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HomeMy WebLinkAboutMiscellaneous - 1611 Osgood Street i }ie hrM,a BUILDING FILE / Location No. U Date !Z c; r--s NORTH TOWN OF NORTH ANDOVER o�,,..° 6 • Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 18822 2 / � wilding InspecT NORTFM O��t-ao TOWN OF NORTH ANDOVER CHus� NORTH ANDOVER, MASS SIGN PERMIT DATE: 10/27/2005 PERMIT 26-06 THIS CERTIFIES THAT Limited Partnership - McLay's Florist— Fantastic Sam's has permission to erect. Externally illuminated Wall Sign P on 1211 Osgood Street provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. ILLUMINATED SINGS ARE PROHIBITED Inspector of Buildings 'G ob a� TOWN OF NORTH ANDOVER 400 Osgood Street SIGN PERMIT APPLICATION Site Owner_ FAip-r/�I�2 ��—(� Tel # ApplicantT( Site Address_(2(I 05&MP SAPI VdA , /(4A- Size of Proposed Sign Map Parcel 8 7�"� Estimated Cost of Sign o0 How attached: (a) Against the wall Illumination: (a) Not illuminated ( ) b) Roof) Ground �( ) (b) Internally illuminated (c (d) Othert�i4S'f�nf ( � (c) Externally illuminated' VN pEl2S�Dt n `77SC10 Vit L Proposed Colors: Background Materials:&UMIAIUM Lettering Border Required Attachments: No permanent/temporary sign shall be erected, or Photographs of building enlarged until an application on the appropriate form Material sample furnished by the Sign Officer has. been filed with .the Color samples Sign Officer containing such information including Site or Plot Plan (Required for all free-standing signs)-2-"ES photographs, plans and scale drawings, as he may Drawings of proposed sign —2 5tFr5 require, a permit for such erection, alteration, Other, specify or enlargement has been issued. by him. Such permit shall be issued only if the Sign Officer determines that the sign complies or will comply with all applicable provisions of the By-Law. Will sign overhang any public road or walkway: Yes ( ) No\ "A If Yes, Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED. c� Date Filed: Sigrrature of Applicant ry �_WITv \\ -7711 - �w�aoo - - ' a j I � : } a 7 •. .� fie_ vmoi'. t, ,O\\VA +rmA j( �Iypp r Al IMMMIMME yvww.y� v„ rte` I ` -71 \ � o�� 9 ti :e,� NORTH .rs "C rasp {j TOWN OF NORTH ANDOVER �%T COW NORTH ANDOVER, MASS SIGN PERMIT DATE: 10/27/2005 PERMIT 26-06 THIS CERTIFIES THAT Limited Partnership - McLav's Florist— Fantastic Sam's has permission to erect. Externally illuminated Wall Sian f on 1211 Os000d Street provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section#6, Voids this Permit. ILLUMINATED SINGS ARE PROHIBITED Inspector of Buildings 6165 Date......... ....�T......... tt NORTH TOWN OF NORTH ANDOVER 1 0 0 A PERMIT FOR WIRING WNW CHU This certifies that ..... .7 ........ 7 ................. Tvp has permission to perform ...... /r/......................................... wiring in the building of.....AI.0-4-4..yS'.:....... ................. at...... .....5.Y.................... .North Andover,Mass. Fee..................... Lic.Noll/..711/7.2................ . LELECTRICAL .... .. �,P� MCAL INSPECTOR Check # 04P QlommonwrnI0 of Massar4usetts Office Use Only Department of Public Safety Permit No int?(.6S- BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & fee Checked T), 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 � /q/as— (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of D 0e-0-- _ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below.12, 11 Location (Street & Number) O_ Sr, IMOwner or Tenant C— T isf Owner's Address Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps_ / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps J Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work — TOTAL No.of Lighting Outlets No.of Hot Tubs No.of Transformers KVA Above tn- No. of Lighting Fixtures Swimming Pool gmd. ❑ rad. ❑ Generators KVA No. of Emergency Lighting No.of Receptacle Outlets No.of Oil Burners Battery Units No.of Switch Outlets No.of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No.of Air Conditioners Tons Initiating Devices Heat Total Total No.of Sounding Devices. No.of Disposals No. of Pumps Tons KW No.of Self Contained Detection/So No. of Dishwashers S ce/Area Heatingmunicipal uniDevices ci Municipal Local[], Connection ❑Other No.of Dryers Heatin Devices KW No.o No. ot Low Voltage No.of Water Heaters KW Signs Ballasts Wiring i No. Hydro Massage Tubs I No. of Motors Total HP OTHER: —yt-- rL INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability jrs ranee Policy including Completed Operations Coverage or its substantial equivalent.YEKO IJ:have submitted valid proof of same to this office. YffrO NO 0 If you have checked YE , please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ElOTHER❑ (Please Specify) 6-1- 06 00i (Expiration Date) Estimated Value of Electrical Work$ /0 �� /0 5 j�sr Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: j� FIRM N A I m �F1 +�rif C Al y � . >�(, LIC. NO. 14 //!�j, ;??— rO .Licensee '�� 7,VV/V A ZZ Signature LIC. NO.�3,V�J Address //0 ' i='1 Sr fue �' Bus. Tel. No. Alt. Tel. No. OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my signature on this permit application waives this requirement,Owner Agent (Please check one) T.1-6l1r1P Nr, PFRMIT FEE g ._� Date. ��. /. 50 a'.". 71 0 PT 4, TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING i ,SSACMUSE� 1 � 'This certifies that ` . . . .u. '"rte' : �^""� has permission to perform-^.^.". . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . plumbing in the buildings of�.,. `. . . 'Q. . . . at . . . . ... . . . . .. North Andover, Mass. / e� i Fee. . . . . . . . .Li .1 No.. . . . . . . . . 4,. ��Ij . . . . . . . . . . . . \� PLUECTOR Check # 665U MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date / k5-0.S Building Locationf f> �"Owners Name Permit# Cv �� In Amount n ` /•y �r�A Type of Occupancy �j�����)4G New 1Tq Renovation Replacement Plans Submitted Yes No FIXTURES s><a>eav� BASMM EE ID R 3�D)HI1D(R 21D ELUM 4II�)HIOCR SQi)HIOCR MEL" 7M R" gIH mm sr 1E I-f++- (Print or type) � Check one: ertificate Installing Company Name Corp. G Address �� © ' Partner. Business Telephone a ep one 9-) Tom/ Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 0 Bond 0 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 applicatio a true and accurate to the best of my knowledge and that all plumbing work and installats perfo d under Permit Iss is application will be in compliance with all pertinent provisions of the Massachus s ate Ply ing Cod r of the General Laws. Bynaicensed '--Type of Plumbing License Title � r,5-c>l7 City/Town is Master Journeyman APPROVED(OFFICE USE ONLY 1-3 ` Date. HORT►, •".o '"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUS� This certifies that ........1.. © .eV7...../*!k..................................... has permission to perform .... �9i?:l � �T .�G...�................... ............ .......... aiT - T.n SrrJ!�9 wiring in the building of.......��........�....................................�.................. at............. 5..'............ ,North Andover,Mass. k Fee.;FS.rf'' Lic.No. �..Z.5&C. f5 ).1. ��'r..... ` ELECTRICAL INSPECTO Check # e:2 _ DE9U7N 'OFPENX3 F= Permit No. BQ4RDOFFMPRE{,FN1IIOiVRBGVLA7Xmwaom 12a Oceupeeey R Fees Checked APPUCATTONFOR PERMITTO PERFORM FI. CTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMB 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Data Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 12-11 OwnerTenant S--)-i ZS Owner's Address Is this permit in conjunction with a building pemtit: Yes[n No a (Check Appropriate Box) Purpose of Building ORF-s5f--2 Utility Authorization No. Existing Service Amps zoVolb OverfteadUnderground � No.of Meters New Servis� Amps Vrh olts Oveead Undapound C:j No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Na of Ugbting Oatlsu No.O(Har Tubs M.of Trsnsamoos TOW No.of UabdUrr Pixuses Swimming Pad Above Below KVA KVA No.of Receptacle OutletsIf I No.of On BOenrs World srotow No.of Emergeocy Ughting Battery Units No,of switch Outlets / 5 No.Of Go Bmnrs No.of Ranges No.of Air CondL Total FIRE ALARMS No.of Zana Teras No.of Disposals Na of Had Total Total hof�and Ton Ky No.of Dishwashers Space Arm Heating KW No. �� Sounding Devices No.of Self CoowbW No.of Dryers Heating Devices Kw Lmd Mwdcipd Other No.of Water Nesters KW Na of Na of Comsection s Balimb No.Hydra Massage Tabs No.of Motors Total HP G!° O'I'fiER• 1 t'' httsanaeCbtm¢Ptsaiaetbthere4ie(ebcfMa�rlsasrhQtia�lLawa ]ha`eaaareYiith yhasroelblkyiddr� or�sr�r�irlec}ival�t YS NO lhnesutrrittedvsidpoaforsamedfzOman YMryauh�eded�dY!?S,Pkairlaredelyped 1NSURA� rM BM M 0'It= BtpiosittaDo dcbSmtt 20-13-oy £�lllsbdVakzdHendralWcrkS Wa ?�bgo,ats 1r�e�tD*Re4tesnd Rohl 7 a�2?-6 S+�tadurldTr el�lkmftafpq*. EBtMNAME xi-VVIE7 L�c�f'rRC3� �, � ��. lCA Lk=Na D)293 ,L U=M i=M c D&F�g) M igro Stgtsirse .z �f`1�L�rr-� LjptZ�NO Sr?225 BudllesUNn 97,'. VS38Z ndIm �1,f�S . � . �_ oZSs 9-,8-3?S-W)Q At'I>'1Nfa � OM1WI�R'SIlV.S[JRAI�WANIIt;Ianswa=thetiheLicQasc��Thei�s=aiaeaotiea�otits�aryirlegiivaimtata�¢iedbYl�fea®di>9dbGa�ILar►s ardttirtmys�r�eanthbprnr�appindmwrli�eslsrequlaszat (Please check one) Owner Agtmt ~ Telephone No, �IiRMtT FEE S DMUN NPOFPUffiRrSUM Permit No. y l� BGM OFFIRBPREVEN7]UNRI GVL47X M 527CBM,aio Occupancy&Fees Ched red APPUCAHON FOR PERAGTTO PERFORM ELECTRICAL WORK _ ALL w09K To BE M3MRMBD IN ACCORDANCE wmt THE MASSACNUSSTS ELECTRICAL CODE,527 cmit 12:00 (PLEASE PRRff IN INK OR TYPE ALL INFORMATION) Date k d Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street RNumber) 11.11 L Owner Tenant , 5;1-1 S _510 n�.S Owner's Address Is this permit in conjunction with a building permit: Yeso No C3 (Check Appropriate Bos) Purpose of Building AA 9 j)R ESSUtility Authorization No. Existing Service Amps Volts Overhead Underpound No.of Meters New SAmps Volts Overhead El Underground C3 No.of Meters Number of Feeders and Ampecity Location and Nature of Proposed Electrical Work No.of L.iandna Oath" No.Gift Tuba No.d Trsnlbrops Total Na of Eighth,$Fixtoms Swimndna Pod' Above Below KVA KVA No.of Receptecta OudetsIf No.of Olt Bum" No.of Erneryeoey Ushdna BwAery Uoiti No.of Switch outiou / _�J No.does Bamsrs No.of Ranaea No.of Air Cad. Total FIRS ALARMS No.of Zorn Tons No of IXspatals Nod Nast Panel TaW� W No.d Deoctim end C� No.of Dishwashers Space Aron Hating KW WdSouming�� Na dSouadlng Dw1ea Na of self comabtsd Dalacti0aftmadWSNo.d Dryers / Homing Devices Kw Local � � Other No.of Water Haters Kw / No,of Na of Connection, sizu Bdiasis No.Hydro Massage Tabs No.of Motors Told Hr t OTHER, klreuaneeC0400 P10 1Dte0F0m*dW*m c1uft lmzdL ws IhPcaci=tLmbft]iets xeFb 'mcb&B or*aibetrrti gxWJ" YES i Ihnestftrtlbdvaidproddsstredfe�m Y$9 � NO I 1<yautmeddd�dYH%Pkaidcrsehtyped 0 NSLRANM BCW[3 On= a �eSPer�j } ��iori�Drle Wadrtoant p-)3 �s g -130HOzOd Ra* teatFltsfalWcdr 5+gttedurld<r Pi3fetlisdpm*. LioeneNa z3�L- Sgftasae �� �� ����r r , I"eNo n tuL L- Budn= dNa c).2� /-3-.3 7.4 z ad*m CA kk-ti-S--- k2 si S - . 0,,,� L, �n ll . Z�s 1 AL'MNa 'CWMUS24SURAHEWAI R-fanawatttgtzUmwd, mmd biamawmworibabmrsiiegP talmgjmdb, ndbCand awn -A ,nddWffWsBl =onihbpeardsppics>btwsitetibfaqulenrtst (Please check ore) Owner Apo Telephone No, oBRM1,T,FEE 2 LIU Location ! r ©S G O®� No. Date 8 ! NORTH TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ ;�1'••°'E<t'' Building/Frame Permit Fee $ �tNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / v " Check #�`' (C, Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING M OTHER THAN A ONE OR TWO FAMILY DWELLING 14�k�04 Section for Official Use Onl BUILDING PERNUT NUMBER: DATE ISSUE 7 SIGNATURE: Q-9-- Building CominJssi2!cr/Ins ior of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number -4�Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage(fl.) 1.6 BUILDING SETBACKS(ft) M Front Yard Side Yard Rear Yard Required Provide Required Provided Requimd Provided �\3 f 1.7 Water Supply ALG.L.C.40.9 54) 1.5. Flood Zone Inforention: 1.8 Sewerage Disposal System Public 0 Private 0 zone— Outside Flood Zone 0 Munk Zs � —,Site Disposal 0 2.1 Owner of Record Name(Print) Address for Service C)—(�.Ccobl IA� L4-(0VCP— oq/\�Ne-- M Signature Telephone 2.2 Authorized Agent Name Print Address for Service: Signature Telephone K 3.1 Licensed Construction Supervisor Not Applicable 0 13 f C94&0 Lceq uc-- rz os-l5'947 Address License Number In Licensed Construction Supervisor. 2-.007 > Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 CA& 00-AJ AJ)L#2.1+-e-- 7- ,6 /2:? 3�3 Company Name Registration Number M ;K- I-en)C, Address 012-4.4 - - - 771 Expiration Date Z � !/. Signature V Telephone scTr 4o� cox .�c l 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. �I Signed affidavit Attached Yea.......0 No.......0 sIcriEo» s PROF SIt>w A i EiSIG �S C'1IO1�1 SIM"" ��R�t���S S°>�R� kS's�} CONS`1�1f3CE�l�`C+C3�'�flL '�'�TC�' R1�?�'�.�'�� �'��{� G�f�C?)�` CE;�►SED,�'� _ 5.1 Registered Architect: Name: c,\ Address X12 2�3 cl 3� Signature Telephone :�32�e�is�el�c�`�'ra�fea�st#in� Area of Responsibility Name: Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Registration Number Address Signature Telephone Expiration Date Name Area of Responsibility I zss Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Ag q✓ "`+rrb�—S �� Not Applicable ❑ Company Name: G1.14,e-r) Le-AueR Aft-onsible in Charge of Construction New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ t• <, Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify /JL%C Z-10/L ;-t LAJ2 Brief Description of Proposed Work: fy ��i�T<c/VS ,4N o / el se-7' also Aez� �• USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1 ❑ A4 ❑ A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ C Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile d 4 ❑ R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels j Floor Area per Floors 813A Total Areas DD Total Height ft Independent Structural Engineering Structural Peer Review Required Yes ❑ No ly SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C� ,as Owner of the subject property Hereby authorize(2-1-C CL \— Ee Qy--L f to act on . My behalf,in all matters relative two work authorized by this building permit application Signature of Owner Date f. -i NOW 5. vY. I, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name Signature pofyOwner/Agent Date Item Estimated Cost(Dollars)to be *rs Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction from(6) 3 Plumbing Building Permit fee (a)x(b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number S^.tl1,* t , '.tl.+.^,C.^}.,Y. S�,72,ff "3t" .l:�iA§r: 4 \. �kl.�l j1;:d N .' 't q.�4i'.i2.'sy;C� ,ti�3Yv`'Y f 4 t}.: t fq v.k p+} �,f57.'...r..p`N1q'.f ryyt$�,� ',vz yl:'�..,3h2,�fi :.� :�i nt�.St".tip. t .''V�^.r>!Iag'.r'l.ri.k-'.:.A{' q` '\d+lT`2'..�'. 3. +.il. r✓rFj�?���.3,".L'i.��a ss�'1frb,1"§`,ah'.:S�r'iA k.i'uvy'..'u�Y:fl,�}1l.,�J iy j. NO.OF STORIES S17E BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 N 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERL4L OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Board§ and Cepartments 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 crd' . &037J93- zo�Z APPLICANT �o 04 - 60 A - 417"e- S PHONE c' 9&--12-3- S 7 71 LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT (S) STREET /Z/1 ST. NUMBER OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR 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 The Commonwealth of Massachusetts Department of Industrial Accidents I � Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): 41 Cy .4_x 1.1'N4ar Address: I &om( Y M'y City/State/Zip: �f4oi /J/# 0307(a fp Phone #:�a3,=�93- dao Z_ Are you an employer?Check the appropriate box: Type of project(required): 1.K 1 am a employer with Al 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' (� comp. insurance required. 13.❑ Other] d *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ^ Insurance Company Name: Policy#or Self-ins. Lic. #: �� �^- "1 �2 —(' Expiration Date: Job Site Address:)2- /l 0S 60Qz 1 City/State/Zip:kL.�n10,6U eta Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and;P1=a1ties jury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for t4eir employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation Policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia -� '� 11 1 t r r � • ' i FROM :ROBERTS INSURANCE FAX NO. :9786833147 Sep. 22 2005 02:14PM Plil AC-0R-D- CERTIFICATE 'OF LIABILITY INSURANCE DATE(MMIDDIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. ROBERTS TNS. AGENCY INC, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1060 OSGOOD STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER, MA 01845 978-683-8073••• ......_...,. _ _ INSURERS AFFORDING COVERAGE NAIC# INSURED ............. .. ....... . ---- COM—CON CONTRACTORS, INC. INsuReRA: ACE USA INSURf:R D. 13 SURREY LANE INSURER C: PELHAM, NH 03076 INSURER D! GUARD INSURANCE GROUP INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW I-PAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT'WITHST'ANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'I'0 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCI•I POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS )NOR AD01 I POLICY EIFO� PATE MNUODATION LIMITS lmvm POLICY NUMBER GCNFRAL LIABILITY EACH OCCURRENCE._— b 1 OOO OOO x COMMERCIAL GENERAL LIABILITY ?REMISES,.Ee occurence j 50.000 CLAIMSMADE �IOCCUR ME D EX P(Any one person) $ 5,000 A GLW-786422-0 01/05/05 01/05/06 PERSONAL ILADVINJURY.. 5 1,000,OOQ., GENERAL AOOREGATF. 5 2JY_Q�L 000 GEN'L AGOREOATE LIMITAPPLI_F..S PER: PRODI)CTS•COMPIOPAGI; j -2 OOO,,,00.,0.,.. POLICY m- H LOC AUTOMODII.�LIABILITY -.. COMBINED SINGLE LIMIT g ANYAUYO (Ee eccloont) ALL OWNCDAUTOS --- BODILY INJURY S SCHEDULED AUTOS (Per person) _ HIREDAUTOS --•- BODILY INJURY j NON.OWNrDAUTOS (Peraccldent) PROPERTY DAMAGE $ (Peraroidnnf) hGARAOF LIARILITY AUTO ONLY-EA ACCIDENT ANYAUTG EAACC j OTI•IER THAN AUTOONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH O(;CUTARENCE j OCCUR CI CLAIMSMADE AOOREOATF. _- _ j ........ ............,.................. __ DEDUCTIBLEI E g RETENTION $ E WORKERS COMPENSATION AND X_ TP'R EMPLOYERS'LIABILITY COWC629978 04/21/05 04/21/06F,1ACH ACCIDENT S 100,000 ANY FROPRIFTDRIpnRTN�R/ENECUTIVE -E D OFFiCFR/MFMRF.R EKCLUDED7 Fl.DISEASE.-FA EMPLOYE j 100,000 Iryee deecrlbelmnor _..'..' _ 8P EO IAL PROVISIONS below E.L.OISEASE.POI,ICYI.IMIT $ 500.000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLE 81 EXCLUSIONS ADDED DY ENDORSEMENT I SPECIAL PROVISIONS FAX CERTIFICATE HOLDER CANCELLATION TOM OF NORTH ANDOVER SHOOLD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCEI,LF.n BFFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL F..NDEAVOR TO MAIL LO DAYS WRITTEN 1MAIN STREET NOTICC TO THE CERTIFICATE..HOI.nF..R NAMEn TO Ti IE LEr1,LIUI I AILUItt i0 OO BO SHALI. NORTH RTH ANDOVER MA 0184 5 IMPOSE NO UBLIGAIION OR LIABILITY OF ANY KIND UPON THE INSURER,I16 AGFN'I'6 OR RVRF.Srd,ITATIVFt,r AU III D REP ENTA I ACORD 25(2001108) ®ACORD CORPORATION 1960 NORTH Town of 0 No. * over, Mass.,-AQ � � � oCb coo, o d COCHICHEWICK �1. RAYED IT E BOARD OF HEALTH y Food/Kitchen PERMIT T D I Septic System THIS CERTIFIES THAT.. � ... FA BUILDING INSPECTOR .. �...... Foundation Inas permission to erect.....W... ......t r. buildings on .......1.�.1.�.......*% &4P*............................•. Rough to be occupied as............. .�.........V...P..........PO.r.........Awk.%!� ................................. 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 By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3CIS PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTI NOTTIts ELECTRICAL INSPECTOR ......... Rough seryi�.. . .. .. .. ...&4.0.W.ft................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.