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Home My WebLink AboutMiscellaneous - 193 CORTLAND DRIVE 4/30/2018 M.3 III BUILDING i JI FILE � THEMORIFOL[1e DED[ ARfJGROUN May 2, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1593916 Insured: MEETINGHOUSE COMMONS Address: 193 CORTLAND DRIVE, NORTH ANDOVER, MA Policy No.: R0623917A Loss Date: 02/20/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Bonnie L. Purcell Sr. Property Claim Adjuster 1-800-688-1825 x1708 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. Ole 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. R Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax:(781)329-1818 i +� NaetN CERT FICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 197 Date: December 9, 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 193 Cortland Drive, North Andover, MA MAY BE OCCUPIED AS single-family IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. ; Certificate Issued to: Meetinghouse Commons, LLC 115 Carter Field Road North Andover, MA 01845 Buil g Inspector NORTH � Town of 4Andover No. C MIC A K E dover, Mass., 1 a COME WICK y�. ADRATED `S BOARD OF HEALTH Food/KitchenPERMIT T D �Q Septic System A BUILDING INSPECTOR THIS CERTIFIES THAT 4 .. ... , ..... .:`................................... Fo ion has permission to erect........................................ buildings on ,�� 3 t? .. 4�!�.. .. .r"r,� .�.rc.... ou ��lit% y to be occupied as........................:........ G.a.�....... c.. . ..... .i..6. ............................................ C r<ey provided that the person accepting this permit shall in every respect conform to the terms of the application on file ininat this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 1 0� 1 Buildings in the Town of North Andover. PLUMWNG INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ' :` PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTO UNLESS CONSTRUCTION STARTS ' r-................................. Service BUILDING INSPECTOR Occupancy 'Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Fin gh Na Lathing or Dry Wall To Be Done Idl Until Inspected and Approved by the Building Inspector. FIRE DEPAR ENT Burner ;�_ Street No. jq SEE REVERSE SIDE Smoke Det. P �� t 0 v Arno tss''`""Stt APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Buildina Permit# 1 ADDRESS/LOCATION OF PROPERTY 3 f- 4 V Map /USC Parcel 3 Lot Number SUBDIVISION DATE REQUESTED FILED/READY FOR INSPECTION 2 7 CLOSING DATE ON PROPERTY: FIVE(6) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: Address C�i (V ` !26 f SIGNED ROUTING, CONSERVATION PLANNING N/ - G h . 4 O B DPW-WATER METER SEWERIWATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY11NSPECTION REQUEST cn DPW ,lam Signature Fite: Application for OC form revised Jan 2007 T6 rye Y 1 A,5-BUv NDA it cERtFED NOTES: \ 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A 1�p \ _s PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT ALI' \ r'' SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, MASSACHUSETTS SCALE: 1" = 80': DATE: JULY 20, 2001 BY THIS \ I FO NTD is OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY I 1 Pa Sefr'' NORTH DISTRICT REGISTRY OF DEEDS. AL 1 ' 1 i �FtOFlED t -_J 2) THE INTENT OF THIS PLAN IS TO SHOW THE AS-BUILT LOCATION / ^ OF THE FOUNDATIONS ONLY. MAP 104C / / S'' t 3) THE FOUNDATIONS SHOWN HEREON ARE NOT WITHIN THE 100 YEAR ~ LOT 28 / / / \ psca FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP i� � / ' \\ l� E�� <� FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY \ _ .1 l"<' > PANEL NUMBER 250098 0007 C, MAP REVISED: 6/2/83. 4) THE CONCRETE FOUNDATIONS SHOWN HEREON HAVE BEEN INSTALLED SUBSTANTIALLY IN ACCORDANCE WITH THE 408 SITE PLAN AS APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD AND RECORDED IN THE ESSEX NORTH DISTRICT COUNTY /� \ `_`_ REGISTRY OF DEEDS AS PLAN #14829. 'fes` l `'�� '�" is- I HEREBY CERTIFY THAT THE FOUNDATION SHOWN HEREON IS THE IL ? y tt / t� -4_ ——— DRIB os�T RESULT OF A FIELD SURVEY MADE ON JULY 16, 2009. 55.44' \ \ �.S4 OFAs il A@e _ " ✓ OUNDATIO -B 1 _—� \ v�� a� CHPoSTOPNER m UNIT #2 0 NDATIO \ t` FRANCHER p' TOP=i 6 8 .80, T UP rtt 5 t.\ $ \ , Na.36116 BITUMINOUS CONCRETE LICENSED LAND SURVEYOR DATE CERTIFIED FOUNDATION PLAN — 25' 1 1 MEETINGHOUSE COMMONS - UNIT 1 & 2 DISTURBANCE ZONE1 GRAPHIC SCALE MEETINGHOUSE ROAD D sa so 100 NORTH ANDOVER, MASSACHUSETTS PREPARED FOR IL MEETINGHOUSE COMMONS, LLC r (IN FEET) 121 CARTER FIELD ROAD r 1 inch = 50 ft NORTH ANDOVER, MASSACHUSETTS 44 Stiles Rood,Suits One r � Salem,New Hampshire 03079 _ C (603j 695-0720 9Lilk � MHF Design Consultoonnts. Inc. ENGINEERS•PLANNERS•SURVEYORS SCALE: 1" - 50' DATE: JULY 16, 2009 DRAWING N0. DESCRIPTION BY DATE DRAWN BY: I CHECKED BY: PROJECT NO. NAME AL REVISIONS JAC CMF 108800 1088CFP.DWG Date...... '.��=g. ... r AORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSf . This certifies that .............�...........�......I..q..2......R.....�..W....... ...................................... has permission to performer .......................... ...... ............................................. wiring in the building of.... ........ . <e...0..... ...... .... ....... . ... .. at... .................... .... .North Andover,Mass. Fee. Y Y Lac.No.,�W ....... ��!/. .............. ELECTRICAL INSPECTOR Check # 9015 Commonwealth of Massachusetts Official Use Only Department Of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/071 (leave blank ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC) -52OWORK (PLEASE PRINTININK OR TYPE ALL INFO RMATION) Date: City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her intention to perform the electrical work dires:esnbed below. Location(Street&Number) Owner or Tenant t Owner's Address S Telephone Is this permit in conjunction with a building permit? j - s Purpose of Building yesG� No ❑ (Check Appropriate Boa) Utility Authorization No. 93 Existing Service Amps / _Volts Overhead ❑ Undgrd❑ No.of Meters New Service FZ: Amps (� / Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity p /9�� tirr,?c//h d-C� � � ✓d Location and Nature of Proposed Electrical Work: /� / Com No.of Recessed Luminaires lesion o the ollowin table m be waived b the Ins ector of Wires. No.of Ceil.-Sus No.of p.(Paddle)Fans Transformers Total No.of Luminaire Outlets No.of Hot Tubs KVA Generators KVA No.of Luminaires Swimming pool Above ❑ In- o.o mergency tg g — No.of Receptacle Outlets d' rnd. ❑ Batte Units . No.of Oil Burners I'VE ALARM No.of?oes No.of Switchzr es No.of Gas Burners -u-01 Detection and No.of Ranges Initia ' Devices No.of Air Cond. Total T No.of Ale ons rttn Devices . g vices No.of Waste .Heat P _ Drs o um p sers p timber ons Self-Contame No.of Dishwasherson/AlertingDevices Space/Area Heating KW Municipal Local P No.of Dryers gesEin A ❑ Connection ❑ �� i g ppliances , Security Systems: No.of water KW No.of No.of Devices or E uivalent HeatersSi s o.of gallants Data Wiring; No.Hydromassa a Bathtubs No.of Devices or E uivalent ' g No.of Motors Total Hp Telecommunications Wiring; OTHER: No.of Devices or E uivalent Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: X00099-- (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: -Unless waived by the owner,no permit for the performance of electrical work may issue the licensee provides proof of liability in includingy ue unless undersigned certifies that such coverage is in force,and has Completed operation" tion"coverage or its substantial equivalent The exhibited Proof of same to the CHECK ONE: permit issuing INSURANCE k BOND ❑ OTHER P mg office. I certify,under the pains and penalties o er'u that the t'n❑formati n on this application is true and complete- FIRM NAME: / Licensee: ,� LIC.NO.: t s vt q/r G� Signature (If applicabl,�entter�exempt"in the license number line.) �' LIC.NO.: d/I Address-4 �) U I U s1 �% 011 -n Bus.Tel.No.:` ff ar?g57 *Per M.G.L c. 147,s. 57-61,security work requires D Alt.Tel.No.:9� OWNER'S INSURANCE WAIVER; I am aware that t e Licensee dores not ehave ty 1 the liability insurance Lic.No. required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑owncov❑erawnne ,�gent Owner/Agent Signature Telephone No. PERMIT FEE: $ `q: ., �,;, v� �` , �� . �� 1 �� G�� ;' i The Comma nwealth o _ ,f'Massachusetts kj Department of Industrial Accidents iOffice of Investigations Viv 600 A�Qshinaton Street Boston, MA 02111 www.mass.gov/dia " Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleatricians/Plambers Applicant Information Please Print Legibly Name (Business/Orgm,ization/Individual): o Address: S City/State/Zip: / ,�.�j I Phone#: . Are you an employer?Check the appropriate box: 1.Q'_am a employer with_:2:L 4. Q I am a general contractor and I Type of project(requites: employees(fu11 and/or part-time),* have hired the sub-contractors 6. ❑New construction 2.[] lam.a.sole proprietor or partner- listed ori the attached sheet.t 7. ❑Remodeling ship and have no tP employees These sub-contractors have $. [j Demolition working for me.in any capacity, workers' comp.insurance. coin . insurance 5. 9 (]Building addition [No workers ' p ❑ We are a corpotatiorr and its required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ 1 aim a homeowner doing all work right of exemption per MGL 1 LQ Plumbing repairs or additions myself[No-work=' 'comp, a 152, §1(4),'and we have no insurance required.] 12.(]Roof repairs q j .employees. [No workers' comp, insurance required.] 13.[].Other `Any applicant flier checks bo> #l must also fill out the section below showing their workers'compensation poiiey information, t liomeownera who submit this affidavit indicating they are doing all work and then hits outside contractors must submit a new afdavit indicating such. �Contmators that check this box must attached an additional sheet showing the nsme of the sub-contractors and their workers'comp.policy i acting such. 1 am an employer that is providing:workers'compensation insurancefor em :information. Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: 6V Expiration Date: s a _ /t .lob Site Address: �� ( e✓�' �.;L�,;( City/State/Zi �/ 1 Attach a copy of the workers' p 4L compensation policy dee Po c3' lar�atiao page(showing the policy number and expiration Failure P date to secure coy � era e g as required tinder 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 andpena/ties of perjury that the Intornration provided above is true and torted Signature, Date: Phone#: Elss7uing only. Do not write in this area,to be co let�d n f . by city or town.of cial n: Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing lrtgpeetor son: Phone#: ti Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." 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 includirfg 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 marntenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of sueb 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 woric 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 toyour situation and,if f necessary, supply sub-corttmctor(s)name(s),address(es)mind 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 cavy 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 Departrnent 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 nunnber.listed below. Self-insured companies should entertheir self insurance license number on the appropriate tine. 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 vviIl 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 starnped or marked by the city or town may be provided to the applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each n 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 bum leaves etc.)said person is NOT.required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as 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, IIIA 02111 Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-77491 www.m2ss.gov/dia Date. .!�r �•�US NORTN 3:�.<, •°;.��,oL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA US This certifies that . . � K has permission to perform . . . . *—A . . . . . !. . .. . .(. . . . . . . . . . . . . plumbing in the buildings of . . . . . . . ff fi;%c,f �`pJ. . . . . . . . . . . . . . . at . .. . . . �. . . . . .(. ll �! . . . . . . . North Andover, Mass. Fee Lic. No.. . . . . . . . . +. . . . ! - .;. : . ..-.,. . . . . PLUMBING INSPEdOH Check # 8224 FOR PERMIT TO DO PLUMBING APPLICATION MASSACHUSETTS UNIFORM Date 9 / (Type or Print) MASSACHUSETTS Permit# NORTH ANDOVER,MASS , r y Owners Name Amount F� y Building Location 'I' e of Occu anc ❑ No 13 Replacement O Plans Submitted Yes New Renovation FIXTURES t - a Ing-" T�D& _ 3RD,H-0M 01W 14 �iFIlJCIZ � 6iti r' 7U1 H Certificate gjHFII // Check one: d� ❑ Corp (Print or type) an Installing Company Name ❑ Partner. Address 4 Firm/Co. usmess Te ephone e b checking the appropriate box: Name of Licensed Plumber: of insurance co erag y Bond ❑ Indicate the t Other type of indemnity ❑ Insurance Covera one of the above Liability insurance policy plication does not waiver: I,the undersigned,have been made aware that the licensee of this application have any Insurance W ❑ th;Ig—nature ee insurance ❑ Agent Owner above application are true and accurate to the I have application will be in performed under Permit Issued for this and Ch ter of the General Laws. b certify that all of the details and information d installations p�(or entered)m I here y e and that all plumbing best of my knowledge, revisions of the Massachusetts State Plumb g Nance with all pertinent p Compliance, lana ure o i use um er By: Type of plumbing License Title cense um el Master Journeyman ic ❑ City/Town APPROVED(OFFICE USE ONLY y - i •`�' \ The Commonwealth o Massachus .t efts 1 Department of Industrial Accidents Office of Investigations 600 Mashing ton Street tiu Boston, MA #2111 Workers' Compensation Insurance Ada ffiBuilders/C Alit Iontractors/Eiectrici cxnnformation ans/Plumbers . Please Print L 'b Name (Business organization/Individual): Address: CitylState/Zig: Phone 4. - Am : . F2.M e you an employer?Chmektthe appropriate box: _ a employer with 4. ❑ I am a generalcosrtractor and IF[] oject(requires:employees(full and/or part-time).* have Wred the subcontractors construction .I am.a.sole proprietor.or partrier- listed on the attached sheet I odeling ship and have no employees These sub...eontractors have working for me in any capacity, workers' comp.insurance. olition[No workers'comp,insurance S. ❑ We are a corporation and its ing additionrequiretij offrcers have exercised their tricalIam ahomeowner do' reP aradditions m self �aIi work right of exemption per MOL bing repairs or additions Y [No'workers comp, tw t52, §I(4) and we have no insurance required.]t employees [No workers' 12.0 Roof repairs COM- nisurance required.] 13.7.0ther "Any applicant tient checks bo>L fE I mum also fill out the section below showing their worlterc'compensation policy information t homeowners who submit this affidavit ind}"eating they nit linin an _ ;Cor►tractats flat ah=k this box must g W0 end then ham outside contractors must subma a new affidavit indica*atmched an aifditiottaJ sheet show' su e neuro of then sub- n cetnrxhrs and thea workers'cow;,p sticy tntormation. !arrt an employer th2i u'pr? rrg:roorlters comperrsatrlen Bel insrrranre or informadon. .f �'enrploy eek ow r o •. athe P �1, and job site . Insurance Company Name: ' Policy#or Self-ins.Lie.# Expiration Date: Job Site Address: . _ City/Stat�p; Attach a copy of the workers'.compensation policy declat-atioo page(showing the policy number and e Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of and da*4 fine.up to$4500.00 and/or one-year imprisonment;as well$s civil penalties in the form of a 57Y}P WORK penalties of a Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the ORDER and a fine Investigations of the DIA for insurance coverage verification. Dffice of I do hereby cerdfy ander the pains and. ea p alties of perjury that the information provided above is true and coned ! Si tart: Date: . Phone#: ---------------- WWW use only. Do not write in this area,to be completed or town.o bJ'Chy 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. Plumbin I 6.OMer g inspector Contact Person: Phone#: Information a and Instructions Massachusetts General Laws chapter 152 requires all emp Sayers to pmvide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract afhire, express or implied,oral or written." An employer is defined as"an individual,partnership,mc:)diation,corporation or other legal entity,or arty two ormore of the'fomping engaged in a joint enhecprise,and includirag the legal representatives of a deceased employer,or the receiver ortnrstee•of an individual,partnership,associatiottn or other legal entity,employing employees.*Howeverthe owner-of a dwelling house having not more than three apa3-ta a is 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 sueb employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state os local Eicensing agency shall withhold the issuance or renewal oft license or permit to opamte a baseness or to construct buildings is the commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance,coverage required" • Additionally, MOL chapter I52,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work- until-acceptable evidence of compliance with the insurance requirements of this clrapter 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-conractor(s)name(s),addresses)mind phoge numbers)along with their certificates)of inamce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpwtneas,arc not requkedito carry workersca-Trrpwmation insurance. Ifan LLC or LLP does have 1 employees,a policy is required. Be advised that this affrdmvit 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 aro required to obtain a workers' oompensation policy,pleaw call the Department at the member.listed below. Self=++tsu'td s aha„]d errt tfie self insiLmnce-license number on dw'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printzd legibly. The Department hes provided a space at the bottom of the affidavit for yon 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%%-ill be used as a reference number. In addition,an applicant that must submit multiple pormit/license applications in any given year,need only submit one affidavit indicatij-Current policy;informafion(if necessary)and under"Job Site Address”the applicant should writm"all locations in (city or gown)."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 isi obtaining a license; or permit not related to any business or commercial venture (i.e. a dog license or permifto bum leaves etre.)said Pon or3 is NOT required to complete this affidavit The Office of Investigations would I'ke 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 Departtnont of Indmtrial Accidents Office of Investtitratiions 600 Washington Street Boston, MA 02111 Tal. #617-727-4900 sxt 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-05 www.mass.gov/dia Date.. pORTF1 3� .6 TOWN OF NORTH ANDOVER O � m • X PERMIT FOR GAS INSTALLATION y ••'`<h / �,SSAONUSEt This certifies that . . . . �. !! �l�� 7cf has permission for gas installation . . . . . . . . . . in the buildings of . . . . (! Az.vx c � . . . . . . . . . . . . . . . . . . . . at . . . . . . . �. . . . . r!�t�( 16. � • ,, orth Andover, Mass. Fed/0(1. . . Lic. No../ �./S 7. ' . . . . d.J. , GAS INSPECTOR Check 697 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 05 NORTH ANDOVER,MASSACHUSETTS Building Locations ��11�9 Permit# 7 1-05 A S Amount$ /`` Owner's Name �( New Renovation Replacement Plans El eP Submitted ❑ U y V F a o U ;D x x o. ° ° o z H Z Q w a w d z o Q F cx w a. w d F _ ° z o z o x o x w 3 a o °x > SUB-BASEM ENT BASEMENT 1ST. FLOOR FT E SII P 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 15TH . FLOOR 6TH . FLOOR 7TH . FLOOR _8TH - -FLOOR (Print or type) ! Check one: Certificate Installing Company Name Corp. Address Partner. usmess Telephone p 1.2fl Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance p licy or it's substantial equivalent. Yes � No E If you have checked yes,please' cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityBond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [:] Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Ch ter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber : '� '7 City/Town MZ45as Fitter License Number Master APPROVED(OMCE USE ONLY) ❑ Journeyman I ••< <.uirurtGtR"Maft o � x kL i .1` usstrchusetts `r ` D�Perrt of frra►itstriarl Accidents 600 Ifrashingtnn Street ,`" Basorr MA 021 Il Workers' Cam ensafaoa . Us�guvldia , P fBsiu-�nee..�d A 'c$at Infflr�atian. vjL, Randers/Coatracfors/Eieehici$as/PiQmirrr� Please Print L N� (Buscncss/br�i�ati�on/individczef) Address Phone Are you as eMPioyeri Q=k.the a I am a I PP�Priste-box: I:[] amp oyar with_ Type of employees(full and/or � a�eral contmator ( 4. I� a o end I prQJ� "e4a�: 2•�I em.asoie.. part-time). have bjMd the sub- 6. []'New cotisbmcbon . proprietor or pmIner• iist�d ship and have no employees on the attached sheer S 7• []R=ode working for me in Tbese su�-ean�r.have o w t any�P�y workers, cam in 8• Q Demolition• - (.N oticars pomp..insurance.. 5. r] qtr p• surance. 9. required. > $.Corporaiion and its E]Build addition 3•❑ i frit a homeowner thing all work °fps have exercised their IQ.f]Electrical �P m additions myself[ND-warlc�,. of dternptitm'Par MIX I I.�]plumb. utscnance'r d-]:tcamp. c' LS?' 9 IK.snd•wa have no ' t epaire or addiiians i ' •MMPI ryme-L(Na wor3 12• Roof r�airs ;Amy aMii=ttth��cheeks boz'f�f mart also f[i I�i�tthe gyp' �►srence raluired.] atbw�sc6mit this a6ida tit auiiCUM9 they,am� an ..a* g tbeiraoricm#'ocnip��poi ,m fbrm tim mit t&is box mus' ""O! and them hila omsidr . I aiF�2 E °� adcE.°fia�sl tahaetshownM'thename of the suh yon tS it a am af'ndnvit iadicetiag a fo1'� p4a►tg:►vQr 'ce�zc � `"°"'a.`x` iwiics man. Foamy midiob.sial I . nstaancc Company Name:' Policy#or Self--ins Job Site Atidrms; ExPasiion Date: Attach a copy of the workrrs+'coM Failure m Ptson policy d�Iar$fiioa page(showing the porcy cumber and secw a coverage as requited under Section 25A of =Pitjtioa date). . fine up to V; 90 wand/or one- IvIC;EL c. 152 can lad to the Of up to X250.00 a y mtPnsonmertt;ae well less civil imposition of c"Minal Penaltim of a. 3 trgainst the viohifor. Be advised flat penalizes in the form of a S'l�P WQRIC ORDER and a fine Investigations of the DLA for inset-Mee cov 8 copy of this mem ma, �rw erage verin"t tion. MXied to the Office of I do ha*certify ander the Pauls and peaaldeS of perjro�,�yt�the irrfarm-6oarn Si p vid ze above it true and troy Phone#: Dft. WAeial use ottfy, Do not write in this arro,m bt conipt��, or town.officio[ Ctfy or Towic Issuing Autfno ' PernzwL+icense# 3'(circle one): 1. Board of Iieattb L Sniiit#ing Dep$rErnent 3.Cityr't'o*w.a aerlt 4. Eierh-ical Ins 6 Ofhei Peator S.Plumbing inspadnr Contact Persalt: I Phone#: I '4 tntormation a nd Itstructions Massachusetts General Laws chapter I S2 roquiras all emp,3oyers to provide worked' =npensafion for thou employees. � Pursuant to this statute.,an rntpfayer is defined as"..:every person in the szrviae of another under any contract of hirt, cowess or iinplied,oral or writtzn." An urrpfaper is defined as"art individual partnership,asmc.3L6iafion,corporation or other legal an*,or any two armors of tlne'foregoing engaged in a joint entm-prise,and includi"g the izgal represerrfetives of a 6i.-=sed employer,brIt receiver ortrustee•of an individual,partnership,associatioon or other legal enmity,employing employees. •However the owner•of a dwelling house having not more than three apartments and who resides therein, or Sic occupant.of the dwelling house of another who employs persons to do maimte:tance,construction orrgn&winds m such dweihthouse or on the grounds or building appurtonent thereto shall nut because of swab aaploytnent be deemed to be an employer." MOL chapter I SZ 925C(6)also states that"every state as-local Beensing agency shd wkbbold the ismanwer renewal of a license or permit to operate a business or too construct boiitrmp in the commonwealth for any applicant who has-cot produced*ceeptable evidence-OV eomprmc a wI&the.insarance covemgue required." Addi ionaliy, MOL chapter 152,PCM states"Neither tt-bt'cammrmwealth nor any of its polificetl subdivisions i l enter into arty eontzad for the MfOn ffieea of pubSic wofiie tmtil•acceptsiile evidence of compliance with the ins==' reQuiremanis.of fhis d apter have beim prod to.tiio CCXtntracfmg atdltm*." ApPficauia Please,fill out Ehc workers'campcnsatian.afndavit compiem-tely,by checking the broms find apply tD your situation and,if necessary, supplysiibrc nr(s)name(s),addresses):>3nd phonc-number(s)along with their cotificata(s)of insurance. Limiled'Liabifitq Companies(LLC)or Limited Limbility.Partnerships(LLP)with no.=ployzes otherilmn the members or.partners,arc not requiredlo cagy woricem'0c)a nsBfion insorstce. lfan LLC c r-LLP dots hive employees,a policy is required. Be advised that this affidavit may be submitted to tate Department of Industrial Accidents fur codirmI m of insurance caverage.. Arco.[:*e sure to sign and date the afbdavrt The affidavit should be retuned to the city or town first the application for Set pewit or license is being rcquestea.,not'tht Department of Industrial Aceidenta Should you have any questionsrepurding the raw or if you arc required m obtain a woi=' . oorapensation policy,picasrcall the Department at tim-ntr .mber.listed below, Self-insured companies should entcr their self insmxncc henna:nornccr on dra'SPropiiate im:. City or Town Offuiars Please be sr>re first the affidavit is complete and printed lcglbly. The Dzparhreeart henprovided a space at Ste bottom of the affidavit for you to fill out in fife event the.Offict of Inve s#igaiions has W contact you reeg$rding the applicant. Please be sum to fill in the parmitflicm=number which w-illi be used as a reference number. In addition, an appiicent that must submit multiple permit/iicense applications in arty given year,need only submit one affidavit indicating•current policy•information(if necessary)and under"Job Site Adds-ess"the applicant should write"all iccations in (city or town)"A copy ot'•the affidavit that has beenofficia;Ily sti:.t nped w markzd by$se city or Mower may be provided to the applicant as proof thats valid affidavit is on rile fear fits permits or licenses Anew affidavit mist be fliexl out tach year. Wheal a home owner or cidzcn is obtaining a li=s- or permit not related to any business w e mmercial vadum (i.e. a dog five m or permit to bum leave-;esti.)said po s&n is NOT.requurd to-completz this afndaviL 'The Oft"ica of Invesnig�ations would deice to thank you in advance fur your cooperation an. you yriu have any questions, please do not.hesitate to give us a call. The Depmtmont's address,telephone and fax ntmtber:. The Commonvim lth of hfimsachuse= Dcparliuen of lmdmtial Ac6dentb . 4ffiice atf'lE�nv�$�ions • • 600 Vdashingeton Ste=t Boston, MA 02111 TeL #617-727-4900 ca-t 406 or 1-977-bfLA.SSAFE R.visexi -26-Q5 Fax#61 7-727-774.9 VVWWMass.govldia