HomeMy WebLinkAboutMiscellaneous - 110 SUTTON STREET 4/30/2018 (2)\.
Q�
Date.............................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... /)r .... C ............. >
..... ...................................................
has permission to perform . ...... ... ....................................
wiring in the building of e
......... . ................................................
......... ................. >./ .......... North Andover, Mass.
Fee../.��2 .............. Lic. No. /�2/ ......................... .................. ................. 12-11. Ave, ......
ELECTRICAL INSPECTOR
Check#
12067
C.ccotystnaracveaat.o�.asac Official Use Only
dUepaetisent o��ire s�wrce� Permit No.
BOARD OF FIRE PREVENTION REGULATIONScc jppncy and Fee Checked
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYP TION) Date: /.;;?City or Town of: _ A�RVJIOW
)JA/- 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 (Stmt & Number)
®vier or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes
Telephone No. 46<S S,533
No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service BUD Amps I Volts O►va*ead ❑ Usdgrd,�
--New Service Amps
_Volts -Overhead ❑ Undgrd
Na of Meters v�
No. of Meters
Number of Feeders and Ampaeity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
-- - - -■van
Na -Strip' (Paddle) ) Fans
- Paddleanaformers
v ■nc ■r■ c■w v iraros,
o oto
TrKVA
No. of Luminaire Outlets
No. of Hot Tabs
Generators KVA
No. of Luminaires
Swimming Pool e ❑ 10- ❑
ffud.grud.
o, a Emergency ng
R!g= Units V
No. of Receptacle Outlets
No. of OR Burners
FIRE ALARMS
No. of Zones
No. ..ofSwitches
No. -of -Gas Burners
I
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eatPont P
Totals:
um r
'---- _ ._..._.___.
ons
_ _._
..-__._..._----
o. o Con n
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Lail ❑ un pa ❑
Cyyonnection
No. ,or Dom
Heating Appliances KW
seen
n , Detin'cess: or uivaknt
No. o Water KW
Heaters J y
o. o o. o
S 3 Ballasts
Data Wiring.
No, of Dvices or f&uivaknt -�
No. Hydromassage Bathtubs
No. of Motors Total HP
ecommunications anegg•
Na of Devices or E uivalent
OTHER:
Auach addttlonat detail ij desireQor as required by the In pectic of Wires.
. ,..
Estimated Value of El ec 'cal Work: S6n ` ' (When required by municipal poli c.,.y.)
Work to Start /) y' %3 Inspections to be requested in accordance with NEC 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: INSURANCES BOND ❑ OTHER ❑ (Specify:) .
I certify, under
FIRM NAME:
Liceusee:
(Ifappticable, end
Address:
r and complete; p�
LIG NO.: 1�p / / ,S
LIC. NO.: JJ?J 7$
Tel. No.: 97Y-G17�9/
Tei. No.:
*Per M.G.L. c. 147, s. 57-6V, security work requires Department of Public Safety "S" License: Lic. No.
OWNER?S-LNSURANCE.WAiVER:-I am aware:thatthe 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) [I owner ❑ owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S �Lf
_ �
i�
r - f � t ' '.1 4 �it3 . - • � 1 • t..i � t
q t n
..• ... � .ter+ _ r •t � .�.�i �.
+ � t y'. •
� ..
` l� t.
.. ''?E � -
_ . v. _...� _ e ._ _ - � , m
J,. _ ... .__ter... � .. _. .. _._.� ,. .. ,.
' .. __� _ .. ry t S _ � _ _ _. _... • ._. ..._ . _ .a��
i /4 r
t ' �
ll s�M t
i �
�i - � r
. 1 - � .'Y .. .. _ _ .._.__ i'.. .. .. .0^tom
I
10320
Datel ........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that... .................................................................
............
ha�. 'ennission to perfo
T nn.- ....... i .................... ..........
p m i nW*
lu bi n the buildings ofl� ...... 01t.k ........ . ........................................
at, k ... ~ .............................................. �4orth Andover, Mass.
Fee.175 .... Lic. No. . ..... .......... a ......................................
INGINSPECTOR
Ch.eck Oe -v—
t
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ' �'fi � MA DATE i PERMIT # � ?
JOBSITE ADDRESS /, 4 �'% OWNER'S NAME h
OWNER ADDRESS f f® J�cJ7�iG7tii - f TEL —FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL fl
PRINT
CLEARLY
NEW: 10 RENOVATION: REPLACEMENT: L71 PLANS SUBMITTED: YES ® NO�]I
FIXTURES -1 FLOOR- BSM
1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM ___._I I I
DEDICATED GRAY WATER SYSTEM 1 _ _- I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER I ! J J _.-i I ._ _} J .f _i _.._....__! .__.__1
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR) ! ___ ____► _.. ' _.__J ( __I _._-J _____i. _, _I _-.____1 ... __ _. I ! ._._____I
KITCHEN SINK l J I �( _.._.._� ...__. I
I � ..__..._- F.._—_I _—_
LAVATORY
ROOF^ORAIN ! � 1--i
SHOWER STALL I _I ..._ _ I _._ I _ f _ _.___J
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
'WATER HEATER ALL TYPES 9/,6:711D
ER PIPING
OTHER ! P l _ ._.J I �I %--.._._I _ .._.___J __...__E ! J
-_-.__-1
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO _
'IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY M OTHER TYPE OF INDEMNITY D BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 01 AGENT 0
SIGNATURE OF OWNER OR AGENT
I 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
and that all plumbing work and installations performed under the permit issued for this application will be in ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
:M—
PLUMBER'SNAME fl 2I LICENSE # I SIGNATURE
mpg JP Q CORPORATION FIA Q# ; LLC
COMPANY NAMEv ;ADDRESS _
_�.
CITYSTATE YY1 ZIP
_ _ G��-/ it TEL '2 l2,9.:Z
FAX L i CELL �� EMAIL -------------- ---- - -... ------ _-.......-- ----- - — --- -
W
H
z
O
H
U
W
a
w
'
o F1
z
a
Z d❑
O � W
w O
z
aLLI
Q w
O a W
Cl
O >co
w �
aco
a
p z
a �
W a
U
J
a
a
LI
x w
H LL
W
H
z
O
H
H
U
W
a
a
a
o
a
-- -
P
0
The Commonwealth of Massachusetts -
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual):
Address:
City/State/Zip:,
Phone
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
have hired the sub -contractors
�• ❑Remodeling
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and' have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
9. F1 Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10. ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11. ❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] i
employees. [No workers'
13. ❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company N
Policy # or Self -ins. Lie.
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 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Sip -nature: 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
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 ofpublic 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 the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massa huse-tls
Department of Industrial Accidents
Office of Investigations
6.00 Washington. Street
Boston} MA, 02111
Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB
Revised 5-26-05 Fax # 617-727.7749
www.mass,govfdla
t,77-7774
1 "30
c
r
4�
5
C
..r
ori
Ao
p V
-
h >
G
z c
•
i¢
LLJ
r �; `
� -
•� o �'�
rim
iwq
Z
_
5
}
•�I^
W 1
.co
r...
;p��K
ate..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
................... ..
This certifies that ... ............. ....... Aci ............................................................. -AI�0.0
&,Q- - , Qct""' �'O"dao'.
haspermission to perform . ..................................................................... t�� .................... V.,
-wmng; in the building of ....... a
............... . .1 . ..........................................................................
,at ..... A.Q ...... hA d
........................................................................... ,NortnAn overMa
'Fee..Q. ....... Lic. No. C . ..... tltr .......
E.
CA OR
Check #
11921
Y
Commonwealth ®f Massachusetts Official Use Only
4
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FORE 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 ININK OR TYPE ALL INFORMATION) Date: M-10 - Z O T 3
City or Town oh 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) 1 l 0 c l o oil SA Y,e�
Owner or Tenant Ro6Q1rT car l".p rY (4 Telephone No.92,RJ
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building -GusN YAoS S Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed EIectrical Work:
No, of Meters
No. of Meters
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans v
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
�No. of Luminaires
Above ❑
Swimming Pool In- ❑
rnd. rnd.
mergeney
o, o Lighting
Battery Units
No. of Receptacle Outlets
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
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
P
Heat Pump
Totals:
Number..
Tons ..."'.........
KW ...,.,:
No. of Self -Contained .
Detection/AlertingDevices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
SecN .o Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications No. of Devices or Equivalent
OTHER:
W a0 Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: bU ' (When required by municipal policy.)
Work to Start: Inspections to be, requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSUAIANCEBOND ❑ OTHER ❑ (Specify:)
Icertify, under thepains andpenalties ofperjuiy, that the information on this application is true and complete.
FIRM NAME:. 00 r» 4s -lc n "a d ,G�Ls�r v��► LIC. NO.: 7"Z ✓ 7-Z>
Licensee: -470 cr 4 Lam, ,SuzIli v,6� V? Sign ature 0�l[e, � LTC. NO.:
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.•
Address: Alt. Tel. No.: 97fr77i 87k
*Per M.G.L c. 147, s. 57-61, security 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.
Owner/Agent EPPJ?-MITFEE.- $
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 P
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
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 IN
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
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comment
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass ®
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth ofMassachusetts
Department oflndustriglAccidents
Office ofInvestigations
600 Washington Street
Boston, MA. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �5&11111g n 4f,74P1'712&1 4 -
Address: o7 7 1n 1180 a
City/State/Zip: Z-d� ,wk1 Phone M I -7f- 7q
Are pu an employer? Check the appropriate box: -
Typo of project (required):
1. I am a employer with 1
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
�• E] Remodeling
ship and'have no employees
These sub -contractors have
workers' comp. insurance.g,
8. ❑ Demolition
'g
working for me in any capacity.
❑ B addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10. Electrical repairs or additions
required.]
3.E\.] I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.0 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
insurance required.]
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.
7 Homeowners who submit this affidavit indicating they pie 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 workers' compensation insurance for my employees. Below is the policy anti job site
information.
Insurance Company Name: I r a e -e (e )�,
Policy # or Self -ins. Lic. if: U s g Z S 3 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 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 maybe forwarded to the Office of
'Investigations of the DIA. for insurance coverage verification.
Ido hereby certify under the pain s andpenalties ofperjury that the information provided above is true and correct. -
sign e: Q-eAt ;a-' If�ut&i' - Date: r0 -10 --Zu 13
Official use only. Do not write in this area, to be completed by city or town official.
City or. Town: Permit/License 0
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 Instructio 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, 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 ofits 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 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 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. Anew 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 Com- monwealth of Massach-vseffq
DepartO; mtofindustrial.A.ccidants
Office OfInvestigations
6.00 Washingtoa Street
Boston, MA 021 It
TO, # 617-727-4.900 ext 406 ox 1-877;MASSAk'F,
Revised 5-26-05 Fax # 617-727;774.9
VV1WW_mace an-VlA;q
I
,l
r . ' Commonwealth of Massachusetts ,
' Department of Public Safety
Security- Systems- S- l.iceme
'License: SSC07000303
ROBERT D SUgLIVAN-
y
27 "1l7IDLAND-si ` r
eLAWRENCE MA 01841 _
y
CarntttissionerT'Expiration:
04/02/014
0
MR,
14
i
27 MI
t&P1 Rl Cl ANS
S S U E S TH E,'F 0 L L OW I NG
CENSE A
I! REf V:ISTE.:iR E D SYSTEM: STEM T E C.H NIEC 71,A
T D SUL L I
r
01841"22
39200
D P - /,�/ /
ate . ............ i ....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certi fies that ....... /,), ......
..., R� ........ .....................................................
...........
.......................... ........
has permission to perform ...... . . ................ /,//- ............. ......
winng in the building of ......
............ .......................
............
at ..... / ........ ............. ....... ............. North Andover, Mass.
�A
...............
Fee . .......... Lic. No ............. X.
. � +L� Pli
Check #
119,19
.y
t
SON Commonwealth of Massachusetts official Use only
Department of Fite Services Permit -No.
BOARD OF FIRE PREVENTION'REGULATIONS
APPLICATION FOR PERMIT TO PERFORM ELECT
WORK
All work to be performed in accOuiu ce with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE AU INFO MATIOM _ Date: 1U
City or Town oh /r- ��, � To the Inspector of Wires:
By this application the undersigoed gives notice of his or her intention to perform the electrical work described below.
Location (Street &11umb'er)
Owner or Tenant-- �P Telephone No.
Owner's Address r
U this permit in conjunction with a building permit? Yes No Q BuDding Permft if
Purpose of Building l% _V_ t f✓� Uialitq Atrthorization No,%�D l 3 % �i
Existing Service ���� Amps " 104 -Malts Overhead '" Undgrd ❑ No. of Meters
New SWAG .^ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampadty�/� J�I�
Location and Nature of Proposed Electrical Worlo / ✓ �.�= �ti �v���-� .
Tenon o the olkwin table be waived the Mr.
No. of Rec�ed Fixtures
No. of Cell,4uap. (Paddle) Fans
o. o
Transformers KVA
No. of Lighting Outlets
No. of Sot Tubs
Generators KVA
NarI'L ating F1iEu�rrs
Sri ag Poo] Above 0 -
d d
❑ o. o Emergency Lignung
Da Unita
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches
No. of Gas Burners
o. Initiatin ctiDem
Na of Ranges.
No. of Air Const. Tons No.
of Alerting Devices
No. of Waste Dlsoge
_ .
Totas:
oo -Contained
Detecdon/A1 Devices
No. of Dishwashers
Space/Area Heating KW
eai ❑ Connection ❑ Other,
No. of Dryers
Heating Appliances -'
ystems:
No. of Devices or uivalent
o. o water
Heaters KWSigns
o• o o• o
Ballasts
Wi
Data rl
No. Of eviees or uivalent
No. Hydromassage Bathtubs
No. of Motors Total Hp
hlbommunknuens
Na uivalent
OTHER:
INSURANCE COVERAGE: Unless waived by the owner, ria permit for the performance of electrical work may issue unles
the licensee provides proof of li$bility i mnuice aandmg "complated operatmn • coverage or in suosumum v*aN w=.. A DO
undersigned certifies that suchcovers in farce, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER 0 (sPOCU )
.xpirstion Date)
Estimated Vahse of Electrical work: -(� brmmich)d policy
•)
Work to Start: ��� � to be requesteti'in accordance v t N EC Rule 10, and upon completion.
I certify, under the jibes and pmatt es of perjruy, that the Information on t is application is true and complete Giernent
Ieraurwrs�x c��s/n�tt�st �e ser, flTe �a cur Q,iy�ca mwd,o, j�davk`.esa4sta� �,�le�d' Orel whh each rroplicarafo� ',�� <� � s
FIRM NAME: //- e S a `% - .4 (' LIC. NO.:�r.
Licensee: .�, �� / g y Signature fr' ,�
livable, enter " npt." in the license lin¢.)
us
• �apy
OWNER' �TSiJRANCE W :. I am aware that the Licensee does �t have the liability insuiraace coverage nomtaily
required �y law. By my signature below, i hereby waive this raluircnmcnt. I am die (check one owner owner's en
t Telephone No. PENT FEE: $
X -
ELECTRICAL PERMIT. NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
A •
1. ROUGH SPECTION:
Passed — 1 Failed --( ] Re -inspection required ($50.00) -
Inspectorsmments:
- •r
(Inspector Sign ure - no initials) Date
2. FINAL INSPECTION:
Passed — [ Failed — [' ] Re -inspection required ($50.00) ( ]
-Inspectors ments:
( spectors' gnatu )no initials) Date
V
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ -]
Inspectors' comments: _
(Inspectors' Signature - no initials) Date
4. INSPECTION — SERVICE:
DATE CALLED NATIONAL GRID: NAME: -
,_Passed — [ ] Failed — ( ] _ Re -inspection required ($50.00).- [ ]
Inspectors' comments:
(Inspectors' Signature- no initials)-:--- Date
5. -INSPECTION - OTHER:
'Passed — [ ] Failed — [ ] Re -inspection, required ($50.00)
Inspectors' comments:
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
~ ACCESSIBLE AND RE -INSPECTION OF $50.00 IS TO BE CHARGED.
l
D c
ate .... 7114 9/2 ......
r � Z., -.� TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... C ...........
has permission for gas installation Y A104AI)
in the buiIdings of ..... A. ...........
at ........ I North Ando M
Fee. ,:?P, OAI Lic. No.
Check#
8249
Nv
" SIN—
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
W
City/Town• /UUg-AAJdo u&A MA. Date: Permit#
-
1¢ f C
Building Location: // ® J CJ %O h/ S I Owners Name: /S z C 9-pG.4 7R us J
-
Type of Occupancy: Commercial Educational ❑ Industrial ❑ Institutional ❑ Residential ❑
New: ❑ Alteration: ❑ Renovation:] Replacement: ❑ Plans Submitted: Yes ❑ No ❑
CIVTI IDCe
- - -'- - - -.-
-
W
W
-
-
-
-
Y
-
Cd
F-
=
IX W
m=
00
LL)
U)
W
U
O=
O
Z
Lu
Cl)
W
Z
o
m
0
W
W
Ce
p
O
0
Q F=-
z
W
Lu
Lu
H
p
LL
>
V
W
W=
Z
(7
J
FW-
W
h
W
O Z
-Q Lu
J
0
O
Z
u.
fn =
W
H
W W
1
O
V
25
0
O
LL
Q
(7
C7
2
2
�
J O
O
n.
�
O
rY
W Z
F- >>>�
Z
W
Q I=-
O
SUB BSMT.
BASEMENT
1 FLOOR
2 No FLOOR
3 R u FLOOR
4TH FLOOR
5 FLOOR
6 FLOOR
VH FLOOR
6 FLOOR
Ld
Installing Company Name:
S' Ct I
C p-117,
rj
PC S b
f nit
Check One Only Certificate #
Address:pab
lbox
aoo(o
City/Town: Mb—n_+A,-j
State: A%1
❑ Corporation
El Partnership
Business Tel:
- MY91'f')
g 51
Fax:
[,Firm/Company
Name of Licensed
Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes -P No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy IJ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent El
By checking this box E; I 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 Knnwl—inn —1 f hnf nu --t, --A e....a-u...:..----_ _ _--.... . _ ... .. -- .... -
.. -- -- --- _.._ - --.-..._.._ r_ ........................` rte...... w... w� uua aNNucauvn ww ue ui
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By ❑ Plumber
Title ❑ Gas Fitter Sig ature of Licensed P�!�FlGas Fitter
® Master p
City/Town ❑Journeyman License Number: 36
APPROVED (OFFICE USE 6N—LY) ❑ LP Installer -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofinvestigations
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): SAS 9 /1r�/
Address:._.
City/State/Zip:✓�Ttr >� i �/ji�I71 t�hone #: �/�� �L /%
Are you an employer? Check the appropriate box:
❑ Iam a employer with
4. El am a general contractor I
employees (full and/or part-time).*'
2. I am a sole or
and
have hired the sub -contractors
listed
proprietor partner-
on the attached sheet. t
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.]
3. ❑ .I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
*Any applicant that checks box #1 must also fill out the
comp. insurance required.]
section betov, ���•_,;, R .: e
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
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contra t rs 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: /'l f� 5'2 % r r 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 ofM.GL 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 u r tJ�e papas and pena ties ofperjuiy that the information provided above is true and correct
Phone #:
Official use only. Do not wr=ite in this area, to be completed by city or town offzciaL
City or Town:
Permit/License
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
3
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 \ 1'
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 certificates) 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
bd returned to the city or town that the applicE:ion for the pemaitor" licynse is being req'aes*.ed, not thr D grt-rent 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 CornmonwealtFi of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1 -8.77 -MASSA -FE
Revised 5-26-05 Fax # 617-727-7749
v w.rnass-gov/dia
Date.. �.! .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
C--YAe
This certifies that ............. .... ................. ........
.4 .............
has permission toperform ......
................. ....
wiring in the building Of .........................................
at ....... t.U) .... .................... ............. . N rth Ando r, Ma,
Fee. ��.6 .. 0 ..... Lic. No.7AD . I . ... ....... . . ...... ..... .....
No
CrRI R
5i�CAL
Check At
087:8
I
Commonwealth of Massachusettts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. U 7, .
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 (MEC), 527 CMR 12.00
(PLEASE PAWT.W INK OR TYPEALL INFORMATION) Date: 6 7
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) 1 10 �Z C �
o , S.
Owner or Tenant n 4 N Cy C 0Ab, CfI Sit �O�Telephone No.
Owner's Address �� .
Is this ermit in t' ' h
pconlunc ion int a building permit? Yes Lam' No ❑ (Check Appropriate Box) 12 � 6 / 3
Purpose of Building 6014 L Utility Authorization No. m ft { { y p
Existing Service A10C Amps ,2ii J t W Volts Overhead [�J' Undgrd ❑ No. of Meters
New Service AW Amps 2162112-0 Volts Overhead ❑ Undgrd No. of Meters �
Number of Feeders and Ampacity G
Location and Nature of Proposed Electrical Work: gE�1 r2VA
Completion ofthe following table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
�1
Outlets
No. of Hot Tubs
Generators KVA
I
Commonwealth of Massachusettts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. U 7, .
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 (MEC), 527 CMR 12.00
(PLEASE PAWT.W INK OR TYPEALL INFORMATION) Date: 6 7
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) 1 10 �Z C �
o , S.
Owner or Tenant n 4 N Cy C 0Ab, CfI Sit �O�Telephone No.
Owner's Address �� .
Is this ermit in t' ' h
pconlunc ion int a building permit? Yes Lam' No ❑ (Check Appropriate Box) 12 � 6 / 3
Purpose of Building 6014 L Utility Authorization No. m ft { { y p
Existing Service A10C Amps ,2ii J t W Volts Overhead [�J' Undgrd ❑ No. of Meters
New Service AW Amps 2162112-0 Volts Overhead ❑ Undgrd No. of Meters �
Number of Feeders and Ampacity G
Location and Nature of Proposed Electrical Work: gE�1 r2VA
Completion ofthe following table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
Outlets
No. of Hot Tubs
Generators KVA
ires
ffofLuminalre
Swimming Pool Above ❑ In-
rnd.
❑ o, o mergency ig mgrnd.
Batte Units
cle Outlets
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiatin Devices •
No. of Ranges
No, of Air Cond. TotaTons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number •
"-"
_Tons .
KW.•...-• No. of Self -Contained
•• Detection/Alertin Devices
NoEof Dishwashers
Space/Area Heating KW
Local ❑Municipal ❑Other
Connection
NoDryers
No. of Water
Heaters KW
Heating Appliances K�'
No. of No. of
Si ns Ballasts
Security Systems:x•
No. of Devices orE uivalent
Data Wiring:
No. of Devices orE uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No, of Devices nr F,nnivalent
OTHER:
Attach additional detail ifdesihe , or as required by the Inspector of Wires.
Estimated Value of Electrical Work: _ �f � oyo . (When required by municipal policy.)
Work to Start: —1 I- - 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
Icertify, under the ains andpenalties ofperfury, that the information on this application is true and cor pieie.
FIRM NAME: tj,0 jL?H S' 1 -F PC(,,,�f/L_ Se,, � c s� LIC. NO.:
Licensee: �j;2�t=S Jjp�LA�� Signature&9hW.4c� t LIC. NO.:
(Ifapplicable, enter `exempt" in the license number line.)
Address: Bus. Tel. No.: S 5iAlt. Tel. No.:
'Per M.G.L c. 147, s. 57-61, security 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 aizent.
Owner/Agent
Signature Telephone No. PERMIT FEE:
. "OU(' xt� c�cxo�
Waifed-•[ J Re-inspseffonxegnxxecT{$�OAO)�[
�ns�ectoxs' comme�afs: - '
(Znspeefoxs' Signature -)10 dials) pate
Passe — [) iailed--[
At -inspection required ($50.00) - [ �
I'ns�eetoxs' commtenfs: -
QGis ectoxs' `ignaiure Sao iniEiaYs) Pate
passed--[
wed-[ ] Re-fuspec�o�xecfui�recf($50.00)�[ �
Inspectors' comments: e
(lwpectoxsl iSignaiure•-'no inifials) Pate
4.IIi�I PECTZO�aT—�E t C ':
sassed-- [,if lyafferl-- [
�nspecfbrs' eo3nzneptfs:
ti
(�s�ectors' �ignatuxe � �.o fn
!fie-inspecfio:
souls)
Date
00R TAGS APX TO BE FREED OUT AND IEDT ON SITE N TBE .APXA TO 3E )WRECTED 19 NOT
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t o e wAA 0 Ge,> -3- Pc,,. 2 t t�
Address: 60s %7l ooi_E: S01-
City/State/Zip:
"1City/State/Zip: M A► t J1 e_a _. K 0. Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and 1
6. ❑ New construction
employees (full and/or part-time).*
2. El am a sole proprietor or partner-
have lured the sub -contractors
listed on the attached sheet.
7• RemoCling
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.[lectrical repairs or additions
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11. ❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.[]Roofrepairs
insurance required.] t
employees. [No workers'
13.[j Ocher
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 are 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 isproviding workers' compensation insurance for my employees Below is thepolicy andjob site
information.
Insurance Company Name:. %tAckaLto L 7 lv S
Policy # or Self -ins. Lic. #: LX -2- _S & U i Expiration Dater`) - 0�z - i2 _
Job Site Address: M9 . Sk `% % U f ---J 57. City/State/Zip:- �. 1�} N 'L� VC
, - i
Attach
CAttach 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 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.
X do hereby certo under the pains andpenalties ofperjury that the information provided above is true and correct.
Siznature: T /4 a Date 6 f
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. AIso 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 (ifnecessary) 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. Anew 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
Depa ent ofladustrial Accidents
Me of Investigations
600 Washitagtom Street
Boston, MA. 0211 t
Tel, # 61.7-727-4900 oxt 406 or I-87MA.SS.AFE
Revised 5-26-05 Fax # 617-727-7749
wwwmztss.gov/dia
4 , X,.b
a
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection - Wetlands
WPA Form 8B — Certificate of Compliance
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
tab
rewm
A. Project Information
1. This Certificate of Compliance is issued to:
KLC Realty Trust, Robert Carberry, Trustee
Name
110 Sutton Street
2
DEP File Number:
')A7 Irnl
--- uy ver
Mailing Address
North Andover MA 01845
City/Town State Zip Code
This Certificate of Compliance is issued for work regulated by a final Order of
Conditions issued to:
Douglas Mund, designgroup/DMDG2
Name
April 25, 2013 242-1591
Dated DEP File Number
The project site is located at:
110 Sutton Street North Andover
Street Address City/Town
Map 17 Parcel 9
Assessors Map/Plat Number Parcel/Lot Number
the final Order of Condition was recorded at the Registry of Deeds for:
Property Owner (if different)
Northern Essex
VA7A Orr)
County Book Page
Certificate
4. A site inspection was made in the presence of the applicant, or the applicant's agent,
on:
11/6/13
Date
wpafrm8b.doc • rev. 12/23/09
WPA Form 813, Certificate of Compliance • Page 1 of 3
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection - Wetlands DEP File Number:
WPA. Form 8B — Certificate of Compliance 242-1591
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
B. Certification
Check all that apply:
® Complete Certification: It is hereby certified that the work regulated by the
above-referenced Order of Conditions has been satisfactorily completed.
❑ Partial Certification: It is hereby certified that only the following portions of work
regulated by the above -referenced Order of Conditions have been satisfactorily
completed. The project areas or work subject to this partial certification that have
been completed and are released from this Order are:
❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the
above -referenced Order of Conditions never commenced. The Order of
Conditions has lapsed and is therefore no longer valid. No future work subject to
regulation under the Wetlands Protection Act may commence without filing a new
Notice of Intent and receiving a new Order of Conditions.
® Ongoing Conditions: The following conditions of the Order shall continue:
(Include any conditions contained in the Final Order, such as maintenance or
monitoring, that should continue for a longer period).
Condition Numbers:
75
C. Authorization
Issued by:
North Andover /
Conservation Commission Dat4 of Issuance
This Certificate must be signed by a majority of the Conservation Commission and a
copy sent to the applicant and appropriate DEP Regional Office (See
wpafrm8b.doc • rev. 12/23/09 WPA Form 86, Certificate of Compliance • Page 2 of 3
ILIMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands DEP File Number:
WPA Form 8B — Certificate of Compliance 242-1591
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
D. Recording Confirmation
The applicant is responsible for ensuring that this Certificate of Compliance is recorded in
the Registry of Deeds or the Land Court for the district in which the land is located.
Detach on dotted line and submit to the Conservation Commission.
To:--------------------------------------------------------------------------------------------------
North Andover
Conservation Commission
Please be advised that the Certificate of Compliance for the project at:
110 Sutton Street
242-1591
Project Location DEP File Number
Has been recorded at the Registry of Deeds of:
Northern Essex
County
for:
KLC Realtv Tru:
Property Owner
Robert Carberry, Trustee
and has been noted in the chain of title of the affected property on:
Date
Book Page
If recorded land, the instrument number which identifies this transaction is:
If registered land, the document number which identifies this transaction is:
Document Number
Signature of Applicant
wpafrm8b.doc - rev. 12/23/09 WPA Form 86, Certificate of Compliance • Page 3 of 3
North Andover Board of Assessors Public Access
f NO orN7
c"
'Ts wwnn r••`ty
gSSACHUSEt
Click Seal To Retum
Search for Parcels
Search for Sales
Summary
Residence
Detached Structure
Condo
Commercial
Page 1 of 1
North Andover Board of Assessors
�46roperty Record Card
Parcel ID :210/017.0-0009-0000.0 FY:2012 Community: North Andover
SKETCH PHOTO
Click on Sketch to Enlarge Click on Photo to Enlarge
,l
Aj
1® 4
110 SUTTON STREET
Location: L110 SUTTON STREE ,-----:M
Owner Name: KLC REALTY TRUST
ROBERT C. CARBERRY, TRUSTEE
Owner Address: 110 LANCASTER ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 34 - 4 Land Area: 1.19 acres
Use Code: 369-OTHER-CULTRL Total Finished Area: 10334 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 821,900 821,900
Building Value: 624,900 624,900
Land Value: 197,000 197,000
Market Land Value: 197,000
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=l 8 8 7976&town=NandoverPubAcc
l
3/26/2012
Coto
N
O O
L— IL
O O
N
0
N N
LL
0
�o
N N C
R
V M M
O 0
�a L
m
W
lLt4Um>2
N y
J
L2�--'7fA
f6 N N
m
.
❑ (a 4i
Q
O
IA
O 4 Ln
C C
J J
a) co (D
C
Lo Co
CO ` -0
O
O O
uCLi
a
N
,�
Z
c�W0E
O
N
N
o 0
L— IL
\
N
0
O O
LL
0
�o
R
V M M
O O
�a L
m
W
lLt4Um>2
a
L2�--'7fA
o
N
.
Z
O
IA
O 4 Ln
C C
J J
o
N
Lo Co
O
O O
N
,�
Z
J
-O
❑ W
E
oM � m
E
��
maU 0
U
W
LL
00
00
Z.
Ln
M rn
w
U
CO
o LY
CL
V
Z��
oQ
oCL LL
a o-
poo
O
'U O
ai C a
U N'
m
ZO
o
2' fa: o
0_ O❑ >—
F.
(D
S
m
EO
a ��
U~
Q.e
J
— . -
� c �
M 01
cn
r
O
e9 �'• e -
\
O
U
O
J.v(nao
ui vi (D Q
'O cCL
m
Co
C'C
90if-Cli,
E
N
X
�
LL
CO O O
W
r
O
a:
Z0 ed
�QQ
C14 C14
COO
cQ
G
❑:/i LL Co
zU) c—
C
Z
W
O
LU
O
O
~
N
a
o
Q -0�
co
O
C 0
00
O
Z
Q Q
ti
!ALU
��
O�
j
Ix w
W
NQ
-
HV
o
MM
Qz
a
O O
— —
rn
OD 00
m
M Ci O co
co
CJO 200
Q
3.
d
0-
O Q
7 7
N
M
0
0
0
0
O
O
0)
0
0
0
0
r;
O
0
N
U
co
IL
N
o 0
N
0
O O
R
V M M
O O
v
O
W o
O
IA
O 4 Ln
C C
J J
-31
Lo Co
N
,�
Z
O O
o
W
LL
00
Z.
Q
M rn
}
�a
Z��
m
poo
O
ZO
o
O 0Lo�
X83„
F.
a ��
w
— . -
� c �
Q Zy
W.�
J J
� N
�'°
O Q
� () <
z o o
)
�
LL
V
- Mol
Z0 ed
�QQ
C14 C14
COO
❑:/i LL Co
zU) c—
(j =
m
Q
U) LO,
JV
a
W }0)ti
Q -0�
C 0
=Wrnrn
>mm
=w
d
a
Z �.�
L J `i O O
o C:)
-
fAOO
MM
d
O O
— —
rn
OD 00
M Ci O co
co
o
,
00
NLO 0
CL
v L� d
H H
O
a cn U)
c o
L -
` a
zLa
U
U) ¢ (L
ci
oma.
m o
OD o
•. C
d
0�
00
v�
vM
7
3
m
m
L
r
L
OC)}
coco
V!
W
W
CL
O
t7
m
to
O
N
(AA �
V
V
V
LILAI
U)
tsf
0)
L V L
J
Om0
LLN Om❑ LL N
Q
M
t
Cl) t
07
0
1-1
0
m
.�
.�
�
LL
o X Q 0 a
2
N O
tJi N O Lei. o
�„a
N
'w� ,orr
m r ❑ m d'
U❑
�
�-N
V� .
V
L
a
a
o
LL
N U.
o
'00)C 40 M
❑O�
VM �(9"t VCOM
L
_
0 Co CL
U m
dm.
Q U d
0 po
ooU)
LU
Y
0
7 7
N
M
0
0
0
0
O
O
0)
0
0
0
0
r;
O
0
N
U
co
IL
a 14
Massachusetts Department of Environmental Protection Provided by MassDEP:
- Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
MTA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
A. General Inf6rmati6n
1. Conservation Commission NORTH ANDOVER
2. Issuance
a. r OOC b. r Amended -00C
3. Applicant Details
a. First Name
DOUGLAS MUND DESIGNGROUP/DMDG2 b; Last Name
c. Organization
C/O THE NEVE-MORIN GROUP, INC.
d. Mailing Address
447 BOSTON STREET
e. City/Town
TOPSFIELD f. State MA g. Zip Code 01983
4. Property Owner
a. First Name
ROBERT C. b. Last Name CARBERRY, TRUSTEE
c. Organization
KLC REALTY TRUST
d. Mailing Address
110 SUTTON STREET
e. City/Town
NORTH ANDOVER f. State MA g. Zip Code 01845
5. Project Location
a. Street Address
110 SUTTON STREET
b.City/Town
NORTH ANDOVER c. Zip Code 01845
d. Assessors Map/Plat# 17 e. Parcel/Lot# 9
f. Latitude
42.70587N g. Longitude 71.13604W
6. Property recorded at the Registry of Deed for:
a. County
b. Certificate c. Book d. Page
NORTHERN ESSEX
4270 30
7.Dates
a. Date NOI Filed: 3/25/2013
b. Date Public Hearing Closed: 4/24/2013 c. Date Of Issuance: 4/25/2013
8.Final Approved Plans and Other Documents
a. Plan Title:
b. Plan Prepared by: c. Plan Signed/Stamped by: d. Revised Final Date: e. Scale:
SITE
DGT SURVEY GROUP EDWARD DIXON, PLS &
IMPROVEMENT
_ NORTH SHORE SCOTT P. CAMERON, P.E. 4/4/2013 1"=20'
PLAN
EXISTING
DGT SURVEY GROUP EDWARD DIXON, PLS Feb. 15, 2013 V=20'
CONDITIONS
- NORTH SHORE
Page 1 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town-NORTH ANDOVER
DETAILS (SHEET 3 DETAIL SHEET (2) EDWARD DIXON, PLS & 3/6/2013
& 4) SCOTT P. CAMERON, P.E.
B. Findings
1.Findings pursuant to the Massachusetts Wetlands Protection Act
Following the review of the the above -referenced Notice of Intent and based on the information provided in this application and
presented at the public hearing, this Commission finds that the areas in which work is proposed is significant to the following interests of
the Wetlands Protection Act.
Check all that apply:
a. G Public Water Supply b r Land Containing Shellfish c. r, Prevention of Pollution
d. r Private Water Supply e r Fisheries f. G Protection of Wildlife Habitat
g. r Ground Water Supply h. r Storm Damage Prevention i. IT Flood Control j
2. Commission hereby finds the project, as proposed, is:
Approved subject to:
a. r The following conditions which are necessary in accordance with the performance standards set forth in the wetlands regulations.
This Commission orders that all work shall be performed in accordance with the Notice of Intent referenced above, the following
General Conditions, and any other special conditions attached to this Order. To the extent that the following conditions modify or
differ from the plans, specifications, or other proposals submitted with the Notice of Intent, these conditions shall control.
Denied because:
b. r The proposed work cannot be conditioned to meet the performance standards set forth in the wetland regulations. Therefore,
work on this project may not go forward unless and until a new Notice of Intent is submitted which provides measures which are
adequate to protect interests of the Act, and a final Order of Conditions is issued. A description of the performance standards
which the proposed work cannot meet is attached to this Order.
c. r The information submitted by the applicant is not sufficient to describe the site, the work or the effect of the work on the interests
identified in the Wetlands Protection Act. Therefore, work on this project may not go forward unless and until a revised Notice of
Intent is submitted which provides sufficient information and includes measures which are adequate to protect the interests of the
Act, and a final Order of Conditions is issued. A description of the specific information which is lacking and why it is
necessary is attached to this Order as per 310 CMR 10.05(6)(c).
3. r Buffer Zone Impacts: Shortest distance between limit of project disturbance and the wetland resource
area specified in 310CMRI0.02(1)(a).
a. linear feet
Inland Resource Area Impacts:(ForApprovals Only):,
Resource Area Proposed
Permitted
Proposed
Permitted
Alteration
Alteration
Replacement
Replacement
4. ❑ Bank
a. linearfeet
b. linear feet
c. linear feet
d. linear feet
5. r Bordering Vegetated Wetland
a. square feet
b. square feet
c. square feef
d: square feet
Page 2 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
r WPA Form 5 - Order of Conditions eDEP Transaction #:557550
t
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
6. r Land under Waterbodies and Waterways
7. r Bordering Land Subject to Flooding
Cubic Feet Flood Storage
8. C Isolated Land Subject to Flooding
Cubic Feet Flood Storage
9. E Riverfront Area
Sq ft within 100 ft
Sq ft between 100-200 ft
a. square feet b. square feet
e. c/y dredged f. c/y dredged
5000 5000
a. square feet b. square feet
1641 1641
e. cubic feet f. cubic feet
a. square feet b. square feet
c. cubic feet d. cubic feet
5000 5000
a. total sq. feet b. total sq. feet
5000 5000
c. square feet d. square feet
g. square feet h. square feet
c. square feet d. square feet
5000 5000
c. square feet d. square feet
5040 5040
g. cubic feet h. cubic feet
e. cubic feet
5000
e. square feet
i. square feet
f. cubic feet
5000
f. square feet
j. square feet
Coastal Resource Area Impacts:
Proposed Permitted Proposed Permitted
Resource Area
Alteration Alteration Replacement Replacement
10. r Designated Port Areas
Indicate size under Land Under the Ocean, below
11. r Land Under the Ocean
a. square feet b. square feet
c. c/y dredged d. c/y dredged
12. r Barrier Beaches
Indicate size under Coastal Beaches and/or Coastal Dunes below
13. r Coastal Beaches
a. square feet b. square feet c. c/y nourishment d. c/y nourishment
14. r Coastal Dunes
a. square feet b. square feet c. c/y nourishment d. c/y nourishment
15. r Coastal Banks
a. linear feet b. linear feet
16. r Rocky Intertidal Shores
a. square feet b. square feet
17. r Salt Marshes
a. square feet b. square feet c. square feet d. square feet
18. r Land Under Salt Ponds
Page 3 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
-- Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Cityfrown:NORTH ANDOVER
a. square feet b. square feet
c. c/y dredged d. c/y dredged
19. C` Land Containing Shellfish
a. square feet b. square feet c. square feet d. square feet
Indicate size under Coastal Banks, inland Bank, Land Under the
20. r Fish Runs Ocean, and/or inland Land Under Waterbodies and Waterways,
above
21. f- Land Subject to Coastal Storm Flowage
c. c/y dredged d. c/y dredged
a. square feet b. square feet
22.
C Restoration/Enhancement (For Approvals Only)
If the project is for the purpose of restoring or enhancing a wetland resource area in addition to the square footage that has been
entered in Section B.5.c & d or=B.17.c & d above, please entered the additional amount here.
a. square feet of BVW b. square feet of Salt Marsh
23.
r Streams Crossing(s)
If the project involves Stream Crossings, please enter the number of new stream crossings/number of replacement stream crossings.
a. number of new stream crossings
b. number of replacement stream crossings
C. General Conditions Under Massachusetts Wetlands Protection Act
The following conditions are only applicable to Approved projects
1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed
cause to revoke or modify this Order.
2. The Order does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or
invasion of private rights.
3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal,
state, or local statutes, ordinances, bylaws, or regulations.
4. The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following
apply:
a. the work is a maintenance dredging project as provided for in the Act; or
b. the time for completion has been extended to a specified date more than three years, but less than five
years, from the date of issuance. If this Order is intended to be valid for more than three years, the
extension date and the special circumstances warranting the extended time period are set forth as a
special condition in this Order.
5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the
issuing authority at least 30 days prior to the expiration date of the Order.
6. If this Order constitutes an Amended Order of Conditions, this Amended Order of Conditions does not exceed the issuance
date of the original Final Order of Conditions:
7. Any fill used in connection with this project shall be clean fill. Any fill shall contain no trash, refuse, rubbish, or debris, including
Page 4 of 10 * ELECTRONIC COPY
L1Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
1 WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
but not limited to lumber, bricks, plaster, wire, lath, paper, cardboard, pipe, tires, ashes, refrigerators, motor vehicles, or parts of
any of the foregoing.
8. This Order is not final until all administrative appeal periods from this Order have elapsed, or if such an appeal has been taken,
until all proceedings before the Department have been completed.
9. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or the Land
Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land,
the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the
proposed work is to be done. In the case of the registered land, the Final Order shall also be noted on the Land Court
Certificate of Title of the owner of the land upon which the proposed work is done. The recording information shall be submitted
to the Conservation Commission on the form at the end of this Order, which form must be stamped by the Registry of Deeds,
prior to the commencement of work..
10. A sign shall be displayed at the site not less then two square feet or more than three square feet in size bearing the words,
" Massachusetts Department of Environmental Protection"
[or'MassDEP"]
File Number : "242-1591 "
11. Where the Department of Environmental Protection is requested to issue a Superseding Order, the Conservation Commission
shall be a party to all agency proceedings and hearings before Mass DEP.
12. Upon completion of the work described herein, the applicant shall submit a Request for Certificate of Compliance (WPA Form
8A) to the Conservation Commission.
13. The work shall conform to the plans and special conditions referenced in this order.
14. Any change to the plans identified in Condition # 13 above shall require the applicant to inquire of the Conservation Commission
in writing whether the change is significant enough to require the filing of a new Notice of Intent.
15. The Agent or members of the Conservation Commission and the Department of Environmental Protection shall have the right to
enter and inspect the area subject to this Order at reasonable hours to evaluate compliance with the conditions stated in this
Order, and may require the submittal of any data deemed necessary by the Conservation Commission or Department for that
evaluation.
16. This Order of Conditions shall apply to any successor in interest or successor in control of the property subject to this Order and
to any contractor or other person performing work conditioned by this Order.
17. Prior to the start of work, and if the project involves work adjacent to a Bordering Vegetated Wetland, the boundary of the
wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place, the wetland
boundary markers shall be maintained until a Certificate of Compliance has been issued by the Conservation Commission.
18. All sedimentation barriers shall be maintained in good repair until all disturbed areas have been fully stabilized with vegetation or
other means. At no time shall sediments be deposited in a wetland or water body. During construction, the applicant or his/her
designee shall inspect the erosion controls on a daily basis and shall remove accumulated sediments as needed. The applicant
shall immediately control any erosion problems that occur at the site and shall also immediately notify the Conservation
Commission, which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary.
Sedimentation barriers shall serve as the limit of work unless another limit of work line has been approved by this Order.
NOTICE OF STORMWATER CONTROL AND MAINTENANCE REQUIREMENTS
19. The work associated with this Order(the "Project") is (1) r is not (2) r subject to the Massachusetts Stormwater Standards.
If the work is subject to Stormwater Standards, then the project is subject to the following conditions;
a) All work, including site preparation, land disturbance, construction and redevelopment, shall be implemented in accordance
with the construction period pollution prevention and erosion and sedimentation control plan and, if applicable, the
Stormwater Pollution Prevention Plan required by the National Pollutant Discharge Elimination System Construction General
Permit as required by Stormwater Standard 8. Construction period erosion, sedimentation and pollution control measures and
best management practices (BMPs) shall remain in place until the site is fully stabilized.
b) No stormwater runoff maybe discharged to the post -construction stormwater BMPs unless and until a Registered
Page 5 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
Professional Engineer provides a Certification that: i. all construction period BMPs have been removed or will be removed by
a date certain specified in the Certification. For any construction period BMPs intended to be converted to post construction
operation for stormwater attenuation, recharge, and/or treatment, the conversion is allowed by the MassDEP Stormwater
Handbook BMP specifications and that the BMP has been properly cleaned or prepared for post construction operation,
including removal of all construction period sediment trapped in inlet and outlet control structures; ii.. as -built final construction
BMP plans are included, signed and stamped by a Registered Professional Engineer, certifying the site is fully stabilized; id.
any illicit discharges to the stormwater management system have been removed, as per the requirements of Stormwater
Standard 10; iv. all post -construction stormwater BMPs are installed in accordance with the plans (including all planting
plans) approved by the issuing authority, and have been inspected to ensure that they are not damaged and that they are in
proper working condition; v. any vegetation associated with post -construction BMPs is suitably established to withstand
erosion.
c) The landowner is responsible for BMP maintenance until the issuing authority is notified that another party has legally assumed
responsibility for BMP maintenance. Prior to requesting a Certificate of Compliance, or Partial Certificate of Compliance, the
responsible party (defined in General Condition 19(e)) shall execute and submit to the issuing authority an Operation and
Maintenance Compliance Statement ("O&M Statement") for the Stormwater BMPs identifying the party responsible for
implementing the stormwater BMP Operation and Maintenance Plan ("O&M Plan") and certifying the following: i.) the O&M
Plan is complete and will be implemented upon receipt of the Certificate of Compliance, and ii.) the future responsible parties
shall be notified in writing of their ongoing legal responsibility to operate and maintain the stormwater management 13MPs and
implement the Stormwater Pollution Prevention Plan.
d) Post -construction pollution prevention and source control shall be implemented in accordance with the long-term pollution
prevention plan section of the approved Stormwater Report and, if applicable, the Stormwater Pollution Prevention Plan
required by the National Pollutant Discharge Elimination System Multi -Sector General Permit.
e) Unless and until another party accepts responsibility, the landowner, or owner of any drainage easement, assumes
responsibility for maintaining each BMP. To overcome this presumption, the landowner of the property must submit to the
issuing authority a legally binding agreement of record, acceptable to the issuing authority, evidencing that another entity has
accepted responsibility for maintaining the BMP, and that the proposed responsible party shall be treated as a permittee for
purposes of implementing the requirements of Conditions 19(f) through 19(k) with respect to that BMP. Any failure of the
proposed responsible party to implement the requirements of Conditions 19(f) through 19(k) with respect to that BMP shall
be a violation of the Order of Conditions or Certificate of Compliance. In the case of stormwater BMPs that are serving more
than one lot, the legally binding agreement shall also identify the lots that will be serviced by the stormwater BMPs. A plan and
easement deed that grants the responsible party access to perform the required operation and maintenance must be submitted
along with the legally binding agreement.
The responsible party shall operate and maintain all stormwater BMPs in accordance with the design plans, the O&M Plan,
and the requirements of the Massachusetts Stormwater Handbook.
The responsible party shall:
1. Maintain an operation and maintenance log for the last three (3) consecutive calendar years of inspections, repairs,
maintenance and/or replacement of the stormwater management system or any part thereof, and disposal (for disposal the
log shall indicate the type of material and the disposal location);
2. Make the maintenance log available to MassDEP and the Conservation Commission ("Commission") upon request; and
3. Allow members and agents of the MassDEP and the Commission to enter and inspect the site to evaluate and ensure
that the responsible party is in compliance with the requirements for each BMP established in the O&M Plan approved by
the issuing authority.
h) All sediment or other contaminants removed from stormwater BMPs shall be disposed of in accordance with all applicable
federal, state, and local laws and regulations.
i) Illicit discharges to the stormwater management system as defined in 310 CMR 10.04 are prohibited.
j) The stormwater management system approved in the Order of Conditions shall not be changed without the prior written
approval of the issuing authority.
k) Areas designated as qualifying pervious areas for the purpose of the Low Impact Site Design Credit (as defined in the
Page 6 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town-.NORTH ANDOVER
MassDEP Stormwater Handbook, Volume 3, Chapter 1, Low Impact Development Site Design Credits) shall not be altered
without the prior written approval of the issuing authority.
i) Access for maintenance, repair, and/or replacement of BMWs shall not be withheld. Any fencing constructed around
stormwater BMPs shall include access gates and shall be at least six inches above grade to allow for wildlife passage.
Special Conditions:
SEE ATTACHED.
Page 7 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided byMassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
MTA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
A Findings Under Municipal Wetlands Bylaw or Ordinance
I. Is a municipal wetlands bylaw or ordinance applicable? r Yes r No
2. The Conservation Commission hereby check one that applies
a. C' DENIES the proposed work which cannot be conditioned to
meet the standards set forth in a municipal ordinance or bylaw
specifically:
1. Municipal Ordinance or Bylaw
2. Citation
Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides
measures which are adequate to meet these standards, and a final Order or Conditions is issued. Which are necessary to
comply with a municipal ordinance or bylaw:
b.
F APPROVES the proposed work, subject to the following
additional conditions.
NORTH ANDOVER
1. Municipal Ordinance or Bylaw WETLANDS 2. Citation CHAPTER 178
p y PROTECTION
BYLAW
3. The Commission orders that all work shall be performed in accordance with the following conditions and with the Notice of
Intent referenced above. To the extent that the following conditions modify or differ from the plans, specifications, or other
proposals submitted with the Notice of Intent, the conditions shall control.
The special conditions relating to municipal ordinance or bylaw are as follows:
SEE ATTACHED.
Page 8 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
(` Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
E. Signatures
This Order is valid for three years from the date of issuance, unless otherwise specified Ll
pursuant to General Condition #4. If this is an Amended Order of Conditions, the Amended 1. DatJ of Original Order
Order expires on the same date as the original Order of Conditions. (
Please indicate the number of members who will sign this form. This Order must be signed by
a majority of the Conservation Commission. 2. Number of Signers
The Order must be mailed by certified mail (return receipt requested) or hand delivered to the applicant. A copy also must be mailed
or hand delivered at the same time to the appropriate Department of Environmental Protection Regional Office, if not filing
electronically, and the property owner, if different from applicant.
Date Date
F. Appeals
The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land subject to this Order, or any ten
residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate MassDEP
Regional Office to issue a Superseding Order of Conditions. The request must be made by certified mail or hand delivery to the
Department, with the appropriate filing fee and a completed Request for Departmental Action Fee Transmittal Form, as provided in
310 CMR 10.03(7) within ten business days from the date of issuance of this Order. A copy of the request shall at the same time be
sent by certified mail or hand delivery to the Conservation Commission and to the applicant, if he/she is not the appellant.
Any appellants seeking to appeal the Department's Superseding Order associated with this appeal will be required to demonstrate prior
participation in the review of this project. Previous participation in the permit proceeding means the submission of written information to
the Conservation Commission prior to the close of the public hearing, requesting a Superseding Order, or providing written information
to the Department prior to issuance of a Superseding Order.
The request shall state clearly and concisely the objections to the Order which is being appealed and how the Order does not
contribute to the protection of the interests identified in the Massachusetts Wetlands Protection Act (M.G.L. c. 131, § 40), and is
inconsistent with the wetlands regulations (3 10 CMR 10.00). To the extent that the Order is based on a municipal ordinance or bylaw,
and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction.
Page 9 of 10 * ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection - Wetlands MassDEP File #:242-1591
WPA Form 5 - Order of Conditions eDEP Transaction #:557550
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:NORTH ANDOVER
iL�i
G. Recording Information
This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located,
within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's
Grantor Index under the name of the owner of the land subject to the Order. In the case of registered land, this Order shall also be
noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions. The recording information on
this page shall be submitted to the Conservation Commission listed below.
NORTH ANDOVER
Conservation Commission
Detach on dotted line, have stamped by the Registry of Deeds and submit to the Conservation Commission..
..........................................................................................................................................................................................................
To:
NORTH ANDOVER
Conservation Commission
Please be advised that the Order of Conditions for the Project at:
110 SUTTON STREET
242-1591
Project Location
MassDEP File Number
Has been recorded at the Registry of Deeds of:
County
Book Page
for.
Property Owner ROBERT C. CARBERRY, TRUSTEE
and has been noted in the chain of title of the affected property in:
Book
Page
In accordance with the Order of Conditions issued on:
Date
If recorded land, the instrument number identifying this transaction is:
Instrument Number
If registered land, the document number identifying this transaction is:
Document Number
Signature of Applicant Rev. 4/1/2010
Page 10 of 10 * ELECTRONIC COPY
DEP FILE # 242 -1591
Findings:
• The Applicant proposes to construct a 3,796 s.f. single -story addition at 110 Sutton
Street.
o The proposed construction is outside the jurisdiction of the North Andover
Conservation Commission (NACC).
e The North Andover Planning Board issued a Site Plan Special Permit for the project on
April 2, 2013.
o Stormwater review by Lisa Eggleston of Eggleston Environmental, recommended that
Stormwater Management improvements be made to an area within the jurisdiction of
the NACC.
e On April 27, 2013, the NACC approved waiver requests of Section 2.4, 3.4 and 7.0 of
the North Andover Wetland Protection Bylaw Regulations.
Therefore, the North Andover Conservation Commission (hereafter the "NACC") hereby
finds that the following conditions are necessary, in accordance with the Performance
Standards set forth in the State Regulations, the local ByLaw and Regulations, to protect.
those interests noted above. The NACC orders that all work shall be performed in
accordance with said conditions and with the Notice of Intent referenced below. To the
extent that the following conditions modify or differ from the plans, specifications or other
proposals submitted with the Notice of Intent, the conditions shall control.
GENERAL CONDITIONS
20. The proposed work includes: construction of stormwater management structures
associated with the expansion of a commercial structure located outside of
jurisdictional resource areas. The stormwater management structures are located in
Riverfront Area, Bordering Land Subject to Flooding, and the buffer zone to Bordering
Vegetated Wetland and Inland Bank. An Operation & Maintenance Plan is included as
part of the proposal.
21. The work shall conform to the following (except as noted in the remainder of this
document where revisions may be required):
Property Owner: KLC Realty Trust.
Robert C. Carberry, Trustee
110 Sutton Street
North Andover, Massachusetts 01845
Applicant: Douglas Mund designgroup/ dmdg2
132 King Street
Groveland, MA 01834
242-1591, Sutton Street 110 1 NACC 4/25/2013
DEP FILE # 242 -1591
Notice of Intent/Stormwater
Report filed by:
Scott Cameron
The Neve -Morin Group, Inc.
447 Boston Street
Topsfield, MA 01983
Received: March 23, 2013
Project Report: Prepared by: Neve -Morin Group, Inc.
Titled: Project Report, Drainage Analysis &
Riverfront Area Narrative
Date: March 6, 2013
Site Plans prepared by: DGT Survey Group - North Shore
18 Center Street, Suite 1
Newburyport, MA 01950
Titled: Site Improvement Plan (Sheet 1)
Existing Conditions Plan (Sheet 2)
Detail Sheet (Sheets 3 & 4)
Date: Feb. 15, 2013
Last Revised: 4/4/13
Stamped by: Edward Dixon, PLS
Operation & Maintenance Plan: Date: March 6, 2013 (attached hereto)
Other Record Documents: Stormwater Review Letter
Prepared by: Lisa Eggleston
Eggleston Environmental
Date: March 15, 2013
Letter from NHESP
Date:
22. The term "Applicant" as used in this Order of Conditions shall refer to the owner, any
successor in interest or successor in control of the property referenced in the Notice of
Intent, supporting documents and this Order of Conditions. The NACC shall be
notified in writing within 30 days of all transfers of title of any portion of property that
takes place prior to the issuance of a Certificate of Compliance.
23. The conditions of this decision shall apply to, and be binding upon, the applicant,
owner, its employees and all successors and assigns in interest or control. These
obligations shall be expressed in covenants in all deeds to succeeding owners of
portions of the property.
24. Failure to comply with all conditions stated herein, and with all related statutes and
other regulatory measures, shall be deemed cause to revoke or modify this Order.
242-1591, Sutton Street 110 2 NACC 4/25/2013
DEP FILE # 242 -1591
25. This Order does not grant any property rights or any_ exclusive privileges; it does not
authorize any injury to private property or invasion of property rights. However, the
NACC, agent of the NACC or the Department of Environmental Protection (DEP)
reserves the right to enter and inspect the property at all reasonable times until a
Certificate of Compliance is issued, to evaluate compliance with this Order of
Conditions, the Act (310 CMR 10.00), the North Andover Wetland ByLaw and
Regulations, and may require any information, measurements, photographs,
observations, and/or materials, or may require the submittal of any data or
information deemed necessary by the NACC for that evaluation. Further, work shall
be halted on the site if the NACC, agent or DEP determines that any of the work is not
in compliance with this Order of Conditions. Work shall not resume until the NACC
is satisfied that the work will comply and has so notified the applicant in writing.
26. This Order does not relieve the permittee or any other person of the necessity of
complying with all other applicable federal, state or local statutes, ordinances, by-laws
or regulations.
27. The work authorized hereunder shall be completed within three years from the date of
this order.
28. This Order may be extended by the issuing authority for one but not more than two
periods of up to one year each upon application to the issuing authority at least thirty
days(30) prior to the expiration date of the Order (Refer to Section 8.3 of the North
Andover Wetland Regulations).
29. The NACC reserves the right to amend this Order of Conditions after a legally
advertised public hearing if plans or circumstances are changed or if new conditions
or information so warrant.
30. Where the Department of Environmental Protection (DEP) is requested to make a
determination and to issue a Superseding Order, the Conservation Commission shall
be a party to all agency proceedings and hearings before the Department.
31. Any future project which proposes a wetland crossing in order to access certain
portions of the property will not be qualified as a limited project roadway under 310
CMR 10.53(e).
32. The following wetland resource areas are affected by the proposed work: Riverfront
Area, Bordering Land Subject to Flooding, and Buffer Zone to Bordering Vegetated
Wetland (BVW) and Inland Bank. These resource areas are significant to the interests
of the Act and Town ByLaw as noted above and therein. The applicant has not
attempted to overcome the presumption of significance of these resource areas to the
identified interests.
242-1591, Sutton Street 110 3 NACC 4/25/2013
DEP FILE # 242 -1591
33. The NACC agrees with the applicant's delineation of the wetland resource areas on
the site as shown on the plans dated referenced herein. -
34. The NACC finds that the intensive use of the upland areas and buffer zone proposed
on this site will cause further alteration of the wetland resource areas. In order to
prevent any alteration of wetland resource areas a twenty five foot (25') No -
Disturbance Zone and a fifty foot (50) No -Construction Zone shall be established from
the edge of the adjacent wetland resource area except as shown as shown on the
record plan referenced herein. The Conservation Administrator and/or other agents
of the NACC do not have the authority to waive these setbacks as established under
the local bylaw. No disturbance of existing grade, soils or vegetation is permitted in
the No -Disturbance zone.
35. This document shall be included in all construction contracts, subcontracts, and
specifications dealing with the work proposed and shall supersede any conflicting
contract requirements. The applicant shall assure that all contractors, subcontractors,
and other personnel performing the permitting work are fully aware of the permits
terms and conditions. Thereafter, the contractor will be held jointly liable for any
violation of this Order resulting from failure to comply with its conditions.
36. The owners of the project and their successors in title agree that the Order does not in
itself impose upon the Town any responsibility to maintain the proposed drainage
system and that said Town shall not be liable for any damage in the event of failure.
By acceptance of this Order, the owners agree to indemnify and hold harmless to the
Town and its residents for any damage attributable to alterations undertaken on this
property pursuant to the Order. Issuance of these Conditions does not in any way
imply or certify that the site or downstream areas will not be subject to flooding, storm
damage or any other form of water damage.
PRIOR TO CONSTRUCTION
37. No work shall be undertaken until all administrative appeal periods from this Order
have elapsed or, if such an appeal has been filed, until all proceedings before the
Department or Court have been completed.
38. This Order shall be recorded by the applicant at the Registry of Deeds immediately
after the expiration of all appeal periods. No work shall be undertaken until the Final
Order has been recorded in the Registry of Deeds or the Land Court for the district in
which the land is located, within the chain of title of the affected property. In the case
of recorded land, the Final Order shall also be noted in theRegistry's Grantor Index
under the name of the owner of the land upon which the proposed work is to be done.
In the case of registered land, the Final Order shall also be noted on the Land Court
Certificate of Title of the owner of the land upon which the proposed work is to be
done. The recording information shall be submitted to the North Andover
242-1591, Sutton Street 110 4 NACC 4/25/2013
DEP PILE # 242 -1591
Conservation Commission on the form at the end of this Order prior to
commencement of the work. Any Order not recorded by the applicant before work
commences may be recorded by the NACC at the applicant's expense.
39. A sign shall be displayed at the site not less than two square feet or more than three
square feet in size bearing the words "Massachusetts DEP, File Number 242-1591."
40. Any changes in the submitted plans caused by the applicant, another Board's decision
or resulting from this Order of Conditions must be submitted to the NACC for
approval prior to implementation. If the NACC finds said changes to be significant,
the NACC will call for another public hearing (at the expense of the applicant). Within
21 days of the close of said public hearing the NACC will issue an amended or new
Order of Conditions. Any errors found in the plans or information submitted by the
applicant shall be considered as changes. No work shall begin on a project until
written approval has been granted by the NACC.
41. It is the responsibility of the applicant, owner, and/or successor(s) to ensure that all
conditions of this Order of Conditions are complied with. The project engineer and
contractors are to be provided with a copy of this Order of Conditions and referenced
documents before commencement of construction.
42. Prior to any work commencing on-site, the applicant shall submit to the NACC for
approval, a detailed and dated sequence of construction, including the installation of
sedimentation/ erosion control devices, grading, construction, and final stabilization.
43. Wetland flagging shall be checked prior to start of construction and shall be re-
established where missing. All wetland flagging shall remain visible and enumerated
per the approved plan(s) throughout the life of the project and until a Certificate of
Compliance is issued so that erosion control measures can be properly placed and
wetland impacts can be monitored. The proposed limit of work shall be shall be
clearly marked with erosion controls or temporary fencing and shall be confirmed by
the NACC. Such barriers shall be checked and replaced as necessary and shall be
maintained until all construction is complete. Workers should be informed that no use
of machinery, storage of machinery or materials, stockpiling of soil, or construction
activity is to occur beyond this line at any time.
44. A row of staked hay bales backed by trenched siltation fence shall be placed between
all construction areas and wetlands. The erosion control barrier will be properly
installed and placed as shown on the herein referenced plans. The erosion control shall
- be inspected and approved by the NACC or its agent prior to the start of construction
and shall remain intact until all disturbed areas have been permanently stabilized to
prevent erosion. All erosion prevention and sedimentation protection measures found
necessary during construction shall be implemented at the direction of the NACC or
its agent. The NACC reserves the right to impose additional conditions on portions of
this project to mitigate any impacts which could result from site erosion, or any
242-1591, Sutton Street 110 5 NACC 4/25/2013
DEP FILE # 242 -1591
noticeable degradation of surface water quality discharging from the site. For
example, installation of erosion control measures may be required in areas not shown
on the plan(s) referenced in this Order of Conditions. Should such installation be
required by the NACC, they shall be installed within 48 hours of the Commissions
request.
45. The applicant shall have on hand at the start of any soil disturbance, removal or
stockpiling fifteen (15) hay bales and sufficient stakes for staking these bales (or an
equivalent amount of silt fence,1 hay bale to equal 3 feet of fence). Said bales shall be
used only for the control of emergency erosion problems and shall not be used for the
normal control of erosion.
46. A check payable to the Town of North Andover shall be provided in the amount of
$5,000 which shall be in all respects satisfactory to Town Counsel, Town Treasurer,
and the NACC, and shall be posted with the North Andover Town Treasurer through
the NACC before commencement of work. Said deposit of money shall be
conditioned on the completion of all conditions hereof, shall be signed by a party or
parties satisfactory to the NACC, and Town Counsel, and shall be released after
completion of the project, provided that provisions, satisfactory to the NACC, have
been made for performance of any conditions which are of continuing nature. The
applicant may propose a monetary release schedule keyed to completion of specific
portions of the project for the NACC's review and approval. This condition is issued
under the authority of the local ByLaw.
47. The applicant shall designate a Wetland Scientist (or other environmental professional
as approved by the NACC or its agent) as an "Erosion Control Monitor' to oversee
any emergency placement of controls and regular inspection or replacement -of,
sedimentation control devices. The name and phone number of the erosion control
monitor must be provided to the NACC in the event that this person has to be
contacted, due to an emergency at the site, during any 24-hour period, including
weekends. Proof of the retained monitor must be submitted to the Conservation
Department on letterhead by the retained consulting firm. This person shall be given
the authority to stop construction for erosion control purposes. The Environmental
Professional will immediately notify the Conservation agent of any matter that
requires attention by the Commission or the agent. The erosion control monitor will
be required to inspect all such devices and oversee cleaning and the proper disposal of
waste products. Cleaning shall include removal of any entrapped silt.
48. At least once during each week in which construction activities occurs on-site and for
as long thereafter as ground remains unstabilized, the applicant shall submit a written
report with photos from the "Erosion Control Monitor" to the NACC certifying that,
to the best of his/her knowledge and belief based on a careful site inspection, all work
is being performed in compliance with this Order of Conditions and that approved
setbacks are being adhered to. The erosion control monitor must visually inspect all
sedimentation/ erosion control measures and assume responsibility for their
242-1591, Sutton Street 110 6 NACC 4/25/2013
DEP FILE # 242 -1591
maintenance on a weekly basis and that they are functioning as intended. In addition,
all wetland resource areas must be visually inspected for siltation, turbidity, and/or
other water quality impacts. The Erosion Control Monitor shall be on site during
and/or following a major storm event of 1/2" inch of rain or greater (24 hour event). to
ensure that soils remain stable, and erosion controls are adequate and secure
49. Prior to construction, the applicant shall permanently mark the edge of the "25' No -
Disturbance Zone" to Top of Bank with signs or markers spaced evenly every 30 feet
incorporating the following text: "Protected Wetland Resource Area" and the
associated rules (1 square for every 3 round markers). This will designate their
sensitivity and assure no further inadvertent encroachment into the wetland. These
permanent markers are subject to review and approval by the NACC. The applicant
shall instruct all agents to explain these markers to buyers/lessees/landscapers and all
persons taking over the property from the applicant. These markers shall remain
posted and be replaced as necessary in perpetuity. Markers may be obtained at the
Conservation Department ($2 round/ $3 square).
50. The applicant and/or the legal owner of that portion of land upon which these Orders
of Conditions have been placed shall provide to the NACC prior to transferring, or
assigning any portion of said land to another party, subject to said Orders of
Conditions, the "Compliance Certification Form Affidavit" attached via "Appendix
A" signed under the pains and penalties of perjury, stating that said applicant and/or
owner has read these Orders of Conditions and is in compliance with each and every
condition. This document shall apply to each of the conditions referenced herein and
shall be provided to the Conservation Department at least five (5) business days prior
to the closing of said land transaction.
51. Once these above mentioned pre -construction requirements are complete, the
applicant shall contact the Conservation Office prior to site preparation or
construction and shall arrange an on-site conference with an NACC representative, the
contractor, the engineer/ wetland scientist and the applicant to ensure that all of the
Conditions of this Order are understood. This Order shall be included in all
construction contracts, subcontracts, and specifications dealing with the work
proposed and shall supersede any conflicting contract requirements. The applicant
shall assure. that all contractors, subcontractors and other personnel performing the
permitted work are fully aware of the permit's terms and conditions. Thereafter, the
contractor will be held jointly liable for any violation of this Order of Conditions
resulting from failure to comply with its conditions. The applicant or contractor shall
notify the NACC in writing of the identity of the on-site construction supervisor hired
to coordinate construction and to ensure compliance with this Order. A reasonable
period of time shall be provided as notice of the pre -construction meeting (e.g. 72
hours).
242-1591, Sutton Street 110 7 NACC 4/25/2013
DEP FILE # 242 -1591
52. All construction and post -construction stormwater management shall be conducted in
accordance with supporting documents submitted with the Notice of Intent, the
Department of Environmental Protection Stormwater Management Policy and as
approved by the NACC in this Order of Conditions.
53. There shall be no increase in the post development discharges from the storm drainage
system or any other changes in post development conditions that alter the post
development watershed boundaries as currently depicted in the Notice of Intent and
approved by this Order of Conditions, unless specifically approved in writing by the
Commission.
54. Water quality in down gradient BVW's shall not differ significantly following
completion of the project from the pre -development conditions. There shall be no
sedimentation into wetlands or water bodies from discharge pipes or surface runoff
leaving the site.
55. All stormwater best management practices shall be continually maintained as
specified in the Operation and Maintenance Plan and incorporated in the Order of
Conditions. The approved Operation & Maintenance Plan is fully binding upon the
applicant and/or owners, successors, agents, associations, heirs and assigns and must.
be adhered to in perpetuity. Maintenance of the stormwater management system shall
be conducted on an annual basis by a Registered Professional Civil Engineer.
Maintenance bills submitted by cleaning contractors (catch basins, stormcepters, etc.)
shall be maintained with annual engineering reports. A log/proof of annual
maintenance activities as required by the Operation & Maintenance Plan shall be
maintained for not less than the prior 5 year period. The NACC reserves the right to
request documentation of maintenance activities for purposes of verification of this
Order.
56. Stormwater management structures/swales shall not be used for snow stockpiling.
No-Salt/No-snow Stockpiling Signs shall be placed at the sediment forebays/swales
and shall be maintained in perpetuity.
57. The applicants, owners, and their successors and assignees, shall maintain all culverts,
collections basins, traps, outlet structures, subsurface storage areas, and other
elements of the drainage system, in order to avoid blockages and siltation which
might cause failure of the system and/or detrimental impacts to on-site or off-site
resource areas, and shall maintain the integrity of vegetative cover on the site.
DURING CONSTRUCTION
242-1591, Sutton Street 110 8 NACC 4/25/2013
DEP PILE # 242 -1591
58. Upon beginning work, the applicant shall submit written weekly progress reports
detailing what work has been done in or near resource areas, and what work is
anticipated to be done over the next period. This will update the construction
sequence. Reports shall be submitted in as part of the weekly environmental
monitoring report (see Condition #48).
59. Dewatering activities are not proposed as part of the filing. No discharge of water is
allowed directly into an area subject to jurisdiction of the Wetlands Protection Act
and/or the North Andover Wetland Bylaw. If emergency de -watering requirements
arise, the applicant shall submit a contingency plan to the Commission for approval,
which provides for the pumped water to be contained in a settling basin, to reduce
turbidity prior to discharge into a resource area.
60. Associated pavement and roadways shall be swept at least weekly during
construction or as directed by the Erosion Control monitor, the Site Supervisor, Project
Manager, or Conservation staff for as long as the site remains exposed and un -
stabilized.
61. Any fill used in connection with this project shall be clean fill, containing no trash,
refuse, rubbish or debris, including but not limited to lumber, bricks, plaster, wire,
lath, paper, cardboard-, pipe, tires, ashes, refrigerators, motor vehicles or parts on any
of the foregoing.
62. All exposed soil finish grade surfaces shall be immediately landscaped and stabilized,
or loamed, seeded and mulched, with a layer of mulch hay. All disturbed areas must
be graded, loamed and seeded prior to November 1St of each year. Outside of the
growing season, exposed soil finish grade surfaces shall be stabilized with a layer of
mulch hay until climate conditions allow for seeding. During construction, any area of
exposed soils that will.be left idle for more than 30 days shall be stabilized with a layer
of mulch hay or other means approved by the NACC.
63. No re -grading in the buffer zone shall have a slope steeper than 2:1 (horizontal:
vertical). Slopes of steeper grade shall be rip -rapped to provide permanent
stabilization.
64. There shall be no stockpiling of soil or other materials within fifty.(50) feet of any
resource area.
65. Washings from concrete trucks, or surplus concrete, shall not be -directed to, any
drainage system, or wetland resource area. If truck washing is to be done on site an
area shall be designated and approved by the Conservation Department.
66. All waste generated by, or associated with, the construction activity shall be contained
within the limit of work, and away from any wetland resource area. There shall be no
burying of spent construction materials or disposal of waste on the site by any other
242-1591, Sutton Street 110 9 NACC 4/25/2013
DEP FILE # 242 -1591
means. The applicant shall maintain dumpsters (or other suitable means) at the site
for the storage and removal of such spent construction materials off-site. However, no
trash dumpsters will be allowed within 50' of areas subject to protection under the Act
or local ByLaw. .
67. Accepted engineering and construction standards and procedures shall be followed in
the completion of the project.
68. During and after work on this project, there shall be no discharge or spillage of fuel, or
other pollutants into any wetland resource area. If there is a spill or discharge of any
pollutant during any phase of construction the NACC shall be notified by the
applicant within one (1) business day. No construction vehicles are to be stored within
100 feet of wetland resource areas, and no vehicle refueling, equipment lubrication or
maintenance is to be done within 100 feet of a resource area.
�LAFTER CONSTRUCTION
'U AfANTVK?1_1�
69. No underground storage of fuel oils shall be allowed on any lot within one -hundred
(100) feet of any wetland resource area. This condition shall survive this Order of
Conditions and shall run with the title of the property. This condition is issued under
the authority of the Towns Wetland protection ByLaw.
70. Fertilizers utilized for landscaping and lawn care shall be slow release, low -nitrogen
types (< 5%), and shall not be used within 25 feet of a resource area. Pesticides and
herbicides shall not be used within 100 feet of a wetland resource area. This condition
shall survive this Order of Conditions and shall run with the title of the property. This
condition is issued under the authority of the Towns Wetland Protection ByLaw and
shall remain in perpetuity.
71. There shall be no dumping of leaves, _grass clippings, brush, or other debris into a
wetland resource area or within 25 feet of a wetland resource area. This condition
shall remain in perpetuity.
72. Upon completion of construction and grading, all disturbed areas located outside
resource areas shall be stabilized permanently against erosion. This shall be done by
loaming and seeding according to NRCS standards. Stabilization will be considered
complete once full vegetative cover has been achieved.
73. Upon approved site stabilization by Conservation staff, the erosion controls shall be
removed and properly disposed of and all exposed unvegetated areas shall be seeded.
74. Upon completion of the project the applicant shall submit the following to the
Conservation Commission as part of a request for a Certificate of Compliance:
a. WPA Form 8A - "Request for a Certificate of Compliance."
242-1591, Sutton Street 110 10 NACC 4/25/2013
DEP FILE # 242 -1591
b. A letter from the applicant requesting a Certificate of Compliance.
c. The -name and address of the current landowner.
d. Signed statements from the individual property owners shall be submitted with
the request for a Certificate of Compliance indicating that they read and
understood the recorded Order of Conditions prior to purchasing their property.
e. The name and address of the individual/ trust or corporation to whom the
compliance is to be granted.
f. The street address and assessor's map/ parcel number for the project.
g. The DEP file number.
h. A written statement from a Registered Professional Civil Engineer (and/ or
Registered Professional Land Surveyor) of the Commonwealth certifying that the
work has been conducted as shown on the plan(s) and documents referenced
above, and as conditioned by the Commission.
i. An "As -Built" plan prepared and signed and stamped by a Registered Professional
Civil Engineer (P.E.) (and/or Registered Professional Land Surveyor) of the
Commonwealth, for the public record. This plan will include:
➢ "As -Built" post -development elevations of all drainage & stormwater
management structures constructed within 100 feet of any wetland resource
area. NOTE: If portions of the stormwater systems exist partially within the
Buffer Zone than the entire structure must be depicted to accurately verify
compliance.
➢ "As -Built" post -development elevations and grades of all filled or altered
wetland resource areas including the encompassing buffer zone which is
regulated as a resource area under the local Wetland Protection Bylaw.
➢ Distances from structures to wetland resource areas. Structures include (but
are not limited to) septic systems, additions, fences, sheds, stone walls,
pools, retaining walls, subsurface utilities and decks.
➢ A line showing the limit of work and the extent of existing erosion control ;
devices. "Work" includes as disturbance of soils or vegetation.
➢ Location -of all subsurface utilities entering the property. ;
75. The following special conditions shall survive the issuance of a Certificate. of
Compliance (COC) for this project:
➢ 25' No -Disturbance Zone and a 50' No -Construction Zone shall be .
established from the edge of adjacent wetland resource areas except in those
locations approved under DEP # 242-1591.. Future work within 100' of
existing wetland resource areas will require a separate filing with the. NACC
(refer to Section 3.4 of the Regulations for performance standards within
these zones) The Conservation Administrator and/or other agents of. the
242-1591, Sutton Street 110 11 NACC 4/25/2013
DEI' FILE # 242 -1591
NACC do not have the authority to waive these setbacks as established
under the local ByLaw;
➢ Resource Area Markers (Condition #49);
➢ Stormwater Management System Operations and Maintenance (Condition
#55);
➢ No Snow -Stockpiling/ No -Salt signage (Condition #56);
➢ Discharge or spillage of pollutants (Condition #68);
➢ Prohibition of underground fuels (Condition #69);
➢ Limitations on the use of fertilizers, herbicides, and pesticides (Conditions
#70)
➢ Prohibition of dumping of leaves, grass clippings, brush, or other debris
(Condition #71);
➢ The attached "Operations and Management Plan", including Best
Management Practices. No additional filings will be required to conduct
maintenance of the above referenced system and plan.
242-1591, Sutton Street 110 • 12 NACC 4/25/2013
A
DEP FILE # 242 -1591
APPENDIX A - AFFIDAVIT
I, on oath do hereby depose and state:
(authorized agent applicant and/or current owner)
(PLEASE CHECK AT LEAST ONE BLOCK)
1. I am the . of
( position with applicant) (applicant name or company name)
the applicant upon whom Order of Conditions
have been placed upon by (DEP or NACC number)
the North Andover Conservation Commission.
&/or
2. I am the of
(position with owner) (owner name)
the owner upon whose land Order of Conditions
have been placed up by (DEP or NACC number)
the North Andover Conservation Commission.
3. 1 hereby affirm and acknowledge that I have received said Order of Conditions
and have read the same and understand each
(DEP File #) and every condition which has been set forth
in said Order of Conditions.
&
4. I hereby affirm and acknowledge that on this day of 19
I inspected said property together with any and all improvements which have
been made to the same and hereby certify that each and every condition set
forth in Order of Conditions are presently in compliance.
(DEP File #)
&
5. 1 hereby affirm and acknowledge that this document will be relied upon by the
North Andover Conservation Commission as well as any potential buyers of
said property which is subject to said Order of Conditions
(DEP File #)
Signed under the pains and penalties of perjury this day of 19
242-1591, Sutton Street 110
(Signature - authorized agent of applicant or owner)
13
NACC 4/25/2013
b Page 21
OPERATION & MAINTENANCE PLAN FOR
110 Sutton Street
North Andover, MA
March 6, 2013
The success of the stormwater management plan depends on the proper implementation, operation,
and maintenance of several management components. The following procedures shall be
implemented to ensure success of the Stormwater Management plan:
1. The contractor shall comply to the details of construction of the site as shown on the plans.
2. The sediment forebays, level spreaders, outlet protection and check dams shall be inspected
and maintained as required in Table 1.
3. Effective erosion control measures during and after construction shall be maintained until a
stable turf is established on all altered areas.
THE MAINTENANCE PLAN
During Construction:
The Contractor constructing the site and drainage system shall be responsible for maintaining the
stormwater system during construction
Routine maintenance of all items shall be performed in order to ensure adequate runoff and
pollution control during construction.
Once construction is complete, the property owner, KLC Realty Trust, Robert C. Carberry
Trustee, shall assume responsibility to operate and maintain the stormwater management
components. The owner shall be responsible for all maintenance activities needed following the
construction. The maintenance schedule shown in Table 1 shall be done in perpetuity.
- Inspections of the sediment forebay, level spreader, outlet protection and check dams as
required in Table 1.
- Cleaning and repair of sediment forebay, level spreader, outlet protection and check dams as
required in Table 1.
Monitoring the erosion control systems until establishment of natural vegetation.
Q
Page 22
Construction Period Pollution Prevention and Erosion and
Sedimentation Control Plan
® A continuous line of erosion control shall be installed in accordance with the
approved plans prior to the commencement of any work on the site. The erosion
controls shall be inspected on a weekly basis and replaced as needed.
® All Disturbed Areas Shall Be Stabilized During And After Construction. During
Construction Temporary Measures, Including But Not Limited Too, Seeding And
Mulching Shall Be Implemented As Needed. All Disturbed Slopes Shall Be
Stabilized With Permanent Vegetative Cover Or Rip -Rap.
Long -Term Pollution Prevention Plan (Also See Operation &
Maintenance Plan)
Street Sweeping:
® Street sweeping shall occur at least twice per year in April and October. The
April sweeping is of note as this is the time of year when sand left from the
winter's snow and ice removal operations is at its peak accumulation. Sweeping
shall be conducted by a high efficiency vacuum sweeper. Current rates for street
sweeping can vary from $25-$100 depending on site specific conditions.
Sediment Forebay and Outlet Protection:
® The sediment forebay and outlet protection shall be inspected twice per year in
April and October. Any significant debris accumulation shall be removed and
disposed of properly. Vegetation shall be controlled by grubbing at least once
annually to prevent woody growth. Dislodged stones or eroded areas shall be
repaired and stabilized immediately as discovered. Inspections and cleaning can
be incorporated into regular landscape schedules and costs for the property. Total
maintenance costs should not exceed $500 per year.
Level Spreader:
® The level spreader shall be inspected twice per year in April and October. Any
significant debris accumulation shall be removed and disposed of properly.
Vegetation shall be controlled by grubbing or mowing at least once annually to
prevent woody growth. If the curb becomes uneven or disturbed in a manner that
flow is no longer being evenly distributed and a concentrated discharge causes
erosion, then the curb shall be repaired to fix this condition. Inspections and
cleaning can be incorporated into regular landscape schedules and costs for the
property. Total maintenance costs should not exceed $500 per year.
Page 23
Debris & Litter:
® All debris and litter shall be removed from the parking area as necessary to
prevent migration into the drainage system.
Prevention Of Illicit Discharges:
® Illicit Discharges To The Stormwater Management System Is Not Allowed. Illicit
Discharges Are Discharges That Are Not Comprised Entirely Of Stormwater.
Pursuant To Mass. DEP Stormwater Standards The Following Activities Or
Facilities Are Not Considered Illicit Discharges: 'Firefighting, water line flushing,
landscape irrigation, uncontaminated groundwater, potable water sources,
foundation drains, air conditioning condensation, footing drains, individual
resident car washing, flows from riparian habitats and wetlands, dechlorinated
water from swimming pools, water used for street washing and water used to
clean residential building without detergents.
o 'To Prevent Illicit Discharges To The Stormwater Management System The
Following Policies Should Be Implemented:
1. Provisions For Storing Materials And Waste Products Inside Or Under
Cover
2. Vehicle Maintenance And Washing Controls
3. Requirements For Routine Inspections Of The Stormwater; Management
System
4. Spill Prevention And Response Plans