HomeMy WebLinkAboutMiscellaneous - 245 BERRY STREET 4/30/2018i
Town of North Andover
ZONING BOARD OF APPEALS
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Minor Modification to Notice of Decision Year 2007
Decision Address: 0 Berry Street
NAME: Kevin Stack MOD"ICATION.DATE:.8-13-2008
ADDRESS: 0 Berry Street (Map 106:D,:Parcel 50) 4P—ETITION:07-QI6
TheNorth Andover Board of Appeals held a regular public hearing on Tuesday August I2, 2008, at 7:30 PM in the
Town Hall top floor meeting room, 120 Main Street, North Andover, MA upon the application of Kevin Stack
requesting that the. North Andover Zoning -Board of Appeals:modify:the Variance decision 2007-016 inorder.to
locate the new single-family dwelling 20 feet from the front lot line.
The following voting members were present: Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Thomas
D. Ippolito.
Upon motion by Joseph D. LaGrasse and 2'd by Thomas D. Ippolito, the Board found. that the request to locate the
dwelling 20 feet from the: front lot line rather than the 2007-01.6 Variance decision's 10 foot setback is a minor
modification and that this modification does not alter the intention of the Variance decision 2007-016. Voting in
favor: Ellen?. McIntyre, Joseph:D, LaGrasse. Richard J. Byers, and Thomas D. Ippolito.
Upon a motion by Joseph D. LaGrasse and 2"d by Thomas D. Ippolito, the Board voted to GRANT Kevin Stack's
request to modify Variance 2007-016 by granting the request to locate the dwelling 20 feet from the front lot line
rather .than the 10 font kP.thF r oranrrA in rt— 1nn7
Site:
O Be Street.(Ma I06:D, Parcel 50), North Andover, MA 10845
Site Plan Title:
Variance Plan of Land, located in, North Andover. MA., owner & applicant,
Kevin Stack, .12295 Genter Drive Spring Hill FL 34,609
Date (& Revised Dates):
7101108
Registered Professional Land :
Michael J. Sergi, #33191, Christiansen &'Sergi, 160 Summer St. Haverhill,
Surveyor.
MA. 01830
Sheet/Drawing:
Dw .No.9300501.2
In all other respects, the original decision remains hi full force and effect as modified hereby. Voting in favor:
Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Thomas D. Ippolito.
North Andover Zoning B and fAppeal
Ellen P. McIntyre, Vice Chairman
Richard J. Byers, Esq., Clerk
Joseph D. LaGrasse
-4ssociafe Afemher
Thomas D. Ippolito
Decision 2007-016 Modification.
M 106. DP50.
Enclosure: Decision 2007-016,
1600 Osgood St., Bldg 20 - Suite? -36- North Andover, -MA 01845
Phone - 97S-688-9541 Fax - 978-688-9542 Wcb - www.tnwnofnorthandnvcr.mm
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Joseph D. LaGrasse
I ;wicl R. Wcktcr
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Thomas I). Ippoliro
Richard M. \'aill:mcourt
Dauiel S. Brac•sc, Esq.
Town of North Andover I own Cici k Time Su!,! >
ZONING BOARD OF APPEALS
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Any appeal shall be filed within Notice of Decision
(20) days after the date of filing Year 2007
of this notice in the office of the
Town Clerk, per Mass. Gen. L. ch.
40A,§17 Pro erty at: 0 Berry Street
NAME: Kevin Stack HEARING(S): August 14 & September 11, 2007
ADDRESS: 0 Berry Street (Ma 106.13, Parcel 50) PETITION: 2007-016
North Andover, MA 01845 TYPING DATE: September 20, 2007
The North Andover Board of Appeals held a public hearing at its regular meeting in the Town Hall top floor
meeting room, 120 Main Street, North Andover, MA on Tuesday, September 11, 2007 at 7:30 PM upon the
application of Kevin Stack, 0 Berry Street (Map 106.D, Parcel 50), North Andover, MA requesting a dimensional
Variance from Section 7, Paragraphs 7.1 (Lot Area), 7.2 (Street Frontage), 7.3 (Yard Setback), and Table 2 of the
Zoning Bylaw for relief of lot area, street frontage, and front and side setbacks in order to construct a single-family
dwelling. Said premise affected is property with frontage on the West side of Berry Street within the R-2 zoning
district. Legal notices were sent to all names on the abutter's list and were published in the Eagle -Tribune, a
newspaper of general circulation in the Town of North Andover, on July 23 & 30, 2007.
The following voting members were present: Eller, P. McIntyre, Joseph D. LaGrasse, Albert P. Manzi, III, David R.
Webster, and Daniel S. Braese. The following non-voting members were present: Thomas D. Ippolito and Richard
M. Vaillancourt.
Upon a motion by Joseph D. LaGrasse and 2nd by Ellen P. McIntyre, the Board voted to GRANT dimensional
Variances from Section 7, Paragraphs 7.1 (Lot Area), 7.2 (Street Frontage), 7.3 (Yard Setback), & Table 2 for relief
of 23,560 sq. ft. lot area, for relief of 50' street frontage, for relief of 20' front setback, and for relief of 20' south
side setback from the requirements of the Zoning Bylaw in order to construct a proposed single-family dwelling;
ner:
Site:
0 Berry Street (Map 106.1, Parcel 50), North Andover, MA 10845
Site Plan Title:
Variance Plan of Land, located in, North Andover, MA., owner & applicant,
Kevin Stack, 12295 Genter Drive Spring Hill FL 34609
Date (& Revised Dates):
7/9/07
Registered Professional Land
Michael J. Sergi, #33191, Christiansen & Sergi, 160 Summer St. Haverhill,
Surveyor:
MA. 01830
Sheet/Drawing:
Dw .No.93005012
Building Plan Title: Floor Plan, Map 106.1), Lot 50 Berry St., North Andover, MA, prepared for,
Kevin Stack, 12295 Genter Drive Spring Hill FL 34609
B Christiansen & Sergi, 160 Summer St. Haverhill, MA. 01830
Date: Jul 6, 2007
Sheet/Drawing: Floor Plan, Front, Right Side, Rear, Left [elevations] Dw . No. 93005008
With the following conditions:
1. The applicant shall provide a sewer tie-in as approved by the Division of Public Works.
Voting in favor: Ellen P. McIntyre, Joseph D. LaGrasse, David R. Webster, and Daniel S. Braese.
Voting in opposition: Albert P. Manzi, 111
Page 1 of 2
IG(?U Osgood Strut. Ruildnig 20 - Su11c-36. North Andover. Massachuscus u18/15
I'lione - 978-688-9541 h'ax - 978-688-95.12 Web - wwvN.toxnu>I'll orth;]Ildover c
CONSERVATION/HEALTH DEPARTMENTS
Community Development Division
1600 Osgood Street
North Andover, Massachusetts, 01845
December 31, 2012
Gregg Fratto
245 Berry Street
North Andover MA
Re: Sewer issue rT �, rt
Mr. Fratto,
Upon the sale of your purchase of yo 4 4� �� i lent was made aware that the sewer
connection on the property was never cd 1 + A amount of puddle water around the
sewer manhole and along the edge of Be ,r - e confirmed that this is sewage, but
both the Conservation and Health Depart, � (� � � ` ' J `l d � � �� ��1+ �� :'graphs.
The North Andover Wetlands Protection ,� �� CJI; �F tj i I �1 Protection Act (M.G.L. c. 131, §
40) and the associated regulations' state t �� J �" ivities: removal, filling, dredging,
discharging into, building upon, or othe, �,�- , �. " "? as" (including creeks, rivers and
streams). The Conservation Commission a ; y �'k + f c i i `�� a wetland resource area and 200-
feet from all perennial streams/rivers.
There is a great public health concern reg �� Z�;�`'' J` L .nd, or into the ground water, to
your family, neighbors and pets. Human viruses that could potentially cause severe
_ _. . tue area affected by the sewer overflow until this important matter is
illness. Please keep children and pets awa,
corrected. The -Health Department enforces the nuisance code regarding unwanted odors, under the authority of M.G. L.
Chapter 111 Sections 31C and 122. It is our duty to investigate and control nuisance conditions. Health Departments are also
empowered by DEP (310 CMR 7.52) to take enforcement nrfinn dor regulations (310 CMR
7.09-7.10). This matter must be addressed imn
Please contact the Conservation/Health Depar
anticipated cooperation in this matter.
Respectfully,
J
Je fifer Hughes
o + scrvationAdministrato,r, North Andover
i -
Michele Grant
Health Inspector, North Andover
itter. Thank you for your
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CONSERVATION/HEALTH DEPARTMENTS
Community Development Division
1600 Osgood Street
North Andover, Massachusetts, 01845
December 31, 2012 -
Gregg Fratto
245 Berry Street
North Andover, MA
Re: Sewer issue
Mr. Fratto,
Upon the sale of your purchase of your property, the Community Development Department was made aware that the sewer
connection on the property was never completed. A recent visit to the site revealed a large amount of puddle water around the
sewer manhole and along the edge of Berry Street. Due to recent precipitation, it cannot be confirmed that this is sewage, but
both the Conservation and Health Departments are concerned. Please see the attached photographs.
The North Andover Wetlands Protection Bylaw (Chapter 178) and Massachusetts Wetland Protection Act (M.G.L. c. 131, §
40) and the associated regulations- state that "no person shall engage in the following activities: removal, filling, dredging,
discharging into, building upon, or other wise altering or degrading wetland resource areas" (including creeks, rivers and
streams). The Conservation Commission also regulates activities on land within 100 -feet of a wetland resource area and 200-
feet from all perennial streams/rivers.
There is a great public health concern regarding the discharge of raw sewage on the ground, or into the ground water, to
your family, neighbors and pets. Human waste contains numerous bacteria and viruses that could potentially cause severe
illness. Please keep children and pets away from the area affected by the sewer overflow until this important matter is
corrected. The .Health Department enforces the nuisance code regarding unwanted odors, under the authority of M.G. L.
Chapter 111 Sections 31C and 122. It is our duty to investigate and control nuisance conditions. Health Departments are also
empowered by DEP (3 10 CMR 7.52) to take enforcement action against violators of DEP's odor regulations (3 10 CMR
7.09-7.10). This matter must be addressed immediately.
Please contact the Conservation/Health Departments by Friday, January 4, to discuss this matter. Thank you for your
anticipated cooperation in this matter.
Respectfully,
l�
Je es
ifer Hugh
o n servation Administr , , North Andover
Michele Grant
�Iealth Inspector, North Andover
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CO CERTIFIED MAIL. RECEIPT
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- 4 r
December 31, 2012
Gregg Fratto
245 Berry Street
North Andover, MA
Re: Sewer issue
Mr. Fratto,
CONSERVATIONMEALTII DEPARTMENTS
Community Development Division
1600 Osgood Street
North Andover, Massachusetts, 01845
Upon the sale of your purchase of your property, the Community Development Department was made aware that the sewer
connection on the property was never completed. A recent visit to the site revealed a large amount of puddle water around the
sewer manhole and along the edge of Berry Street. Due to recent precipitation, it cannot be confirmed that this is sewage, but
both the Conservation and Health Departments are concerned. Please see the attached photographs.
The North Andover Wetlands Protection Bylaw (Chapter 178) and Massachusetts Wetland Protection Act (M.G.L. c. 131, §
40) and the associated regulations state that "no person shall engage in the following activities: removal, filling, dredging,
discharging into, building upon, or other wise altering or degrading wetland resource areas" (including creeks, rivers and
streams). The Conservation Commission also regulates activities on land within 100 -feet of a wetland resource area and 200-
feet from all perennial streams/rivers.
There is a great public health concern regarding the discharge of raw sewage on the ground, or into the ground water, to
your family, neighbors and pets. Human waste contains numerous bacteria and viruses that could potentially cause severe
illness. Please keep children and pets away from the area affected by the sewer overflow until this important matter is
corrected. The .Health Department enforces the nuisance code regarding unwanted odors, under the authority of M.G. L.
Chapter 111 Sections 31C and 122. It is our duty to investigate and control nuisance conditions. Health Departments are also
empowered by DEP (3 10 CMR 7.52) to take enforcement action against violators of DEP's odor regulations (3 10 CMR
7.09-7.10). This matter must be addressed immediately.
Please contact the Conservation/Health Departments by Friday, January 4, to discuss this matter. Thank you for your
anticipated cooperation in this matter.
Respectfully,
J
North Andover
Health Inspector, North Andover
2632
s4f
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. ��
Application by the undersigned is hereby made to connect with the town sewer main in / Street,
subject to the rules and regulations of the Division of Public Works.
a '� 'L
The premises are known as No.
or subdivision lot no. l 7
Owner Address
Contractor
Address
Applica 's Signature
PERMIT TO CONNECT
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at r2er
subject to the rules and regulations of the Division of Public Wor
Inspected by
Date
TH SEWER MAIN
%,
Street
Street
Divi on of Public Works
By
See back for rules and regulations
V
C'
7/10
/DL/2d
RULES AND REGULATIONS FOR GOVERNING THE INSTALLATION OF SEWER SERVICES
1. No unauthorized person shall uncover, make any connections with or opening into, use, alter, or disturb any public sewer
or appurtenance thereof without first obtaining a written permit from the Division of Public Works.
2. All costs and expense incident to the installation and connections of the building sewer shall be borne by the owner. The
owner shall indemnify the (town) from any loss or damage that may directly or indirectly be occasioned by the installation
of the building sewer.
3. A separate and independent building sewer shall be provided for every building; except where one building stands at the
rear of another on an interior lot and no private sewer is available or can be constructed to the rear building through an
adjoining alley, court, yard, cr driveway, the building sewer from the front building may be extended to the rear building
and the whole considered as one building sewer.
4. Old building sewers may be used in connection with new buildings only when they are found, on examination and test by
the (Superintendent), to meet all requirements of this ordinance.
5. The size, slope, alignment, materials of construction of a building sewer, and the methods to be used in excavating,
placing of the pipe, jointing, testing, and backfilling the trench, shall all conform to the following requirements. The sewer
shall be 6"diameter SDR 35, PVC pipe. Minimum slope shall be 1/8" per foot. The minimum depth of sewer shall be four
feet below finish grade. Sewer pipe shall be installed on a stable trench bottom of hard durable crushed stone to a
minimum (6) inch depth below the pipe. After the pipe has been installed, crushed stone shall be brought up to the crown
of the pipe. Care shall be taken to carefully grade and compact the stone, and prevent pipe displacement. The remainder of
the trench shall then be backfilled in one foot lifts with mechanical tamping after each lift.
6. Whenever possible, the building sewer shall be brought to the building at an elevation below the basement floor. In all
buildings in which any building drain is too low to permit gravity flow to the public sewer, sanitary sewage carried by such
building drain shall be lifted by an approved means and discharged to the building sewer.
7. No person shall make connection of roof downspouts, exterior foundation drains, or other sources of surface runoff or
ground water to a building drain which in turn is connected directly or indirectly to a public sanitary sewer.
8. The applicant for the building sewer permit shall notify the (Superintendent) when the building sewer is ready for
inspection and connection to the public sewer. The connection shall be made under the supervision of the (Superintendent)
or his representative.
9. All excavations for building sewer installation shall be adequately guarded with barricades and lights so as to protect the
public from hazard. Streets, sidewalks, parkways, and other public property disturbed in the course of the work shall be
restored in a manner satisfactory to the (town).
Town of North.Andover
ZONING BOARD OF APPEALS t
Clhcrt P. \I:mrt lil; P::y. G%rrirrrrna -
f li6cn I'. \(clnh•ro, 1'rrz-(:hnrrrurnt -
-Richard I.'lixt-rj, I:sq, Clerk E HORTt( ,y!Q SEP 12 P 1! n,
Richard tl. %'aitlxncourt o
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1-hmn t: 1). 1111). Ant, s t :"
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August 15. 2008
Kevin Stack
12295 Genter Drive
Spring Hill FL -34609
i
RE: O:Berry Street (Map 106:D., Parcel.50)
North Andover, Massachusetts 01845
Regarding your request for a six (6) month extension of your. Variance:
Please be advised that the Zoning Board of Appeals approved a six (6) month extension relative to the :premises
affected at the 0 Berry Street (Map 106.1), Parcel 50), North Andover, Massachusetts:
The Zoning Board of Appeals voted to extend for a period of six -months the Variances: granted by: the 2007-016
decision to and including March 11, 2009 (without the extension, the variance would expire on September 11, 2008)
at the regular August 12, 2008 meeting upon a motion by Joseph D. LaGrasse and 2°a by Thomas D. 1ppolito, Mass.
Gen. L., ch. 40A, a 10 allows the Variance permit :granting authority:to "extend the time for exercise of such rights
for a period not to exceed -six months".. Voting.in favor: Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers.
and Thomas D. Ippolito.
{
J
North Andover Zoning Board of Appeals
Ellen P. McIntyre, Vice Chairman
Richard J. Byers, Esq., Clerfi
Joseph D. LaGrasse
Associate dlemher
Thomas D. Ippolito
cc: Town Clerk
Philip Christiansen
ZBA file 2007-016
M 106. DP50.
1600 Osgood St., Bldg 20 - Suite 2-36. North Andover, ;MA 01845
Phone - 978-688-9541 Fax - 978-698-9542 Web - w•ww•.townuinorthandover.cona
Town of North Andover :
ZONING SOA.RD OF.A.PPEALS : -
111acer i'. \lastas III; F•::y. Chainrmn _
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Richard "L
7t
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August I5.2008
Kevin Stack
12295 Genter _Drive.
Spring :Hill FL 34609
RE: 0$erry Street .(Map 106.D, Parcel .50)
Forth_ Andover', Massachusetts 01845
Regarding ypur request for a six .(6) month extension.of your Variance:
Please be advised that the Zoning Board of'Appeals approved a six (b) moriih extension relative to the premises
affected at the 0 Berry Street (Map _ 106-_D,. Parcel 30), North Andover. Massachusetts:
Thz he Varances.grdiued by the 2U07-016
tea: nof for Boardof appa
:decision to and including March 11,.2009 (without the. extension, the variance .would'elpire:oa September 1-42008)
2008)
at the regular August 12, 2008 meeting upon a motion. by kseph D. LaGrasae and 2d by Thomas D. Ippoliti. lvtass:
Gen. L., ch. 40A. 10 ailo�vs the Variance _pefmit granting:authon y to "emend file time for exercise/of such. rights
for a period nut. to exceed:six months7. Voting in.favor.. Ellen P. W ntym Joseph D. LaGrasse, Richard 7. Byers.
and Thomas Di Ippolito. .
North Andover Zoning Board of .
Ellen P. McIntyre,' Vice Chairman
Richard . Byers, Esq., Clerk.
Joseph LaGras
D
co
Asciale. Afemher'
Thamas D. 'ippolito
cc: Town Clerk
Philip: Christiansen
ZEA :file 2007-016
M 1D6DI'50 .
16W tkgood St.. 13* 20 - Suite 2-36. North Andovcr, MA 61845
Phone - 978-688-9541 Fax - 978-698-9542 Wcb - ti- w.townc�fnorthandover-coni
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CONSERVATION DEPARTMENT
Community Development Division
June 26, 2008
Kevin Stack
12295 Genter Drive
Spring Hill, Florida 34609
RE: Modification to DEP File# 242-1399
Berry Street, Map 106D Parcel 50
Dear Mr. Stack:
On June 11, 2008, the North Andover Conservation Commission approved your request to
modify DEP File #242-1399 for the above referenced property. The modification allowed for
revisions to the previously proposed house layout. Revisions included expansion of the
house footprint to the west to accommodate single level living, an access ramp on the Berry
Street side of the dwelling, and reconfiguration of the driveway and garage. The new plan of
record is titled "DEP File No 242-1399 Site Plan Modification, Map 106D, Lot 50 Berry Street".
and was prepared by Christiansen & Sergi, and dated May 21, 2008.
As a result of this approval, several conditions require modification.
Condition #32: On the previous plan of record, dated September 20, 2007, only a portion of
the driveway was permitted in the fifty -foot (50') No -Construction Zone. The new modified
plan dated May 21, 2008, permits construction of portions of the house and garage in this
zone. The order continues to provide for no disturbance of existing grade, soils or vegetation
in the twenty-five foot (25') No -Disturbance zone.
Condition #47: On June 11, 2007 the Natural Heritage and Endangered Species Program
(NHESP) issued an opinion that the proposed project met the state -listed species
performance standard for the issuance of an Order of Conditions. Any changes to the
proposed project "may require an additional filing with NHESP." Revised plans must be
submitted to NHESP under Tracking No. 07-22388 for comment before work may begin.
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www.townofnorthandover.com
'0* Please feel free to contact me should you have further questions.
Sincerely,
NORTH ANDOVER CONSERVATION COMMISSION
Jennifer A. Hughes
`Adonservation Administrator
CC: Christiansen & Sergi, Inc.
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www.townofnorthandover.com
CONSERVATION DEPARTMENT
Community Development Division
Modification to Order of Conditions
The NORTH ANDOVER CONSERVATION COMMISSION agreed to accept
Applicant: K 1R 'S JZ4.--1� .
Stn" ►,Li L '�, L E'tvae u Ll 607
s
as a Modification to the Order of Conditions issued in File 242- ,i ` dated and
recorded in Book # 1-151 and page
Issued by the NOPTU_A�gOVF.,1k CONSERVATION COMMISSION:
e -
Vol -
On this /d"`" of before me pjersonally ap ared S,t Mass o me
day month/yr
known to be the person described in and who executed the foregoing instrument and
acknowledged that he/she executed the same as his/her free act and deed.
Notary Public
P-1 DON INA M. WEDGE
Coi,,i,ipld' EIITH Or
Idi Comm. Expires Au . 7.20;'13
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www.townofnorthandover.com
\lhen P. tilanr.i 111, 13sc1. C.Z>ai;nur,
Isl)nu P. mclntyrc, I Z;' -Chairman
Richard 1. 11 vers, L:5(1, (:..icrk
loscph D. I'IC;rasse
1.):n id R. \Vol)ster
A ;o,iale Al"'Whers
Thom:;.~ D, Ippolito
Richard N4. V:61lancollo
Daniel S. Brac•se, Fs(I
Town of North Andover
ZONING BOARD OF APPEALS
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r0`tT�eo '6''9.V
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The Board finds that owing to circumstances relating to the specific soil, shape and topography conditions affecting
0 Berry Street (Map 106.1), Parcel 50) but not affecting the Residential 2 zoning district in wh, ich it is locateda
literal enforcement of the provisions of Paragraphs 7.1, 7.2, 7.3, & Table 2 would involve substantial hardship,
financial or otherwise, to the petitioner. The Board finds that there was no written or spoken opposition. The Board
finds that desirable relief may be granted without substantial detriment to the public good and without nullifying or
substantially derogating from the intent or purpose of the North Andover Bylaw.
Note: 1. This decision shall not be in effect until a copy of this decision is recorded at the Essex County Registry of
Deeds, Northern District at the applicant's expense. .2. The granting of the Variance and/or Special Permit as
requested by the applicant does not necessarily ensure the granting of a building permit as the applicant must abide
by all applicable local, state, and federal building codes and regulations, prior to the issuance of a building permit as
required by the Inspector of Buildings.
Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant,
it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit
granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the
date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse
and may be re-estabiished only after notice, and a new hearing.
No Andover Zoning oarof ppeal
ert P. Manzi, III, Esq., Chairman
Hen P. McIntyre, Vice Chairman
Joseph D. LaGrasse
David R. Webster
Associate Member
Daniel S. Braese, Esq.
Decision 2007-016.
M 106.DP50.
Page 2 of 2
I!iUtl Osgood Street, 13uildino211 -Suite 2-+i:,. North An(Iocel, M'L'Ss�tchusetts (11845
Phone - 1)78-ii88-95.11 F t\ - 978-688-9512 1 cb - \vel .1o«rnofiwrthrindmcr.cotn
Town of North Andover
ZONING BOARD OF APPEALS
Umi PMa%r II1, 1(<y. C:bainnml
i{lien 11. Mchin rr, I i e-C.G,//nudn
1-1 p10RTN
Richard 1. li,.rrs.li<y. Clrrk-
OE S.ao 4v
Date (& Revised Dates):
7!01/08
R,ch:u,i \I \ aillancunrr
o t
gg _ J
Sheet/Drawing:
Dwg.No.93005012
I lwims 1). 111polin,
�+
ll.rnial �. liracsr, I(:y.
�'1.. +wr.e • �4`
Minor Modification to Notice of Decision Year 2007
Decision Address: 0 Berry Street
c 0 -
Town (:Lrk Pane Stamm
This is to certify that twenty (20) days
have elapsed from date of decision, filed
without filing of an appeal. v.
Date �t!Oi
Joyoo A: Bradshaw
NAME: Kevin Stack I MODIFICATION DATE: 8-12-2008
ADDRESS: 0 Berry Street (Map 106.D, Parcel 50) PETITION: 2007-016
The North Andover Board of Appeals held a regular public hearing on'Tuesday August 12, 2008, at 7:30 PM in the
Town Hall top floor meeting room, 120 Main Street, North Andover, MA upon the application of Kevin Stack
requesting that the North Andover Zoning Board of Appeals modify the Variance decision 2007-016 in order to
locate the new single-family dwelling 20 feet from the front lot line.
The following voting members were present: Ellen P. McIntyre. Joseph D. LaGrasse, Richard J. Byers, and Thomas
D. Ippolito.
Upon a motion by Joseph D. LaGrasse and 2ud by Thomas D. Ippolito, the Board found that the request to locate the
dwelling 20 feet from the froth lot line rather than the 2007-016 Variance decision's 10 foot setback is a minor
modification and that this modification does not alter the intention of the Variance decision 2007-016. Votint, in
favor: Ellen P. McIntyre, Joseph D. LaGrasse, Richard ]. Byers, and Thomas D. Ippolito.
Upon a motion by Joseph D. LaGrasse and 2nd by Thomas D. Ippolito. the Board voted to GRAT4T Kevin Stack's
request to modify Variance 2007-016 by granting the request to locate the dwelling 20 feet from the front lot line
�fi— rhan the 10 font cethacl, vranted in the 2007 reouest ner:
Site:
0 Berry Street (Map 106.1), Parcel 50), North Andover, MA 1084
Site Plan Title:
Variance Plan of Land, located in, North .Andover. MA., owner & applicant,
Kevin Stack, 12295 Genter Drive Spring Hill FL 34609
Date (& Revised Dates):
7!01/08
Registered Professional Land
Surveyor:
Michael J. Sergi, #33191, Christiansen & Sergi, 160 Summer St. Haverhill,
MA. 01830
Sheet/Drawing:
Dwg.No.93005012
In all other respects, the original decision remains in full force and effect as modified hereby. Voting in favor:
Ellen P. McIntyre, Joseph D. LaGrasse, Richard J. Byers, and Thomas D. Ippolito.
North Andover Zoning Ward of Appeal
Ellen P. McIntyre, Vice. Chairman
Richard J. Byers, Esq., Clerk
Joseph D. LaGrasse
Associeve Afemhei
Thomas D. Ippolito
Decision 2007-016 Modification.
M 106.DP50.
Enclosure: Decision 2007-016.
1600 Osgood St., Bldg 20 - Suite 2-36, North Andover, MA 01 845
Thune - 97S-698-9541 Fax - 976-688-9542 Web - www.tnwnofiiorthandovcr.cnm
ii 1t;
_;
December 7, 2006
Mr. Kevin F. J. Stack
12295 Genter Drive
Spring Hill, Florida
34609
Re: Berry Street, Map 106.1), Parcel
Dear Mr. Stack,
Please be advised that as the owner of record of the above property, the Building
Department needs to inform you that the temporary construction trailer on your lot has
not received an Application for Certificate of Occupancy and a Certificate of Occupancy
as required under 780 CMR 110.00 Application for Permit and 780 CMR 120.0
Certificate of Occupancy.
Please contact me as soon as possible at 978-688-9545 about the process for providing
the required Application for the Certificate of Occupancy. My normal office hours are
Monday -Friday 8:30-10:00AM and 1:00-2:OOPM.
Sincerely,
Gerald A. Brown
Inspector of Buildings
cc: Alison McKay, Conservation Administrator
Susan Sawyer, Health Administrator
Curt Bellavance, Director
Mark Rees, Town Manager
file
BUILDING DEPARTMENT
Community Development Division
Kevin F. Stack II
12295 Genter Drive
Spring Hill Fl, 34609
Re: Permit Extension — 2009-476
Dear Mr. Stack,
September 10, 2009
Pl ed that I am in receipt of your request for an extension on your Building Permit
issued245 Berry S on March 10, 2009. I will permit an extension for 6 months from the date of this
letter on ermit 2 9-476.
If you have any questions please feel free to call me at the Building Department.
Regards,
Gerald A. Brown,
Inspector of Building.
1600 Osgood Street, Suite 2-36 North Andover, Massachusetts 01845
Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthondover.com
09/1012009 08:10 MD
,
Mr.Gerald A. Brown Inspector of Buildings.
I'am requesting an extension of six months due to my
iFather (Kevin F. Stack Sr.) medical condition which has not been
good for some time now.1 will be acting on my fathers behalf on the
matter of 2.45 Berry St North Andover, In which I have just recieved
funding,. I will be starting the project as soon as the bank releases the
funding. If you need to contact me you- can reach me at
(617) -315 -3312 -cell or my home number,352-684-3784,or my dad
cell -352-279-6282.Or you could also call my mother at her office, her
private line is 352-754-4091. 1 would like to thank you for all your help
and for always going that extra mile for my dad and his family.
Kevin F. Stack Il
12295 Genter Dr
Spring Hill FL, 34609
Thank you Sincerely
Kevin F. Stack it
P.0021002
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN, MA 01833
978-352-8318 fax 978 —352-2858
cell: 978-502-5921
July 27, 2011.
Mr. Kevin Stack
245 Berry Street
North Andover, Ma 01845
RE: Stack Residence, 245 Berry St., North Andover, Ma. 01845
Dear Mr. Stack
As you requested I visited the site July 13, 2011 and again July 27, 2011 to review
the installation of the Engineered Materials consisting of LVLs utilized in the framing
of the above project. These were designed using Boise BD CALC 2.0 by others dated
May 13, 2010. Plans were prepared by LAM project R10-1 dated Feb. 9, 2010.
At my July 27, 2011 visit you had completed the additional work requested
Based on the above site visits and based on what I could visibly see I can certify
that to the best of my knowledge the LVLs members utilized in the framing as shown on
the drawings are installed properly and meet the loading conditions of the Massachusetts
State Building Code for l&2 Family Residences. All other framing requirements of the
drawings and code, including but not limited to materials, nailing schedules, blocking,
connections and other details are the responsibility of the licensed construction
supervisor responsible for the project.
Should you have any questions please do not hesitate to call.
Yours truly,
6?�wrence H. Ogden. P.E. Structural 27765
"LAWRENCE
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TOWN OF NORTH ANDOVER
FO P
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Check # 136
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Check One Only Certificate #
❑ Corporation
❑ Partnership
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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
Massa Aetts General Laws, nd that my si nature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Ag t Owner ❑ Agent M7
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 C e and Chapter 142 of the General Laws.
B Type of License:
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Title ❑ Gas Fitter Signature of Licensed Plumber/ s Fitter
Master _ `
City/Town ❑Journeyman License Number: �� l
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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at
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PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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Owners Name: &IN
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❑ Replacement: ❑ Plans Submitted: YesR1 No ❑
FIXTURES
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Name of Licensed Plumber:
Check One C"�J}' Certificate
❑ Corporation
❑ Partnership
❑ Firm/Company
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 I SURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa efts General43aws, a that my sign re on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner's A en ®weer ❑ Agen;,
1 hereby cefy that all of the details and information I have submitted (or entered) regarding this application are true a o
Knowledge and that all pt��mhing work and i nstallatiors 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. n' a""Glian to the all ' o, my
By_
Title
Type of Licenser
❑ Plumber Signature of Licensed Plumb r
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Name of Licensed Plumber:
Check One C"�J}' Certificate
❑ Corporation
❑ Partnership
❑ Firm/Company
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 I SURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa efts General43aws, a that my sign re on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner's A en ®weer ❑ Agen;,
1 hereby cefy that all of the details and information I have submitted (or entered) regarding this application are true a o
Knowledge and that all pt��mhing work and i nstallatiors 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. n' a""Glian to the all ' o, my
By_
Title
Type of Licenser
❑ Plumber Signature of Licensed Plumb r
E]Jourter 1�� `
❑Journeyman License Number: /(o
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`COMMONWEALTH OF MASSACHUSETTS
PLUMBERS AND.ryGASFIT.TERS
LICENSED AS A MASTER PLUMBER v 1
_ISSUES THE ABOVE LICENSE TO j'
,-,,THOMAS A NUNZIA.T\\011 r
T;11 ALFRED TERR
2 1
MEDFORD MA 02155 640 I
#' CpNTROL,*
if this 019234
IDivisi license is tMPpRT
S °n of pro f l ost or ANT
i cite destro
Yed
If your 71Q BOstopSsMq �2y 1g 61 pp notify 1 �yWa BOarq of the.
na
RenOf ewal t alae Me or orgress shown i h'ngton"St.,] r
Thls li ApptiOat" address tO . s rtInsU3" v t
as aR� � is s AiWaYs refer re proper fy Your -.
ooa
r asci It is a to the to your mailing of rd r
nor ed to any Personal
rsonal pnPro lsvile ions of thllCense nu next r
posteq as required by a , Keep h/s j en t bean nea
e On Your lJ
Name (Buss Orgaoii i/Individua(): !`- MAS
Address:_
Cziy/State/Zip: ���.� 02%
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
A
Department oflndustrial.Accidents
i X.
Office of Investigations ,
have hired the sub -contractors
600 Washington Street
Boston MA 02111
2.0 I aim a sole proprietor �=
www.mass.gov/dia
VVorkers' Compensation insurance Affidavit: Builders/Contractors/Jf;+ lectricians/Plumbers
Name (Buss Orgaoii i/Individua(): !`- MAS
Address:_
Cziy/State/Zip: ���.� 02%
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I air a general contractor and I
6• New construction
employees (full and/or part-time).*
have hired the sub -contractors
2.0 I aim a sole proprietor �=
listed on the attached sheet. �
7• F1 Remodeling
s4ip 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
g. Building addition
required.]
officers have exercised their
10.❑ Electrical repairs or additions
3. ❑ I air a homeowner doing all work
right of exemption per MGL -
11.0 PIumbing repairs or additions
myself. [No workers' comp,
c.1-52, §1(4), and we have no
12.0 Roofrepairs "
insurance required.] T
employees. [No workers'
13.0 Other
*A
comp, insurance required.]
ny 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 aie doing all work and thep hire outside contractors must submit anew aefdavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors aiid 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:
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby ce��er the paiFV7• Ade Of perjury t g the information provided above is true and cot',rect.'
11
Phone #• 1/0,/,7 [� 17 F—o %
Official us,e 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 bean employer."
MGL chapter 152, §25C(6) also states that "every state or local Iicensing 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 maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. AIso 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 Tieing requested, not the Department of
Industrial Accidents. Should you have any, questions regarding the law or ifyou 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
ofthe 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 pen-nit/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 pen -nit 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:
Tho Commonwealth of Massachusetts
Dgartmcet of Industrial Accidents
Office of Tnvestiptions
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ex -t 406 or 1-877—M. AsSAFE
Revised 5-26-05 Fax # 617-727-774g
www.mass.gov/dia
w
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t
I b Date ............ l�
"" '• " TOWN OF NORTH ANDOVER
0
p PERMIT FOR WIRING
This certifies that .................................... /rte
has permission to perform W ..
wiring in the building of
...�.........s......T�
.
7..........................
.............at .Z.P. .......Q�............S
.......... ,North dover, Mass.
1°
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ELECTRICAL NSPECTOR
Check # 30
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as���h������F1/071
Official Use Only
.,. nl
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS dFeeChecked
leave blank
APPLICATION FOR PERMIT TO PERF O- RM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASEP-RINTMINK OR TYPE ALL INFO
\\ City or Town o£ 7�011� Date:_
By this application the undersiAed gives no ' e of his or hex intentio n perform the electrical ctor wj'W iresr:
Location (Street �& Number) a- YS -
Owner
s k described below.
Owner or Tenante
_ ) rimer. Telephone No.?B/ R66 pi
Owner's Address _0
\ k,,J Is this permit in conjunction with a building permit? yes
�• Purpose ofBuilding A C,jl`0e,JC aNo ❑BLDG PERMIT #
Utility Authorization No. Q
Existing Service Amps / _Volts Overhead
❑ Undgrd ❑ No. of Meters
New Service a 0 Amps IV /�-t/0 golfs Overhead
Number of Feeders and Ampacity P�T Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work:
n li 12 u _ 7.0;,t e .✓eh, , y2.
of Recessed Luminaires
of Luminaire Outlets
90 No. of Ceil. Susp. (Paddle) Fans ,4-
0
4-
0 INo. of Hot Tubs
of Luminaires1/0 (Swimming pool
No. of Receptacle Outlets 660
�o. of Switches
fo. of Ranges
.o. of Waste Disposers
o. of Dishwashers
C). of Dryers
o. of Water
Heaters
30
IN9..Hydromassage Bathtubs
INo. of Oil Burners
No. of Gas Burners
No. of Air Cond.
JYVM_
d. grnd ❑
/ Total
Tnne
table may be waived by the Inspect,
Ivo. of Total.
Transformers KVA
Generators KVA
ALARMS INo. of Zones /
Detection and n
itiating Devices jf
of Alerting Devices
space/Area Heating KW Local ElMunicipal
❑ Other
Heating Appliances KW SecuritConnection
y Systems:
No. of No. of Devices or E uivalent
No. Data Wiring:
Si s Ballasts No. of Devices or E uivalent
No, of Motors Total HP ' Telecommunications Wiring:
No. of Devices or Eauivalent
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 000 . 00 (When required by municipal policy.)
Work to Start:
_=��V7 L_ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INS URANCE CO GE: 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 ,r BOND ❑ OTHER ❑ (Specify:)
I cert, under the pains and penalties ofperjury,
FIRM NAIL: _ that the information on this application is true and complete..cj2.��'S
Licensee: cUG ! Moi? /=► ✓1 ,a LIC. NO.; ��
Signature LTC. NO.:
Addres
(If dyes able, enter exempt" to thy license number line.)
s: L w U,.1 Bus. Tel. No.:
"Per M.G.L.c 147, s 57 61, security work requires Department o Public 1941 A21i2,duj2—) Safe "S" Licen Alt. Tel. 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
Owner/Agent am the (check one) ❑owner ❑owner's agent.
Signature Telephone No.' PEPWTFEE:
$_,3/7. 63
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOTTfT SMAT,T.
Y -
Inspectors' comments:
2. FINAL INSP ION;
Passed — la", Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
(Inspectors' Signature - no initials) j �..t .r ' Date �y
3. UNDER GROUND INSPECTION:
Passed — INZ Failed — [ ] Re -inspection required ($50.00) - [ ]
Inspectors' comments:
r.
L (Inspectors' Signature - no initials) Date
4. INSPECTION — SERVICE:
DATE CALLED NATIONAL GRID: NAME: ,
Passed — M 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.
.-
The Commonwealth of Massachusetts
Department of XndustrialAccidents
Office ofrnvestigations
600 Washington Street
Boston, MA 02111
UW www.mass gov/dia
Workers' Compensation Insuran.ee Affidavit: Builders/Contractors) Electxicians/Plumbelrs
Applicant Information. Please Print Legib
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet. r
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.E1 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.] i
employees. [No workers'
comp, insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling .
8. ❑ Demolition
9. ❑ Building addition
1011 Electrical repairs or additions
I L El Plumbing- repairs or additions
12.11 Roofrepaixs
13. El Other
'nny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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 isproviding workers' compensafion insurance foY my employees. Below 1 the policy and j h site
information.
Insurance Company
Policy # or Self -ins. Lie.
Sob Site
Expiration Date:
City/State/Zip.-
Attach
ity/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 imprisonm.ent,. 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Mo Hereby certify under the pains andpenalfies ofTErjury that the information providedabove is true and correct.
Siemature• Date
Official use only. Do not write M this area, to be completed by city or town officiaz
City or Town: PerrnitlLicense
Issuing Authority (circle one):
Z. Board ofHealth 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
G Other
Contact Person: Phone