The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 137 BERKELEY ROAD 4/30/2018 (2) 137BERKELEY----�.�ROAD� -10/047.C-0059-000.0 '1 < pORr , TOWN OF NORTH ANDOVER F p Y PERMIT FOR WIRING S74 US This certifies that ........... �44�..... ......GT..... ................................ ; lzs permission to perform ... f1 .. c4( ......................... wiring in the building of................. f� .............................................. at.....�. .. ......... %North Andover Mass. c�Q nn t ... Lic.No..?....,/.�� }............... . ...)I rI� f . ELECTRICAL INSPECTOR V �J- Check # r 9216 y ��' ,.per i • i �\ CorntnoMalth of Massachusetts Official Use Only Department of Fire Services Permit No. 2 f� BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (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 (PEEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER �Wires-..- :I O ntion to,perform the electrical work described below. By this application the undersigned gives notice of his or her inteTo the Inspector of Location(Street&Number) /3 /�,i Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boz) Purpose of Building_ �,h l, jf�, Utility Authorization No. v� Existing Service Amps / Volts Overhead ❑ Und rd g ❑ ' No.of Meters New Service Amps ! Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: jMP��acto I y T Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool AboveF-1ln- o.o mergency ig g crrnel r—A Battery Units --, No.of Receptacle Outlets No.of Oil Burners FIR_ ALARMS No of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat PSP Number_ Tons KW _ No.of Self-Contained To Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW SecuritySystems: No.of Water No.ofo. No.of Devices or Equivalent A Heaters KW Si s Ball of Data Wiring; oasts. No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: No.of Devices or E uivalent OTHER: !hddi V�, Attation detail if desire , r as required by the Inspect f Wires. Estimated Value of Electrical Work: (When require by municipal poIicy.) Work to StartInspections 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 coveXe is in force,and has exhibited proof of a to th permit issuing o ce CHECK ONE: INSURANCE r BOND ❑ OTHER [3 (Specify:) I l Z ?j 2,01 G I certify,under the pain d penalties of perjury,that he in ormation o t� application ' FIRM NAME: ® Z.IC t✓T fC C pp 4s true and complete -- LIC.NO/-4-M3 Licensee: c) N c 104 Signature (If applicable,enter"exempt"' t e lice7e number line.) LIC.NO.: Address: l f� Bus.Tel.No.:izlff Tel.No *Per M.G.L c. 147,s.57-61,security work req es Depm artent of Public Safety"S"License: Alt' L c.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 El owner's agent Owner/Agent Signature Telephone No. P ERMIT FEE.$ � ti.j �� ^e+�:Y r .:� �. ._ �• , ' i5 �. ,� � , ` i � i h C� d !, w, .. r. 1 " J 1 + I Alf Location No. 0 36 Date d NORTH TOWN OF NORTH ANDOVER 3? OL ► y ' Certificate of Occupancy $ s CMM E<�' Building/Frame Permit Fee $ sRUs Foundation Permit Fee $ Other Permit Fee $ gra TOTAL $ fl Check # 1746 - Building,Inspector 77-01-2004 10:34am From-OPENWAVE T81 1.64 6642 T-13C P.003/003 F-384 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT ACE6NCATIGN TO COIVMUCT REPA1 R>EXOVATE, OR PEMOUSH A ONE0R TWO FAM L Y DWEL Twsw uTiLDINO PERWT NUNMER: O 7 DATE ISSUED: 0 7-4 SIGNTATIJ ; ' Building Ccimmissioner/in for of Buildings 1 z SECTION 1-SITE INFORMATION0 ]-1 P MMY Address; 1.2 ! Map and parml lJum6er: N o,r �� l7)A t'�I g X15 Map Number Parcel Numbn 1.3 Zoriaglnfattmatim' l.A ihapaty DinlMsims: O . ZoninZonin MLrict Pr sed Use Lac Arw F —'1I) 1.6 131JUDING SETBACKS ft Front Yard Side Yard Rear Yard Required PM;T RegAred Provided ed Provided 1.7 Planar Supoly M,GZ.CAo. Sa) 1.5. Flood Wie mlbmsrdoo: 1,A s—.RP Di*0"l syrt m: i2aoe Oueida Flood 7A UT G Muaicip•i 7 on Sipta Mul,System :1 Public 0 nr{s,.e D I Yes llz� SECTION 2-PROPERTY OWNPERSHEPIAUTHORIZED AGENT - M 2.I wner of Record ne(Print) Addresg fvr 9erviea Y�I10 ' M • f(off Signature Telephone 2.2 Qwnor of Rccard: x Q Name Print Address for Serviec: 'g 1 M Si nature Tele hone �Q SECTION 3-CONSTRUCTION SERVIC S 3,1 Liumscd Construction Superviwor. Not Applicable C L ccnsed Consinicuon Supervisor. Lica0 �11 Go�.,�ll ! a l�e+i� '►ti W1� necNumtter S > Expiration Date r ignaturo TcJophone r 3.2 Registrtcd Hama Improvement Contractor Not Applicable 0 v Co i6ny NOM e Regishs ion Number r r65b Expiration Datc Si atura Tel nes i SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 6 2Scm workers Campensatinn Insurance nfdavit must the completed and submitted with this appliedon. Failure to provedc this affidavit will rosult in the denial of the issuance afthe buildin mit. 5i ncd affidavitAttaohcd Yes.......0 No.,..1...0 SECTIONS Description of Pru osed Wolk check au. ticable New Construction 0 Existing Building ❑ Repair(s) 0 Altcm iona(s) 0 Addition 0 1 Accessory Bldg. 71 Ex-molition ❑ Other ❑ Specify Briet sorption of Proposed Work SECTION 6-ESTIMATED CONSTRUCTION COSTS Itnn Estimated Cost(Dollar)to be OFFICIAL USE ONLY Can lcted b•pairut applicant 1. Building � (a) Building Permit Fee w+l Multi lien 2 Electrical (b) Estimated Total Cost of CfODD Construction 3 Plumbing Building Permit fee Iq x(b) 4 Ivkchmcal(.HVAC) s Fire Procxrion 6 Total 1+2+3+4+5 Cheek Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WE LN, OWNER `AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. as OwnerlA"14 . I I - uthoraal Agent of subject property \ rlereW a%h e t b'14 �L'}� N to acl on qty h h 1, in 1J�i;isiclatim to�Nurk atrtltorived by this building permit application. Signaturc of r Date SECTION 71) OWNER/AUTHORIZBD AGFNT DECLARATION I, x Owner/Authorized Agent of subject PmP�Y Hcrcby declare that the,statements and information on the forgoing application arc true and accutd0:.to Lie best of my knowledge and belief Print Nuns Si attire of Owner/A gent Da:e NO-OF STORIES SIZE BASEMENT OR SLAB SITE OF FLOOR TlivQERS l 2 No3 SPAN DlgffNSIONS 014 SILLS DN ENSiONS OF P0815 DD,T-NSIONS OF GIRDERS HEIGHT OF FOUNDA110N THICKNESS SVE OF FOOTING X MATERIAL OF CHMNEY I5 BUII.DNO ON SOLD)OR FILLED LAND IS BUILDNG C ONNE=D TO NATURAL GAS LINE H."I 100/100 d Oi -1 iVS9 V9b IL 3ndlN3dt7-Woad WeV9:Ot voa2-ia-i( FORM U - LOT RELEASE FORM Ff,64- /g,y/I/ J_6 x a o ? 1712-1 o INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fro Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or,requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** / APPLICANT /o 9,0110 /fit4PHONE ( LOCATION: Assessor's Map Number J PARCEL SUBDIVISION LOT (S) STREET - 136t44La. "' ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** CO ENDAT N O� W AGENTS: � i ERVATIOIN ADMINIST TOR DATE APPROVED DATE REJECTED , COMMENTS TOWN PLANNER DATE APPROVED" DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 07-01-2004 10:54am Frcm-OPENNAVE T 964 $542 7-19C P 002/003 F-364 MORTGAGE INSPECTION PLAN 137 BERKELEY ROAD .NO, ANDOVER , MASS. SCALE: I"N 40' MAY 25 , 1999 WILLIAM G. MY REGISTERED 4AND S(IRV£r0R 30 CAPTAIN CR. -TEWKSBURY, MASS, '\ t� to". " , i. 20,250 S. F. r o co EXISTING DWELLING M I I • o 100,00, '_ BERKELEY . ROAD -- I HEREBY CERTIFY TO THE TITLE INSUR OR AND TO THE BANK THAT a ASA THE DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES �b �►LjHOFAjj,� CONFORM WITH THE TOWN OF NO. ANDOVER ZONING REGULATIONS REGARDING SETBACKS FROM STREETS AND LOT LINES. %"� WILLIAM 1 FURTHER CERTIFY THAT THIS DWELLING 13NCT � OCATED IN THE ( "� u n FEDERAL FLOOD HAZARD AREA/A$, SHOWN Op YAP DATED JUN. 15 1989 TREY G J/ 250096 , \ 'No 13947 s REGISTERED LAND SUR EYOR �(A�a551CfaP+C �`�Si1RVE�3'flA THIS' PLAN FOR MORTGAGE PURPOSES-NOT FOR BOUNDARY DETERMINATION. >mrjTyy { BOUNDARY INFORMATION TAKEN FROM•N.E.R D, PLAN 10247 ron & donna arrbo deck north andover ma. /lo XZo /,-2e cc . 0 zo f Z4 1� 0 zo y�y 4'-0 3/16" 20'-0" Iii ,—___--� •t. c..a n qfy (ra'✓' i� l( r!d•�a/w ' �(1 +�,(pcY SLC Y8 The Commonwealth of Massachusetts u h Department of Industrial Accidents l Office of Investigations W� Boston, Mass. 02111 Workers`Compensation Insurance Affidavit Name Please Print Name: t;,/-L l JL4— C6 � Location City (r,' w�4 � rr . Phone 2 "5- I 5-I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers'compensation for my employees working on this job. Company name: Address City Phone#: Insurance.Co. Policv# Company name: Address City Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as wellas civil.penalties in the form da_STOP WORK ORDER_and.a fine of.(.$100.D0)_a rtay against-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. / Lq v Signature C�� Date Print name C sw-,1...- Phone# �'� 7l 5 Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required E] Licensing Board r-1 Selectman's Office Contact person: Phone#: F, Health Department Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Lu.,w w (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 06-30-2004 06:30pm From-OPENWAVE M 664 6642 T-146 P.001/002 F-W YUN Zo 04 or,too rM WILLIAM COMRTOri rE03 O'Do 7255 BILL CONI ATON BUILDING& REMODELING,LLC 121 LOWFLI, ROAD WINDHAM,N-H. 03087 TEL: (603) 898-7155 P170P OSAL Rojo &Donna Arbo 137 Berkley hoed North Andover,MA 978-6$8-5466 NOTICE: All home improvement contractors and subconirwtors engayW in home improvement, unless speoilleally exempt front r*siv-ation by provisions of Chaptcr 142A of the General Law9,me be registered with the Commonwealth of Ma3sachusetts, ?hank you for allowing:Is to quote your prgjerL We propose to ltirialsh all material and perforru all labor necessary to complete the following; Project Description: 20X16 Beck 1. Dismantle and Re hove vAlsting deck 2, Install concrete r-dled tubes 3. Frame deck all pressure treated lumber 4t. SM X 6 X 20'%sithor Best Coraposltc Decking(color redwood) S. Weather Best white rafts 6. 00 set of stairs 7. Patch hole in wail from old AIG unit S. Clena up and haul debris ole the This proposal does not Include any Hidden damages that are oneavow over rlre cnnrse Of the job and additional work required by local building inspectors. PRICE: HILI Conston Building and Remodeling,LL.C.agrees to du all wont►deserrbed above for the total price of S"8,btA,ao Payments to be made as follows: Deposit or$2.666.00 Received 0818-zDW Maw From-Sai ma T156 Ta-OPENVIAVE Pace o01 06-30-2004 05:30pm From-OPEN'NAVE 781 664 6642 7-i48 P.002/002 F-22V 4 JUH 3Ei B$ @G:E+I Pri WILLIAM COHATON GG3 090 7155 P. (32 2�payment of 52,667.00 whom silo woA.Is completed mid Woes Poured 0 payment of$2,667.00 when docking sad railing are.cam plered Balance of 5620.00 substsnti caro of a dwork Cootractoes Signature" Date: Acceltitaiice of Proposal The above prier, specifications,and conditions ars satisfactory and are hereby accepted. Bill Connon Buildiag&Remodeling,LLC is authorized to do the work as specified. Paymont will be made me stated above, DO NOT SIGN THIS CTffTIiERE ARE ANY VIANK SpA awaer's Signat ; Date urC Qwiiar's Rights and Benefits; The owner may havo 3-day cancellation tights under une yr mora of Mass. 0e11.Uw Chaoptcr 97, Section 48;Chap. 140D, Section 10;Chapter 233D, Section 14. The owner is ertitlad to certain rights nd beneliis udder Mass.tion,Law Chip. 142A 8a0e1vod 06-80.2704 06,0Eam From-608 368 T166 To-3p RAVE Papa 232 NORT#q Town of _ Andover d3Y - =a dower, Mass., '7-/� - a0 LAKEo COCMICHEWICK TED PP I S U BOARD OF HEALTH PERMIT T D - Food/Kitchen Septic System !� BUILDING INSPECTOR THIS CERTIFIES THAT......LCONa/a(.�F...7�b +AP /4 R�Q ........ Foundation has permission to erect.��f b�;.*........ buildings on ....�.�t.�...... ..... .. y ... ............:.... Rough 1 .. g to be occupied as... *44 Y C6 k � � � Chimney . • provided that the person accepting is permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. W r)/ CO �D PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT 19N T TS Rough ...... ........ . service ........ UILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building - - GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burnet Street No. �� SEE REVERSE SIDE smoke Det. NORTH Town of Andover . N No. W over., Mass., g—3'o?dy`� -- r L.'A WICK OOATED C =a-a:m BOARD OF HEALTH Food -tchen Septic Sy PERMIT T Septic Sy m THIS CERTIFIES THAT........... ....... ........... BUIII)ING INSPECTOR F datio 40 our' has permission to erect......IS. .................. bu- logs on ..... .... —7......aq�o!�....... ....i-el..... ........ ...... Rough to be occupied as.... U t6^e a cl Pacb CQ I i &P re a r-- Chi ey provided that the personaccepting'th 1"in 'con 'rmto*thetermsof 'e*ap*p'1`ication*`o*n''111 Chi this office, and to the provisions of the odes an BV-Laws relating to th I spection, Aftera i and Construction Buildings in the T wn of North Andove y S- 91 PLUMBING INSPECTOR VIOLATION of the ning or Building Reg ations olds this Permit. Rough PE E S IN 6 ONTHS Final UNLESS ON UCTI STARTS ELECTRICAL INSPECTOR Rough .......... ...... .... ...... .... ......... Service BUILDING INSPECTOR Final Oc ancy P it Required to Occupy Building GAS INSPECTOR Rough Display in a w Cons) ous Place on the Premises — Do Not Remove I Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE1 Smoke Det. GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation ,Footing,Foundation, Frame, Insulation,Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing,heat,elec,etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girts-solid brick or steel plate bearing at foundations '/7"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min.22x30 w/3'headroom above). Crawl space access.(min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. %of required glazing shall be openable. Bedrooms required min.20x24 egress window or door. Vent attic spaces-"proper vent",soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging,clean joints,8"solid @ combust.Surf. DECKS: Separate permit required: Lag to house,provide flashing. Rails min. 36'high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc.pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupying structure. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: L 07 -3 C SIGNATURE: Buildin Commissio r/I for of BuildingsDate SECTION 1-SITE INFORMATION z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O 67 I' �� )LQam/ll�e ' �p U� �� 1 Map Number DarceM�lurnb /v .`.3SESSORS CTX 1.3 Zoning Information: 1.4 Property D'm Ifff OSS ...all tltli { °-7RM1T RIEND�MO 11Zonis DisYrid Proposed Use Lot Areas I - Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard- Required ardRe red Provide Required Provided R red I Provided 1.7 Water Suppty M.G.L.C.40. 54) 1.5. Flood Zone Infomutioo: 1.8 Sewerage Disposal System: - Public 0 Private 0 1 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT l ,2.11 Owner of' Record X !V 'Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O z .Signature Telephone M SECTION 3 CONSTRUCTION SERVICES QD 3.1 Licensed Construction Supervisor. No[ Applicable 0 Licensed Construction Supervisor O License Number lddress Expiration Date tgnature Telephone Fianna .2 Registered Home Improvement Contractor Not Applicable p v ompany Name Registration Number T r. Idress r Expiration Date ^� nature Telephone L, A 116 SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes....:..0 No.......0 SECTION 5 Description of Proposed Work(check all a licable New Construction ❑ Existing Building 0 Repair(s) ' ❑ Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: T �h S ► I�t Iruy1� G�yy c ro�n.� o uo 1 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be w Completed b permit applicant E s x 1. Buildings,-� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee(a)x(b) �!_ 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> r+ as Owner/Authorized Agent of subject property Hreby authorize to act on My behalf;in'1},ir(attu►relative tR w rp k authorized by this building permit application. Signature of Owmer Date SECTION 7b OWNERJAUTHORIZED AGENT DECLARATION I. ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE a NORTH 0 of , T O - LA E lover, Mass., COCKICMEWICK �qs RATED 4 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...................mIJ.IY. ......... ..r. .0............ .... Foundation has permission to erect......I buildings on.....�..� ! �c� KZ � �`f ��.`.'�.... Rough e.. . ................................... ........... to be occupied as R• u OV Ge /`� d t G r"O o~C1 P%*I 1 ws re J r --nn Chimney ............................................ ....... �C provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Daws relating to the I spection, Alteration and Construction of Buildings in the Town of North Andover. y �/u�,— g AI ..._ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTELECTRICAL INSPECTOR Rough STARTS � Rough ;� V`... C... . .. Service BUILDING INSPECTOR -Final -Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building. Inspector. Burner Street No. SEE REVERSE S 1 D E Smoke Det. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1 hIS.So .fai'Off[Ct>}t tI§C`�til BUILDING PERMIT NUMBER: /'ZV-17 DATE ISSUED: SIGNATURE: Building Commissio' r/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property.Address 1.2 Assessors Map and Parcel Number: O 4 L J ttr �A �V i� �'I Map Number Parcel Number ( 1.3 Zoning Information: 1.4 Property Dimensions: Zonis g District Proposed Use Lot Area(so Frontage(fl) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqwred Provided Requi red Provided 1.7 Water Sapply M.QL.C.dO. 34) 1.5. Fl Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private 0 - Zone .Outside Flood Zone 0 Municipal 0 On Site Disposal System SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record If ...-;.•° j V Q Name(Print) Address fog Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Address Expiration Date signature Telephone i.2 Registered Home Improvement Contractor Not Applicable ❑ v I ;ompany Name m Registration Number r Adress Expiration Date ^z gnature Telephone 1� SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ' ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �hs ► I �wh hvv7c w'fX l o SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cast(Dollar)to be ONI:Y, Completed by PCtrait a licant „a a ., z t = µ 1. Building (a) Building Permit Fee s Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee ta)x(t) 4 Mechanical HVAC `T 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, n o as Owner/Authorized Agent of subject property Hreby authorize to act on My behalf,in' matters relative tQ work authorized by this building pennit application (� �A Si nature of Owner Date ' SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ], as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name 7DDENSIONS e of Owner/A ent Date WA STORIES SIZE ENT OR SLAB FLOOR TIMBERS 1 2 3 IONS OF SILLS OF POSTS IONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFUNMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I Pb S FORM - U - LOT RELEASE FORM INSTRUCTIONS: .This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT )) ( j�� HONE -c��' S (A(, ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION SLOT NUMBER TREET �t(ICP I e jj d J 1 STREET NUMBER 3� l.....0..........NNON....E.■ ..OXEN.. ................................ OFFICIAL USE ONLY RECOWdENDATIONS OF TOWN AGENTS G DATE APPROVED '7�2 O y \ CONSERVATION ADMM7ATOR DATE REJECTED CONBAENTS DATE APPROVED TOWN PLANNER DATE REJECTED COMIVIbNTS DATE APPROVED FOOD INSPECTOR-IMALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMNIENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE i 78' 664 6642 T- K P MAO! F-e84 A04 10:64an Prcm-OPENWAVE MORTGAGE INSPECTION PLAN 137 BERKELEY ROAD' NO. ANDOVER , MASS- SCALE: Im z 40' N AY 25 1 1999 WILLIAM G. TROY REG/SrBREO LAND 5l)RV45rOR 30 CAPTAIN CR. -TEWKSBURY, MASS. nor as , 20,250 S. F. 0 rn 18` N EXISTING OW ELLIN G i 1 M ,Y +^� 100.00 BERKELEY - ROAD I, I HEREBY CERTIFY TO THE TITLE INSUROR AND TO THE BANK THAT ►��NOF/ ES THE DWELLING IS LOCATED ON THE LOT AS SHO WN AND THaEQULATOIONS� CONFORM WITH THE► TOWN OF NO• aNDOvER ZONIN v/a/ WILLiAl, REGARDING SETBACK5 FROM STREETS AND LOT LINES,OCATED IN THE fj I r° 1 FURTHER CERTIFY THAT THIS DW ELLiNe l3 NOT 4• ��- ;g 198 . ' RbY FEDERAL FLOOD HAZARD AR�rA SHOWN Op MAP DATED ZSQ098 ,� '`c REGISTERED LAND SUR EYOR m a�'pS�R�t� TMIS� PLAN FOR MORTOASE PURPOSES—NOT FOR BOUNDARY DETERMINATIOM. �� »♦ w BOUNDARY INFORMATION TAKEN FROMtN.E.R.D. PLAN ,0247 i t%ORTFi 0VM Of Andover No. 0 over, Mass., 8-3—cpogo COCHIC MF WICK C2 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.........;Dcp IV-N..4THIS INSPECTOR ....... .... Foundation ........................ has permission to erect......1.8........................ buildings on ...../.L Rough to be occupied as..... R o m C1 P%*I I &P r- C Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and Byl.1aws relating to the I spection, Alteration and Construction of Buildings in the Town of North Andover. y 01,6- gr PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .........1.14. ........... Service BUILDING INSPECTOR Final OCCUParV-y Permit Required to oCaVy Building GAS INSPECTOR Display in a Conspicuous Place on the Promises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE __Jj Smoke Det. Date.. � .�.°.`'.. .. ... .. f- NOFT/y Af✓ - pf 32 °' TOWN F NORTH ANDOVER O 9 ' PERMIT FOR GAS' NSITALLATION 9SSACMUSE, \ff/ This certifies that . . . ... . . 1 . c has permission for gas installation . . . . l o!�'.S. . . . . . . . . . . . . . . in the buildings of . . . . .A.!' A .&. . . . . . . I . . . . . . . . . . . . . .. . . . . . at . . .,� .�. . . �l�h. `. :/. . . . . . . . . . . . . .. North Andover, Mass. Fee. .3.v... . Lic. No... /. .`.. . . . �t!.^-�,-�.L.. . . . .. . . . GAS INSPECTOR Check# 6872 `` W` i 4 MASSACHUSETTS UNIFORM APPLICATION FOR PERK r TO DO GAS (Type or print) fffTNG NORTH ANDOVER,MASSACHUSETTS Date_ R Building Locations 1 " Pennrt# . -7 t- Owner's Name Amount$ New❑ Renovation E Replacement ❑ Plans Submitted. ❑ �'�'�"' � a w W) jW Z , W O Uco WW Q Z L 2a J y p w F W 4 p z y W SU 6 -BASEM ENT I A S E M ENT u' a C a p tST. FLOOR 2N D. FLOOR 3RD . FLOOR 4TH. FLOOR TH . FLOOR 6TH . FLOOR 7TH , FLOOR. 8TH. FLOOR (Print or type) Name Qneck one: Certificate In lin ,Co ,any Address °rp usmess a ep one + ❑ Partner. f�47� cs7 Name ofLicensed Plumber or Gas Fitter E... Firm/Co. INSURANCE COVERAGE 1 have a current liability insurance policy or it's substantial equivalent Check one: If You have checked yes,please indicate the type coverage by checking the apYespropriate ❑ Liability insurance policy app priate bo No �� Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver 1 am aware that the licensee does n_ o�$_e the Insurance coverage Mass. General Laws,and that my signature on this.permit application waives this requirement. required by Chapter 142 of the Signature of Owner or Owner's Agent Check one: r hereby certify that all of the details and information 1 have submitted(or entered)Owner in 0 a Agent 0 best of my knowledge and that all plumbing work and installations PPlion are true and accurate to the compliance with all pertinent provisions of the Massachus Perf°rmed under Permit Issued for this application will in C r.l4 neral ws. 8y Signature of Licensed Plumber Or Gas Fitter Title umber City/Town ❑ Gas Fitter � License cumber �_ aster APPROVED(OFFICE USE ONLY) Journeyman +> _ QJ Maszchmseiis � De art f Industr'! .� `/,� P ►Hent o 1OI Accalents. to �,f��ce of Ircvesfi;afions 600 wash Street L'ns�°at MA 02111 11�7orkers, Compensation Insurance Affidavit: A cant Information guiders/Contractors/Electrictsns/plumbers I Name (business/Organization/individual): Please Print LeaibIv Address: City/State/Zits: /7 �'/1�`'� �► �V Are you an employer?Check the appropriate box: 1.❑ I an a employer with em to e- 4 ❑ I am a gerrer�l contractor and f . Type of project(required): p Y s(full aetor part-time)." have hired the sub-contractor; -6•. New c, ?.❑ I am a so}e proprietor ar partner- IistEd construction ship and have no empioyees These M t e attached sheet t 7• �-'R odeling. working for me in any capacity work contractors have 8, [] DemoIition [No work='comp. insurance 5..❑ We area comp. Insurance.. 9. required.] a corporation and its ❑ bui}ding atidifion 3.❑ I an a homeowner doing all work ng t a have exercised.their I U:[j Electrical repairs or additions myself.[No.workers'comp. c. 152 .-xcm bion S 1 4 and e MGL I 1 []Plumbing repairs oraddirions insurance required.] t ( �, have no 'Mploye:es, [No workers' 12'r�� Roof repairs "Ani!atppiieantIharchecksbax#I.muss!sofifl out the set tion beluwnhoirt5ttrattceregthred] 13-[Other 'ilomeownets who submit.titis agdeatt indieariatg tka ung th.-ir workers'Camp= 1Conua;tots than check:this bax.mvst �'era`airy uc_ra;W. , Pensation Polley information, attaci:ed an additional sheet showire2 the Even hir outside eanu aciurs naaast s ' name of the s unmii n new atndavir indi.;.bng-.::Ch. • I atn an_"attpl0}>er that is providine wort: 'Como ns cor.�actots and their workers'-comp,poI icy,iniomastioa. 4jormatiort �s�c ce or f ny employe_s Below,is the pow,�job site r Insurance Company Name: Policy#ar Self-.ins. Job-Srt~Address: Expiration L?atc: Attach a copy of the workers' compensation tic d cla Crty/3tatr/Zip. policy ration a Failure to secure coverage as required under Section 25A of Race(Showing the policy Dumber and expirarion date) fine up to S11500.00 andlor one-year im sonme MGL c. 152 can lid to the of up to.5250.00 a day against the vio}ator. Be ad s that a co ofimposition a R tion W criminal penalties of a as civil penalties in the form of a STOP WORK ORDER Investigations of.the DIA for insurance coverage v_sed t tion. PY of this statement May, RDER and a fine be forwarded to the'Office of I do hereby certifj,ander the palmi andpenaw W oJ'per�a�,that the in or Si otrafvre: .T mafion provided above is true and correct Phone Official ase onl v. ZZ hat write in Phis area to be.eorrtpleted.h, 3 citj,or to wn official City or Towa: IssuiaQ Autho ' Permrt/L,icense# o rely(circle one): 1. Board of ficalth 2. Buiidine 6.Other ' department 3. City/Town_perk 4. Electrical inspector 5.Plumbirta Inspector Contact Person: Phone LUIVI tl<;<aLIVU canu jaist ucrio IS �.. MassachusettsGeneral.Laws chapter IS2 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 cfhire, express or implied,oral or written" An employer is. as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foren a jo going engaged in enterprise,and includi_-i:ng the legal representatives of.a deceased employer,or the receiver or trustee of an individual,partnership,associate on or other legal entity;employing employees. However the owner of a dwelling house having not more than.three ap,atherein,rtments and who resides or the occupant of the dwelling house of another who employs persons to do maintrn- ance,construction or repair work on such dwelling house or on tete grounds or building appurtmiant thereto shall not because of such employment be deemed to be an employ." MGL chapter 152,§25C(6)also states that"every state o.r local licensing agency shall withhold the issuance or renewal of a license or permit.to operate a baseness or to construct bufidiags in the commonwealth for•any applicant who has not produced acceptable evidence of compliance with the insurance covera;e required." Additionally, MGL chapter 152,§25C(7)states"Netthe:r 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 ofthis chapter have been presented to the r.(�ntractingauthority." APPricants Please fill out the workers'compensation affidavit compi-etely,by checking the boxes that apply to your situation and,if necessary,supply sub-conuzz-tors)name(s),address(es).and phone number(s)along with their cerdficate(s)of insure. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or.partners,are not required to catty workers'compensation insurance. If an LLC or LLP does have_ employees, a policy is required Be.advised that this afficj.avit maybe submitted to.tlm-Department of Industrial Accidents for confirmation of insurance coverage. Also lbe sure to sign and date the affidavit. Theaffidavitshould 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 re= rding the.law or..ifyou are required to obtain a workers' compensation policy,please call the Depwiment at the nQinber1is+5d below. Self-ensured=—.npaZies should enter their Self-insurance license number on the appropriate line. City or Town Ofncinis Please be sure that the affidavit is complete and printed le »biy. The Department has provided a space at the bottom of the.af-ndavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appli=L Please be sure to fill in.the p-_Tmitr5=se number which will be used as a reference number. In addition,an applicant that must submit multiple p=nMicerise applications in arty given year,need only submit one affidavit indicating current policy infarrnation(if necessary)and under"Job Site AdeLress"the applicant shodid write"all locations in I (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 Iicenses. A new affidavit must be filled out each year.Where a home owner or citi=n is obtaining a lines or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said p=sor, is NOT required to complete this affidavit. The Office of investigations would like to-thank youin 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 fay,number The CoTnmonwealth of Massachusetts Dcgartmemt of Lmdusirial Aeead=u Office of f$vestigatiEora 600'Wast i cin Street Briton; 1A 02111 TeL # 617-727-4900 Cz=406 ar 1-8 7 7-MASSAFE Revised 5-26=05 Fay;#61 7-72.7-7749 '-��ss.gov/die TOWN OF NORTH ANDOVER PERMIT FOR WIRING CMU5 This certifies that .j-:- ............................. has permission to ...... .......... wiring in the building of .. . ........................................................................ .... .. .................. North Andovcr,-Mass. 0 . Fee. ........... Lic.No.............. ............ ELECTRICAL INSPECTOR Check # 8856 r � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. _ S8S-?� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank 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 W INK OR TYPE ALL INFORMATION) Date: 4.e, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or2h�er iinlren ion to perfVe electrical work described below. Location(Street&Number) 4-5 f ift� .2 Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with buil g permit?? Yes No ❑ (Check Appropriate Box) Purpose of Building J' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: , Completion of the ollowin table maybe waived by the Inspector of Wires. No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs t Generators KVA No.of Luminaires •7) Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. grnd. BattM 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 Tota —Initiating Devices No,of Ranges / No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ...ons KW No.of Self-Contained Totals: "" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ElMunicipal F1 Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Noof Heaters KW .Signs Ballasts. Data of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: —r�� Attach additional detail if desire ,or as required by the Inspector of Wires. Estimated Value of 'lectrical Work: (When required by municipal policy.) Work to Start: 6 12-1Inspections 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 Ii bili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of s e&tthbe pt issuing ofd , CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains a d penalties of per' ,that the "formation on h appticafiIle on is true and c�e. P FIRM NAME: �/b td J pe LIC.NO.: l5 Licensee: sT'p,o 'gin ��y(47%J Signature LIC.NO.: (If applicable, ent exe t"in th license number lin ) Bus.Tel.No.: Address: .� Al..Tel.No.: *Per M.G.L c. 147,s.57-61,security wor equires Department of ublic 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 Signature Telephone No. PERMIT FEE.$ a r"� 3 1 �� .� �� i i Date. . y/��•�.5. . gORTM TOWN OF NORTH ANDOVER L � .. PERMIT FOR PLUMBING SSS" US This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform `.�. . . . . . . . . . . . . . . . ... plumbing in the buildings of . . .�)�I . . . . . . . . . . . . . . . . . . . . . . . .,. .. . . . . ... . . . . . . .. North_Andover, Mass. at. . .�.�. .�. . �-�.!�.fit. t. . f. . : . . .•. . . . Fee. Lic. No.. .��.`. .` ' . . . . . . . . . . . . . . . . . . . . . . . ... . PL MBING INSPE TOR Check 8162 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS p! Date V �r O -/ Building Location // �� Owners Name �(� Permit# "w-L S. Amount _ Type of Occupancy New Renovation ri Replacement ® Plans Submitted Yes No FIXTURES x ¢� O � O � w w x w z o wCr W W x a BffiVENT � MH-OOR MFLOCIR 4Mff-aR M H-0m sa HAOCR - 7M HTS six EM -777 1 14- (Print or type) ii!! �^ Check one: Cer'.ficate Installing Company Name /�T4n �- �Cn2C�y f1�� Grp Address 7�1L�� / /% ❑ Partner. Business Telephone c7 2 y Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the tVPe of insurance coverage by checking the appropriate box: � Liability insurance policy IJV' Other type of indemnity ❑ Bond ❑ Insurance Waiver; I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installationsVbiation will be in compliance with all pertinent provisions of the Massachusetts Laws. By: Signature CTTI—CeMeU elUMDer Ty c Plumbing License Title City/Town icense um er Master Journeyman ❑ , APPROVED(oFMCE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents 1� � J Office of Investigations 600 WashingWn Street Boston, MA 02111 t www nuns gov/dia . Workers' Compensation Insurance Affidavit. Builders/ContractorgMiectricia>as/piambers APPlit:ant Information Please Print Le—gbly Naiie(Business/Organization/individual): Address: City/State/Zip: Phone#: . Are you an employer?Check.the appropriate box: 1.❑ I am a employer with 4, ❑ I am a general contractor and I Type of Project(required): employees(full and/or part-time).' have Dared the sub-contza.ctors 6. ❑Now coristr uc6on 2.❑ I am.a.sole proprietor or partner- listed on the attached sheet! 7• ❑Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me m any capacity, workers' comp.insurance. [No workers'comp,insurance 5. 9. ❑Building addition raqp ❑ We are a corporation and its officers have exercised their 10-10'Et�>n�i impairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOL 11,❑Plumbing repairs or additions myself[No-workers'comp, Q 152, §1(4),and we have no insurance re uired t 12.❑Roof repairs q ] .employees.[No workers' comp. insurance required.] 13,❑Other 'Any eppiicent that checks ho>L'it l must atao t fill out the section blow showing their workrt'bornpensatioe policy information. Homeowners who submit this aff'i'davit indicting they aim doing all wank end the him outside contractors must submit a new affidavit indiaeting such _ Contractors that check this box must attohed an additional sheet showitig.the nitro of the sub-conmiceocs and their wodorrs'care colli—,ir£omiation am an et�loyer that is pri?Vi g workers'compensatson rmw'awe or a Lo ees: Below it the o information. f my mF Y p lacy and job site . Insurance Company Name: ' Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers'compensation policy declaratiou page(showing the policy number and expiration dates}, Failure to secure coverage as requited.under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Investigations of the DIA for insurance coverage verification. Office of 1 do hereby certify under the part and penaltieet of ped'"?that the information provided above is true and roma Si tore: Date: Phone#: Of�`Icia!use only. Do not write in this area,to be completed by city or town offidd City or Town: PermitlLicense# Fssuing Authority(circle one): 1. Boa of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Iusptxtor 5.Otber Contact Person: Phone#: Information a nd I structions ' Massachusetts General Laws chapter 152 requires all emp 3 oyers 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." r An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'formgoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver ortiust—m of an individual,partnership,association or other legal mitity,employing employees.'Howeverthe ownerof 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 maizrtenance,construction or repair work m such dwelling house or on the grounds or building appurtenant thereto shall not because of sueb eiuployment be deerned to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency sball withhold the issuance or renewal ofa 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 iusnrance'coverage required" Additionally,MOL chapter 152,§25C(7)states"Neitbar tine commonwealthnor any of its political subdivisions shall enter into any contract for the perforarance.of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the coritracting authority." Applicants Please fill out the workers'-compensation-affidavit completaly,by checking the boxes that appiy.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 requiredito carry workers'cornpensalaon insurance. Ifan 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 sigh and-date the affidavit. The affidavit should be returned to the city or town that the application for the perimit or license is being requested,not-the Department of Industrial Accidents. Should you have any questions regal-ding the law or if you are required to obtain a workers' compensation policy,please call the Departrnent at the nurnber.listed below. Self i_neured oorn Pc should enter that self=insurance license number on the•appropriate-line, City or Town Officials Please be sure that the afndavit 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 appliomt. Please be sure to fill in the permit/license number which vvilI 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 n=ssary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of'the affidavit that has bem.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 fimae permits or licenses. A new affidavit must be filled out each year.When: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 Cali. The Department's address,telephone and fax number. The Commonwcalth of Massachusetts Degarttnet of Fndustial Accidents Office of Investigations " 600 Washington Street Boston, MA 02111 TeL 9 617-7274900 Ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass-gov/did J