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Town of North Andover
�o * 1600 Osgood Street
R �"��K•�" Bldg.20 Suite 2-36
��SSgcHus� North Andover,MA 01845
Phone: 978-688-9545
Fax: 978-688-9542
Gerald Brown,Inspector of Buildings
January 4,2011
BY HAND
Joseph M.Pelich
1915 Great Pond Road
North Andover,MA 01845
Re: Pro er : 1915(a.k.a.,Lot 1)Great Pond Road(Assessors Map 35,Lot 108),and
0(a.k.a.,Lot 2)Great Pond Road(Assessors Map 35,Lot 61)
Zoning Determination
Dear Mr.Pelich:
I have met with Attorney John Smolak and reviewed the materials he had provided to
me in our meeting on January 3,2011,including the attached recorded Site Plan,to determine
whether Lot 2 would constitute a buildable lot.
Based upon the information provided,it appears that the ANR Plan which created Lots 1
and 2 was endorsed by the Planning Board on April 22,1985,and recorded with said Deeds as
Plan No.10041. Thereafter,it appears that both lots were conveyed to separate parties. At the
time ANR Plan was recorded,the R-1 Zoning required a minimum of 1 acre of lot area,and a
minimum of 150 feet of street frontage.
At the Annual Town Meeting in May,1987,the R-1 minimum lot size and lot frontage
were amended by Article 8 to require 2-acre zoning and 175 feet of frontage within the R-1
Zoning District.. Since the creation of each lot,as depicted on the Site plan,predated the Town's
amendment of the R-1 Zoning District in 1987,the 1987 zoning amendments with respect to
minimum lot size and minimum street frontage do not apply to either Lot 1 or Lot 2 pursuant to
Section 6 of M.G.L.c.40A. Therefore,Lot 2 is a buildable lot,separate and apart from Lot 1.
However,the development of Lot 2 would first require the issuance of a Watershed
Protection District Special Permit issued by the North Andover Planning Board in accordance
with the Watershed Protection District requirements under Section 4.136 of the North Andover
Zoning Bylaw,and based upon my experience with such approval process,there is no reason
why such a Special Permit would not be issued in due course.
Please let me know if I can be of further assistance.
Sin�ely,
r/f,,,w,�� w
Gerald Brown
O Inspector of Buildings
Enclosure
1
John T. Smolak, Esq.
SMOLAK & VAUGHAN T- 978-327.5215 ( F:978-327-52111
i T rd F . c, f L ,, ;i.
January 3,2011
VIA EMAIL
Gerald Brown
Building Commissioner
Building Department
Community Development Division
Town of North Andover
1600 Osgood Street
North Andover,MA 01845
Re: Pro er : 1915(a.k.a.,Lot 1)Great Pond Road(Assessors Map 35,Lot 108),and
0 (a.k.a.,Lot 2)Great Pond Road(Assessors Map 35,Lot 61)
Request for Zoning Confirmation
Dear Gerry:
As a follow-up to our meeting on January 3,2011,this firm represents Joseph
Pelich regarding the lots referenced above. As we discussed,Mr.Pelich is requesting
confirmation from you,in accordance with Section 7 of M.G.L.c.40A, that Lot 2 as
shown on the attached site plan is a buildable lot.
OTheProperty
The record owner of 1915 Great Pond Road is 1915 Great Pond Road Nominee
Trust,on which is Iocated Mr.Pelich's residence("Lot 1"). A copy of the latest deed
into the owner of Lot 1,which was recorded with the Essex North Registry of Deeds in
Book 10761,Page 240,is attached. Lot 1 is depicted on the Town of North Andover
Assessors Maps as Map 35,Lot 108.
The record owner of 0 Great Pond Road is Cochichewick Realty Trust("Lot 2")
which remains an undeveloped lot. A copy of the latest deed into the owner of Lot 2,
which was recorded with said Deeds in Book 6783,Page 345,is also attached. Lot 2 is
depicted on the Town of North Andover Assessors Maps as Map 35,Lot 61. Copies of
the Assessors Cards for both Lot 1 and Lot 2 are attached.
Both Lot 1 and Lot 2 are depicted on a plan entitled"Plan of Land Located in
North Andover,Mass.Owned by Richard Parziale," dated March,1985,and recorded
with said Deeds as Plan No.10041 (the"Site Plan"). The Site Plan was also endorsed as
"Approval Not Required" by the North Andover Planning Board on April 22,1985 prior
to recording("ANR Endorsement").
The Site Plan depicts Lot 1 as having 45,894 s.f. (1.05 ac)of land,with 150 feet of
frontage on Great Pond Road. The Site Plan depicts Lot 2 as having 49,200 s.f. of land,
with 150 feet of frontage on Great Pond Road.
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{00022360,N I jEast Mill,21 high Street.Suite 301,North Andover.NIA 01845
W\'1'\A'.SN, IOLAKVAUGIIAN\ 0019
SN1OLAK & VAUGHAN LLP
Gerald Brown
Building Commissioner
January 3,2011
With respect to current zoning,both Lot 1 and Lot 2 are located within the
Residence 1 (R-1)zoning district as described in the Town of North Andover Zoning
Bylaws. For lots within the R-1 Zoning District,the Minimum Lot Area is 87,120 s.f. (or
2 acres),and the Minimum Street Frontage is 175 feet.
At the time of ANR endorsement in 1985, the Minimum Lot Area was one acre,
and the Minimum Street Frontage was 150 feet,for a lot located within the R-1 Zoning
District. At the Annual Town Meeting in May,1987,the R-1 miiumum lot size and lot
street frontage were amended by Article 8 to require 2-acre zoning and 175 feet of
frontage for lots located within the R-1 Zoning District.
Since the creation of each lot,as depicted on the Site plan,predated the Town's
amendment of the R-1 Zoning District to thereafter require,a Minimum Lot Area of 2
acres,and Minimum Street Frontage of 175 feet in 1987(colectively, the 1987 Zoning
Amendments"),the 1987 Zoning Amendments do not apply to either Lot 1 or Lot 2
pursuant to Section 6 of M.G.L.c.40A. As a result,Lot 2 is a buildable lot,separate and
apart from Lot 1.
Further,both Lot 1 and Lot 2 lie entirely within the Watershed Protection District
as defined under Section 4.136 of the Zoning Bylaws. Since the Property was depicted
O on a lot which was recorded before the date of enactment of amendments to Section
4.136 on October 24,1994,the zoning amendments and new zones created on that date
under Section 4.136 do not apply to the Property. But if Lot 2 was to be developed, the
developer of such lot would need to obtain a Watershed Protection District Special
Pernut issued by the North Andover Planning Board in accordance with the Watershed
Protection District requirements in effect prior to 1987,and there is no reason why such
a Special Permit would not be issued in due course.
Accordingly,since Mr.Pelich has asked that we seek this determination from
you as part of a financing,we request your zoning confirmation of the items described
above,addressed to Mr.Pelich,at your earliest convenience. Thank you.
Si -erely,
i �JG'vt�
ohn T.Smolak
JTS/
•
- Bk 10761 PS240 115770
05-23-2007
QUITCLAIM DEED
John R.Keilty,Trustee of the Great Pond Realty u/d/t dated April 18,2002 and
recorded with the Essex North District Registry of Deeds in Book 6783,Page 338,for
nominal consideration of less than One Hundred Dollars paid, grant to Joseph M.
Pelich,Trustee of the 1915 Great Pond Road Nominee Trust,u/d/t dated May /:!�,
2007 and recorded with the Essex North District Registry of Deeds herewith and a
mailing address of 38 Sargent Street,North Andover,MA 01845,with Quitclaim
Covenants,
dover
7
A certain parcel of land on the northerly side of Great P d Road,NOrth� entitled Essex
County,Commonwealth of Massachusetts,being sho as Lot#1 on aP n entialetled
See
"Plan of Land located in North Andover,Mass.,Owned
arzi
1"=501,dated March 1985,drawn by Merrimack Engineering Services,Andover,Mass.,
filed with North District of Essex Registry of Deeds as Plan.#10041. Said Lot#1 is more
particularly bounded and described as follows:
NORTHERLY by land now or formerly of Angus Realty Trust,in two lines
having a total length of one hundred fifty and no/100(150.00)feet;
b other land now or formerly of Richard F.Parziale,being Lot#2
- EASTERLY Y
on said plan,three hundred and nine 97/100(309.97)feet;
SOUTHERLY by the northerly line of Great Pond Road,one hundred fifty and
no/100(150.00)feet;
WESTERLY by land now or formerly of Joseph and Patricia Bartolotta,three
hundred fifteen and 60/100(315.60)feet.
Containing 45,894 square feet of land according to said plan.
For Grantor's title see deed of Alfred Matthews,
In dated April 18,2002 and recorded
with the Essex North District Registry of Deeds in Book 6783,Page 341.
Executed under seal this eday of May,2007.
fitness J n R.Ke' ru ee
rent Pond al rust
�b� 1
f
Bk 10761 Pg 241 #15770
COMMONWEALTH OF MASSACHUSETTS
Essex,ss.
On this day of May,2007 before me,the undersigned notary public,personally
appeared John R.Kellty$Trustee of Great Pond Realty Trust proved to me through
satisfactory evidence of identification,which was a driver's license,to be the person
whose name is signed on the preceding or attached document in my presence
6M'
otary PU Ii
My commission expires:
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O O O
Residential Property Record Card
PARCEL ID:210/035.0-0108-0000.0 MAP:035.0 BLOCK:0108 LOT:0000.0 PARCEL ADDRESS:191SLOT 1 GREAT POND ROAD FY:2011
PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 10761 Road Type: T Inspect Date: 04/09/2008
Tax Class: T Sale Date: 05/22107 Page: 0240 Rd Condition: P Meas Date: 03/25/2007
Owner: Tot Fin Area: 4096 Sale Type: L Cert/Doc: Traffic: M Entrance: X
PELICH,JOSEPH M. Tot Land Area: 1.05 Sale Valid: B Water: Collect Id: SGC
Address: Grantor: KEILTY,JOHN R. Sewer: Inspect Reas: M
1915 GREAT POND ROAD
NORTH ANDOVER MA 01845 Exempt-B/L% 1 Resid-BIL% 1001100 Comm-B1LP/° Indust-BIL% / Open Sp-BIL% l
RESIDENCE INFORMATION LAND INFORMATION
NBHD CODE: 6 NBHD CLASS:6 ZONE: R2
4
Style: CL Tot Rooms: Main Fn Area: 1844 Attic: Se Type Code Method Sq-Ft Acres Influ--YIN Value Class
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 2252 Bsmt Area: 1828 9 yP
Roof: H Full Baths: 3 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 206,910
Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: G 2 R 101 A 2178 0.050 380
Masonry Trim: 60 Ext Bath Fix: 2 Tot Fin Area: 4096 DETACHED STRUCTURE INFORMATION
Foundation: CN Bath Qual: L RCNLD: 513383 Str Unit Msr-1 Msr-2 E YR-Bit Grade Cond%Good P1FIEIR Cost Class
Kitch Qual: L Eff Yr Built: 2007 Mkt Adj: PG S 600 0.00 2007 G G 150.1150 17,400 1
Heat Type: FA Ext Kitch: Year Built: 2007 Sound Value:
Fuel Type: G Grade: V Cost Bldg: 513,400 VALUATION INFORMATION.
Fireplace: 3 Bsmt Gar Cap:3 Condition: E Att Str Vail: Current Total: 738,100 Bldg: 530,800 Land: 207;300 MktLnd: 207,300
Central AC: Y Bsmt Gar SF: 816 Pct Complete: 100 Att Sir Val2: Prior Total: 772,800 Bldg: 565,500 Land: 207;300 MktLnd: 207,300
Att Gar SF: %Good PIF/E/R: 111100
SKETCH PHOTO
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1916 GREAT POND ROAM
Parcel ID:2101035.0-0108-0000.0 as of 1/3111 Page 1 of 1
BK 6783 PG 345
QUITCLAIM DEED
I,Alfred Matthews,III, of Peabody,Essex County,Massachusetts("Grantor'l,for the
consideration of Eleven-Thousand and Two-Hundred and Fifty Dollars($11,250.00),grant to
John R Keilty as Trustee of the Cochichewick Realty Trust,under declaration of trust dated April
18,2002,("Grantee'),with QUITCLAIM COVENANTS,
A certain parcel of land on the northerly side o o North Andover,Essex
County, Commonwealth of Massachusetts,being sho - as Lot#2 on ap)an entitled`flan of
Land Located in North Andover,Mass.,Owned by Richar arzrale,"Scale 1"-50',dated
March 1985,drawn by Merrimack Engineering Services,Andover,Mass.,filed with North
District of Essex Registry of Deeds as Plan#10041. Said Lot#2 is more particularly bounded
and descnbed as follows:
NORTHERLY by land now or formerly of Angus Realty Trust,one hundred fifty and
no/100(150.00)feet;
EASTERLY by land now or formerly of the Stella Sobel,in two lines having total a r
length of three hundred twenty-one and 30/100(321.30)feet;
SOUTHERLY by the northerly lime of Great Pond Road,one hundred fifty and no/100
O (150.00)feet;
WESTERLY by land now or formerly of Michael Parziale,three hundred nine and
97/100(309.97)feet.
Containing 48,200 square feet of land according to said plan. APR 10'02,-H247
Being the same premises conveyed to the Grantor herein by deed of Richard F.Parziale,
dated February 12, 1988, and recorded in the Essex North Registry of Keds in Book 2677,Page r° i
73. j
Executed as a sealed instrument this /k—&y of April,2002. Z
b4assachusetts Deed Excise StampoFRE TTI�WS III G
in sum of $, 52.44 $
affixed and cancelled on this COMMONWEALTH OF MASSACHUSETTS
Iisstrument.
SUFFOLK,ss. April f;� ,2002
Then personally appeared the above-nam ed a a&nowledged the
foregoing fi strument to be his f ve act and deed fo
P1#LlC
My Cornmiso6n Expires: 04F
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Property Record Card
Load fiype Y Inspect Date: 7SGC
00.0 MAP-035.0 BLOCK-006i LOT, PARCEL ADDRESS 9 3AT POND ROAD x'201 Meas Date:
PARCEL -0061-00 U$e:Code: 13i .. Sale;!'rice: ii2,25o Page: 0345 Rd Condition: M Entrance:
PARCEL INFORMATION Tax Class: T Sale Date: 04!17102 Cert/Doc: Traffic. Collect Id:
Sale Type: L, Water.
Tot'Fn'Area: 0 Sewer. Inspect_Reas
Owner: Tot Land Area: 1.91 Sale Valid: B S,AEFitgb Ill.
PELICH,JOSEPH Grantor:•► - 0 1 Open Sp-BIL% I
Address: Comm-Blip/° Indust-BIL 1°
1915 GREAT POND ROAD Resid-BIL% 100!100
NORTH ANDOVER MA 01545 Exempt-BIL% I LAND INFORMATION
NBHD CODE:6 NBHD CLASS: 6 ZONE: R2 •Value Class
Type `Coda rNlethod Sq-Ft' `Acres' lnflu:YlN" 64,250
Seg 131 A 0 1.000 418
1 P 0,110
2 R 131 A 0
VALUATION INFORMATION
64,700
64 700 Bldg: MktLnd: 64,700
, 0 Land:
Current Total: 0 Land: 3,200 MktLnd: 3,200
Prior Total: 3,200 Bldg:
PHOTO
SKETCH
Available
Page 1 of 1
Parcel ID:210/035.0-0061-0000.0 as of 113111
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Interstates - - Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
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Roads North Andover.Additional data provided by the Executive Office of -
L t Easements ,�. 0e� 'e'e 00 Environmental Affairs/MassGIS.The information depicted on this map is
Q MVPC Boundary 3 _• for planning purposes only.It may not be adequate for legal boundary -
F ,' - "'- 9 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
Municipal Boundary MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING - -
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• i ;, 1' OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Permit# 229 (9-25-2006) Date: FebrupU 6. 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 1915 Great Pond Road
MAY BE OCCUPIED AS Single Family Dwelling ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Joseph Pelich
1915 Great Pond Rd
North Andover MA
Building inspector
i
00RT#j
own of : Andover
0
No. Z
�,o A dover, Mass., disvp 0(p
COCMIC MEWICK
AORATE0 P'f �y
`S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
--11U ING INSPEC
THIS CERTIFIES THAT 1�..0. !.. '�..�.�....
'
..... ........................................... ............. ...... ........... ......
Foundatio
has permission to ere �.1. it Ings o ..�.q..1.Jt.. !��t....�� .�� ���i Rough
to be occupied as..
provided that the p'e'
s.... ' ..'.. . ................... ° y
Chim e
provided that the per on ac mg this permit shall i very 44-tf nforml to _ terms of the application on file in
this office, and to the provisions of the Codes and B -Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. 35/104 .BA �O��j. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. L 3E
f
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCT19Y STARTS ELECTRICAL INSPECTOR
°ll$
..... ...... .. Service
BUILDINNG"` SPECTOR
Fin
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough �l
Display in a Conspicuous Place on the Premises - Do Not Remove F0
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner'—� lz
Street No. \%'s
y
SEE REVERSE SIDE smoke Det.
Of ttieo e A~G
APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
0
SAC14U BUILDING PERMIT #
cwus�
ADDRESS/LOCATION OF PROPERTY:
Map_,5:2�_Parcel 0K Lot Number
SUBDIVISION: q�
DATE REQUESTED FILED/READY FOR INSPECTION: C)
CLOSING DATE ON PROPERTY:
FIVE(5)
DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
APPLICANT SIGNATURE
Permit Issued to: �(n - (�
�.,� ^I �\ ��5ii i 7� ��S►�1�6
Address: `q '
ROUTING
CONSF4RVATION
�l�J
PLANNING
DPW-WATER METER
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW
SIGNATURE
File:Application for OC form revised Jan 2007
/
f MORTp TOWN OF NORTH ANDOVER
°•''` � "° OFFICE OF
1 � BUILDING DEPARTMENT
=o> + 1600 Osgood Street
Building 20 Suite 2-36
1SSACHUS�t North Andover, Massachusetts 01845
Telephone(978)688-9545
Gerald A.Brown Fax (978)688-9542
Inspector of Buildings
AFFIDAVIT FOR FINAL COST OF CONSTRUCTION
In accordance with the provisions o the Massachusetts State Building Code, Article 1, Section 110.4
and 114.2, the total estimated cost of the construction including all related construction costs* of the
building located at /7/ 5 Gr-plaj POOH 64y amounts to
$ 3 60 D
I, .being the person referred to as the owner
identified below, do solemnly swear that the statements made herein are strictly true and correct and
made in good faith.
*Related construction costs included all work done with or concurrently with the work contemplated
by the Building Permit including demolition, plumbing, heating, electrical, air conditioning, painting,
carpentry, landscaping, site improvement, etc. Furnishings and portable equi ment are not part of the
total construction costs.
Signature of Owner
COMMONWEALTH OF MASSACHUSETTS u
2009
Then personally appeared the able named a�'2 k {i -06nd
Made an oath that the above statement is true. _
Before-,,Me,
Me,
No Public
OFFICIAL USE:
I
Final Cost:
Original Estimate cost of general work: --- -- �- -- -----
Cost Difference:
Additional Fee Required:
TO AMEND FEE UNDER PERMIT NO.: --- m_. -- -- -�- ----- -----
Inspectional services DepaAment 2005
FAmIcostaffidavitform Strict code enforcement makes the town safer
Before buying renting leasing check zoning
r i
s_.
.......... .........
40PTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
ss s�
�^-- This certifies that .....:. ��- �� -`"-.-�-
.........................................- ........................
has permission to perform ...... .................tea - a .................
wiring in the building of.. :.............................................................
at....�.��'5... ' `—�� `!�. -.- 1�.. e.'- North Andover,Mass.
Fee .c ...... Lic.No.�'. `'F�v' :?f ...... .... ...................
ELECTRICALINSPE&MR
Check # /
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7233
Official Use Only
Commonwealth of Massachusetts
I Permit No.
Department of Fire Services _o
BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupancy and Fee Checked !�1/07] leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3-/ °-4�) 7
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her nt�n to perform the electrical work described below.
Location(Street&Number) f �y
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a bui ding permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Net..; Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion o the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ at o Units Emergency Lighting
rnd. rnd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
^' No.of Switches No.of Gas Burners No.of Detection and
Initiatinia Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pum Number Tons K.W. No.of Self-Contained
TotalsDetection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances Kms, Security Systems:*
No.of Devices or Equivalent
No.of WaterKW No.of No.of Data Wiring:
Heaters Si ns Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: f��� �� (When required by municipal policy.)
Work to Start: 3-/ —p 7 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [?J' BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.://Z�7 G
Licensee: i�ir'/`T 7�I"!>6� Signature LIC.NO.:
2-V,5-7
(If applicable,enter/"exempt"in the license number lin .) Bus.Tel. N,o.:7�/23�d
Address: 1 t/ 11". �rSm��i� �c ivy �igtl�uS fyJ A , UIgG� Alt.Tel. No.:-7kl o 26 e,6 f 0
*Per M.G.L c. 147,s. 57-61,security work requires epartment of Public Safety"S" License: Lic.No. �66 .3
OWNERS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent.
Owner/Agent
I� Signature Telephone No. PERMIT FEE: $
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The Commonwealth of Massachusetts
k1iDepartment of Industrial Accidents
Office of Investigations
600 Washington.street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): 5 J J ®
Address: ao h�i mm e.^sm 1A mr
City/State/Zip: S4 09 o S Af 0150 6 Phone.#: )F 1 - Z_3 3 46/ 3
Are you an employer?Check the appropriate box:
Type of project(required):.
1.❑ I am a employer with 4. ❑ I am a general contractor and I
eg)ployees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
2.R am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
o workers'co co # 9. ❑Building addition
[N comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.❑Plumbing repairs or additions
myself.f No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
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.
t 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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
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.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as 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 andpenaldes qLneriury that the Information provided above is true and correct
Si ature:
Phone
Official use only. Do not write h 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#:
L
Information and Instructions
Massachusetts General Laws chapter 152 requires all employdrs 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."
hold the
ce
MGL chapter 152,§25C(6)also states that"everyness or to construct buildings inthe comstate or local licensing agency sall monwealth fornanyr
renewal of a license or permit to operate a buss
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 a ro riate 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 permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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
Fax#617-727-7749 ---
Revised I1-22-06 www.mass.gov/dia