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HomeMy WebLinkAboutMiscellaneous - 18 Edmands Street1 Commonwealth of Massachusetts 100091137 � Asbestos Notification For A-�D , Decal Number JUL 2 2 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT '`"P°irta"t A. Asbestos Abatement Description When filling out forms on the computer, use 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied only the tab key residence of four units or less? 0 Yes ❑ No to move your cursor - do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: RIRIKER CHARD 18 EDMUND ROAD a. Name of Facility North Andover b. Street Address 101845 2015197962 AM c. City/Town d. State e. Zip Code f. Telephone Number INSTRUCTIONS 3. Worksite Location: 1. All sections of this BASEMENT BASEMENT form must be a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room completed in order to comply with 4 DEP notification requirements of 310 CMR 7.15 5 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 6. 7. 8. 9. Is the facility occupied? ❑✓ Yes ❑ No Asbestos Contractor: FAIR QUALITY EXPERTS INC a. Name ATKINSON 03811 c. Ci /Town d. Zip Code AC000167 f. DOS License Number h. Facilitv Contact Person ANTONIO CONTRERAS IED MORGAN I IPROSCIENCE I 7/18/2009 a. Project SI 8AM-5PM c. Work hour: 10. a. What type of project is this? ❑ Demolition ✓❑ Renovation ❑ Repair ❑ Other, please specify: 11. a. Check abatement procedures: ❑ Glove bag ❑ Enclosure ❑ Cleanup ❑✓ Full containment ❑ Encapsulation ❑ Disposal only ❑ Other, specify: 23 HALL FARM ROAD b. Address 6038946465 e. Telephone Number g. Contract Type: ❑✓ Written ❑ Verbal b. Describe b. Describe 12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors? anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 (603)894-6465 (800) 621-1189 (603) 894-7044 FAX July 7, 2009 Air Quality Experts, Inc. Asbestos Removal 23 Hall Farm Road Residential -Commercial -Industrial Atkinson, NH 03811 AirQualityExperts@AQENH.com North Andover Health Department 146 Main Street North Andover, MA 01845 Dear Sir: RECEIVED JUL 2 2 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Enclosed please find a copy of notification sent to the state for an Asbestos Abatement Project. The job will take place on July 18, 2009. Project: Richard Riker 18 Edmands Road Any questions concerning this matter should be directed to my attention. Sincerely, Christopher Thompson President Commonwealth of Massachusetts Asbestos Notification Form ANF -001 A. Asbestos Abatement Description (cont.) 100091137 Decal Number 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 90 0 a. I otal pipes or ducts (linear ft) D. I otal other surfaces (square c. Boiler, breaching, duct, tank 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: surface coatings Lin. ft. Lin Sq. e. Corrugated or layered paper 90 pipe insulation Lin Lin. ft. Sq. ft. g. Spray -on fireproofing Lin. ft. Sq. ft. i. Cloths, woven fabrics Lin k. Thermal, solid core pipe Lin. ft. insulation Lin. ft. 14. Describe the decontamination system(s) to be used: 3 CHAMBER DECON I. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (q): 2 PLY POLY 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: d. Insulating cement Lin Sq. c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver # f. Trowel/Sprayer coatings Lin. ft. Sq. ft. h. Transite board, wall board Lin Sq. ft. _0 j. Other, please specify: Lin. ft. -0 So. ft. I. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (q): 2 PLY POLY 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a. Name of DEP Official b. Title c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver # e. Name of DOS Official f. DOS Official Title g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver # N _0 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes ❑✓ No -0 B. Facility Description f�N RESIDENTIAL �0 1. Current or prior use of facility: �o _ 2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No RICHARD RIKER 18 EDMUND ROAD 3' a. Facility Owner Name b. Address �0 NORTH ANDOVER, MA 01845 201-519-7962 o c. Ci /Town d. Zip Code e. Telephone Number area code and extension amU_ 4. a. Name of Facili Owner's On -Site Manager b. On -Site Manager Address M!MOMMEMMOZ Q �Q c. Cityfrown d. Zip Code e. Telephone Number (area code and extension) anf001 ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 Note: Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 B. Facility Description (cont.) 5' a. Name of General Contractor c. Ci /Town d. Zip Code f. Contractor's Worker's Comp. Insurer 6. What is the size of this facility? 100091137 Decal Number b. Address e. Telephone Number area code and extension q. Policv Number h. Exp. Date mm/dd a. Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos -containing material from site to temporary storage site (if necessary): AIR QUALITY EXPERTS, INC. a. Name of Transporter c. City/Town d. Zip Code 2. Transporter of asbestos -containing waste material SERVICE TRANSPORT GROUP, INC. a. Name of Transporter BRISTOL, PA 19007 c. Cit /Town d. Zi2 Code 3. a. Refuse Transfer Station and Owner 4. IMINERVA ENTERPRISES INC MINERVA ROAD e. State D. Certification b. Address e. Telephone Number from removal/temporary site to final disposal site: dd. Zip Code e. Telephone Number PRESIDENT 07/06/2009 b. Final Disposal Site Location Owner's Name d. Date mm/dd/ i WAYNESBURG JAIR QUALITY EXPERTS, d. Ci /Town 44688 23 HALL FARM ROAD f. Zip Code g. Telephone Number The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. ICHRISTOPHERTHOMPS1 IChristopher Thompson a. Name b. Authorized Signature PRESIDENT 07/06/2009 c. Position/ritle d. Date mm/dd/ i 6038946465 1 JAIR QUALITY EXPERTS, e. Telephone Number f. Representing 23 HALL FARM ROAD q. Address ATKINSON, NH 03811 h. City/Town I. Zip Code anf001 ap.doc - 10/02 Asbestos Notification Form - Page 3 of 3 This certifies that ..... %&--A..... (.................................................... has permission to perform ....i �. ............ Date ..... 4,1 .1••�/......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING plumbing in the bujdc *ngs of........... at./9 ... c r ........................ Fee- .. v.0. Lic. No. C( .9, Check # z 3o ;�-- ...... ................. , North Andover, Mass. Pi. 6 I�PTO-R V f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY -L I MA DATE PERMIT # JOBSITE ADDRESS S1 ✓Citi ,n OWNER'S NAME POWNER ADDRESS VVI TELE,FAX } TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL O RESIDENTIALE 11 PRINT CLEARLY NEW: O RENOVATION: REPLACEMENT: DiPLANS SUBMITTED: YES Q NO FIXTURES -1 FLOOR--> M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB f 9_n1======= CROSS CONNECTION DEVICE _.r__ JE---I DEDICATED DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM —__1 [_____J .._...._i ____ DEDICATED GRAY WATER SYSTEM (- DEDICATED WATER RECYCLE SYSTEM I DISHWASHER E ___J __j DRINKING FOUNTAIN ! FOOD DISPOSER FLOOR/AREA DRAIN 1 f INTERCEPTOR (INTERIOR) KITCHEN SINK I _. J ,__ _.___! __.__..__(-_-___(! ! _._..__ ._..._.._t _ ! . 6' ._ ._ —J= LAVATORY ROOF DRAIN_f ! I .---f ____E _.._..! ___ .! ._._._i ._.__ .--_-__-( --.._- f----._._ J l _J ( SHOWER STALL SERVICE /MOP SINK (_..___.A _.-___I TOILET URINAL -__J WASHING MACHINE CONNECTION _ _( ! _._.. s 4 _ i .. _..3 _j _.E WATER HEATER ALL TYPES WATER PIPING OTHER __j _j I__._! ___-._! ! i--_._# .------- ._-`` ...__-.-f I ._..._I f f - — — _'..�E ....__......._I __..___k _-____E E ____I ._., i ___. _( -.__-_ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES , . NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Di OTHER TYPE OF INDEMNITY Q BOND O 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 10 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 compliapee with rti t pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELAZ41aa LICENSE # SIGNATURE YIP Ell JP fta/0" CORPORATION . i #©PARTNERSHIPO# LLC COMPANY NAME ADDRESS CITY _ ISE- _..._..._.__f STATE ZIP 7 I TEL FAX CELL f EMAIL J H O O H U W a w oo z N O ~ W ❑ CIO W O u W z p ¢ w M LLI w c a O z a W F- CL IL C/3 ui x w LL H F+' U a z a The Commonwealth o, f'Massachusetts - Department of IndustritclAceldents O, lee of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia 'W orkexs' Compensation Insurance Affidavit: But tiers/Cont°actors/Eiectr i.ei .A.pplieant IMormation _ • Pleas Name (Busyness/OrganizationLindividual):Y_ . Address: 00 4 G � G City/StateMp:!�)ti %� /7 Phone #: �(j 27 l Are you an employer? Check the appropriate box: Type of project (required): LEI I am a employer with 4-E] I am a general contractor and I 6. ❑ New construction oyees(fulland/or part time)* Va�mp have Rued the gab -contractors listed on the attached sheet. ❑ Remodeling 7.2, a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. ❑ Demolition 8. working forme in any capacity. workers' comp. insurance. g, L] Building addition [No workers' comp. insurance 5. ❑ We area corporation and its 10.[] Electrical repairs or additions required.] 3. El X 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.QRoofxepairs insura-acarequire4.1 employees. [No workers' 13.❑ Other comp. insurance required.] ,!Any applicautthat checks box#1 must also fill outthe section bel6w showing their workers' compensationpolicy information. T'Homeowners who submit this affidavit indicatingtfiq Aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheAthis box must affached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information. lam an emyloyer that is providing workers' compensation insurance for my erriployees Below is thepolley andjob site Yinformation. insurance Company N, Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach, a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure covexage.as requ4 dunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do Hereby ce/rt�" V uit' er tI ai ripe Ities ofperpry that ti information provided aboveistrue and correct. Signature: // �-� 7 Date: 9— C• ^ ` official use oxi. 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 S. Plumbing inspector 6. Other Contact Person: Phone #: Information and Instructio s Massachusetts General Laws chapter 152 xequires all employers to provide woxkers' 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 j oint enterprise, and including the legal representatives of a•deceased employex,. or the receiver or inistee 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 o coupant 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 beenpresentedto the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, X necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation. insurance. 1f an LLC or LLP does have employees, a policy is xequired. Be advised thatthis 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 *orkers' compensationpolicy, 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. Th addition, an applicant thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current PORGY information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or towh.). " A- copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit -lion file for future Hermits or licenses. Anew affidavit must be filled out each year. "Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit 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: TN Co onwsalihofMassachv.:sPi�s DapaxI eAt ofIndus-Wal A,ccidento offloe ofJAVesugWoua. 60 W45bi tgoa Street B0ston4 02111 Tel. ff 61.7-7-27-4.900 at 406 or 1-877-MASSAFE Revised 5-26-05 Fax 0 617-727-7749 ' vFw4v.S�aS�,g4v�ci%a Location �Mt7-s S'7— No. 2- Date cit TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 11 /1,7 1 102 9317 40,00 PAID $ Building Inspector Div. Public Works PERMIT NO. SS'Z n d APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP d,40.©0 LOT NO. 2 RECORD OF OWNERSHIP IDATE (BOOK ;PAGE — ZONE I SUB DIV. LOT NO. LOCATION i PURPOSE OF BUILDING (11vsC l• -•V OWNER'S NAME ? I /1�/�, h,25 !Gl [/✓// /C�. J� 4/ i 1h,259:5 NO. OF STORIES SIZE OWNER'S ADDRESS L `�� . s!/!�� G f/ /✓ BASEMENT OR SLAB ARCHITECT'S NAME - SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �JLj�`J� SPAN DISTANCE TO NEAREST BUILDING %J �J �x/`' N' _— DIMENSIONS OF SILLSo -- --- DISTANCE FROM STREET W ``L1L7}' , /`^�/� !/ fRREAR '. POSTS DISTANCE FROM LOT LINES — SIDES �/G� ! :J " GIRDERS AREA OF LOT FRONTAGE IGHT OF FOUNDATION THICKNESS IS BUILDING NEW WE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION gyp, t IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM T6 REQUIREMENTS OF CODE v C d J BUILDING CONNECTED TO TOWN WATER�e J BOARD OF APPEALS ACTION. IF ANY S BUILDING CONNECTED TO TOWN SEWER Ll/� S BUILDING CONNECTED TO NATURAL GAS INE INSTRUCTIO S SEE BOTH SIDES x./17////���� A 6C- `ITT PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE F ED SIGNATURE OF OWNER OR AUTHORIZED AGENT ' d FEE PERMIT GRANTED Q 19 l 3 PROPERTf INFORMATION LAND COST ,FAT. BLDG. COST EST. BLDG. COST PER 6Q. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY OUILDINO INSP[CTOR OWNER TEL. JI 75/ CONTR. TEL. # CONTR. LIC. # H.I.C.# 1©65-72 BUILDING RECORD 1 OCCUPANCY HOT W'T'R OR VAPOR 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- AGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. INGLE FAMILY-0' MULTI. FAMILY :::J-!OFFICES WOOD RAFTERS _ APARTMENTS I CONSTRUCTION 2 FOUNDATION RADIANT H'T'G 8 INTERIOR FINISH CONCRETE PINE B 1 2 13 _ CONCRETE BL K. —I BRICK OR STONE HARDw D PIERS PLASTER _ ELECTRIC DRY VIALL UNFIN. 1st 13rd NO HEATING _ 3 BASEMENT AREA FULL FIN. B M AREA '/. 1/2 '/ FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS CONCRETE EARTH -HARD-D COMIACN ASPH. TILE B 1 2 3 �_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR II POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBRELMANSARD HIP BATH (3 FIX.) TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING 6 FRAMING 11 11 HEATING i - STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING 0 x w v ° w° � L p U) (n z z A m °- [i E U c ii Ow (A Z co m a m a rz° c x 0.4oa � W° � w°' cn w U rL � � = r� c° x d w w v cA z to .� cn o =a U v� : a co z V U O.� C C R R Q C Ocs N p Q ...CA Qq C/) Y E S Z c � o m C �+ ux M € U V' p N N ' c 7 m � N _R m c N N o �O C W m U m O ►-1 d: cpa � W acr n ....: mor in V N O L Q V �Z O C O` O C H y m C c cm H CD O COD r O L r O W c0 -2 = .� E v:;;vN p C.3 CD O_ O O O COO _ i p aim l•7 U Cl s NO 2 co cm Ip.— y O �O mm CD 3� co L Cc o Cl. CL CMa CA 0 = c v J � O CD c Z V h C 0. M M �l Z2 F/! " HEIGHT: THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF THE HOLDER WHEN EN - OTHERS • RIGHT THUMB PRIM I GAGEOINTHISOCCUPATION. NOT VALID UNTIL SIGNED BY �C �SEE AND OFFICIALLY IG � STAMPED - OR - SklRE OF iN IAI�SIONER `I SIGN-AnURE OF LICEMEE _oNER MSIGN NAME IN FULL ABOVE SIGNATURE LINE t -• COMMONWEALTH OF DEPARTMENT OF PUBLIC SAFETY 1010 COMMONWEALTH AVE. _ MASSACHUSETTS BOSTON,_IAA 02215 1 r- EXPIRATION DATE : r' - - '' CAUTION { RESTRICTIONS EFFECTIVE DATE LIC -NO. FOR PROTECTION AGAINST THEFT, PUT RIGHT THUMB o - PRINT IN APPROPRIATE BOX ON LICENSE. c fl BLASTING OPERATORS MUST INCLUDE PHOTO. ( PHOTO (BLASTING OPR ONLY) FEE: - HEIGHT: THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF THE HOLDER WHEN EN - OTHERS • RIGHT THUMB PRIM I GAGEOINTHISOCCUPATION. NOT VALID UNTIL SIGNED BY �C �SEE AND OFFICIALLY IG � STAMPED - OR - SklRE OF iN IAI�SIONER `I SIGN-AnURE OF LICEMEE _oNER MSIGN NAME IN FULL ABOVE SIGNATURE LINE - SG�C.+E.:� �' a ZC� �Fi�'�.: SAw.1. l4._ s4a 1✓ '�`` :, �, r,)k y1 C=-. 44v-*- C..G. i ! "- L_ ztc juG lM L5 U V E U L JAIL 14 19-02 LBLILDMIG S G�iLTIF'Y T1.1 01= FS�T� S+dow►,,j AI�,� �+o�,. TFtE, TFl E. o F; -v- S@."tr'S. VSE o F' —1714 E. 8 V t . p Ad G = u S�1oW�i Ccstr�PCy LZ�-%Y 124—A W rrri TKEzQ►.1IUGt-AP W-tel►u ATIoU.i o1= Ir.e�s,�G. Alffl�Y 4.lNE.tt1 CoU3T�.t�GYe—fl, Ar t l z•4•t R2 mm i «i7DT1Gl✓'� 'J Q X �i o _ EiXl4STt�Ce i ! "- L_ ztc juG lM L5 U V E U L JAIL 14 19-02 LBLILDMIG S G�iLTIF'Y T1.1 01= FS�T� S+dow►,,j AI�,� �+o�,. TFtE, TFl E. o F; -v- S@."tr'S. VSE o F' —1714 E. 8 V t . p Ad G = u S�1oW�i Ccstr�PCy LZ�-%Y 124—A W rrri TKEzQ►.1IUGt-AP W-tel►u ATIoU.i o1= Ir.e�s,�G. Alffl�Y 4.lNE.tt1 CoU3T�.t�GYe—fl, Ar t l z•4•t R2 mm Location C7-/, No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 7C Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee Sewer Connection Fee at6r,,Connection Fee $ do TOTAL Building uilding Inspector Div. Public Works / PER.AU - NO. O v f APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. I,/ PAGE 1 MAP_ ;VO. LOT NC. R AUT RI D AGENT 2 RECORD OF OWNERSHIP '.DATE BOOK '.PAGE ZONE SUB DIV. LOT NO. LOCATION I('y -�_JIM k5jSD_ PURPOSE OF BUILDING Ljj1^ OWNER'S NAME W I'� I ��YL a„ p �� l/ 1"�1 2'y1 !(ED`S, NO. OF STORIES / SIZE y OWNER'S ADDRESS J Q CaM _ V �i fMQ ,/s _� ,�V' BASEMENT OR SLAB/ C rA- -D� ARCHITECT'S NAME i, i n t SIZE OF FLOOR TIMBERS IST I 2ND 3RD BUILDER'S NAME KGS v I, -q , -&I I - SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES /z I REAR,3e3'j_ 1 GIRDERS AREA OF LOT &0Q0 Sr VV FRONTAGE Ly�� �V HEIGHT OF FOUNDATION THICK ESS SIZE OF FOOTING X IS BUILDING NEW IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND 0 1 j l WILL BUILDING CONFORM TO REQUIREMENTS OF CODE �G�' IS BUILDING CONNECTED TO TOWN WATER y�5 BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER f OJe5 IS BUILDING CONNECTED TO NATURAL GAS LINE es INSTRUCTIONS SEE BOTIJ SIDES PAGE 1. FILL OUT SECTIONS 1 - 3 i PAGE i2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED /AND APPROVED BY BUILDING INSPECTOR DATE FILED / SIGNATURE - WNE R AUT RI D AGENT OWNER TEL. # / CONTR. LIC. k PERMI G N D JAN 14- Rp? i, i n t 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INS CTOR BUILDING RECORD 1 ) CCUPANCY 12 SINGLE FAMILY IES rOiFQORFTC MULTI. FAMILY ES APARTMENTS q CONSTRUCTION 2 FOUNDATION %'7 S INTERIOR FINISH CONCRETE PINE 3 1 2 13 _ CONCRETE BL'K. BRICK OR STONE HARDW D_— PIERS PLASTER DRY WALL UNFIN. _ 3 BASEMENT AREA FULL FIN. B'M'TAREA _ V, 1h '/. N_O B M'T FIN. ATTIC AREA FIRE PLACES _ _ HEAD ROOM MODERN KITCHEN 4 WALLS II 9 FLOORS CLAPBOARDS B 1 X 2 �_ _ 3 _ DROP SIDING WOOD SHINGLES ASPHALT SIDING CONCRETE EARTH HARDW D ASBESTOS SIDING COMIAGN VERT. SIDING ASPH. TILE STUCCO ON MASOt;IRY STUCCO ON FRAME BRICK ON MASONRY;_ BRICK ON FRAME ATTIC STRS. 8 FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY ST NE ON jRAME 1 SUPERIOR ADEQUATE I-1 POOR NONE 5 OF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS X AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GOAL B'MI 2nd I _ 1st 3rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. to O O z LU am > W o � �X W eke c; C� 00 LLJ 0- O 0o c �C O N Z o: U V) W J ZD S 1 L a W) C WD .0 oe oc oc 0 O ~ v oc W d H 0 Z Z Z O Z z V zr H W in V E 96 7 J W L L O Y C 3 C 7 C O Q cr w 2 U U. ii U) iI Q ii m LU am > W o � �X W eke c; C� 00 LLJ 0- O 0o c �C O N Z o: U V) W J ZD S 1 L a W) C WD .0 Location Date l% No. TOWN OF NORTH ANDOVER Certificate of Occupancy $s--00 Building/Frame Permit Fee $ Foundation Permit Fee $ ------ Other Permit Fee $ i Sewer Connection Fee $ Water Connection Fee $ ---- S, rs+� TOTAL Building Inspector Div. Public Works FOM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRES (AS IGN D BY D.P.W. STREET APPLICANT %/I�` j PHONE bg3'70,( 2 DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER llATE REJECTED CONSERVATION C MMISSION DATE APPROVED f/ CONSERVATION ADMIN. DATE REJECTED BOARD OF HEALTH llA'I:E APPROVED HEALTH SANITARIAN DA'Z'E REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY . PERtIIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION,. T" � 0 U f DATE 11 n .... _ ..__. IBUILDING DEPAR -MENTI This form shall be signed by the agents of—th- ann ng and"Itealth Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. I GEeT I Fri eO F0;u L-1 AF+tT1 C ►.1 R_ A lrocprr�o to t-1 vmr&a Q�yoy�tz.�N[ass S c oo► c. _E, :1 " = 20' 'p, ,-t=, : -7:j-plK-A. 14-,, t4q 2 c2rT1-1 A u fl av E.� Nt A 5S. I LOT 14� L1.0 . 88 1 3 12:1 �1 l T Z�/2 Sro2y � lilt Exts� G -s Af2. t � JAN 1 412CCD A o '3 L I12�IE tG r- , = G�.tZ.Tir-Y T1.1Arrc tel=S�T� S�-1aw►J AiZE �o� THE THE. dF'FSt�Ts uS�C. ©� Tt+4e- 1�>Utt.pttjC-a 7= *.FV.,=M W rr-H THEzot.11UCs �E•TE�CZt..�►�..J A`T'tot, 1 pl= �ot.1 I�JG �f l__.Ava lS o l� CiouFp2.M Ty oQ� Uot.1 Co1� F-o2�'i f7"Y LLg9=r-H A U floNE.P w H t. t.1 Co u ST tZ.t,GT�D. am 13M CERTIFICATE OF USE & OCCUPANC 7own of North .$`sr' A} iia ` ' r Building Permit Number 0 1 5 Date AUGUST 25, 1992 THIS CERTIFIES THAT THE BUILDING LOCATED ON 18 B D M A N D S ROAD MAY BE OCCUPIED AS LIVING ROOM W /BATH IN ACCORDANCE. WITH THE PROVISIONS OF THE MASSACHUSETTS STATE MOLDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. of NORTH 9 02 yet `EDa, 0 m CERTIFICATE ISSUED TO W i t t i a m W i t k i n z o n "af 18 B man b R ADDRESS No,%th Andoven MA Building Inspector a O V4,r= uj• • L m a w O, o: -=== oLU, Z 0 ceo am J �1 i V4,r= �j A W 0 Q OAFm r U Z v 0 2t 0 c 3 0 rte. O U r � ` O a 4 t- W-2 h J is r in r N �3 " •jai+ 1101-,0 0 W 0 a a a Z 0 N i o o w � CL n A� s i ! i N �3 " •jai+ 1101-,0 0 W 0 a a a Z 0 i i Locati M Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee f, Sewer /Connection Fee Water Connection Fee TOTAL Building Inspector Div. Public Works PERMIT NO. 0 � APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP dJO. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE ZONE SUB DIV. LOT NO. �— LOCATION i r/ PURPOSE OF BUILDING OWNER'S NAME J! 1! NO. OF STORIES BASEMENT OR SLAB �./ _ OWNER'S ADDRESS A ,8 �(•`®�Au O L.aG(6f�� ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 9 SPAN _ _ DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR "' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FAILED AND APPROVED BY BUILDING INSPECTOR DAT"ILED �/ / 7 SIGNATURE OF GKVNER OR AUTHORIZED AGENT FEE PERMIT GRANTED ,9 V MAR - 6 OWNER TEL N -wl�%,3 7 CONTR. TEL. M �' 3 PROPERTY INFORMATION LAND COST .✓i EST. BLDG. COST ' / ©6l EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY r BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S -ORES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION !I .8: INTERIOR FINISH CONCRETE PINE HARDWD B _ 1 _ 2 13 _ _ CONCRETE BIL K* BRICK OR STONE PIERS PLASTER DRY, WALL _ _ _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T AREA, _ '/, '/� 3/, FIN. ATTIC AREA NO B M FIRE PLACES _ _ HEAD ROOM MODERN, KITCHEN -77 4 WALLS I 9 FLOORS CLAPBOARDS CONCRETE EARTH HARDW'D B _ 1 22 f 3 I_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING COMMON ASPH. TILE VERT. SIDING STUCCO ON MASONRY STUCCO ON FRAME _ .BRICK ON MASONRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I -I POOR--]_ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD A TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. _ STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS' _ 7 NO. OF ROOMS GAS .' OIL B'M'T 2nd _ Ilk 13rd I ELECTRIC'S`' ' NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. ,l 4! In pry IKO ' Ault, gL�!LL 'V. oe 99 G et a V as .., 2 d ., w G y O d E E O r u ccO a W N W W Z Z Z LL � 0 Z W O z Z V CIC m � � � • a 7 o t o o m.� o E CC U LL c LL cc C0 LL Q lL m (A gL�!LL 'V. A.:_ s. G a V as .., 2 d ., w G y O d E E r u gL�!LL 'V. z 4 h Z s H > w W) !X 7 LLJ OD ai F— C G c° W m ICL O eke G c 0 N a+ r 0 z E" Q ri O I V) W n Sil H H .E ba CL. S O V tv 1 rte, 00 a a c Ir A.:_ F O a V as .., 2 d ., w ar �> O V d z 4 h Z s H > w W) !X 7 LLJ OD ai F— C G c° W m ICL O eke G c 0 N a+ r 0 z E" Q ri O I V) W n Sil H H .E ba CL. S O V tv 1 rte, 00 a a c Ir Location /8 Z 4M V'y mss" + No. 3190 Date Q S,. TOWN OF NORTH ANDOVER o• • s Certificate of Occupancy $ Mus EI Building/Frame Permit Fee $ 3� nc Foundation Permit Fee $ Other Permit Fee $ TOTAL $ iCheck # `f -0 Y 7846 Building Inspector f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 7fiW' BUILDING PERMIT NUMBER: 77D I DATE ISSUED: SIGNATURE: ( 64 Building Comim'ssioner/InEeEtor of Buildings Date 1..�1 Property Address. ,G ee4a,--16 /0 1.2 Assessors Map and Parcel 020 - Map Number Numb?),d -696!e�' Parcel Numbs //i 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided RaqWred Provided 1.7 water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ -\. "1v A- K �r r'.it. J i V TV I" R&aK2Xf1'%%J r Ja%JXLi1S•L At7MI'l 1 I " " v� .� i r r v �. r c � I "-j 1 2.1 Owner of Record 2.2 Owner of Record: Name Print 4 SECTION 3 - 3.1 Lice c Licensedy4sti Ad Signature 3.2 Registered F Company N[jrne T SERVICES Improvement Contractor Telephone Address for Service Address for Service: I CIC -111 Not Applicable ❑ 0, 2, License Number 040 Expiratio D to Not Applicable ❑ Registration Number Expiratio I 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 it. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work 1 SFCTION 6 - F.STIMATF.D CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Co eted by permit applicant OFFICIAL USE ONLY 1. Building /9 (�(✓ '�'� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing 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 O�R CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Herebv authorize !�(/��,e�ll �Y. to act on by this building permit Si ature of Owner Z / Date 4J SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION IP 1, 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 Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2 ND SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 3 IN 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: (Location of Facility) Signature of ermit Applic t Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector E The Commonwealth of Massachusetts Department of1ji dustrial Accidents Office of/m/estigamolls 600 Washington Street, 7"h Floor Boston, Mass. 02111 tion - - Insurance Affidavit: Building/Plumbing/Electrical Contractors I am a homeowner peTfon-ning all work myself. Project Type: El New Construction Remodel I am a sole Proprietor and have no one working in any capacity. El Building Addition I am an employer o.viding workers' compensation for my employees working on this job. Y 0M lihone 4: 13 JU3 ranee Co. 'ZIAVO INV C. v *# xclo I am a sole proprietor, general contractor, or li -o--m-e—o--w--n,^,e,,ri --(c--r-cle one) and have hired the contractors listed below who have the following workers' compensation polices: company: name: address: city: 7 4 insurance -co . 07 &.71. OX Dol1cv;.# 4 TAM Company name. address: city: p6iie M a. insurance co. policy # y#Jl"'M +Y7 rig Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP 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. .1 do hereby c 'pli4 under d pains and e all' ry th a e information provided above is trite and correct. ah ken tes o pe uh Signature Z� I I �Kz // Aezl Print name official use only do not write in this area to be completed by city or town official city or town: permit/license # —E]Building Department El check if immediate response is required ElLicensing Board ElSelectmen's Office contact person: phone #; E)Health Department (revised Sept. 2003) E]other Workers' The Commonwealth of Massachusetts Department of1ji dustrial Accidents Office of/m/estigamolls 600 Washington Street, 7"h Floor Boston, Mass. 02111 tion - - Insurance Affidavit: Building/Plumbing/Electrical Contractors I am a homeowner peTfon-ning all work myself. Project Type: El New Construction Remodel I am a sole Proprietor and have no one working in any capacity. El Building Addition I am an employer o.viding workers' compensation for my employees working on this job. Y 0M lihone 4: 13 JU3 ranee Co. 'ZIAVO INV C. v *# xclo I am a sole proprietor, general contractor, or li -o--m-e—o--w--n,^,e,,ri --(c--r-cle one) and have hired the contractors listed below who have the following workers' compensation polices: company: name: address: city: 7 4 insurance -co . 07 &.71. OX Dol1cv;.# 4 TAM Company name. address: city: p6iie M a. insurance co. policy # y#Jl"'M +Y7 rig Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP 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. .1 do hereby c 'pli4 under d pains and e all' ry th a e information provided above is trite and correct. ah ken tes o pe uh Signature Z� I I �Kz // Aezl Print name official use only do not write in this area to be completed by city or town official city or town: permit/license # —E]Building Department El check if immediate response is required ElLicensing Board ElSelectmen's Office contact person: phone #; E)Health Department (revised Sept. 2003) E]other T Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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. v. � �.: m 5' :�.� - r ,�.. r ku-x �..r hs � '`t" �. �' Yx'x92i J' a'i3 � 3 �,a'' br 5 ^.-"+.4'" _ ke y.� '4P��..' �" �-�'- •. �t _' �'. , 4 ,,,e,afi� rrsr.k�>t��iu� �'�t�� �1r� ,_��^�`�.�€x Rr• , � rr��'�sr�t���'s,�T 7d"�x.� . F ���� Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 member listed below. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. Y t c 'r. .ry ,� r i t S +} 5 ii, t ix+. z i%ry-k Ews �jp,,,t1 f i 1 ..s k'.. ..t . -} .lr £ r��!. i +. 4 {",.,L. , } r r.3y i':-iwu�hs�«r61�2 The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street '71b Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 CA rA co 0�: O C c CID 0 CD 3� -o O Q o C- Q. CD< c �p� C JO 00 O Z 4D C. W C uj LU U) W W W U) : C C a a a O CN O C U V a UW aO d C O :mc :moo oCD CD Ea w c a ON a y ?oam w C7 w 2 CD0 IL. U w :tsca O C acis E mm o C3 �m3; y t O �� 0 cn O C c CID 0 CD 3� -o O Q o C- Q. CD< c �p� C JO 00 O Z 4D C. W C uj LU U) W W W U) : C C ' m C :;F 4 O CN O C U V aO d C O :mc :moo oCD CD Ea w c :z ON a y ?oam CD0 IL. :tsca O C mm C3 �m3; y t O �� o p : _ y W y C y cv COM /, •; dJ m Q ♦7 �� � C y Q O C1 y CD Z m d C Q = O O ` m C 0:5 Cpp N ~ S C, ~ yCOD • O� W a0.. O 'mo W 44 �E COL6 v��y o COD d •� O�8 CA m CD =tea.-m� O C c CID 0 CD 3� -o O Q o C- Q. CD< c �p� C JO 00 O Z 4D C. W C uj LU U) W W W U)