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Miscellaneous - 225 ABBOTT STREET 4/30/2018
225 ABBOTT STREET 210/038.0-0078-0000.0 i I 4 1 North Andover Board of 4ssessors Public Access Page 1 of 1 North Andover Board of Assessors � s s �SSwcHus� roperty Record Card Click Seal To Retum Parcel ID :210/038.0-0078-0000.0 FY:2013 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels ' Search for Sales Kai Summary { Residence - .. Detached Structure Condo 225 ABBOTT STREET Commercial Location: 225 ABBOTT STREET Owner Name: ARRIA,LAURIE C/O ARRIA,RICHARD Owner Address: 225 ABBOTT STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:6-6 Land Area: 1.07 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1203 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 333,700 322,600 Building Value: 124,500 115,200 Land Value: 209,200 207,400 Market and Value: 209,200 Chapter Land Value: LATEST SALE Sale Price: 320,000 Sale Date: 02/27/2009 Arms Length Sale Code:Y-YES-VALID Grantor: FROST Cert Doc: Book: 11441 Page: 148 http://csc-ma.us/PROPAPP/display.do?linkld=2252226&town=NandoverPubAcc 3/18/2013 Residential Property Record Card PARCEL—]D:210/038.0-0078-0000.0 MAP:038.0 BLOCK:0078 LOT:0000.0 PARCEL ADDRESS:225 ABBOTT STREET FY:2013 PARCEL INFORMATION Use-Code: 101 Sale Price: 320,000 Book: 11441 Road Type: T Inspect Date: 07/30/2010 Tax Class:. T Sale Date: 02/27/09 ' Page_ 148 Rd Condition: P Meas Date. 07/30/2010 Owner: _ s - Cert/Doc _;��•En _ _. Tot Fin Area:--- 1203`�� Sale Type: P "Traffic: M trance X ARRIA, LAURIE Tot Land Area: 1.07 Sale Valid: Y Water. Collect Id RB CIO ARRIA,RICHARD - Grantor: FROST Sewer: Inspect Reas: S Address: 225 ABBOTT STREET Exempt-B/L% I Resid-B/L% 100/100 Comm-B/Ip/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: RN Tot Rooms: 6 Main Fn Area: 1203 Attic: NBHD CODE. 6 NBHD CLASS: 6 ZONE 173 : 6 - Story Height: 1.00 Bedrooms: 3 Up Fn Area: Bsmt Area: 1203 Seg Type Code Method Sq-Ft Acres�minflu-Y%N` Value ClassT .__- - ----.�_ - - -- - 1 P 101 S 43560 1.000 _ 208,621 Roof: G Full Baths: 1 Add Fn Area: Fn Bsmt Area. -, Ext Wall`. FB Half Baths: Unfin Area: Bsmt Grade`. 2 R 101 A 0 0.070 532 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 1203` DETACHED STRUCTURE INFORMATION Foundation. CN Bath Cual. TRCNLD. 115281 w Str Unit Msr-1 Msr•--2 E-YR-Blt Grade Cond'%Good P/F/E/R Cost Class Kitch Qual: T Eff Yr Built: '1979 _ Mkt`Adl: G1 S 576 0.00 19$8 A A 50///50 9,200 Heat Type: HW Ext Kitch: Year Built: 1965 Sound Value: Fuel'Type: O Grade. A.- Cost Bldg 115,300 ` VALUATION INFORMATION Fireplace: 1 Bsmt Gar Cap: Condition: AG Att Str Vail: _ Current Total: 333,700 Bldg: 124,500 Land: 209,200 MktLnd: 209,200 Central'AC: N Bsmt Gar SF: Pct Complete: AttStr V612 Prior Total: 322,600 Bldg: 115,200 Land: 207,400 MktLnd: 207,400 Att Gar SF: %Goode/F/E/R:^ /100/100179 Porch Type Porch Area Porch Grade Factor P 34 W 120 SKETCH PHOTO 1011 u� YY ieµ y 10 120 S H } FMB 4 q.Ft t 1203 Sq.Ft ,`' 27 27Xt �a 75 225 ABBOTT STREET Parcel ID:210/038.0-0078-0000.0 as of 3/18/13 Page 1 of 1 9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t` CITY 7? _ MA DATE 0 ( PERMIT# JOBSITE ADDRESS OWNER'S NAME _t �] POWNERADDRESS _ S/�7►"�i — _ TEL ' ��� w_ FAX k TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL EI RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES® NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM I I [ ,1 _._ Iw J _ ..._ _____J --Ji DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN € ...._.._._[ ___.....E -._-.__. ----•-_J - -J ------€ -.....__[ .----1 _-----( __._._E ...--.-J -----__i __J ._...._.� FOOD DISPOSER I ......-11 -_..____f FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ( -F-71 ........__._.... LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL J -..______t -_--J __._..__J ..__..-..1 .._... _._...--[ J ... i i ..___...( '._...__._J .._._1 ._.._._--.J WASHING MACHINE CONNECTION _ u WATER HEATER ALL TYPES _( _- _j [ JE WATER PIPING __.._.!_ [ OTHER INSURANCE COVERAGE: 1 have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES('NO �1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lffi/" OTHER TYPE OF INDEMNITY EJ BOND Q 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 01 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true nd a curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c m ane th ertin vis' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME D mli tO lrK LICENSE# _(3 a& L1SIGNATURE P1/IPg"' JP Q CORPORATION I S 1 PARTNERSHIP O#f_ LLC I COMPANYNAME fir, t4 ,yo +.H IiO ADDRESS I 6 CITYZIP � (ISTATE � a ( � s. TEL -- T FAX S CELL 761'W9'3 d' EMAIL m Vm 'r-6'. ROUGH PLUMBING INSPEnCTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes ,/-mcl r.. THIS APPLICATION SERVES AS THE PERMIT ❑ - [] FEE: $ PERMIT# /moo PLAN REVIEW NOTES e Date. 9573 TOWN OF NORTH ANDOVER te PERMIT FOR PLUMBING SSACHUS (�.l1.1 {v P.4.41 This certifies that . . . . . . . . . . . . . . . . . has permission to perform . A'ryl .. . . . . . . . . . . . . . . . . . . . . plumbing in the build'ngs of �!� . . . . . . . . . . . at . . . . . 275. . . . . . ort ndover, Mass. Fee2�-�. .��/.Lic. NoA, P M� . . . . . . . . . . . . . . . .'• •Fat'• . ` �� PL WING INSPECTOR Check ." The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): �'�'Iy rn�NBJ �' + h5r, (i-& Address: )6 City/State/Zip: l'►►� i� YYl1 - 62-1 S3 phone#: Are yoy,an employer?Check the appropriate box: Type of project(required): 1.2I am a employer with ;�L 4. ❑ I am a general contractor and I 6. ❑New nstruction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7 emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 131-1 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. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. i am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ?ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ane 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify n� thepains a�ena ofperjury that the information provided above is true and correct. Ii nature: Gf Date 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.##617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . �f�. nn c�l�k�-r-4� has permission to perform .�(?'j. r ,LJ � , �! wiring in the building of . . . -; , , , , , , . . . . . . . at . . . e . . . . . , orth Andover, Mass. Fee .�L, � Lic. No. 0/�_ --4 . .Q. ELECTRICAL INSPECTOR Cheek# r 11250 t li Commonwealth of Massachusetts Official Use Only ' Permit No. Z–S,0 Department of Fire Services Occupancy and Fee Checked L., BOARD OF FIRE PREVENTION REGULATIONS [Rev-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 t (PLEA SE PRINT IN HK OR TYPEALLWOR MATIOA9 Date: l City or Town of. NORTH ANDOVER To the Inspector off Wires: By this application the undersigned gives notice of hisAr her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant t, Telephone No. Owner's Address Is this permit in conjunction917 a bijilding permit? Yes No El (Check Appropriate Box) Purpose of Building fal" Utility Authorization No. Existing Service 900 Amps J /;P-i)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 of the following table may be waived by the Inspector of Wires. No.of Recessed LuminairesNo.of Ceil.-Susp.(Paddle)Fans No.of Total 3 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] No.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No,of Zones No.of Switches 9 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. 1 TotalTons 11 No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: "1* *""""""""" ""'""""'"' Detection/AlertinR Devices • No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of DryersHeating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: o Attach additions detail if desired,oras required by the Inspector of Wires. Estimated Value of El ctrical Work: j90 (When required by municipal policy.) Work to Start: / ,�/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 T5ragc,is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 16 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: — Licensee: Signatur LTC.NO.: (If applicable,enter"exemp ' to telicens mb r line.) Bus.Tel.No.. Address: 6„1e Q e4,7 d�qA Alt.Tel.No.: *Per M.G.L c. 141,-s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S 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 PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: A Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed ❑' Re-Inspection Required($.)❑ Inspectors Co nts: Inspectors Signature: Date: FINAL INSP ION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: f /Z- Gn z Date: p g DEB WEINHOLD ...TOWN OF MERRI AC,MA. .......dweinhold@townofinerrimac.com P The Commonwealth of Massachusetts fu Department of Industrial Accidents Office of Investigations kwj. 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Le0bly Name (Business/Organization/Individual): Al/'1 Address:_ 1 City/State/Zip: /14- 0,4 F Phone#: 6 [ 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 1 6. ❑New construction epaployees(full and/or part-time).* have hired the sub-contractors 2.[�am a sole proprietor or partner- listed on the attached sheet. 1 ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition [working for mein any capacity. workers'comp,insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site formation. isurance'Company Name: olicy#or Self-ins.Lie.#: Expiration Date: i f >b Site Address: � � �� City/State/Zip: //J/p/, finkal�ofi - .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lvestigations of the DIA for insurance coverage verification. do hereby certify ins and pengrlties of perjury that the information provided above is trite f and correct. mature: Date: �7T f lone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall µ 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." j Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the perinit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.##617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax 4 617-727-7749 www,mass,gov/dia 9 i Date. NpRTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that . . �H. . . . . . . . . . . . . . has permission to perform .l v!�!-4� ,74! ... ... . plumbing in the buildings of . . �' 'Q. . . . . . . . . . . . . . . . . . . . . . . at . . 2 ZS- /�� !�.. . . . . . . . . . . ., North Andover, Mass. Fee. Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1J t U PLUMBING INSPECTOR Check # r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING R ,, 1 City/Town: �t(�_ �JJDb��.6Z , MA. Date: Permit# Building Location: 22 5- 46130-71' S'`: Owners Name: Al2,1?��} Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential[[]� New:❑ Alteration:❑ Renovation:❑ Replacement:[]r Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED Z SYSTEMS LU z z V, ou W Y W OU at 0 Z a w Z ~ Z Q �, Z Q Q Vf z M N h w LUQ ?� Vt x Vf w r W in LA O a X Q Q c FL o 3 0 3 = c ° o W M Wj a = W W z 1 � 3 a a o o > > o = o Q a a a ~ v a LLA z a a m m c c x o Q (D (D 3 SUB BSMT. BAS11MENT / JIT FLOOR 2ND FLOOR 3"D FLOOR 4'FLOOR 5'FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Check One Only Certificate# !� Installing Company Name: �'iJ N`�NI�Y�f 1 P� r � )rJC% a 154 Corporation Address:16i C SON) City/Town: State: fV El Partnership Business Tel: -)E1, -3115'?-ti J3 Fax: ❑Firm/Company Name of licensed Plumber: J64J f"6C.IJt,1,C4I aYL INSURANCE COVERAGE: �/ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes [2 No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ 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 ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ber Signa ure of Licensed Plumber-' City/Town aster License Number: /3 d��o APPROVED(OFFICE USE ONLY) ❑Journeyman VII/IQ/2011 10:54 FAX (81 yJJ y445 MANIINI INJUXANGE [MQ U1/UU1 CORD CERTIFICATE OF LIABILITY INSURANCE OPID S DATE(MM/DDrrrYY) XCC0N-1 11 10 11 RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Jartini Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Common Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 565 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn MA 01001-0665 Phone: 781-935-0220 Fax;781-933-9445 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A., Hartford insurance—Eompany Ren McConnell Plumbing & INSURER e: Safety Indemnity ins Cc 33618 Heating Inc. INSURER C: 19 Chardon Road INSURER D'. Medford MA 02155 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANI:E AFFORDED BY THE POLICIES DE6CRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MW AUDI POW LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE NIM/D DATEIMM/DDIM LIMITS GENERAL LIAMUTY EACH OCCURRENCE S 1000000 X COMMERCIAL,'ENE PAL LIABILITY OSSBAUR1324DW 07/19/11 07/19/12 ERENII$ES(Ea occurence $500000 CLAIMS MADE FXOCCUR MED EXP(Any one person) $10000 A X Business Owners PERSONAL BADV INJURY 51000000 N GENERAL AGGREGATE $2000000 OEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000000 X POLICY71 )ECT LOC M^ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ H ANY AUTO 6213463 06/14/11 06/14/12 (Eaeooldenq ALL OWNED A(ITOS BODILY INJURY 5 100000 X SCHEDULED Al ITOS (Per person) X HIREDAUTOS BODILY INJURY $300000 X NON-OWNED AUTO$ (Peraceldent) -- PROPERTY DAMAGE $10 O O O O (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO IS PXCES$/UMBRELLA LIABILITY EACH OCCURRENCE ! OCCUR [� CLAIMS MADE AGGREGATE $ 5 � DEDUCTIBLE 5 RETENTION S 5 r WORKERS COMPENSATION AND X I TORYLIMIT5 I EE-'a"- A EMP SUABILITY 20 ANY PROPPROPRIETOR/PARTNi:R/EXECUTNOBWECRJ2603 01/20/11 E / / 01/20/12 E.LEACH ACCIDENT $100000 OFFICERIMEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $100000 If yea,deaufbe under SPECIAL PROVISIONS below E L.DISEASE-POLICY LIMIT $ 500000 OTHER D!$CRIPTION OF OPERATIONS)LOCATIONS I VEHICLES/EXCLUSIONS ADDED BT ENDORSEMENT/SPECIAL PROVISIONS � RE; Operations of the named insured.Corporate officer excluded from Workers Compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN147 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL Plumber inspector IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR FAX; 978-688-9542 REPRESENTATIVES. N_ Andover MA 01645 AVMPRIZEDREP EB NT/WVE„ , ACORD 26(2001/09) (J/y//(l J ®ACORD CORPORATION 1980 Date../l/9I/�. . ... ... . WORTH Of o? '` TOWN OF NORTH ANDOVER PERMIT FOR GASINSTALLATION 'ISS CH P This certifies that . . ?!�. . ./y /.t t'1�I e.G L. . . . . . . . . . . . . . ..L has permission for gas installation in the buildings of . ��!Q. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 at Fee.,?P:OD. Lic. No.A3o . GASINSPECTOR Check# WOO 7887 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: PJ MA. Date: ( I Permit# Building Location: X25 Owners Name: A Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES Ui Z ui N to v = D w 0 W W O m z I— LLJ Q 0 -j U N H U) 00 z w z o w D W m 0 N W w W m 0 Q a I— ❑ W X w a w w w z go_ m =0 LU w w z W W W > v w z 0 -� H 1•- O z O LL N w w W O W IX Q C= W W m W O z O N > z Q U ❑ ❑ LL (� (� 2 2 J O d � � H > > > � O SUB BSMT. BASEMENT / 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR ST FLOOR 6T'-FLOOR 7T'-FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: M�A)r LJ P1,6 4-T& iIJG 2 ( S ['Eorporation Address: Iq eI�t�DAj City/Town: 0116DRA& State:-MA- E]Partnership Business Tel: 78!- :?T5- o9-c/.3 Fax: ❑Firm/Company • Name of Licensed Plumber/Gas Fitter: wo V14f^Afjol INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes RNo❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 2' Other type of indemnity ❑ Bond ❑ 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 waves this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Typ f License: By lumber Title El Gds Fitter Signature of Licensed Plum r/Gas Fitter Luster City/Town ❑Journeyman License Number: )130" APPROVED OFFICE USE ONLY ❑LP Installer COMMONWEALTH OF MASSACHUSETTS im"PA-01.19ERS AND LICENSED AS A MASTER PLUMBER i ' ISSUES THIS LICENSE TO I KENNETH P MCCONNELL :JR m 19 CHARDON ROAD MEDFORD MA 02155-224 13086 05/01/12 760851 • : • 0A • 1 6 NpRTN pF , TOWN OF NORTH ANDOVER ,^ ti0 FOr y a p9 PERMIT FOR MECHANICAL INSTALLATION �,SSACHUSEt This certifies that . . . . . . . . . . . . . . . . . . . d . . � �jll . . . . . . has permission for mechanical installation . . /fir—. . Imo. . ... . °:.. . . . in the buildings o . . � f 1I11y (.(.c.. . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . ?.`� TA 4-- �l`. . . . . . . . . . . . . .. North Andover, Mass. Fee W ` . . Lic. No. . . . . . . . . . . . . . . . . . . . . . . . . . . •GAS•+NSPECTOR WHITE:Applicant CANARY: Building Dept. IPINK:Treasurer fa Commonwealth of Massachusetts Date-. Sheet Metal Permit i (n !l �� Pit � ermu 1 Estimated Job Cost: $ G� Permit Fee: $j Plans Submitted: YES NO `- Plans Reviewed: YES NO Business License# Applicant License# »B Business Information: Property Owner ��///Job Location Information: Name: , J�- �� 24f4 ,r��iJ�i�� Street: 7� _ /,1,v �7/- ����rn Street: _,;�S 6 City/Town: �✓©��r�I 17 City/To Telephone: - 2 Telephone: Photo I.D.required/Copy of Photo I.D. attached: YES V_ NO Staff Initial -1/M-1-unrestricted license —2M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq.ft./2-stories or less Residential: 1-2 family.J Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq.ft.�.L over 10,000 sq.ft. Number of Stories: Sheet metal work to be completed: New Work:v. Renovation / HVAC J Metal Watershed Roofing Metal Chimney/Vents Air 17u4Q- \\, � I Provide detailed description of work to be done: Q.. Supp % GJ 1��`�4 r r� D-rGT y r q r / C O•�a�2 rl S al l C� I p y INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxn,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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection e Date Comments Type of License: By ❑Master Title ❑Master-Restricted ptyrrown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ Check at vwwv.mass.govldpl Inspector Signature of Permit Approval ,J R Commonwealth of Massachusetts Date. Sheet Metal Permit �� Permit# � � 1 Estimated Job Cost: $ G� Permit Fee: $ I Plans Submitted: YES NO Plans Reviewed: YES NO Business License# _j�f� Pp ��,�}}��042-' 701 Applicant License# Business Information: IProperty Owner//Job Location Information: Name: �, %4. S ll2?-ft,4 W17 �trcjlf)�rjName: ReCM'7gTc� i17'r. Street: 7� �� L,10,(4,r4 Street. �o�J Goff Sf City/Town: I/®��ri/ 17-4- City/To n: �/o r i '� �o P"(f gX02—7 l7— 302 7-3— Telephone: 7-81— � Telephone: 9` Photo I.D. required/Copy of Photo I.D.attached: YES-d— NO Staff Initial �4/ -1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq.ft./2-stories or less Residential: 1-2 family V Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq.ft.j— over 10,000\J/sq.ft. Number of Stories: Sheet metal work to be completed: New Work: v Renovation: V HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: / J� /7y- 07-1 Su ;i 1 o� �`flc>" r> �cT eve- c Q �! �F9r��e� S FJ _ INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[],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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments k Type of License: By ❑Master Title ❑Master-Restricted ptyrrown ❑Journeyperson Signature of Licensee Permit# F�Journeyperson-Restricted License Number: Fee$ Check at www.mass.govldpl Inspector Signature of Permit Approval i I A. i ` r 3COMINONWEALTH OF MASSACHUSETTS` A5 A MASTER-UNRESTRICTED r. ISSUES THE ABOVE LICENSE TO. ' i WIL:L-fAM 'A BILLINGS i 77 ELM - WOB,URN MA 0.1801 :1.856 7686 01/28/13 984443 :. ` Fold,Then Detach Along All Perforations^ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . e../ . . has permission to perform C;V(P P ./9rr. . �,��/Ld?GA/ wiring in the building of . �. , . ,�}. , v 7T 440.. at . . . . ..4.RrZ-,�, -- orth Ando 'er, Mass. Fee . � . �. . Lic. No. . dO . . ELECTRICA NSPE R Check# t 10994 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ( f Ulu Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or h��ent�n I perform the electrical work described below. Location(Street&Number 9- � A,4 c Owner or Tenant C, d Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utilit Authorization No. [ }3!H L 2 I — Existing Service_&b Amps Volts Overhead Undgrd❑ No.of Meters New Service Amps J Ln Volts Overhead❑ Undgrd No.of Meters t Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �aZug n,>o 5 if f✓i L 42 - Completion of the following 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- ❑ No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones of No.of Switches No.of Gas Burners No. InDetection and Initiatin Devices No.of Ran es No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis posers Heat Pump Number Tons J.KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[IMunicipalConnection El Other No.of Dryers Heating Appliances KW Security DevicSystemes Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work'' (When required by municipal policy.) Work to Start: `y 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 cover e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE EV BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjwy,that the information on this[application is true and complete. FIRM NAME: LIC.NO.: Licensee: �j,r,,,�� S, ! 1 Signatur LIC.NO.: (If applicable,enter "exem t"in the licens number line.) Bus.Tel.No.: 1`n l 7.S"h 3'�Gy I Address: `� A V1 �1{a � ?�/W,+�`✓� M4 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S 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/AgentPERMIT FEE: $ Signature Telephone No. 1 i r • !u�JC'��1.,1.,�.11.��ck�t•-e�•-t,��[-yey+ci�il•�Y��.y�,�S�l�®p�.�i�.jy;��.yr�c/-�,7� .li�tyd JuLSII.�J.`�.4�.x�JG®�1.: it _ Ju'31�]tL.l.11�-Rl,�t.tlgl�'J..�L'+P✓.L V,C�.".^ , • •.�_ • — . �'�sset�•-�j �� �+'aileH•�j J ate-xnspect�oxtx'equixed'(��'OAD)�j � inspectors'co7mxnexts: ' (7Cnsper axsyszgnatuze-no inkfals) r plate :2.RMALMTAC�fom, $'asset--j � �+'aflec�-•j � � ate-�nspectiou�'e�uixe�($ 0.00)-•[ � • ---------------- i 3�5�iectars'coJmlrlents: (iisiectazs' `zgnature xtoWflah) Date S.IMP+P,+ROrT"WR CX`IOX.- 'assed•— �'aziec��j ) �te�nspeetio�xe�uzrea�(��0.00)�j J . asliecta s'Comment; , lnspectors� gna -ttofsa`f�aTs) ]ate ��( }��-tri• yr �+•�+}��7-��•�t r 15P.L'tLAAOJ,V"!-7J'��,4 Y.•.V^+: sse�-- �'a�e�--j � �e xnspectionrequire�(�50.OD)•-j � ' r�pectbrs'eo7m3�te�zfs: (us�ectoxs,sigaktuze-iofniWS) Date ITERA CTkON -OMR,' ;erg- j msec - [ - • 'Re-Iaspect�onzec�utxed(��O,OD)-[ � actors'coz�mentso _ , luspector�� zgnatuze� toxnitials) Date ' 5 n,R`H A Qk..Q AP-9,. OTIT Aft T,W,, cffT Q' *g q1"`d'�`+ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers st&ylicant Information Please Print Legibly Name (Business/Organization/Individual): l �tt'E•� {t^ l Address: City/State/Zip: Mil-0�4- Phone#: j7 Are you an employer?Check the appropriate box: Type of project(required): 1111 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2AA am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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 anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy or Self-ins.Lic.#: Expiration Date: Job Site Address: t1`)- � �a�D City/State/Zip: 4IUC"1/"'e/^j11 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 un 7eee pains a d penalties of perjury that the information provided above is true and correct. Si nature:-r / / Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the !� receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." , Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)namc(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia