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Miscellaneous - 240 STEVENS STREET 4/30/2018
N 9917 Date........ ... /.,.y.. ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.......... ............%....f -,. ......... ......... .............. 7. has permission to perform ....... ..`.:'............y/...........I.. ....... ".. ........... wiring in the building of .................... 7 ... .......... at .... ....... ................................. .North Ando , M S/* /X0, /,�4, , M Fee ..... ......... A LECMCAL . INS Check# COMMO'7wealtrh Of -Massachusetts Department Of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Use Only Permit N . f Z C7 / Occy and ee Checked % cupan 'Lev- 1/07] (lea bl APPLICATION FOR PERMIT TO PERFORM ELECTRICALink) All work to be performed in accordance with the Massachusetts Electrical Code .00 (PLE,M.E PMTWINK OR TYPE INFO (MEQ), s27 cAM 12.00 City or Town oh 2YOA9 Dater By this application the undersi)e�dgies% ofhis or her intention perform the electrical wTo the-Thspectoi ork Wires: Location (Street �i Number) / '7 �� scribed below. Owner or Tenant Owner's Address Telephone No. Is this permit in conj�tig1with a building permit? Yes Purpose of Building � t r , - � No ❑ BLDG PERIVIIT # Existing Service /00 Ams / Utilat,�Authorization No. P l0 / 2 G Volts O h Yeaead Undgrd ❑ No. of Meters New Service 200 Amps //0 /22 b Volts �--�/ Overhead E� Undgrd ❑ No. of Meters Number of Feeders and Ampacity . Location and Nature of Proposed Electrical Work. X0. of Recessed Luminaires vo. of Luminaire Outlets 10. of Luminaires To. of Receptacle Outlets ro. of switches ' o. of Ranges o. of Waste Disposers fo. of Dishwashers C o. of Dryers 0 o. of Water Heaters KW IM No. Hydromassage Bathtubs 1 OTHER: vwcenon of me following table may be waived by the Inspector of Wij No. of Ceil.-Susp. (Paddle) FansNo. of No. of Hot Tubs Total, Transformers VA � Generators Swimming Pool Above El❑ gruJgArnd. !VA o. o mergency ig ting O JNo. of Oil Burners C-1 Batte Units FIl2E ARIUS No. of Zones (] No. of Gas Burners No. of Detection and No. of Air Cond. Total Initiatin Devices Heat Pump Number Tons ns No. of Alerting Devices Totals: "_ ". '..... ........ KW•....•.• No. of Self -Co Detection/Alertin Devices C) Space/t9 rea Heating IOW Local ❑ Municipal El Other Heating Appliances KW Connection 0 Security Systems:.. No. of No. of No. of Devices or Equivalent d Si s Ballasts o Data Wiring: No. of Motors Total HP ' No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or Equivalent Z-11 Estimated Value of Electrical Work: Attach additional detail ifdesired, oras required by the Inspector of Wires. Work to Start: / (When required by municipal policy.) IORE-13 / 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, CHECK ONE: INSURANCE ❑ BOND ❑ and has exhibited proof of same to the permit issuing office. OTHER Specify:) d cert, under Plte p fns andPenalties ofperjury, that the information on t� FIRIM[NAME: dne application is trace and com-plefe /V Licensee: F, LIC. NO.: _t C Signature (Ifapplicable, enter "exempt" in the license nu er lin .) LIC. NO.: Q 2 LC' Address: G Bus. Tel. No.: a ' *Per M.G.L.c 147, s 57-61, security work requires Department of Pub Safeiy S Licen Alt' Tel. No.: - -3/ OWNER'S INSURANCE WANIJR: I am aware that the Licensee does not have'the cenliabLIC. NO.: required bylaw. my s' a el , I hereby waive this requirement. I am the (check one insurance coverage normally Owner/Agent- _ ) ❑ owner ❑ owner's agent. Signature Telephone No. 9 g PERMIT FEE: $ / �i0- ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 2. FINAL INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: U (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - do initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Idl- V T'he Commonwealth ofMassachusetts Department oflndustrial.Accidents Office oflnvestigations 600 Washington, Street Boston, MA 02111 UV www.rnass.govklia Workers' Compensation Insurance Affidavit: Builders/Contractors)Eleetriciaars) PZumbers Applicant Information Please Print Legibly NaInc (B.usiuess/Organizatioivindividual): %�,� / f zaQ -/ r � G>f Address:.q q4 5a P� City/State/Zip: . O 2/ �/& Phone #: 7�� g , 2 -/D 7,( Are you an employer? Check the appropriate box: Type ofproject (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. 2 mployees (full and/or parE-time) have hired the sub -contractors 6W construction 7. ❑ Remodeling 2. 1 A I am a sole proprietor or partner- listed on the attached sheet. x . ship and have no employees These sub -contractors have 8. ❑ Demolition working for me. in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. E]Building addition xequired.] officers have exercised their 10.0 Electrical repairs or additions 3.E1. I am a homeowner doing all work right of exemption per MGL 11. ❑ PIumbing 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. n Other comp. insurance required.] 'any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information Homeovyners 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Al -,417 -e Policy # or SeIf-ins. Lic. #: Expiration Date: lob Site Address: Z,id J5ll£'i S �t City/StatelZip 461 1 ligr, Aitach a copy of the workers' compensation policy declaration page (showing the policy number and expirations date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a RUE) 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains andpenaldes ofperjury that the information provided above is true and correct. /o F= 53 // OfTicial 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): I. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ContactPerson' Phone 04, j a v 6 SALEM, STREET LDE-N02148 2 All Perforations 0 Fold, Then Detach Along F9 Forte MEMBER REPORT Level, Wall: Header software 2 piece(s) 1 3/4" x 11 1/4" 1.9E Microllam® LVL 1❑ All Dimensions are Horizontal; Drawing is Conceptual M Eie5t�1� i�i7RJU iItE/YWVCi4F Member Reaction (lbs) Ys [lL�li 2856 @ 0 3413 Passed (84%) fr 1� - - Shear (lbs) 2163 @ V 3/4" 8603 Passed (25%) 1.15 Moment (Ft -lbs) 6248 @ 4' 4 1/2" 18558 Passed (34%) 1.15 Live Load Defl. (in) 0.091 @ 4' 4 1/2" 0.292 Passed (U999+) - Total Load Defl. (in) 0.128 @ 4' 4 1/2" 0.438 Passed (U818) - - PASSED "OFA ARTKIA W. POSE ST:iiJi,"1i}R,gL No. 30734 System: Wall Member Type : Header Building Use: Residential Building Code: IBC Design Methodology: ASD • Deflection criteria: LL (U360) and TL (U240). • Design results assume a fully braced condition where all compression edges (top and bottom) are properly braced to provide lateral stability. • Bracing (Lu): All compression edges (top and bottom) must be braced at 8'9" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to.achieve member stabilitv. Loadsi�ut#on I1idbie Raaf RyUFIrsupsort $u.ppflt : Vlfill h =5ead Mrs I�#s�r f Rbt#f f �nnvtr;f Access©rfe$ 1.50" 1.50" .. c1l1t�E� J �isrntc , 1.50" 835 /131 / 0 /1890 / 0 / 0 None 1 - Trimmer - Spruce Pine Fir 2 Trimmer - Spruce Pine Fir 1.50" 1.50" 1.50" 835 /131 / 0 /1890 / 0 / 0 None Loadsi�ut#on Tributary , �ritiol Raaf : Vlfill h =5ead Mrs iwe al7t>tFW IAf#rid $eISt1V1C Gomtnents 1 - Uniform(PLF) 0 to 8' 9" N/A 180.0 30.0 0.0 432.0 0.0 0.0 Residential - Living Areas Renovations to 76 old Village Lane North Andover, MA Snow Load = 55 psf Fortel" Software Operator Arthur Rose Arthur W. Rose, P.E. PLLC (603)622-6066 awroseeng@ewroseconstrLICtion.com Job Notes 1/26/2011 7:45:11 AM iLeveM-) Forte'"' v2.0, Design Engine V5.1.0.3 Page 1 of 1 PORAVAS DESIGN & CONSITTIN(T February 4, 2011 Building Department Town of North Andover 1600 Osgood Street North Andover, MA 01845 RE: Steel and LVL (Engineered Lumber) installations at the Halloran Residence, 240 Stevens Street, North Andover, MA 02845 To Whom It May Concern, This letter is written to confirm with the building department that the steel beams and LVL's (engineered lumber beams) for the new addition at 240 Stevens Street have been designed according to the load conditions prescribed by the Massachusetts State Building Code for One and Two Family Dwellings, 7t" Edition. Further, Mr. Halloran (the Owner) has worked closely with this office during the framing of the structure to ensure that the proper sizes of beams were procured and the installation was according to the plans provided. Should you have any questions regarding this letter or the project in regards to this matter please feel free to call me at 339-927-1579. 1 can also be e-mailed at pdcdesign I @gmail.com if this method is more convenient. LBe Christopher A. Poravas Cc: Leonard Halloran (Owner) N0.30294 BOST%, M*S. �Z 49 Applct.oi) Street, Melrose, MA 02176 - Phonc: 339-927-1579 - Email: pAcdesigi)l@glnail.com If 10 t Date. ?10.' ..... -•��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING'`' �SSACMUS� This certifies that. , .... S�� .(� .. X r has permission to perform .... plumbing in the buildings of ..................... at .... S `'. ` `... ............ .North Andover, Mass. e I - . Fee. ....... Lic. No... ? ..... ...... PLUMBING INSPECTOR Check # 7 5 �6 Date.. j/1. ! ......... %` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S,gSSAC MUSESS zoll This certifies that .:S/7U. 4 G Cl `t A G has permission for gas installation ..11117 P A in the buildings of ... Q .�'../�`: ........... . at .. 2 [f ®.... /.'c North Andover, Mass. Fee.. �1 ... Lic. No... 3 c c . ...... :...�4 t... . GAS INSPECTOR Check # '' 5 �/ C -N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING urICity/Town: A'00— '-4 lTw66 t/ -e- k MA. Date: � A- Iff Permit# Building Location:-L(Z> S TFu,QwS f I- Owners Name: /,, o/L 4,1 /-J Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ F_ New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FlYTI IRRA CO Wfl: CO Z H y m= Cl) V F_ 2 X CO Cl) v O I J V � z y 0= W w W Lu �I z F- 0 z z W O °° � w O 1-- Q H nL Fn � W Z o w a O Q W w= x ir W 1--W Q W W z J W Z N= W J H I— O z --I C7 LL fA Z Z W W F - w w M H W z �- N v D u- t9 Q Q m w O z t 7 =_ O 0~ w H>>> O a. SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 FLOOR --i 'FLOOR 6 FLOOR 7 FLOOR -i 'FLOOR Installing �- ��D��D C O'k� Check One Only Certificate # Company Name: 7`- AddressZ3 �l/�/�% /� // City/Town!��`< f� Z State: B=Corporation /a �✓ .�1�- El Partnership _ �/ Business Tel: �} %� '�� � J J Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: 4G/'R /9- S t��1A47� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 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 ❑ Sionature of Owner or Owner's Aaent ; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to me Desi OT my r%nowieage ana mat an piumomg worK and mstaiiations 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. Typqaf License: By lumber -� Title El GG s Fitter Signature f Licensed mber/Gas Fitter aster City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer I FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING " G` ,�t 3 f City/Town: N��Z� J�MDo`� �"2- , MA. Date: � � Permit# Building Location: c9 -C/,0 5 /E7/-cyJS S r Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes ❑ N9,6 FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes WNo ❑ 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 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. By Type of License: Title Plu ber Signatu of Licensed umber City /Town aster 3 APPROVED OFFICE USE ONLY ❑Journeyman License Number: DEDICATED z SYSTEMS tA Y O W > LA LA C C Z Z ~ h (A Y H Q = LA t%i LU�C� Z O Q Q W Z W Q m 4A C ~ d' H N H W } = Z Q H R , CQC Vf = C Imo- I n o U x� 2 W Q Q OC 0 W LLL 3 O C 3 W o O = C Z W Ln 3 J a LL Z oc na z _J 0 Ln W Q he = = a O cc Q a o o Z Q >> 0 a o= o Y Q Z v=i H H W a a a a= z Q a CD m c o U, x Y 3 g o: �, LA�� 3 3 3 o e� u a Q Q to 3 SUB BSMT. BASEMENT 1' FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR Check One Only Certificate # Installing �o ((060—'0 ¢ S6 � Company Name:' w Z 3 a���� �� � ll �-Ebrporation Address: ! C 44� City/Town: State: — ❑ Partnership Business Tel:97,F4t 47 3 J Fax: ❑ Firm/Company Name of Licensed Plumber: /�L �2 F� 4 S d Z 6 rte/ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes WNo ❑ 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 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. By Type of License: Title Plu ber Signatu of Licensed umber City /Town aster 3 APPROVED OFFICE USE ONLY ❑Journeyman License Number: W% TOWN OF NORTH ANDOVER 0 0. PERMIT FOR WIRING This certifies that ..... ....................... has permission to perform ".......... --" . ..... I .............................. .............. wiring in the building of ' ...... ................................................... .......... 7 . . . ...... .............. ,North Andover, Mass. ... .... . ...... ..... ...... Fee ............. Lic. No . ............. ................................ . ELECTRICAL . INSP . Ecro;U� .... Check # 8059 .11, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. U� f Occupancy and Fee Checked Lev. 1/07] (jPavr hlanl 1 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 EX OR TYPE ALL INFORMATION) Date: 3 —.2- 7 — b City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) (9 5 D -5—o€y e� ,3 -- Owner or Tenant CID IQ. -ELI I - A" 0a Telephone No. Owner's Address ja✓i-du h2 A f„OvItit fil- Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service/ 60 Amps L!2 l Q-110 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: /I„_ _I- _ r_71 No. of Recessed Luminaires �•�On y ,��r uuowtrs No. of Ceil.:Susp. (Paddle) Fans ravie may be waived by the Inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency ig g rnd. rnd. Batte 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Self -Contained No. of Waste Disposers Heat Pump Number Tons KW_ -._ ........... ........ .... __....... ....... Totals: Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW unicipal Local ❑ Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo. Heaters KW of No. of No. of Devices or Equivalent Data Wiring: Signs Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunicationswiring: 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: 3 ^ J,7 D � 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this applica true and complete. FIRM NAME: G LIC. NO.: --7vlv Licensee: %je�jv�c-�%p��� Signature LIC. NO.: (If applicable, enter "exempt " in the license number line) Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signaturebelow, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. 01 ? $ 6 5 S $ PERMIT FEE: $ ( �' 2, p-L 2-e '9 L9 The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 { i www.»zass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers Aoulicant Information Please Print Lembly Name (Business/Organization/Individual):_ C�� �7/j/C' C 8 � C Address: S�Tr/c�s S City/.State/Zip: Mo a? hone #:. Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.A I am.a.sole proprietor or partner- listed on the attached sheet x s tp and have no employees These sub -contractors have working for me .in any capacity. workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No -workers' comp. c. 152, § l (4), and we have no insurance required.] t employees. [No workers' comp, insurance required_] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. Q Demolition 9. Building addition 10.❑ Electrical repairs or additions I 1.❑ Plumbing repairs or additions 12.[] Roof repairs 13.❑ Other -Piny appucant that checks bo' # I must also fits out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire otnside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contracton and their workers' comp, policy information. I am an employer that is.providing workers' compensation insurance for my employees: Below isthe 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. 1 do hereby certjify r the pains and penalties of perjury -that the information provided above is true and correct. Signature: 14� 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 P� 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 -contractors) 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 cant' 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 cityor 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 numberlisted below. Self. -insured companies should enter their Self-insurance license number on the appropriate fine. 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 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 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 42111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax:9 617-727-7744 Revised 5-26-05 www.mass.gov/dia , .. 12 - 12 `?-31-e' 6, Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING - This certifies that .......... ..................... 7� ... ....... ... ...... .................... has permission to perform` -, ................ ...................................... wiring in the building of A—/ . ........ .- ...... .... ................................................ i ........... ........... ............. .......... . North Andover, Mass. Fee ............................................. . 1400� 0 j �b w A&� Lic. *Oc c:,P;7V ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. YO&3 Occupancy and Fee Checked J9, d� [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 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: V f City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) :7 e7� ;r— Owner or Tenant p a,� �h,� �1�Telephone No. Owner's Addresses Is this permit in conjunction with a building permit? Y s es No ❑ (Check Appropriate Box) Purpose of Buildingel� , Utility Authorization No. Existing Service -= / /-70 Amps j>d / �y4jVolts Overhead Z,""Undgrd ❑ New Service Amps i / Volts Overhead 2111' Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 2 -- No. of Meters No. of Meters_ _-••��•• �-..�.�. —i uczuu y aeszrea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: .(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 .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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains nd penalties of perjury, that the, information on this application is true and complete. ME FIRM NA:LIC. NO.: Licensee: Signature (If applicable, enter "exempt " ' t zcense number 1'ne.) / �� LIC. NO.:.%d27yT Address: _•l S'® Lam, s/�, / /Iyy�_ Bus. Tel. No.: 41 Alt. Tel. No.: *Per M.G.L c. 147, S. 7-61, sec 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 Signature Telephone No. PERMIT FEE: $ /�11, ' � s�1 wI r The Commonwealth of Massachusetts Department of Industrial Accidents OIr ffice of Investigations 600 Washington Street Boston, MA 02111 t' j www nzass.gov/dia Workers' Compensation Insitranee Affidavit: Builders/Contractors/Eiectricians/Plambers Applicant Information Please Print Legibly Name (Business/Organizafion/Individual); Address: City/<State/Zip: % Phone 9:. /% e5 g� Are you an employer? Check the appropriate box: ' l . ❑ I am a employer with 4. ❑ I am a general contractor and h . Typeof project (required): loyees {foil and/or part-time).* . have hired the sub -contractors 6• ❑ New construction 2. I am a.sole proprietor. or partner- listed on the attached sheet t7. emodeiing ship and have no employees These sub -contractors have 8. ❑ Demolition` working for me .in any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.) 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 10•❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions myself. [No -workers' comp. c..1.52, § I(4),'and we have no 12.❑ Roof repairs insurance required:) t employees. [No workers' 13'[] Other comp. insurance required_] r• -••,-rr••• —-bmi uou ff I must also nu 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 af{davit indicating such. $Contractors that cheek this box must attached an additional sheet showing the name of the sub -contactors and their workers' comp. policy ininmution. l am an employer thW-is pr4?viding:workers' compensation insurance for my. employees: Below it the policy and job site information. Insurance Company Name: Policy # or Self= -ins. Lie. #: Expiration Date: Job Site Address: City/state/Zip: Attach a copy of the .workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure 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 cedlfy u ndirrthe pains and penalties of perry that the information provided above is tme and correct nate• Official use only. Do not write in [his area, to be completed by city or town official itm 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 a i1d 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 includirng 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 that, 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." MOL 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.olF compliance with the insumnce'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 -contractors) name(s), address(es) and phone numbers) 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 an 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/iicense 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 ofthe 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 fut a 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 bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investiptions 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 lndustdal Accidents Off ee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 Ext 406 or 1-8.77-MASSAFE 1 3-26-05 Fax # 617-727-7744 www.mass.gov/dia r i Date. .3•�' .:i/. . S "ORT1y pf „ao TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ...... .. ........... . in the buildings of ., � . c'�........ - ........ ....... . at -.41".�.�,� , North Andover, Mass. Fee -:'q..... Lic. No.. e: .. ;�..... .......... GAS INSP2CTOR Check # 6425 G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date 5/20 2008 Permit # Building Location 240 STEVENS ST Owner Tel# 978 375 2978 Owner's Name LEN HALLORAN Type of Occupancy RESIDENTIAL New 1-1/1 Renovation❑ Replacement FIXTURES Plan Submitted: Yes❑ No❑ Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter JOHN LIPINSKI Check one: Certificate ZCorporation Partnership Firm/Co. INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ No 1:1If you have c ecked y s, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application . true a ac ate to the best of my knowledge and that all plumbing work and installations performed under the permit issu r this ap icati n ' e ' ompliance with all City/Town APPROVED (OFFICE USE ONLY) its State Gas Code and Chapter 142 of the Ge ral ws. Type of License: X umber Signatur of i nv9p mber or Gas Fitter as fitter • •Master License Number • -Journeyman TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �1 Permit NO: ' Date Received a d d f a Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION TJ int PROPERTY OWNER Dv N t, r . -Rah Print _- MAP NO: "PARCEL: i ZONING DISTRICT: Historic District yes no Machine 'Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family dditio Two or more family Industrial Iteratio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: e O r S`I � c,, ir a� t Dv 3 �f � 4 e c IdentificatAn PI ase T, or Print Clearly) ® h OWNER: Name: L e0 �� 41, .1 r A � Phone: 7 7�-37��o` Address: d 7 s-�edens N CONTRACTOR Name: Phone: Address: Supervisor's Construction License Exp. Date: Home Improvement License: :Exp. Date: 1024V48 ►>Eske'o ? C -o ARCHITECT/ENGINEER Hmznco Vzemz -CN- ,s Foaw✓as Phone: 5'S1- 12-1 -1519 ' Address: 40t APP_ET,1 mer. HsLave MA o2_n (, Reg. No. -3 6 _ I q FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ; 000°dD FEE: $ Check No.: �? %S Receipt No.: 92,3 Li 7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL =PublicSewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM %Al C� Sly DATE REJECTED DATE APPROVED PLA, NING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on O f i (� Signature COMMENTS �ALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Si nature & Date r. � Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: 2 Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: Ili 20 S ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work, ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan L3 Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 Location 7 y Y-7',, No. C) Date ?1,�S �U TOWN OF NORTH ANDOVER Certificate of Occupancy $ r� s�CMUs <� Building/Frame Permit Fee $000 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / 23.34 r Building Inspector z W F-4 W c c m c ai • L V Z O L �b0 .� 0co y c ,C y O I cm C c W4 .r o V)ro a O U o, U 0 .r U w O U � w O H w W O W cn w p = C E-� w - z _ Q o F-4 W c c m c ai • L V Z O L �b0 .� 0co y c ,C y O I cm C c C y.+ O Q.— p 'C H v V U m m CLf=•+ O W = C TZT CD eov 0 o o - c O � a. CL E Q CF c 0 ca COD Z v 4ZL+ C- N V O Cc c c cc Q. CO) a G C. N C" m N ga m -o = C �N N C O m o \: H m m CC,* Q � C m v H O C (\X; Q! H m _ m ms, c N a0+ N 0 a O coo W C A== t •N r.+ C=,* f � � •o d t = Z LU ®CJ CD � CMt= y CD ` H •a g O Cc =�CLm:mb F-4 0 U) U) W W V9 LLIW W W ai • L V Z o 0. �b0 .� 0co y c I cm C c CAco Q.— p 'C H U m m CLf=•+ TZT CD eov 0 o o - a. CL cmQ ^^0 c 0 ca COD Z v 4ZL+ CL V O Cc c c cc Q. CO) 0 U) U) W W V9 LLIW W I 61A OOD oU- IYA �00D roo 'enc gt�o0 s`��n 0 Tsoo Ccs LOD „sin a�yS r 0� n S 2n q a� �—a�� µpRTPI TOWN OF NORTH ANDOVER yb"dog OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 !q ADgATID 'pPi15 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:JI) I)OID JOB LOCATION: s� 2 Number Street Address HOMEOWNER Name PRESENT MAILING ADDRESS Y, Ovzr- Home Phone A0 City Town Map/Lot 79, '3 7� —)97,? Work Phone "-tuttis S7 - State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section .108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requi ern ts,�t� that he/she will co ply with said procedures and requirements. t \ 11 n T HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kv 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Q �h� C� � 11� ro 1/l Address: ) q 0 75+( U Chs_ City/State/Zip: No t�v Q� Q Phone #: � 1 � '3 iE_ Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 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 ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. YJ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other :.u;; 4j;pll au: coni :marry, nox �r must a'.S'O t i out the section below showing their womers' 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 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. #: Job Site Address: Expiration Date: 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 fore 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 c fy n he rs aid penalties of perjury that the information provided abl9vels true and correct Signature: h Q� Date: a� d 0' 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. PIumbing 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 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 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 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 # 617-72.7-7749 Revised 5-26-05 www.mass.govfdia REScheck Software Version 4.3.0 Compliance Certificate Project Title: Additions and Renovations to the Halloran Residence Energy Code: 2006 IECC Location: North Andover, Massachusetts Construction Type: Single Family Project Type: Addition/Alteration Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: 240 Stevens Street North Andover, MA Compliance: Maximum UA: 251 Your UA: 247 Designer/Contractor: Chris Poravas Poravas Design & Consulting 49 Appleton Street Melrose, MA 02176 339-927-1579 pdcdesignl@gmail.com Floor 1: All -Wood Joist/Truss:Over Unconditioned Space 900 30.0 0.0 30 Ceiling 1: Cathedral Ceiling (no attic) 300 30.0 0.0 10 Ceiling 2: Flat Ceiling or Scissor Truss 600 38.0 0.0 18 Wall 1: Wood Frame, 16" o.c. 1870 21.0 0.0 91 Window 1: Wood Frame:Double Pane with Low -E 181 0.350 63 Door 1: Glass 100 0.350 35 Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2006 IECC requirements in REScheck Version 4.3.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. C 1-1 5 0CLA JAS t.;,� I i 3 zzo 10 Name - Title Signature Date Project Title: Additions and Renovations to the Halloran Residence Data filename: C:\01-Projects\Residential\Halloran-iWndover\Halloran-NorthAndover.rck Report date: 01/13/10 Page 1 of 3 LEt REScheck Software Version 4.3.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Cathedral Ceiling (no attic), R-30.0 cavity insulation Comments: ❑ Ceiling 2: Flat Ceiling or Scissor Truss, R-38.0 cavity insulation Comments: Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: Windows: ❑ Window 1: Wood Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Note: Up to 15 sq.ft. of glazed fenestration per dwelling is exempt from U -factor and SHGC requirements. Doors: ❑ Door 1: Glass, U -factor: 0.350 Comments: Floors: ❑ Floor 1: All -Wood Joist/Truss:Over Unconditioned Space, R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed lights are either 1) Type IC rated with enclosures sealed/gasketed against leaks to the ceiling, or 2) Type IC rated and ASTM E283 labeled, or 3) installed inside an air -tight assembly with a 0.5" clearance from combustible materials and a 3" clearance from insulation. Sunrooms: ❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U -factor of 0.50 and the maximum skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Vapor Retarder: ❑ Vapor retarder is installed on the warm -in -winter side of all non -vented framed ceilings, walls, and floors; or it has been determined that moisture or its freezing will not damage the materials; or other approved means to avoid condensation are provided. Comments: Materials Identification and Installation: ❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value. ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R -values and glazing U -factors are clearly marked on the building plans or specifications. Duct Insulation: Project Title: Additions and Renovations to the Halloran Residence Report date: 01/13/10 Data filename: C:\01-Projects\Residential\Halloran-iWndover\Halloran-NorthAndover.rck Page 2 of 3 o Ducts in unconditioned spaces or outside the building are insulated to at least R-8. a ❑ Ducts in floor trusses above unconditioned spaces or above the outdoors are insulated to at least R-6. Duct Construction: Ll Air handlers, filter boxes, and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. F1 All joints, seams, and connections are made substantially airtight with tapes, gasketing, mastics (adhesives) or other approved closure systems. Tapes and mastics are rated UL 181A or UL 181 B. Lj Building framing cavities are not used as supply ducts. ❑ Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. F1 Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International Mechanical Code. Temperature Controls: Thermostats exist for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor is provided. Circulating Service Hot Water Systems: Cj Circulating service hot water pipes are insulated to R-2. ❑ Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Certificate: Lj A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window U -factors; type and efficiency of space -conditioning and water heating equipment. NOTES TO FIELD: (Building Department Use Only) Project Title: Additions and Renovations to the Halloran Residence Data filename: C:\01-Projects\Residential\Halloran-1 Wndover\Halloran-NorthAndover.rck Report date: 01/13/10 Page 3 of 3 Y41,... w REScheck Software Version 4.3.0 Compliance Certificate Project Title: Additions and Renovations to the Halloran Residence Energy Code: 2006 IECC Location: North Andover, Massachusetts Construction Type: Single Family Project Type: Addition/Alteration Heating Degree Days: 6322 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 240 Stevens Street Chris Poravas North Andover, MA Poravas Design & Consulting 49 Appleton Street Melrose, MA 02176 339-927-1579 pdcdesignl@gmail.com Compliance: Maximum UA: 251 Your UA: 247 Floor 1: All -Wood Joist/Truss:Over Unconditioned Space 900 30.0 0.0 30 Ceiling 1: Cathedral Ceiling (no attic) 300 30.0 0.0 10 Ceiling 2: Flat Ceiling or Scissor Truss 600 38.0 0.0 18 Wall 1: Wood Frame, 16" o.c. 1870 21.0 0.0 91 Window 1: Wood Frame:Double Pane with Low -E 181 0.350 63 Door 1: Glass 100 0.350 35 Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2006 IECC requirements in REScheck Versions 4.3.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. �,-..,1 .r�CG.�J (.��tr•9--Q-QJ �it-a-CL\S o(�AJAS � ���j�'�O� U Name - Title Signature Date Project Title: Additions and Renovations to the Halloran Residence Report date: 01/13/10 Data filename: C:\01-Projects\Residential\Halloran-1\Andover\Halloran-NorthAndover.rck Page 1 of 3 REScheck Software Version 4.3.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Cathedral Ceiling (no attic), R-30.0 cavity insulation Comments: ❑ Ceiling 2: Flat Ceiling or Scissor Truss, R-38.0 cavity insulation Comments: Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: Windows: ❑ Window 1: Wood Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes Frame Type Thermal.Break? Yes No Comments: Note: Up to 15 sq.ft. of glazed fenestration per dwelling is exempt from U -factor and SHGC requirements. Doors: ❑ Door 1: Glass, U -factor: 0.350 Comments: Floors: ❑ Floor 1: All -Wood Joist/Truss:Over Unconditioned Space, R-30.0 cavity insulation Cnmmants- Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed lights are either 1) Type IC rated with enclosures sealed/gasketed against leaks to the ceiling, or 2) Type IC rated and ASTM E283 labeled, or 3) installed inside an air -tight assembly with a 0.5" clearance from combustible materials and a 3" clearance from insulation. Sunrooms: ❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U -factor of 0.50 and the maximum skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Vapor Retarder: ❑ Vapor retarder is installed on the warm -in -winter side of all non -vented framed ceilings, walls, and floors; or it has been determined that moisture or its freezing will not damage the materials; or other approved means to avoid condensation are provided. Comments: Materials Identification and Installation: ❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value. ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R -values and glazing U -factors are clearly marked on the building plans or specifications. Duct Insulation: Project Title: Additions and Renovations to the Halloran Residence Report date: 01/13/10 Data filename: C:\01-Projects\Residential\Halloran-iWndover\Halloran-NorthAndover.rck Page 2 of 3 ❑ Ducts in unconditioned spaces or outside the building are insulated to at least R-8. a Ducts in floor trusses above unconditioned spaces or above the outdoors are insulated to at least R-6. Duct Construction: Fi Air handlers, filter boxes, and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. L1 All joints, seams, and connections are made substantially airtight with tapes, gasketing, mastics (adhesives) or other approved closure systems. Tapes and mastics are rated UL 181A or UL 181 B. Building framing cavities are not used as supply ducts. r-1 Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. F-1 Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International Mechanical Code. Temperature Controls: ❑ Thermostats exist for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor is provided. Circulating Service Hot Water Systems: F-1 Circulating service hot water pipes are insulated to R-2. ❑ Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Certificate: F-1 A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window U -factors; type and efficiency of space -conditioning and water heating equipment. NOTES TO FIELD: (Building Department Use Only) Project Title: Additions and Renovations to the Halloran Residence Report date: 01/13/10 Data filename: C:\01-Projects\Residential\Halloran-1\Andover\Halloran-NorthAndover.rck Page 3 of 3 Permit N0: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received y �t1•cy 16• •rO\ o � Residential TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial No. Commercial All eration of units: Repai , replacement Assessory Bldg Others: Demolition Other _ (-o M -b \t 9. DE gRIPTI UI-.Vvum U tsc rmcrur<mcv. 0.0 I a k U�C� 0 a t`�. , a n� 101- IIt r — CQ1r�evll Type or Print Clearly) 0 rare 979 _.3 - I g OWNER: Name: 1-Zav\cLr Ob t`S Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ��0 00 FEE: $ -44-1) Check No.: Receipt No.: 02.0 NOTE: Persons con actingrVifh un1°qAiste�red contractors do not have access to the guaran end Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well. Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 No Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special .permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location S)gO � V N o. `J Z Date > �� �aRTN TOWN OF NORTH ANDOVER F Certificate of Occupancy $ s 9 <<' Buildin /Frame Permit Fee $ s�►cNut Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # N 20914 Building Inspector Permit NO: 5--, BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 7 109 p tt�eo..tib�.ry� O 4 .ib 4 h TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial ration No. of units: Commercial QtLpa-b replacement Assessory Bldg Others: Demolition Other X ::"."T�4L ..y �°�4•$ '�i'+�..'�'y yyyyy� := U�' iH- �''tl ]$..y "N` `v'4 '.s. i� -3:i.. S d _ DE C�RIPTI UI- WUK U tst rKtrUKMtu: 0 (Y\ T, � 4n0 % rD1(n Wa 5 It"p-eC I2Vt� �e ale �►`� OCL 4 Painf ��roU��ov`1_ 979-375-- 978 t #-,StorL 6c,� tiU 01 OWNER: Name: V Q -b via V' on Jlea'�e Type or Print Clearly) a 10 rarl Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. d� Total Project Cost: $ FEE: $�� Check No.: 3 Receipt No.: 02,E 5 NOTE: Persons coniractingrVifk unrAistered contractors do not have access to the guaranty fund W x O w uav+ Via+ o w v n U z �•`i C ,0 [dPQ o o d5 EpE�. W a O w tj a p U 00 z w w � CO o cn �' co • � o c � o ` C N O C v V •dam c M CL. � ocac s co Ea CF .,, CD o �• y-. N «c=o. o. � o $ c" a.mm - L ca W. 3 = m C m � N C m O ACa = C C �Em o mo cm CLC N O O Of N• Sd O ' 2 O O m CS Ucjm h Z O r R: c O C D. Q Cup loy O C •O x o�o. 3 N 0 ~' 0 N CL. o m r W 0 Z:s.0 �.. F.. •N at O c Z W•E3 `. a; O v v pf Vi c o:2 O� _ a O ti O H z $ CL *- F-4 v 0 O z o. O h � C C! I C C CD C .0 MA 0 m m � H .c 3� m L d rCaa C3, � c Cc v ca C Z CD CD CL. LD No c C C . y.r � C _c Q. h LU U) V9 W W 19 W N TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please pgij ;DATE: 3 101o g — 30B LOCATION: Telephone (978) 688-9545 Fax (978) 688-9542 Number Street Address Map/L.ot HOMEOWNER ¢ �a r•� ora -9)9--3 ? S — 9 79 Name Home Phone Work Phone PRESENT MAILING ADDRESS Jt- Pck VAZA k City Town State 0d elf zip Cade The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and that he/she will comply with said procedures and requirements. i A HOMEOWNERS APPROVAL OF BUILDING OFFICIAL Revised 10.1005 Foam Homeowom Exemption BOARD OF kPPF,:V_S 689-9541 CU.NSERVNFION 638-9530 I1E.UAli 688-95.30 PL.1\'NING 6K8-9535 The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations 600 Washington Street .Boston, MDQ 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers [)plicant Information 1 1GaDC Name (Business/Organization/Individual): D A �. sti 0 4- A r\ Address: '44() () Sjx ty, S-! City/State/Zip: Are you an employer? Check the appri 1. ❑ I am a employer with ' employees (full and/or part-time).*' 2. ❑ I am a sole proprietor or partner- ship and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers' comp. insurance required:] t Phone.#: - 1- q —'�% S ^ A 4 7 fiate box: 4. Q I am a general contractor and I have hired the gub-contractors listed on the attached sheet These sub -contractors have employees and have workers' COMP- insurance.: 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required I Type of project (required);, 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building. addition ME] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box 91 must also fill out the section below showing Hotheir workers' compensation Policy information. t meau:iers who submit this afildavit indicating they are do ng all work and then hire outside contr _etors 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 mp. policy state whether or not those entities have employees. If the sub -contractors. have employees, they must provide their workers' eo ori number, I am, an employer that is Providing workers' compensation insurance for my employees. Below is thepolicy.andjob site information. Insurance Company N Policy # or Self -ins. Lic. #: Job Site Attach a copy of the workers' Failure. to secure coverage as r fine up to $1,500.00 and/or one-yc of up to $250.00 a day against the Investigations of the DIA for insw I do hereby rertiX under the at,, Expiration Date- city/state/z ip: uensation policy declaration page (showing the policy number and expiration date). 3 under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties •of a imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine �dator. Be advised that a copy of this statement may be forwarded to the Office of �coveraee verification penalties ofperjury that the information provided one 1#.:d. use only. Do not write in this area, tb City or Town: or town officiaC Pertnit/License # Issuing Authority (circle one): L Board of Health 2. Building Departm 6. Otherent 3. City/Town Clerk Contact Person: abo ais fru and correct VO /6 1� 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information as d 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." i An employer is defined as "an individual, partnership, association, corporation or other legal entity, of 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 spar caents 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 "ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,bpera`ie to bnsiness or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." i Additionally, MGL chapter 1,52, §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 -contractors) name(s), address(es) and phone number(s) along with their cerdficate(s) of insurance. Limited Liability Companies (LLQ 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign .and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law, or if you are required to obtain a 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 Invest ptiores 600 Washington Street. Boston, MA 02111 Tel. # 617-727-4300 ext.406 or 1-877-MASSAFE ` Revised 1122-06 Fax # 617-727-7749 .,.mass.govldia