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Miscellaneous - 14 WINDKIST FARM ROAD 4/30/2018 (2)
N 0 Date 7y.kA 0, TOWN OF NORTH ANDOVER 7 PERMIT FOR WIRING This certifies that ...... ..... ..................... rLe has permission to perform . ....... .......... ..................................... wiring in the building of ....... .......................... Pat ...... 47 .0, North Andover, Mass. Fee...(,.}`.............. .Lic. No F2�V.7 ...... .... .. Check # S A 4 A THE COMMONV WEALTH OF MASSACHUSET T S DEPARTMMWOF PUBLIC SAFELY BOARDOFFIREPREvEmoNRIsGmnoNS527CMR12.00 Office Use only Permit No. Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 —/— / (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date b Town of North Andover The undersigned applies for a permit to perform the electrical work described below Location (Street & Number) 1 % W tI r4 l�j� S " IG�-A— Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Purpose of Building Existing Service Amps �Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Overhead Overhead To the Inspector of Wires: ME (Check Appropriate Box) Utility Authorization No. Underground M No. of Meters Underground IZ3 No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total— No. of Lighting Fixtures Swimming Pool Above El Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of i 1 Hydro Massage Tubs Signs No. Motors Bailasis of Total HP huuano ampe. %WarttOtheleglme iazofMasstdlmmGMIWLaws Ihaveaa=1LiabHit 1RrdtrePbkyinchdmgCbmpi& MCmuagporilsmbonialeWivalat YES Ihavesubrrliwdvafidproofofsametothe0ffic YESFT ffyouhavedrelmdYES, pie gfhebox. I � �er 1S4SURANCE BOrD OTIC (Plea9eSpeafy) � ,�' NO L/ mrofcovu age �� Esi WdVahteofacaxalWak$ WiodctoSM / /hpecfimD&ReWesldd Ralgh Final - rltt4�Ilvu�lE�ieP�aafpe'`II'rCGtr�`e� — eG�r",`� LiarwNo. 2ff %1 (1-- Iice�ZCr �eV�— Signattue - Li=wNo 2 4 702 �CJ /� (�/� �'�Ll�t �/� (� 3U2 � Busu>r�Te1.No. _ �?d _ti7�!"'l/7 ArtirPcc / gQ�—� AltTel. No. OWNER'SINSURANCEWAIVFR;IamawatetUdrLmwdoesnothawthem uanoeco cri aksW l verage eQuivalentasraqu¢edbyMassadxisetLsG=alIaws and dot mysigrMireon IhispmnitVplicxtion wartsdz mquiterrlalt (Please check one) Owner M Agent Telephone No. PERMIT FEE $ �,J signature of Owner or Agent a,. ry� Of o Use Only Q �lmt m"10fult if Mttssa l'tto Permit No. Itpftent of Public Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 no Peave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date or Town Of- NORTH ANDOVER To the Inspector of Wires: The udersioned applies for a permit to perform the electrical work described below. Loc di tion (Streit S Number) 1- (l b1JA10 Owner or tenAnt tJZ d 1 /AG f�tl Owner's Address l b 11-14 -I'L4A) ;�,i� f cST Is this permit In conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) ourpose.,�of Building Utility Authorization No. Thy 1-9 Existing Service Amps .r._./ Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service .4100 Amps 1/1 510D Overhead ❑ Undgrnd JZ No. of Meters I Number of Feeders and Ampacity _ I Location and Nature of Proposed Electrical Work _fin/Ji"/�G -77:4,zpAe � 5-i z cit GL r it 15Y - o / >r 71"' X. A ,/- if eLtd_.A. &HEM: INSURANCE COVERAGE: Pursuant to the requirementls of Massachusetts general Laws �C I haw* a current Liability Insurance Policy including Completed Operations Coverage or Its substantial equivalent. YES NO = I have aubntitt0 valid proof of same to the_ Offics. YES NO = It you have checked YES, please Indicate the type of Coverage by checking tMr p priats box. ` INSURANCE CBOND 1= OTH C (Please Specify) (Expiration Date) t atlA tod Value of Electrical Work S NYork to Start - - - Inspection Oats Requested: Rough Final e tailed under the Penalties of perfu r FIRM NAME SIJ 1c/l� i/L`7"Y G C 4 C- UC. NO. r. � Signature LIC. NO. 4,)c, y � � ,/7- (�nm,/tr'/ Alt. 1. AilsNo. A4dfa / ,�_„ Alt. 1b1. No...��a�r •- J OWNER48 INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or Its substantial equivalent as ra- tauired by Maseaehusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEES (Signature of Owner or Agent) 1-6565 C, 140. of Ughtinp Outlets No. of Hot TUbs No. of Thneformers Tbtal KVA No: ,of Ligtttteq Fixtures Swimming Pool Above In. ❑ ❑ gmd. gmd. Generators KVA d No. of Emergency Lighting Niel. of Asci otfole outlets , No. of Oil Burners Battery Untie No. of Switch butl`ts No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No, of Ranges !' No. of Air Cond. Total tons Initiating Devices No. of OTs piesis ' No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Diahwaih to Space/Area Heating KW Detection/Sounding Devices LocalMunicipal Other ❑ Connection ❑ No. of Dtgere. Heating Devices KW 61 Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wring No. Hydro Mill"a6a 'IUbs No. of Motors Tbtal HP &HEM: INSURANCE COVERAGE: Pursuant to the requirementls of Massachusetts general Laws �C I haw* a current Liability Insurance Policy including Completed Operations Coverage or Its substantial equivalent. YES NO = I have aubntitt0 valid proof of same to the_ Offics. YES NO = It you have checked YES, please Indicate the type of Coverage by checking tMr p priats box. ` INSURANCE CBOND 1= OTH C (Please Specify) (Expiration Date) t atlA tod Value of Electrical Work S NYork to Start - - - Inspection Oats Requested: Rough Final e tailed under the Penalties of perfu r FIRM NAME SIJ 1c/l� i/L`7"Y G C 4 C- UC. NO. r. � Signature LIC. NO. 4,)c, y � � ,/7- (�nm,/tr'/ Alt. 1. AilsNo. A4dfa / ,�_„ Alt. 1b1. No...��a�r •- J OWNER48 INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or Its substantial equivalent as ra- tauired by Maseaehusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEES (Signature of Owner or Agent) 1-6565 Date...........1....1 1008 TOWN OF NORTH ANDOVER PERMIT FOR WIRING lo SSACHUS This certifies that ......... ........................ has permission to perform ....... .......... . .................... wiring in the building of .... � / .........I, fe-jc ...... C �A ........ JA.'. ........ 10. . :e.v .. : .................. . North Andover, Mass. Fee.... �514.-AO. Lic. No....� �.M .............................................................. ELECTRICAL INSPECTOR 50. 00 PAID o6/20/97 11:40 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Location (, 1PRAkv,51 %R6N fwd �l No. � Date NORTq TOWN OF NORTH ANDOVER 9 ' Certificate Occupancy of $ CMUs t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3� Check # 72-34 / �( ✓ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE .OR TWO FAMILY DWELLING x. � v I, x f BUILDING PERMIT NUMBER: DATE ISSUED: C- SIGNATURE: Building Commissioner/I ctor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1 ,el uJitijk-/"Q—/Z ykR� Map Number F Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re aired Provided 1.7 Water Supply M.G.L.C.Q. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private D Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System- 0 SECTION 2 -. PROPERTY OWNERSBE P/AUTHORIZED AGENT 2.1 Owner of Record d �^ c F/ 6 0 r 1314 N KI -Yr 64ae" A M �l U C9 Name (Print) Address for Service: 9A- 38-go6Z Signature Telephone 2.2 Owner of Record: Name Print Address for Service: r t. Signature; Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 6N NEA 2 . K -icensed Construction Supervisor: kddress !-L re Telephone .2Registered Home IImmp�rovement Contractor 1 1 C FS Co 031t2�JC�t,nOL) .ompany Nalme .ddress /% „ (2�g/-SDc) re Not Applicable ❑ License Number C3 - Z' (- D4 Expiration Date Not Applicable ❑ /o2303 Registration Number V-/2- D Expiration Date T M Z 0 0 z M 0 onr M z G) I SECTION 4 -WORKERS COMPENSATION (1VLG.L. C 152 § 2546) 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 buildin rmit. Si ned affidavit Attached Yes ....... No. p' SECTIONS Descri tion of Pro osedWork cheekalla lica.ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work: IX/ /203 cy 3 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Costo (Dollar) to be lC; Com leted b etmit a licant�rEgN =qF 4 1. Buildings a a'.,nk (a) Building Permit Fee yZ �yd Multi lier 2 Electrical (b) Estimated Total Cost of 3 Plumbin Construction 4 Mechanical Building Permit fee �,� x (b) HVAC 5 Fire Protection 6 Total.l+2+3+4+5 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHENber OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner/Authorized Agent of subject property Hereby authorize My behalf, in all matters relative to work authorized by this buildin to act on � g pern�it application. Si nature ofOwner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date 1,_,k Eih R k0err) property >aAuthorized Agent of subject Hereby, declare that the statements and information on the foregoing application are tete and accurate, to the best of my knowledge and belief Print Name of NO.. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TIMBERS SPAN DIMENSIONS OF SILLS DMFNSIONS OF POSTS DiMENiSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS _3L/.. UP PUO 1INU Y MATERLAL OF CHNNEY IS BUILD114G ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO .NATURAL GAS LINE — 4 L N m m m m y v m ap CO) 10 CD 0 C2 H d d O CO) 5 0 CO) i-: d CD CSD a. y CD 0 CD C CD dc cc C wo'c O 01 = O �•(A O Q H coSo y CL C HC2 m man Z �� vift =r CL -1 ,,, Crn o m �O Cl) dp y COD O®m: a a � o .� SO oa� .« z4c 0. W O O H• A ��vp :.dip �� a' a = ' Vf^J O ? CC2 CL a• VJ O ® N ►� m :; a► n O �3 H= ti d d C cn oc w — n V =n ' co cn >: C='1 m O CD : O : IL z� o •: cn �c on r a CD Z cn w0m cnCD o: = W n C2,1 Z 0 a a o o = d° ., wp? 7' G7 C17 �'' n 7d w ,.� �.., w n p oCc � w o by d �^ n y Q. x rD p W M omi The Commonwealth of Massachusetts Department of Industrial Accidents Offfeeoi/nyesligal/ans 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit location: 7i 1 6w 4r7/17�lO er city �N'd of_,t %%%%p phone # / A 6?7 ❑ I am a homeowner performing all work myself. Zg,,I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. comnanv name. ❑ I am a sole proprietor, general contractor, or homeowner (circle one) the following workers' compensation polices: and have hired the contractors listed below who have ,,... 41 -ill lJVigUCllk a3 well as avu pcn:uaes in me form of a 6 1111' WORK ORDER and a fine of $100.00 a day 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 ns and penalties ofperjury that the information provided above is true and correct. Signature Date r Z %: "C' Print name �� I�i.�� !? .. eae-i ...... _ .._ ._..._..._. Phone# -S - official use only do not write in this area to be completed by city or town official ,_.:...... city or town: permittlicense # -Building Department _ __ .... check if immediate response is required C]LiceinsingBoardOSelectmen's Office OHealth Department contact person: phone #; -Other (revised 3/95 PIA) c � ' 1 ✓ o-/- BOARD LBOARD OF BUILDING REGULATIONS { License: CONSTRUCTION SUPERV18OR Number,C8 058245 Birthdate {03/24/1943 Expires: -03/24/20:06 Tr. no: 21031 Restricted: 00 KENNETH B KEEN'; 21 HEWITT AVEQ N ANDOVER, MA 01845 Acting Ca mis ones 4 Board of Building Regulations and Staedards HOME IMPROVEMENT CONTRACTOR Registration: :108383 xpiraiion 8%18%2004 Type DBA KEEN CONSTRUCTION:CO: Kenneth -Keen .' 21 Hewitt Ave No. Andover, MA 01845 - - -- Administrator �Zo !w Nfr� AJ 5k ; FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from 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 (�J:f} Al E'IEM19 4 P#IvC LOCATION: Assessor's Map Number /©q SUBDIVISION nn nn STREET L V j K 16T PHONE 72- 731-9a4 Z PARCEL LOT (S) 0() ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS INSPECTOR -HEALTH INSPECTOR -HEALTH COMMENTS l �06NS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ O (L PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm P�A) or 7 "t_ CAN - - ------------------ 4`1 14 WinWSt rarm xd. N. Andover, MA 01845 (978)738-8062 Contract # 1613; Appendix'A Date:4/25/04 Finish Basement: • Build partition walls creating approx,, 950 sq. ft. of finished area • Create mud area Mom garage) with a finished closet,. 3/4 bath, family room, computer area, golf closet,, and. area for refrigerator and freezer. • Frame elevated floor for bath • Supply &install Andersen double hung window next to slider in computer area • Supply & install Andersen gliding window (approx. 4'x 2') in family room above concrete wall if possible Attempt to leaverear wall of stairway open to family room • Balusters or'/2 wall to be -priced accordingly Supply=& install -R-13 'insulation and,vapor barrier on all- exterior walls Hang blueboard and sk ncoat plaster.finished-walls • Supply& install five 6= panel hollow core Masonite doors • Supply & install one 6 -panel hollow :core Wsonite unit pair Supply & .install trim on windows, doors, and base to match existing • Paint walls and trim (2. coat finish, 2 neutral colors) Supply & install, standard (#704) 2' x T revealed edge suspended ceiling throughout finished area Supply & install` ceramic the iiimud urea, hallway & bath ($3:25/sq. I. the allowance); (approx. ,150 sq. ft.) Supply &.install carpetin remaining finished area including stairs ($22.00/sq.,yd. installed- allowance) Electrical: -Supply & install 14 recessed light fixtures in ceiling switched on dimmers • Supply & install 2 TV cable- outlets, 2 phone outlets, & l computer cable outlet • Supply &. install., outlets to code . • Supply & install thermostat and wiring for heat PIumbing: - Supply & install one zone of forced hot water heat off of existing boiler • Supply &. install stand-up shower, vanity sink; pump. toilet and all fixtures for 3/4 bath • Run gas line to kitchen for future cooktop Ot KEEN CONSTRUCTION CO. c 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 Tel: (978) 691-5201 Fax: (978) 682-3231 Submitted - --- ...... ..__� ' �1 _\1 .- ,........... ..: .-..._ G _... PHONE DATE > C/S = Customer Supplied S + I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: Construction related permits: WORK SCHEDULE PROPOSAL All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. REGISTRATION NO. F.I.D. NO. MA. H.I.C. 108383 04-325-8052 ....... .... .... . .... . Contrac willcnot begin the work or order the materials before the third day following the signing of this Agreement, unless specified hese in writing. Contractor will begin the work on or about — (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by 2.6 — L �A — (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractorl, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of : Payment to be i de as follows: upon signing Contract; upon completion pf 4 ; n�pO o of ; shall be made forthwith upon completion of work under this contract. Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whichever amount is greater. U C k• ti dollars ($ E.. 2, KENNETH B. KEEN Name of Contractor / Designated Registrant 21 HEWITT AVE. Street Address N. ANDOVER, MA 01845 City / State (978) 691-5201 (978) 682-3231 Phone Fax Name o! Salesman � ,• i/ -moi'?" � �.. � Ap rfIzedSin.fu �•- _t' Note: This proposal may be withdrawn by us if not accepted within days Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. "I „ DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Date J IMPORTANT INFORMATION ON BACK Plo- w W 00 O W J W IL 0 W � I- z < C t7 W < O <W z 0 0- W m IL L 0 m k I W Z W M I U I \ W < Z x 'J V z J O NO 0 a V V\ 4Z o K < K 3 13 d J 2 Z m 0 0 0 Z 0 Z N WN •� J N W z 0 r W 0 C G U G U 0 U 0 O J m F \\ m N d 0 Z 0 z 1 J m W z W z W Z m W C 0 V� 0 0 F LL 0 0 0 U U0 0 Z J z 0 LL LL 0 0 Z Z Z W m 0N Z w LLit U) J N L Z N m W m I N m W F m y m m m m m m V J s 0 < v r 0 4 U 0 0 0 z z O M t`"I. � 0 0 J > W V 0 W O ^ \A�(� W rc Z < Z v Z N W m LL 0 N O 7 m r r W H W z j z 0 Z L 0 Z 0 u m W rc r 0 r F L ILZ 0 J O W W L < Z W i W Z N i J i 3 Z<< O U 0 < W Z 0 < O N U z O W C W m W r0 J 0 Z 0 0 Z Z_ p J < W O (L � W m W W = K O U < U < U < 4 < 7 0 ] 7 m 0 K �N II` z< FWN O 0 0 < m D O IO < N m N 3 m z 0 m 0 Z F v FL W r ay�ee. z 0 L 0 0 0 r 0 u u u L J J L p O O G L LU ` H ~ J U J "MI J U W F z F f m 3 0 o V m O V U Z d IA z 0 F U F- z M r z W (7 O W N E 0 I F ] C 0 00 O W J W IL 0 W � I- z < C t7 W < O <W z 0 0- W m IL L �y1TO G1 0yn AAy 0<DD*On mZ_'D aCD D;tn 3 V 8mm 00 01 O,Do100x-4 111 OOZn nr�i�mTQ0, A al0 " W o0ZZ N >0IZ ~ 0rm 0 �Q.mOD mm mmn7KAOR N DOTS OOo D N7C nn yam W p p TO O " r 0 N 0 A T m m p; y 0 rii VI 00000 (-^ ON -) N v a O; "� C m ti ti. m T Din; O 0J0 xN ZZp 2000 Nx p 0-� mm w ZDT Z T fn N rD Z2 r nT ZZZtn ZZ0 p to 0 1; O p0^o- Zm 0 p AD ZD;T30p000 n 3 H Om C to 3 a s w N O n O r N m x 3_ G m 0 m m 0 D �i O n N D 3 m p {< Z NmONT {� Z`;"Z N Z 0 o <{ ~ Z O 0 " _ 1 1 1 1 1 1 1X1 I I I I I I I I I I I I I I I_ I 111JI 0 Z^'OG7CpDxmTT tt;OZ7c :Elw DN D nS n TTT COT ST ZI Qin p� DZDpp OT r �ODQ +aDOy Ov ii �ODDO lC QAZZ Z A D '"'N mrn n<..� mrn T;AAZ Om T�DpZ TQ mA xzo?;vr oTor�mDo�xO�A n ?So=m ATa� Z`m�rn n nm Z �n D �Z x�n DOOZ?3ZAnp� -Dim p AZO , ZD Z mxOp QC OmmOmN<�3 x v m �A �^ m 7cmnti T 0 { O m 0m >z T y�Ox m"' Cf1Nma . Z OZ< 70 -si pA �rn m A T I y 0 m DD I I I w f0i Z T m Z N x T Z Ll� O Z w op Z 0Zs A ILII I`. II z SOr N N 0r0 Zm nN-0-1 0 COX o inxo „ 3Dy ! X01 L.l amx �� �► 100 ria m6` o MWE 'aAm ��z c mW0 msz v_ r rom 2 4 6) r- -4 Day m ?_Z A =0 0 >4 O n2 10 Nm m 00 I 1 FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ************.****Applicaannt fills out /t/his section***************** APPLICANT: ���/ LL5/ ,�C� Z G Phone LOCATION: Assessor's Map Number Subdivision Street IGENTS: ficial RECOMMENDATIOSO fl ` Conservation Administrator Comments Planner Comments Food Inspector -Health Septic Inspector -Health Comments Parcel Lot (s) 1Z ,2 t St. Number Use only************************ Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections`��J u� 2 97 - driveway permit ICJ o �i re Department JArnt �f ,6� y c,� v ,� �wV/- j�,w ' Received by Building Inspector Date N a v h Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) GLC- ,v_itic�l�i �,PO /e Map and Parcel : Purpose of Application (check below) Phope Number of Applicant: mingle Family _ Two Family - 2 ;J7, l -y I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. KThe lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. iture of Owner or Authorized Agent who signed the Attached Building Permit ate' form must be attached to the Building Permit upon application for such permit. A . " 0 z 9 0 M CO O 0a 0z 0 U a I 44 CC a 0 m MA �E /cD O m m HCD Z a a O O C O ` cm< ca O C h O v CL CA 'O 0 Z0 C L) V � � CML C C G_ cc c M C2 a m CF z x A v E E 5 3 �/✓� c vo OW U t; ca A' 0 c� � os ) w° d U w a W � ~Ey m �mo z o 0 M CO O 0a 0z 0 U a I 44 CC m MA �E /cD O m m HCD Z O O C O ` cm< ca O C h O v CL CA 'O 0 Z0 C L) V � h C CML C C G_ cc c M C2 m CF z o c N E 5 3 �/✓� c vo OW t; ca too 0 � os ,4' •• m V! C _ • m C � ~Ey m �mo y m m C OQ C � BIC C,3 y C-3 Z 0 d C' O a o imc m=o = m r a g y m r W o .0 � =0 y fl.z �° c 0 •- 403� v m d oo► h m� O� CL 0 M CO O 0a 0z 0 U a I 44 CC m MA �E /cD O m m HCD Z O O C ZE cm< ca O =� C O v CL CA 'O 0 Z0 C � CL � h C C G_ cc c M C2 Date.". �..�. "oRTh TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 49 ,SSACNUS� This certifies that ...�e.,.�. H.� ................ . has permission to perform .'....`.— plumbing in the buildings of ............................... Y. ... �North Andover, Mass. Fee./ .Y..... LIC. NoS G.� � .. ....... :... `l� �..c .!�........ . PLUMBING INSPECTOR Check # 6,,/ 9 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building ��-Owners Na TION FOR PERMIT TO DO PLUMBIN 0 / of Occupancy` za4l ..O New Renovation ri Replacement, FIXTURES Date O Permit #---�G?� Amount A Plans Submitted Yes No (Print or type)�T , � / �� � Check one: Certificate Installing Company Name _. V t S �( �L� „r Corp. Address '5--z L0i je- U '4' .r.S V,� n Pnrtnar ;lephone /�� �l �Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate_ the type of insurance coverage by checking the appropriate box: Liability insurance policy ung" Other type of indemnity El Bond D Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance ignature Owner F-1 Agent M 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 instal ns pe rmed undFP*tIssuedfo this application will be incompliance with all pertinent provisions of the Massac e State g Codhapter I4 of the Gene aws. a By:I - 710mre of Licensearjumoer OVER (OFFICE USE ONLY Ty e of Plumbing License icen um er Master 0— Journeyman CERTIFICATE OF USE & OCCUPANC ' Y' Town of North Andover I, Building PerTit Number Date .a THIS CERTIFIES THAT / THE BUILDING LOCATED ON 1 `� MAY BE OCCUPIED AS SAIN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 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Vd r� ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING } This certifies that . I� c S o��N e-' .............. has permission to perform .......1 ...................... . plumbing in the buildings of .. e„ .5 0.0 ....................... . at ... ) �..W..I.'.4 �0.4 .. R j:....... , North Andover, Mass. Fee .as�i... Lic. Nol(p? . .Mb ......... I .......... ... PLUMBING INSPECTOR Check # `11 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YI MA DATE _.L" / ! PERMIT# JOBSITE ADDRESS i OWNER'S NAME L ltl, kp a-1.._ POWNER ADDRESS _ TEL FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: ® RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES[]I N00 FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB IE .M__� : _I i _► __.__ I ___i _I __-_-� % �__ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _._.__ ( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ! _..__.. _I ( I ( ___ -_I A _ _ 1 _ _._ ___. i J DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _ I .__...__( I ___..._I FOOD DISPOSER FLOOR/AREA DRAIN i _._...._1 i f ._.._ I 1 1 1 f __._.._. f INTERCEPTOR INTERIOR f l ___..._._i 1 _..__J ._._J I 1 __.._._1 ......__.� i ___-__.i KITCHEN SINK LAVATORY ! - - - -f -- - - -1 -_..._.I ._....- I _ I -- 1 .. J _:_..- i ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET I .----_-.._( _. _ __. _..__ _ _1 ( .__-._.J -- _I -__ -_i i ._.. I � _.___1 URINAL .___.._ 1 � __._._.Ii ...__.__._l I `r F- -I l WASHING MACHINE CONNECTION _, l ._ ..._, _ _ .._I _ . _ _-I .._.... f - ? . _.. 1 _ ._ ._ -A WATER HEATER ALL TYPES I --i ---i WATER PIPING _ ._I ._ 1 ._ _f _._..._1 I OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES f NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ba OTHER TYPE OF INDEMNITY P11 BOND ..I 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 i AGENT __f 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 compliance with al inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME %ithon Ski► - 'nom_ ( LICENSE# F%(0�O5-_I SIGNATURE MP[A JP Q CORPORATION 0# PARTNERSHIP 0# LLC COMPANY NAME (,' �J111 AD DRESSra) Mavn;n _I CITY STATE ZIP -3 TEL FAX — 1 CELL { EMAIL H °z 0 H U W [Tk o F] z O � � p w O Z W aLLI _ ~ W I-- � W p Q w CL O w co a p z w � � a U J LL CL a V) LU Y w F- LL H o H U z z Po � 0 V x The Commonwealth of Massachusetts Department of IndustrialAccidena Office of Investigations 600 Washington Street Boston, MA 02111 ,. www massgov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly [dame (Business/Organization/Individual): Address: -.3 ( Hocln4r,;n / City/StatI; �^c z:), /1'l� Dl re� 3 Phone 4: 2 ,re you an employer? Check the appropriate box: Type of project (required): [� I am a employer with.� 4. ❑ I am a general contractor and I 6. El Now construction employees (full and/or part-time).* ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t ?• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 1011Electrical repairs or additions required.] ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t' q ] employees. [No workers' 13.F1 other comp. insurance required.] y applicant that checks box # i must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. stractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n iin employer that is providing workers' compensation insurance for my employees. Below is the policy and job site w. -nation. „ trance Company Name: gle i'qn eel L—Ie icy # or Self -ins. Lid. #: to I_Z V6 q 6 a 3 /-1Sg - = / Expiration Dater Site Address: / �( Wie& 4 Kms/ /- &d4 VP/ City/State/Zip: 0���%� ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). nre to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of :stigations of the DIA for insurance coverage verification. hereby certify under the pains andpenalties ofperjury that the information provided above is trice and correct. tature: Date: ��� /-3 ao w: 7�1-h-V Y DDe3 Dficial use only. Do not write in this area, to be completed by city or town official. :ity or Town: PermitUcense # 'suing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector . Other Inform flon and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 )f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. °lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current )olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or :own)" 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 ,ear. 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. 'he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Depaxtm,ent of L dasttlal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1.877-,MASSAFE Date .........C%...... ...1... - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 1/1 /`' f'................./G (e- 1 70— ........................................,................................................. has permission to perform ............ ! / wiring in the building of ..............!. ..7..............%... "F...... .............................. c at ....... ........... .........`...ry. u..... .'..5.7............../tee r*North Andover, Mass. Fee. 2 v S Lic. No.'/i�3 t`�t%Lr' �' 4 ................./.... ................. ....!.f.:........................ °'Check # ,' J ELECTRICAL INSPECTOR � /// Cof incwealth of ALassachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONIS Official Use Only Permit No. <! 6 Occupancy and Fee Checked [Rev. 9/05] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordabcob with the Massachusetts Electrical Code (MEC), 5A7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: G) a I � :� I City or Town of. L . AnAcycy To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. W Location (Street & Number) 1(� l yL a k [s �' gr (h W _ Owner or Tenant A i VLA LGl r p Telephone No. ( _2�ls b Owner's Address 7 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / New Service Amps Number of Feeders and Ampacity "c -Its Overhead ❑ Jndgrd ❑ Volts Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans r o ora Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool ove ❑ n- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of electron andInitiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers eat ump Totals: um er ons No. of Self -Contained Detectibii/Alerting Devices al Connnneccti❑ Other. tion No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW o. of No. of Data Wiring: Heaters Signs Ballasts ITelecommunications No. of Devices or Equivalent No. H ydro:rassu a Bathtubs 3 g No. of Motors Total HP ►rmg: No. of -Devices or F uivalent OTHER: ` Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Viork 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 liabi ' insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coi rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEio BOND ❑ OTHER ❑ (Specify:) 3 I certify, under th ains and penalties o e 'ury, tha .he information application is true and complete. FIRM N IrwC ,tris L C. NO.: Licensee: } ignature ! LIC. NO.:at fit (If applic ent "e c t" t ' nse bei nef Bus. Tel. No.. S Addres .1OU Alt. Tel. No.: *Security ystem Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE Vi'ABTR: 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/A ent Signature Telephone No. PERMIT FEE. $ Z 10ne,,� t, A A1;;e/;. rex n r-: ta" 0-4, /P. � -)-- -Z. , tr2-� R -h -r PAO,4:i,� /bnoi-e t -cm 3e l �i �C-9/ 0 -ZS--/ --,2 i 0 The Commonwealth ofMassachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mas� gov/rlia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I( Ila e Q I n Addr0CS' Oh Ad 1 dlld " C1lD 64 \ /VUI e 11 1 f 04_M� City/State/Zip; Are you an employer? Check the appropriate box: - Typo of project (required): 1. ❑ I am a employer with 4. ❑ T am a general contractor and T 6. ❑ New construction employees (full and/or part-time).* 2. ❑ T am a sole proprietor or partner - have hired the sub -contractors fisted on the attached sheet. �• F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g• Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner, doing all work officers have exercised their 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.) q ] 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. I Homeowners who submit this affidavit indicating they 2're 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 provirli Yworkers1compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �C�V11(5 5 1 nsVV—el? t"' CIA ("1AA w —t Policy # or Self -ins. Lie. #: O(/)o 8�- -7 ( Expiration Date: a'/r/q Job Site AddressA/ 0) t n 6141, i S T .A rM/ z d 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 DTA for insurance coverage verification. X do hereby certtfy under Phone #: andpgnal4les ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - C'nnfnvt'PPrcnn: • Phone Information and Instruction'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 employd 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 complianceWith 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-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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. De 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 —thaz -if mit 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. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Mass.,gchusPtts Departrxteut of ladustl ial .Accidents Office of Iavestigatito.0 600 Washiagtou Street Boston} MA 021 X Z Tel, # 617-727-4900 eyt 406 or 1:-877-MASS.AFB Revised 5-26-05 Bay, # 617-727-7749 . . . . . . . . . . . . . . ...... 4R.", -bw 't 43 v i;h JU irlkluw, D 4", N, 'IV -`41 IONAL 4o v OFe" Ps' *T, IF1113 fo "a P,, f,`FNU& lSER SLERIA, (Ink