings Andrew Melnikas, Fire Chief Paul Gallagher, Police Chief Board of Health Members 1600 Osgood Street, North Andover, Massachusetts .01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com fl Location Cr No. 01 (D —" 1 Date Check #� 26843 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee 5i641) $ 3-O -- TOTAL $ `Building Inspector Ov f�ft * *\ rr•'' �+ C J � D Q h 0<L P ' 4p. 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' � t r.•..�Yr• 3,. �n r � . , ' '"�+3"r maw `•wr'.a3s:i'..k. ,•.._ .. b c" `. °if�..r�v� . .IJ_ Location No. 013-111 Date Check # 2os,z� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee-`"��,J $ ,91• 60 TOTAL $ _ t7- ,i' Buil6ing Inspector. rj * * `LU _M O a z a � _ w n' O LLZ O fn �../ z a, 3 O (f) N rj * * r _M O N o F- W _ r r•. _ 3 AlHMO 1 a, U N O O C O N N Q - cu cn c O a) co +, `n N O. X -r-o J O Ln E 00 O a) r C -0 O .� � O a) O '- N O V' /� >^, cu m W W` -0 ca ca _ U)a m a) in0-CU = in n E wL- -0 a J 0)U Lo LO N cn O c0i 0 � O cajC: = ++ O .o CO C U) cn *k O N > CL Lo O L N U OCU ., O vi C N --aO N -0 C :p > • M cu M O N ?> Q U N O re C 27) U s.) — >O i N O 0) 4- c: .C: p O Q O O c t N OO N Mz O 000 T- Q C C o a o 0 cc O .O O = O � � a LW /F— W N2 w a W a cn z U) w F— Z_ J J } J J z W F— z 16 m vl _M O N F- r LU W_ N LL C O � U -W F" U _Cl) Q W m cm IL F- Fn cn c O a) co +, `n N O. X -r-o J O Ln E 00 O a) r C -0 O .� � O a) O '- N O V' /� >^, cu m W W` -0 ca ca _ U)a m a) in0-CU = in n E wL- -0 a J 0)U Lo LO N cn O c0i 0 � O cajC: = ++ O .o CO C U) cn *k O N > CL Lo O L N U OCU ., O vi C N --aO N -0 C :p > • M cu M O N ?> Q U N O re C 27) U s.) — >O i N O 0) 4- c: .C: p O Q O O c t N OO N Mz O 000 T- Q C C o a o 0 cc O .O O = O � � a LW /F— W N2 w a W a cn z U) w F— Z_ J J } J J z W F— z 16 m i a 0 CT - 751 I'l! °14 cin 'd C� 9 0 H �ao''UO U cd 0 �i to t b m �4 M O I z Cd 0 0 0 I lelr 9b c� a� o C zi 9b U cd N , . p -d 78 C6 8 � 0 o o cd o S 4-1 y Oco N bb .� n•� o .9b Rip, M0 zt Q o 9b 3 '24o z Cd 0 0 0 I lelr 9b a� 9b p -d i." 4-1 y Oco N bb .� n•� o co o Rip, M0 z Cd 0 0 0 I lelr F9 ! 36 sq ft Vertical Cup Wall Sign 94.5" 00 DMG^,C3CC° .040 Aluminum cabinet 1 12" x 3116' aluminum mouming brackets 5511 wttn 'sCreWs mouming holes / 1/4to blocking + Em!o—d"copr Flet vinyl vinyl graphics second surface Color and Material Notes: Faces to be cap -over style with embossed cup logo clear solar grade polycarbonate Colors: Background Color to be white Vinyl colors to be: 00 Orange - 3M 03630.3123 DD Magenta - 3M #3630.1379 Dark Brown- 3M #3630.59 All vinyl to be applied to second surface Aluminum Cabinets to be painted Benjamin Moore Nightshade Ernemaily Illuminated I a CL 0 -ey ca c 13 (D LL w M � L C o ° 13 `0 oa 0 p CL 5". 1 1 ll M if � r Y ' 3 � 1 Y Check klo 26839 � OAU� � y Date TOWN OF NORTH ANDOVER V, Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector W H m 2 w a w Q Z C) U) W c 16 N Q X C X J O N J O 2 U fn c c (n O SU y-. O C Q +' N O c O � C (n �: O O O ._ L cn O c u (if -0 �— O U) m N _= E a .M a) cn X cn O U J J � C) rn •= C Cn CLp CD c .E U co c U N M.0 O cu U) O Lf -r-O C N I— - Rf > :3 L +� O (�6 _ c U I U) -a N U '> U)I U) N U ° O L c 0 M O M X _ c c Y c Q J Q O ~ C 7rI M �_ C O 0) O Z }, N O 0O � N L p O v, (- U O C N H -00 �-- c -0d cn O E O O 'O C O N r LG LL cn c t - c a)O O O 4- 00 O H O W 0 cn O C E +� O W 2 N �+ W H m 2 w a w Q Z C) U) W c 16 N Q --_____ Yh3I -(- �w !op �U tnee + fih-- y: j;l bylaw. �u � The Complete Sign Service Design • Fabrication Installation • Maintenance All Types of Signs & Letters U.L. Listed Electric Signs Wood and Sandblasted Large Format Digital Printing Truck Lettering 65' Crane and Bucket Service Routed Signs Shipping Address 654 County Road Acton, ME 04001 Fax 207-477-2740 Mailing Address 654 County Road Acton, ME 04001 Email: scott@dasco-signs.com www.dasco-signs.com Scott Stanton (207) 477-2956 DASCO SIGNS NO: mf t. V I C) 0 z O "d ccs O cd cd bbA O 9b 7 a i a �I 70..E U ol bU On coo x 0 z O "d ccs O cd cd bbA O 9b 7 a i a ,-, ol bU bbA U o O� C " VII O bA " N 1 .O 0 z �.0 cd � �c o N N C-) L7 N 's bA C�3 bA .s: � sCyA c6 4. d �. O O >'4+S' Ni200�o� ;c 109. o 10- �� O 01 w r O O O � z.t3��o O cd p >� O Z �� L"� �+ �•bAc�3 "OQV) to 0 z O "d ccs O cd cd bbA O 9b 7 a i a ,-, bU N N C 4Oi bo ;� 01 ._ cd a1 bA ¢+ O'� aa�.,�U�cnCaO 0 z O "d ccs O cd cd bbA O 9b 7 a i a ^L' W 0_ •C Q 3 D Z L- O 0- 0 0 Q ^� A CD O rE .0 U) cn C) z0 0) CDU 0 a_ U) 0 Z c N lie 0 0 � o > O Q- 0 L a Location No. bi �A - \�- Date Check # .26841 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector M O N r O Q. O 7 Lp t IJ .dw L O O '+r Z ® U p Q Q. 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Massachusetts General Laws, Chapter 272, Section defines 'obscene" as follows: I. appeals to the prurient interest of the average person applying the contemporary standards*of the county where the offense was committed; 2. depicts or describes sexual conduct in a potentially offensive way; and 3. lacks serious literary, artistic, or political or scientific value. 15. Permanent Sign - Any sign permitted to be erected and maintained for more than sixty (60) days. 16. Primary Sign - The principal accessory sign which may be a wall, roof, or ground sign, as allowed in Section 6.6. 17. Projecting Sign - Any sign which is attached or suspended from a -building or other structure and any part of which projects more than twelve (12) inches from the wall surface of that portion of the building or structure. 18. Roof Sign - Any sign erected, constructed, and maintained wholly upon, connected to, or over the roof or parapet of any building with the entire support on the roof or roof structure. 19. Secondary Sign - Is a wall, roof, or ground sign intended for the same use as a primary sign but smaller dimensions and lettering, as allowed in Section 6.6. 20. Sign - A sign is any structure, mechanically or electrically driven, still or moving device, light, letter, figure, word, model, banner, pennant, trade flag, or representation that is designed to be seen from outside the lot on which it is erected. It advertises activities, goods, places, persons, objects, institutions, organizations, associations, businesses or events, products, services, or facilities available either on the property where the sign appears or in some other location. The definition includes electric signs in windows or doors, but does not include window displays or merchandise. A sign may be permanent or temporary. 21. Sign Size (Area) (a). For a sign, either free-standing or attached, the area shall be considered to include all lettering, (- - wording and accompanying designs and symbols, together with the background, whether open or enclosed, on which they are displayed but not including any supporting framework and bracing =which=are-inride3rtal t6 -the -dis la - itself -- = - - - (b). For a sign painted upon or applied to a building, the area shall be considered to include all lettering, wording, and accompanying designs or symbols together with any backing of a different color than the finish material of the building face. (c). Where the sign consists of individual letters or symbols attached to or painted on a surface, building, wall or window, the area shall be considered to be that of the smallest rectangle or other convex shape which encompasses all of the letters and symbols. 22. Temporary Sign: A sign permitted to be used on a short-term basis for the duration of no longer than sixty (60) days unless otherwise specifically provided herein. 23. Wall Sign - Any sign affixed to, suspended from or painted on a wall, window, marquee, or parapet. 6.4 Administration and Enforcement I. Enforcement -The Building Inspector is hereby designated as the Sign Officer and is hereby charged with the enforcement of this Bylaw.. 72 a. The Sign Officer and his duly authorized agents shall, at reasonable times and upon presentation of credentials, have the power to enter upon the premises on which any sign is erected or maintained in order to inspect said sign. b. The Sign Officer is further authorized, upon notice as herein provided, to order the repair or removal of any sign which in his judgment is a prohibited non -accessory sign, or is likely to become dangerous, unsafe, or in disrepair, or which is erected or maintained contrary to this Bylaw. The Sign Officer shall serve a written notice and order upon the owner of record of the premises where the sign is located and any advertiser, tenant, or other persons known to him having control of or a substantial interest in said sign, directing the repair or removal of the sign within a time not to exceed thirty (30) days after giving such notice. If such notice' and order is not obeyed within such period of time, the Sign Officer and his duly authorized agents shall, at reasonable times and upon presentation of credentials, have the power to enter upon the premises on which said sign is erected or maintained and repair or remove, or cause to be repaired or removed, said sign. All expenses incurred by the Sign Officer and his duly authorized agents in repairing or removing any sign shall be assessable against any person who failed to obey said notice and order and shall be recoverable in any court of competent jurisdiction if not paid within thirty (30) days after written notice of assessment is given by the Sign Officer at any such person. 2. Permits: a. No permanent sign shall be erected, enlarged, or structurally altered without a sign permit issued by the Building Inspector. Permits shall only be issued for signs in conformance with this..Bylaw. Permit. applications shall_ be accompanied by two. (2).pr-ints-of.scale-drawings-of- - the sign, supporting structure and location. A copy of any relevant special permit shall also accompany the application. All ground or roof signs shall be registered and identified as ' required by Section 1407.0 of the State Building Code. b. Notwithstanding anything to the contrary in this Bylaw, any permanent sign authorized under this Bylaw may contain any otherwise lawful, non-commercial message which does not direct - ---attention to -a -business or -to a service -or -commodity --for sale in lieu -of -any message or content - described in the applicable regulation. 3. Non-conformance of Accessory Signs: Any non -conforming sign legally erected prior to the adoption of this provision, may be continued and maintained. Any sign rendered non -conforming through change or termination of activities on the premises shall be removed within thirty (30) days of order by the Building Inspector. No existing sign shall be enlarged, -reworded, redesigned, or altered in any way unless it conforms to the provisions contained herein. Any sign which has been destroyed or damaged to the extent that the cost of repair or restoration will exceed one-third (1/3) of the replacement value as of the date of destruction shall not be repaired, rebuilt, restored or altered unless in conformity of this Bylaw. 4. Street Banners or Signs - Street banners or signs advertising a public or charitable entertainment or event, by Special Permit from the Board of Selectmen. Such a sign shall be removed within seven (7) days after the event. 6.5 Prohibitions: 1. No sign shall be lighted, except by steady, stationary light, shielded and directed solely at the sign. Internally lit signs are not allowed. 73 ,I 2. No illumination shall be permitted which casts glare onto any residential premises or onto any portion of a way so as to create a traffic hazard. 3. No sign shall be illuminated in any residential district between the hours of 12:00 midnight and 6:00 a.m. unless indicating time or temperature or an establishment open to the public during those hours. 4. No sign having red or green lights shall be erected within sight of a traffic signal unless approved as non -hazardous by the Chief of Police. 5. No animated, revolving, flashing, or exterior neon sign shall be permitted. 6. No pennants, streamers, advertising flags, spinners or similar devices shall be permitted, except as allowed by the board of Selectmen. 7. Corner visibility shall not be obstructed. 8. No sign shall be erected, displayed, or maintained upon any rock, tree, fence, or utility pole. 9. No sign shall be erected, displayed, or maintained if it contains any obscene matter. 10. Flags and insignia of any Government when displayed in connection with commercial promotion. 11. No sign shall obstruct any means of egress from a building. 12. Projecting signs are prohibited. 13. Non -accessory signs are prohibited except for directional signs as allowed in Section 6.6, B. 14. No signs shall be attached to motor vehicles, trailers or other movable objects regularly or recurrently located for fixed display. 6.6 Permitted Signs (Fee Required) A. Residence District - Accessory Signs - The following signs are allowed in a residence district as well as all other districts. I. Primary wall and roof signs attached to or part of the architectural design of a building shall not exceed, in total area, more than ten percent (10%) of the area of the dimensional elevation of the building as determined by the building frontage multiplied by the floor to ceiling height of the individual business or as specified in applicable sections of the by-law. _2. One (1) sign, either attached or ground indicating only_ the name of the ownu or occupant, -spree num-er-arid permitted uses ox occupations engaged in thereon, not to exceed two (2) square feet in area. Such sign may include identification of any accessory professional office, home occupation, or other accessory uses permitted in a residence district. Ground signs shall be set back a minimum of ten (10) feet from all property lines and a minimum of forty (40) feet from all residential districts or structures. 3. One (1) sign oriented to each street on which the premises has access, either attached or ground, pertaining to an apartment development or a permitted non-residential principal use of the premises, such sign not to exceed ten (10) square feet in area. 4. One (1) unlighted contractor's sign, not exceeding twenty-five (25) square feet in area, maintained on the premises while construction is in process and containing information relevant to the project. Such sign shall be removed promptly after completion of the construction. 5. One (1) unlighted identification sign at each public entrance to a subdivision.not exceeding twelve (12) square feet in area; to be removed when the subdivision roadway is accepted by the Town. 6. Ground signs shall be set back a minimum of ten (10) feet from all property lines and a minimum of forty (40) feet from all residential districts or structures. 7. Off -premises Signs: Only signs pertaining exclusively to the premises on which they are located or to products, accommodations, services or activities on the premises shall be allowed, except that an off -premises directional sign, designating the route to an establishment not on the street to which the sign is oriented, may be erected and maintained within the public 74 right-of-way at any intersection if authorized by the Board of Selectmen or on private property if granted a special permit by the Board if Appeals. Such sign shall be authorized only upon the authorizing agency's determination that such sign will promote the public interest, will not endanger the public safety and will be of such size, location and design as will not be detrimental to the neighborhood. At locations where directions to more than one (1) establishment are to be provided, all such directional information shall be incorporated into a single structure. All such directional signs shall be unlighted, and each shall be not over four (4) square feet in area. B. Temporary Signs: Temporary signs shall be allowed as provided below, and provided that they comply with the following: (a) Unless otherwise specified in -the Bylaw, temporary signs must comply with all applicable requirements for permanent signs, including issuance of a sign permit. 1. Temporary signs, of not more than twelve (12) square feet in area, erected for a charitable or religious cause; requires no sign permit and is to he removed within thirty (30) days of erection. The Building Inspector shall maintain placement controls. 2. One (1) temporary unlighted real estate sign advertising the sale, rental or lease of the premises or subdivision on which it is erected to be no larger than twelve (12) square feet. The Building Inspector shall allow a sign larger than twelve square feet if The property fronts on a State Highway, such as Route 114 or Route 125 and a larger sign is needed for legibility purposes; The total area of the sign does not exceed 10% (10 percent) of the wall area it is to be located upon. Such sign shall be removed fourteen (14) days after sale, rental or lease. 3. One (1) temporary- unlighted sign not larger --than twenty fve.(25) square -feet -indicating -the - name and address of the parties involved in construction on the premises. 4. Temporary signs not meeting requirements for permanent signs may advertise sales, - special events, or changes in the nature of an operation, but shall not otherwise be used to advertise a continuing or regularly recurring business operation and shall be removed promptly when the information they display is out of date. The sign(s) must be removed -----within -thirty-(3 0) days -of -erection: - - - - - - 5. Temporary signs pertaining to a candidate or ballot question appearing on the ballot of an election duly called in the Town of North Andover shall require no sign permit and shall be allowed in all zoning districts. Such signs permitted by this Bylaw: (a) shall only be permitted on private property; (b) shall not exceed six (6) square feet in area per sign and shall not exceed in aggregate twenty-four (24) square feet in area per lot; (c) shall not be higher than three (3) feet above ground level; (d) shall be stationary and shall not be illuminated; 6. Temporary A -frame Sign Permit. The Building Inspector may issue a permit for the temporary placement of a freestanding A-frame/sandwich sign which (i) announces a performance, an event, or is for directional purposes;. ii) must be securely anchored so as to not blow over and is professional in appearance; iii) must be removed at the close of each business day and at the expiration of the permit; iv) may not obstruct a public or private walkway, or be placed on public property. The maximum area shall not exceed eight (8) square feet on each side, and a maximum height of five (5) feet above the ground. The temporary permit may impose limiting conditions, including among other matters the number allowed at each business property location. 7. Unless otherwise specified in this Bylaw, temporary signs pertaining to other non- commercial issues shall require no sign permit and shall be allowed in all zoning districts. Such signs shall be subject to the limitations set forth in subsection (5) (a) -(e) above. 75 8. Identification Signs or entrance markers for a church, or synagogue shall not exceed a combined total of thirty (30) square feet and provided that there shall be no more than two (2) signs allowed on the premises. 9. Notwithstanding any other provisions of this Bylaw, signs may be erected for posting land; example, no hunting, no trespassing, etc. C. Residence Districts: Non -accessory Signs - Directional signs by Special Permit from the Board of Selectmen, limited as follows: 1. Two (2) signs for each activity, not exceeding 6"x30" in size. 2. Ground signs not exceeding eight (8) feet in height. D. Business and Industrial Districts: Accessory All signs pennitted in residence districts as provided in Section 6.6(A) and 6.6(B), except that temporary real estate signs may be as large as twenty-five (25) square feet. Each owner, lessee, or tenant shall be allowed a primary and a secondary sign. Said sign may be used as ground, wall, or roof signs. No lot shall be allowed to have more than one (1) ground sign structure. 1. Primary wall and roof signs attached to or part of the architectural design of a building shall not exceed, in total area, more than ten percent (10%) of the area of the dimensional elevation of the building as determined by the building frontage multiplied by the floor to ceiling height of the individual business or as specified in applicable sections of the by-law. 2. One (1) permanent ground sign of not more than twenty-five (25) square feet in area and extending not more than eight (8) feet above ground level. Larger or taller signs may be allowed by Special Permit of the Board of Appeals, if said Board determines that the particular sign will not be incongruous with the district in which it is to be located nor injurious to traffic and safety conditions therein (1998/31). 3. For premises having multiple occupants, a single sign, either attached or ground, identifying those occupants. The total area of attached signs including this one, shall not exceed ten _ percent (10%) of wall area, and the area of any freestanding sign allowed under this paragraph shall not exceed twenty-five (25) square feet. 4. Temporary unlighted signs inside windows, occupying not more than twenty percent (20%) of _ Yheirea of tk�Wirxdow requires no"sign permit: " " --- " "--�- 5. No sign shall project more than one (1) foot over any public right-of-way shall be covered by appropriate liability insurance as determined by the Building Inspector and verified by a certificate of insurance filed with the Town Clerk. 6. Service stations or garages may divide the allowed wall sign area into separate, smaller wall signs indicating separate operations or departments. A freestanding ground identification sign of fifty (50) square feet with price sign incorporated is allowed. 7. For active fuel dispensing Service Stations, with multiple tenants, on the same lot: One single free standing ground identification sign of 50 square feet is allowed, which is to include within the 50 square feet, the identification of the multiple tenants on this same lot. The Service Station identification / information shall be at least 60% (may be greater) of the total free standing ground sign. Pricing information, if advertised, to also be within the allotted square footage for service stations. The maximum height (including pylons) of this free standing ground sign shall be 16 feet from ground level (1998/30). 8. Building directories (if located outside) may be affixed to the exterior wall of a building at each public entrance. Such directory shall not exceed an area determined on the basis of one (1) square foot for each establishment occupying the building. 9. Traffic Control orientational and guidance signs located on private property, up to four (4) square feet in area, displayed for purposes of direction or convenience, including signs identifying parking, fire lanes, rest rooms, freight entrances and the like. 76 n E. Shopping Centers t 1. Signs are permitted in residence districts, except that temporary real estate signs may be as large as ten (10) square feet. 2. Signs attached to a building or its canopy, parallel with the facade and not projection above the roof -line, advertising the name of a firm or goods or services available on the premises, provided that the total area of all signs erected on, any wall by any occupant may not exceed twenty percent (20%) of the portion of the wall area assigned to that occupant. In no case shall any occupant's sign total more than two hundred (200) square feet facing any single street.. 3. For any retailing complex comprising three (3) or more enterprises on a single lot and fifty thousand (50,000) square feet floor area or more, one (1) ground sign for each street on which the development fronts, containing the name or other identification of the area .occupied by the complex. Each sign shall be no larger than one hundred (100) square feet. Such sign shall not be located within ten (10) feet of any property line or the line of any way, and no part of the sign shall be more than twenty (20) feet above the ground level. 4. Temporary, unlighted signs, inside windows, occupying not more than fifty percent (50%) of the area of the window requires no sign permit. F. Office Parks 1. Signs as permitted in residence districts, except that temporary real estate signs may be as large as ten (10) square feet. 2. One (1) sign for each street upon which the premises has frontage, identifying a subdivision of lots for office development. This sign shall be no greater than eight (8) feet in height and no larger than twenty (20) square feet in area except where the property fronts on a high-speed, Iimited .access highway, in which case a.special exception-may-bbe-granted for -a -larger -sign -if_ required for legibility. 3. Signs for individual properties or tenants shall be limited to a single sign no larger than three - (3) square feet per tenant. Individual tenants must have Letter of Permission from property owner. The Board of Appeals may grant a Special Permit for an exception for a larger area where this will not impair legibility of other signs or be incongruous with the surroundings, --based- upon consideration -of -the -number of occupants -and signs per building, size of building and integration of sign and building design. G. Industrial Districts 1. -Signs as permitted in residence districts, except that temporary real estate signs maybe as large as twenty-five (25) square feet. The Building Inspector shall allow a sign larger than twenty-five (25) square feet if: a) The property fronts a State Highway, such as Route 114 or Route 125 and a larger sign is needed for legibility purposes; b) The total area of the sign does not exceed 10% (ten percent) of the wall area it is to be located upon. Such sign shall be removed fourteen (14) days after sale, rental or lease. 2 Signs attached flat against the wall or canopy of a building, or projecting not more than six (6) feet above such wall, advertising the name of the firm or goods or services available or produced on the premises; provided that the total area of all such sighs does not exceed twenty . percent(209/o) of the area of the side of the building to which they are attached or two hundred (200) square feet, whichever is less. 3 One (1) ground sign, containing the name or other identification of the use on the property, for each street on which the property fronts, each sign is limited to an area of one hundred (100) square feet. Such sign shall not be located closer than forty (40) feet to any property line or twenty (20) feet above ground level. 77 H. Guidelines 1. The following are further means by which the objectives for signs can be served. These guidelines are not mandatory, but degree of compliance with them shall be considered by the .Board of Selectmen, Planning Board, Zoning Board of Appeals in acting upon special permits authorized by the Zoning Bylaws and by the Building Inspector in issuing a sign permit authorized under this Section of the Zoning Bylaw. Efficient Communication: 1. Signs should not display brand names, symbols or slogans of nationally distributed products except in cases where the majority of the floor or lot on the premises is devoted t manufacture or sale or other processing of that specific product. 2. Premises chiefly identified by a product name (such as a gasoline or auto brand) should devote some part of their permitted sign area to also displaying the identity of the local outlet. 3. Signs should not contain selling slogans or other advertising which is not an integral part of the name or other identification of the enterprise. 4. Sign content normally should not occupy more than forty percent (40%) of the sign background, whether a signboard or a building element. 5. Signs should be simple, neat and avoid distracting elements, so that contents can be quickly and easily read. Environmental Relationship 1. Sign design should take into consideration the scale of the street to which the sign is oriented and the size, brightness, style, height and colors of other signs in the vicinity. 2. Sign brightness should not be excessive in relation to background lighting levels, e.g., averaging not in excess of one hundred (100) foot lamberts in the downtown or similarly bright areas and not in excess of twenty (20) foot lamberts in unlighted outlying areas. -- 1. Signs should be sized and located so as to not interrupt obscure or hide the continuity of columns, cornices, roof eaves, sill lines or other elements of building structure and where possible, should reflect and emphasize building structural form. 2. Sign material, colors and lettering should be reflective of the character of the building to which the sign relates, just as sign size should be related to building size. 3. Clutter should be avoided by not using support brackets extending above the sign or guy wires and turnbuckles. Landscaping, Buffering, Lighting 1. In Shopping Centers and Office Parks, landscaping shall be provided and maintained in accordance with planting approved by the Planning Board and incorporated as part of the plans on which the Special Permit of the Board of Appeals is based. 2. In all industrial districts, landscaping shall be provided and maintained in front yards and in side yards abutting public ways for aesthetic reasons to break up lines of buildings and for screening accessory facilities under the requirements discussed below. Specifically, in all Industrial and Business Districts, landscape screening shall be provided adjacent to: a. Abutting existing residential properties; and 78 b. Abutting limited access highways in addition to the landscaping in front and side Yards mentioned above. Landscape screening shall consist ofplanting, including evergreens, the plantings to be of such height depth as is needed to screen adequately from view from abutting area any unshielded light source, either inside or outside. (Section 6 amended May 6, 1996 Annual Town Meeting, Article 21) 79 C] � 7!� 0 Gerald Brown, Inspector of Buildings November -15,201-1- Mr, James A.,Che palis . 41ocke Street, Apartment -3 - Andover, MA 01910-4031 Mr. William chepufis- 1018-Osgbod- street N6rtfi'Arfdd'VM',, W 01845 Town of North Andover 1600 Osgood Street Bldg. 20, Suite 2-36 North Andover, MA 01845 Phone: 978-688-9545 Fax: 978-688-9542 Ret 1619-,0sgoGdSt-reet,, North-Andoveri MA-0194'55 Dear Sir(s)',, P I 6ate: be -,a dv W6d INA - lip 6h -1 hSP La Ct ib h �date &Obtbbeik I 1� 2011 i0fthe�st tuttute- b!0"XM'9g'-6'M Si*k fvhas`b0eWdbie ih9V*%Wjding-4s 51 i unsafe—structure—.roof faied .water5" ' : } both ex"its blacked; porch colas411 uf ing.,uni bi A le W �POU009th-- 6ha t b. rtg Please contact Ifie U11ding Department Vo that we may "begin the protoss 10 re mody this: in atimeI h y Tas"dn. '#1easet V8-S8o'9545. 'derafd trown, Suilding- inspector 4,' Curt b4ftavance, birector Community bevetopment Susan S-awyer,'Health,Department Andrew Meinikas, Fire thief -'Mildesktop/iQts bnood'st. Date.7.'5-�3 • 4ffLN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...6e q %��.. ................ r has permission for gas installation in the buildings of .... .. ...v..t............ ... at .....S) ........... , orth A er, Mass. Fee./00-K.. Lic. No. ,66.f... GASINSPECTOR Check # s 8770 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _(/ n� U _ V MA DATE PERMIT # S JOBSITEADDRESS O S e_ OWNER'S NAMES 417 OWNER ADDRESS TEL, FAX OCCUPANCY TYPE COMMERCIAL[N EDUCATIONAL E] RESIDENTIAL® NEW: RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES r . NO® APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE j�( I �I_ ! _!! INFRARED HEATER ;•1! �!_TT {I� r : ^{!I I -. LABORATORY COCKS ' (�� II— I I _ I� •_ I__ wl l_ I� (�— ! I _ _ MAKEUP AIR UNIT OVEN���. POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ®NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 th_$ my signature on this permit application waives this requirement. s CHECK ONE ONLY: OWNER 0 AGENT OF QIWNLR M AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and-iccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliagce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME - J[4uQPa LICENSE #� SIGNATU 3.s MP j'MGF ® JP 0 JGF ® LPGI ® CORPORATION ®# PARTNERBHIP#� LLC[]# COMPANY NAME: 7tAe/ ADDRESS CITY STATE ZIP ' TELT /> ��� .4✓��fc/ FAX CELL EMAIL-�' w F O z , z 0 F -F U a � z � a , z w h C Z a z o dp w C �- w a O. a Z U w : 3 a a W a � a w � LU Cw7 o a a a. x F °- a a W . Fc . Cd w F J O z._ F U W x � � This certifies that .. �e. G f �,1/J d � has permission to perform ...�............. plumbing in the buildings of. ., ... _ _ .... . at ... i'Cs t''IE' j ........... North Andcker, Mass. Fee .67S. - .&o Lic. No..�.�� �.... . PLUMBI�INCTBfd-�� Check # IVI p89`ACHUSE7TS UNIFORM APP1-KATION FOR A PERMIT TO PEKlrutaw rLuln� �� __ _. -- _ o / MA DATE / PERMIT # Lift A OWNER'S NAME JOBSITE ADDRESS 101 TEL FAX '.. P OWNER ADDRESS EDUCATIONAL [3 RESIDENTIAL TYPE OR., OCCUPANCY TYPE COMMERCIAL E PLANS SUBMITTED YES NO® PRINT RENOVATION: © REPLACEMENT:13 CLEARLY NEW: :IXTURES Z FLOOR B� 1 2 3 4 5• 6 7 8 9 10 11 12 13 14 )EDICATED GAS10JUSANU JT01=VI )EDICATED GREASE SYSTEM 5EDI6ATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER . DRINKING FOUNTAIN FOOD DISPOSER . FLOOR I AREA DRAIN INTER CEPTOR_(INT1=}ZIRIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALLTYPES WATER PIPING OTHER ,.-,v:_ a V INSURANCE COVERAGE: I have a current liabil' msurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® BOND E3 OWNER'S INSURANCE WAIVER lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Geral Laws, an my signature ori this permit application waives this requirement �„!� _ CHECK ONE ONLY:` OWNER E] A'GENT SI TURE 0 OR AGENT all of the details and intortnation I have submitted or entered regarding this application -are true and accurate to the best of my knowledge I hereby cerhiy med under the permit issued for this application 41 be in compliance WM all Pertinent provision of the and that all plumbing wank and installations Perfor Massachusetts State Plumbing Code and chapter 142 or the .General taws._ PLUMBERS NAME d - LICENSE # � SIGNATU MP� JP❑ CORPORATION ®# PARTNERSHIP®#=L40#� COMPANY NAMEJ ADDRESS fi- �. STATE ZIP 2 TEL. - CITY., .EMAIL FAX CELL ; 1 ._ -r lnriAmmund Final ,`�_ `\- � W I.. L The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance ,Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ute' ) Cc.. Address: City/State/Zip: J VA , ss , Phone #• I j—"S Z yG G 7 Are you an employer? Check the appropriate box: 1. ® I am a employer with f 4. ❑ I am a general contractor and I employees (full and/or part-time)." have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they ale doing all work and then hire outside contractors must submit anew 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 Nam Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:- I 1 ©SS �� st City/State/Zip:. NO rn& JC3V e_ ` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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. X do Hereby certify udder the pain d peV111es ofperjury that the information provided above is true and correct. V . - Phone #: (, 1 7 S' S L `�C G Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: 001, _ 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 employeils 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 maybe 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 tha 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. # 617-727-4900 at 406 or 1-877, MASSAFE Revised 5-26-05 1'`40 617"727-7749 WWW.mass,govldia - (. COMMONWEALTH OF MASSACHUSETTS": PLUMBERS AND GASFITTERS• s LICENSED ASA .MAST•ER PLUMBER ISSUES THE ABOVE LICENSE TO:' i oj GElbRGE M MURPHY . i '3FO�sAl EzR WATERT.OV9N MA 0..2471 1232 G6.55 05/01/14 186 LICENSE NO. EXPIRATION DATE SERIAL NO. •''.'. p • F. A II 0 Date .711113.. . i TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform ..Gt.� �.. a'1_ .. /'f v-4— , plumbing in the buildings of. . , ..��� , 1.4 at ..,�o,/! .�G�. 41' ....... .... , North Andover, Mass. Fee. Lic. No. p/ $ .. /� ................... ... PLUMBING INSPECTOR Check # / U P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE I A -I PERMIT # 10d � JOBSITE ADDRESS -4 1 OWNER'S NAME OWNER ADDRESS TEL[ JIFAX OCCUPANCY TYPE COMMERCIAL 0I EDUCATIONAL NEW: © RENOVATION: J3 REPLACEMENT: El FIXTURES 7 FLOOR BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL �- WASHING MACHINE CONNECTION TER HEATER ALL TYPES RESIDENTIAL ER PLANS SUBMITTED: YES © [31 10 1 11 1 12 1 13 1 14 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES F-�j NO �1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R . OTHER TYPE OF INDEMNITY QI BOND F1 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ® AGENT 0I • hereby certify 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 'Ind 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. V PLUMBER'S NAME c v ,-----{ LICENSE # a ,,,,f" I SIGNATURE MPR , JP © CORPORATION Q#PARTNERSHIP Q#LLC �I # COMPANY NAME ; ADDRESS CITY I STATE yv�C ZIP q TEL FAX LF CELL �� EMAIL � ~ p W w O CL LLJ ® < Nuj LUco z w 5 a W d O z a � w a � U a J a a a � = w The Commonwealth of Massachusetts Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Address: PQ, a 0K It, L U City/State/Zip: +�+�•o.,.-b M4L_ Phone #: `7 Are you an employer? Check the appropriate box: Type of project (required): 1. F I am a l 4 employer with . ❑ I am a generacontractd I or an ` --�_ 6. [M New construction employees (fall and/or part-time)." have Hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attached sheet. ❑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 10.❑ Electrical repairs or additions required.] officers have exercised their 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' 13.[J Other comp. insurance required,] !Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. #: Expiration Date: h Job Site Address: 10 05, e�. Ciiy/State/Zip: �%7 f,— +VQc,� ter' Attach a copy of the workers' compe ation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 certjQjxnder the polis anoenalties ofperjury that the information provided above is true and correct. 1 ") r _4 9"Z - VcG ? 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 #: y.. Information and Instruct ion's 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;`einploying employees. However the owner of a dwelling house having not more than threes partments 6r�'a vho r'e'sides tlf'erein, or the;occupant of theme dwelling house of another who employs persons to do maintenance; construction or repair v, r -k on such dwell ag- ouse or on the grounds or building appurtenant thereto shall not because of such employiifent be deemed to be an employer." MGL ehap6r.152j §25C(6) also 'states that every state or local licensing ageficPshall vvitlilio�d 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 confirmationof insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be refumed 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 16gibly: The Department lfas-provided a space atthe boff m 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 Coin011Wealth of Massacliu.sPtts Department ofZndustrial Accidents office oI>aestigaona 600 Washington Street Boston? MA, 021 X 1 TO, # 61.7-727,4100 ext 406 or t-877:,MASS.AF Revised 5-26-05 Baz,4 617"727-7741 www-Mas$,govNia c 0 A t 120NV'IC LTH OF MASSACHUSETTS; 1[vERS A[,j I G1Gi'ii% r� ' 4 Ll '..! �EIJ AS A`.1C,URNIt (11AAN F- ISSUES THE�ABOVE LICENSE TO; E" i d J 1111R1'IlY I N,RI'LL ROA1.) 1,1N COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS ,LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: GEORGE M MURPHY �b 3.0 MERRIL RD: 'ATERTOWN MA 02472-1232 6655 05/01/14 186.190 EXPIRATIONNO. I Date ..... 7.-1.- ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......,%/...........r ..................... has permission to perform ..... � 1 ..................%j...,.,......................................:,...................... wiring in the building of.....: Aft k iw / .............................................................................. at ... :80 ../` ����� si !� `'�`� ,`North Andover, Mass. ..................................................... . Lic. No. 2a..�. �,......... ...... ......................... ..... f / ELECCRICAL IN ;$ MR I Check # ! ! `� 11710 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 11710 Occupancy and Fee Checked [Rev. 1/071(leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MLC), 527 CMR 12.00 (PLEASE PRINT MAW OR TYPE ALL MFORMATIOA9 Date: �7 %� 3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) / © / O d 5 6 �—GuD 577 Owner or Tenant (i 'FV Telephone No. Owner's Address � %+7 LP—tli Gvi A ?Z- '�r /l'I Is this permit in'conjunction with a building permit? Yes P—' No ❑ (Check Appropriate Box) Purpose of Building 6- I �t 5 �— Utility Authorization No. - Existing Service Amps // / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 'C14�W Amps /01 U /off 06 Volts Overhead ❑ Undgrd No. of Meters _ Number of Feeders and Ampacity " Location and Nature of Proposed Electrical Work: kt" l Xr= IL -4v 17 -f Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of'Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires �v Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency ig mg Batter Units No. of Receptacle Outlets 351� No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Totals: Number W- - - I Tons "-' "-'._.."' IKW I '""'"......""-... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs - Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: / 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGM 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 suchcove ge is in force, and has exhibited proof o�same to a permit issuing office. CHECK ONE: INSURANCE BOND El OTHER ❑ (Specify:) C / Icertify, under theains and enalties ofperjury that the information on t1 is application is true and complete FIRM NAME: �, L'2 C-�fll t�'�1C, LIC. NO.: D O.3 3 " Licensee: .146(3�'�" !?�J �'� d` Signature LIC. NO.: afapplicable, enter "exemp ' in the license nxm_be'r dine.) // Bus. Tel.,No.•� Address:'(P/dl /�' �[�G�O La �a Alt. Tel. No - *Per M.G.L c. 147, s. 57-61, security work requires Department ofublic 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. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring,shall be uniform throughout the Commonwealth, and applications shall be filed Pass on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an Re- Inspection Required ($.) ❑ electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written Inspectors Signature: request of either the owner or the installing entity stated on the permit application. Date: ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this Pass 0 il purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With Re- Inspection Required ($.) ❑ limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection. Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 il Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com ents: Inspectors Signature: (*k Date: %-Z-I PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 'Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ° ROUGH INSPECTION: Pass M X Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com ts: `l Inspectors Signature: Date: FINAL INSPECTION: Pass (] Failed Re- Inspection Required ($.) ❑ Inspectors Co nts Inspectors Signaturev Date: u DEB WEINHOLD ...TOWN OF MERRIMAC, MA.........dweinhold@townofinerrimac.com The Commonwealth of MassachusettsLn - Department of IndustrialAccidints Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `` Please Print Legibly Name (Business/Organization/Individual): Address: "�D , O IV, City/State/Zip:1�-w Phone #: Are yQu an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).` have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' ' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicIpt that checks box N 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. I am an employer that is information. Insurance Company Nam workers' compensation insurance for my employees Below is the policy and job site Policy # or Self -ins. Lic. #: j! I K291 Expiration Date: / Y Job Site Address:GS, City/State/Zip: Ik 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 DTA for insurance coverage verification. I do herebycerci nder thepains an nalties of perjury that the information providedaboveisstrue /and correct Simature: Date: Phone #: -2 Ll 6 `71, 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. EIectrical 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.p'ermit/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 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. w 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, # 617-727-4900 ext 406 or 1-877rMASSA.FB Revised 5-26-05 Fay, # 617-727-7749 wwxw.mass,govfdia Date ..U/, 113 ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... -,� /S S,�o eo ................................................................. ........................................... has permission to perform -IC 11%� ^ S 5ee'c",-1 ... ;,:4� ...................... -/ .............................. . ........... ... 404L,, Q. MK*"*-"* wiring in the building of,,,,,,,,,,,,,,, ........................................... ....................................... at „11d.1e ............ ........................ . Djorth Andover, Mass. Fee .............................. Lic. No. ELE CAL L &SPECr* *0 R' Check # -k, 11008 ►1 _ -C-N Commonwealth of Massachusetts Official Use Only off Department of Fire Services Permit No. Occupancy and Fee Checked 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 (NEC), 527 CMR 12.00 (PLEASE PRINT IN)YK OR TYPE ALL MFORIVIATIOA9 Date: E 2/- 2 0/ 3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1c40,S7'lier y Owner or Tenant �14 /'� A�-e� a /�, e- - y Telephone No. y%�' 6& 2 2 3�Z Owner's Address cD-c�l o If, e,4/i,',4e. .ST/lre 7' /r e// -r- /``4 Is this permit in conjuncts— unction buildin permit? Yes R] No ❑ (Check Appropriate Box) Purpose of Building // / Dov 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: Comoletion ofthe following table may be waived by the Inspector of Wires. No. )6f Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. o mergency Lighting Batte its No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons. "' KW ....."""....."". No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security No. of DevicysteDevic s:Y Z 3 es or Equivalent No. of Water KW r Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. dromassa a Bathtubs cry g No. of Motors Total HP Telecommunications Wiring No. of Devices or Equivalent OTHER: Attach additional detail if desired; or as required by the Inspector of Wtres. Estimated Value of Electrical Work: /S o O O > (When required by municipal policy.) Work to Start:,E-2/- Zo/ 3 Insp ctions 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INS CEM BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and enalties ofperjury, that the information on this application is true and complete. FIRM NAME:. 1919 'f iS ScCv h, ' 7 LIC. NO.: Licensee: ,,,.. es /2 elk --r Gs ?;,L Signature LIC. NO.: 2Y90 2 afapplicable, enter "exempt" in the license number line.) Bus. Tel. No. - ,6&> z 1 k 232 l Address: Alt. Tel. No.: 4/o,7 fGk noo *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.. Do a 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) J] owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ 1 / Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: hi accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an P electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15; 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass (] Failed Re- Inspection. Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPEC ON: p Pass Failed 0 V Re- Inspection Required ($.) ❑ Inspectors Comme Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: n, u ✓' Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com " The Commonwealth of Massachusetts 02 Department of IndustrialAccidints Office of Investigations IF 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ��ti ^t `S Sri-, //- Address: 023 �'n�'e •�� 7' �A� e City/State/Zip: Phone #: 322 7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).` have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [*'7o workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1;en a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. 5New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0 Other Irevfl. iy *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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. Lie. #: Expiration Date: Job Site Address: /O/k City/State/Zip: 1-9 clo— � � ^x D/-FY_c 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 e 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 un#f the paIN andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License - 2/- Zo/ 3 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 #: a � 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 ofhire, 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 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 Gore onwealth, of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel # 617-727_4900 ext 406 or 1-877. MASS.A.Fr Revised 5-26-05 Fax # 617-727-7749 www=ass.gov/dia i NO W • U WO M. 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