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Home My WebLink AboutMiscellaneous - 270 GREAT POND ROAD 4/30/2018031�5 Date ... 61P.:nI T I . , 5 '. 41 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ C .............. has permission to perform ..... W— �/0'4'( E— ............................................................ wiring in the bui ....... 4 ............................... Wing of L & L--*� �) ..................................... at,;., . . ....... & .... ............ jP-PP . ......... North Andover, Mass. Fee.10:04'0'. Lic. No).Z50.26 .......... ............................. .... .. ......... ELEcrRICAL INSPE OX, Check# Ib 3d V Commonwealth of Massachusetts Official Use Only Permit No. 7 S— Department of Fire Services. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] O,av,blak) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEA'SE PRINT IN INK OR TYPE ALL MFORALI TI04V), Date: 10k;// I City or Town of- NORTH ANDOVER- To the ilTs�eiqtor of Wires: By this application the undersigned gtves. notice of his or her intention to�erfbfm.the e- Yal work described below. C J k Location (Street & Number) rec, -f- - b - Owner or Tenant owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building_ -SI,f�o � :4,— M i ( v Utility Authorization No. 1 15�z cl Existing Service Arh�s Vol Overhead 0 UndgrdE] �o.'of.Meters New Service 9&Q Amps IdG /o?4VC17olts OverheadE] Undgrd J�r No. of Meters Number of Feeders'and.Ampacity C� Lec4j�:: --ID A O.J12 7�J&.,-, C;ro Location and Nature of Proposed Electrical Work: 1, -Ug I'd -1 Acvh rt � ei cp r u, �, lo -F17 t- Y7 . rn 14-Z)VVIL f-werkAr-'7 co"Iti 1-/ - - Cnvglpfinn nf the following table may be waived bv the Inspector of Wires. No. of Recessed Luminaires No. of Ceill.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El Jn- grnd. grnd. No. of Emergency Lighting BattM Units No. of Recevtacle Outlets No. of Oil Burners - FUREE.A.LARIMS JNo. of Zones N—o.ofDetection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Total Ton-, No. of Alerting Devices Heat Pump I Number I Tons KW No. of Self -Contained No. of Waste Disposers Totals: I _** .......... I ... ......... ........ ................. ... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Mum*c'P]al Other Local Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No..of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equival nt elecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices- or Equivalent OTHER: Attach additional detail if desired, or as required by the inspector oj 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 suhstantial equivalent. The undersigned certifies that such c�'verage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 31 BOND El OTHER F-1 (Specify:) I certify, under thLpeins andpenalties ofperjury, tha e information on this application is true and completa FIRM NAME: lepe-Ir —LAC - goi� LIC. NO.: Licensee: ignwhilre .27 LIC. NO. _21 (If applicable' r he lie nse n b line) No.: C kr X4 e Bus Tel Address: cj�r ?9V e Alt. Tel. No.: 9ZV -!Z�00 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License- Lic. No. ' "' OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) F71 owner ' 0 owner's agent. Owner/Agent Signature __ Telephone No. FPE"IT FEE. $ 4�t log;non weal li,6-1 O�AUSSAUZ� Department of Ind—frial Acciden Office of Investigations 600 Washington Street Boston, MA 02111 www.nzass.gov1dia Workers' Compensation Insitrance Affidavit.- Builders/Contractors/Elertriciansiplumbers A�Rlicant Information Please Print Le-vibl Narrie (Business/Organization/individual):_. Addres�: 3A0E7f-&- Phone Are you an employer? Check.the appropriate box; It 24m a employer with — 4. 0 1 am a general co ' ntractor and I employees (full dnd/or part-time).* 2.. 1 am asol e proprietor or have hired the sub�-contractors listed , partner- ship and have no em 19yees P on. the attached sheet 7bese su&coritract*ors -have I working fior meil ahy capacity. [NO, wOrkers'comp. insurance workers' comp. insurance 5. We are a corporation and its required.) 3.0 1 am a homeowner doing all work bfficers have exercised their right of *exemption per MGL myself. [No-workirs, comp. c. 1.52, § I (4),'and we have no insurance required.] t employees. [No workers' comp. insurance required-] Type of project (required): 6. [] New construction 7. El Remodeling 8. Demolition 9. Building addition I 9k Electrical repairs or additions I I E1 Plumbing repairs or additions 12-E] Roof repairs 13.[].Other X 't L MUSI aisOn" outthesection below showing thairworkers'6ompensation policy t 14oMeoWn 6rS Who Submit this affidavit Indicating they are doing all work and then him outside contractors must submit a new -affidavit indicating such. 4contmaors th'at check this box must anac hod an additional sheet showing. the name of the sub-contmetors and theu- workers'cOMP. Policy m1bri-nation. am an MPIOYer that isprqvidingwoMM' COMpensadois itasurancefor W. employees. informadom .1 11—% — Below is the policy andjob site Insurance Company Name: Policy # Or Self -ins. Lie. #: 6--1 ft --::I� 70 Expiration Date: limti Job Site Address: /Zip. Attach a copy of the Worke City/State/Zip Ts'. 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 imprisonmenti 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 I rivestigations of the DIA for insurance coverage verification. I do hereby cerfiYjy4ander the pa��wzdpenafties ofperjury that jile information p,.iWd,,h05, is traq and colrect, M M KM M Off'cialuseo'"'Y- DO not writell this area, to be com-pletedhy city or town Official City or Town: Fermit/License Issuing Authority (circle one): I -Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. 6. Oth&r Plumbing Inspector Contact Person: Phone#: 9 9' Date. . /4,9A. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ............. has permission to perform 4�;K ... /� ... , plumbing in the bui ' Idings of ................. at ...... Z'A W.I.? 1. 4Y... ..... No Andoy r, Mass. F e e,/, !-� �,L?L i c. N o. . 6--K 4!� . lrc�kKe,(I. U. �� ...... .2 PLUMBING INSPECTOR Check # MASSACHUSETrS UNIF—O—RM—A—pp—LI—CA—Ti—o—N—FO—R—pER—MI—T —TO—DO �PL UMBING Ci'Y/Town:- 0'0 alhQ Q �-4e- MA. Date: Permit#' Building Location:- I fi 49 Owners Name: Type of occupancy: Commercial EducationalEl Industrial [—] InstitutionalEj Residential New:[4I Alteration:0- Renovation: PlansSubmitted: YesF] No DEDICATED V) 0 FIXTURES < < LU X 0 0 LU En Ln Ln > 0 On 0 L! LU En En < to Cn U P 0 Ln LU Cn LU 12 < ow z LL.1-�:0=9WQ00W-W!3z LU LO = Z Inn L LL. Mo Ln 0 0 0 M �4 R; Z =n LLI LU < no co _j LL 0 tn C) (n =3 SU13 BSMT. BASEMENT .1' FLOOR 2 ND FLOOR 3 R FLOOR 4' FLOOR �TH FLOOR 6' FLOOR ?TH FLOOR ;) FLUUK I I I I I PlansSubmitted: YesF] No DEDICATED V) 0 < < < X 0 0 LU En Ln Ln 0 On C, I I I I I I I I I 111stallin,g ci- a rne: h e 0 ne Cni SidirvAt9 -,-, —qOW,/ ;1 142 Address: /,e? -7 A��orporatiorj Business Tel Fax: El Partnership El , Firm/Company Name of Licensed Plumber: I INSURANLr L;LJVFPAr.r:- I have a cu rrentRatUftylnsurante policy or its substantial equivalent which meets the' requirements o*fMGL.Ch-142Yes01�'NoE1 If You have checked �Les, please indicate the -type Of coverage by checking the appropriate box below. A liability insurance policy. Other type of indemnity Bond E] 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 m . �7�� Y signature on this Permit application waives this requirement. Check One Only 0 wnier or Owners A ent Owner E] Agent erebycertif that all of the details and in MaLlUn I nave submitted (orenk I III I III, L KnOWledgea d that all p!Llmb,!q- work and'�' 11 11111� I I Is I 11111"EilICIII :11 % 11,11i 1 . g installations performed under the per I I rate to the best of try Pertinent pro islon of th assachusetts State Plumbing Code mitissued for ih!� �ppllcation wifibe in o -- - - - -0 '- -1, - — and Chapter 142 of the General Laws. c mpliance with all 3y ZW Type of License: id y 'itle ------------- R�<umber SignatuI of L-Icensecl PAmber Ityrrown FtWaster - PPROVED, FFICE SE ly, E]Journeyman License Number: '7 s The Commonwealth ofMassachusett Department oflndustrialAccide�ts Office ofInvesfigationg 600 Washington Street Boston, MA 02111 UV VWW.Mt7_SS.go-P1dia Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/,Plumbers wh Ucant fnforimnfin-n Name (Business/Organization&dividual): Address: ajo,+ City/State/Zip: /9 e-2 Phone I Are you an employer? Check the appropriate box: I-Ellamaemployerwith JA_,7,) 4- El I am a general c Ontractor and I employees (full and/or part-time).* 2. Ell am a sole proprietor or have hired the sub -contractors listed partner- ship and have no employees oil the attached shget I These sub -contractors have working for me in any capacity. [No workers' comp. insurance Workers' comp. insurance. 5. El We aie a corporation and its required.] 3. El I am a homeowner doing officers have exercised their all work myself [No workers, comp. right of exemption per MGL c. 152, § 1(4), and we have no insurance requiredJ T employees. [No workers, comV, msurance re ;r -,i J Type of project (required): 6. RWew construction 7. EIRemodeling 8. EJ l5emblition 9. El Building addition 10. 1:1 Electrical repairs or additions I I -El Plumbing iepairs or additions 12.0 Roofrepairs 13 -El other L !Any applicant that checks box #Ixnust also fill Out the section below showing their work T Horneowners who submit this affidavit indicating they are doing all work end then hire o ers Compensation policy infolm�tion. tContractors that check this box Must attached an additional sheet show! g t utside contractors must submit anew affidavit. in c in h P he name Of the sub-cOntractors and their workers, comp. pol cyd' at gsuc 1 information. 1am an eMP10Yer that isproviding W�;rkers' compensation insUrancefor inf0imation. MY elVoYees- Below is thepolicy andjob site Insurance Company Name: Policy # Or Self -ins. Lie. #: Expiration Dat . e Job Site Address:�� A��,e �7- f ,>c A_" .2.��tity/State/Z ip. Attach a copy of the workers, co'mpensation Policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required uhder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fincup to $1,500.00 an&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 vidlator. Be 'advised that a copy ofthis statement may be forwarded to the Office ok Investigations of the DI,� for insurance coverage verification. r do hereby cerityy under ffiepains andpenalfles OfPerjury that the 171forinationprovided above is true and correct. "ol A A- 'A A In Off"clal use on&- Do not write.in #11s area, to be completedby cily Or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CitYlTo" Clerk 6. Other 4. Electrical Inspector 5- Plumbing Inspector CODtact Person: Phone #:_ Date .... &:�. �. ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This cer tifies that ..... .......... ....................... ... 4S 3:;i ( � has permission to perform ...... �5 -/.7-/ ......... S. -y- ........... ng in the building of ............ ............................................ at .... Z frA, 9' .................... -? North Andovei, Mass. Lic. No. 1.1-W6 ............... Fee. -.S-0 ......... 4 I LECMI AL INSPEGMR Check # 10605 (flmmonivaalik ol Va-maclwetb official Use Only 2,padnwd W3i- S -11"J Permit No. —IoLa� occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12-00 (pLEASE pRINT IN INK OR TYPE ALL INFORMA TION) Date:— To the Inspector of Wires: City or Town of perform the electrical work described below. By this application the undersigned gives notice ofhis or her i9wntion t o Location (Street & Number) 6— /p, 6 Telephone No. Owner or Tenant A7— owner's Address is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building r -I - Utility Authorization No. Volts Overhead Undgrd No. of Meters Existing Service — Amps - New Service Amps Volts OverheadF� . Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires WNo. of Receptacle Outlets No. of Switches No. of Ranges 0 0 0- 0 0 0 f f f R Sw ec P -a i n e tc g p h e t s a e c s No. of Recepta 'e Outlets No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs Completion 2Lthe of Ceii.-Susp. (Paddle) Fans No. of Hot Tubs Above Swimming Po I rnd. iNo. of Oil Burners INo. of Gas Burners FNo. of Air Cond. TT Space/Area Heating KW Heating Appliances KW No. of 0. of Si 7,ns Ballasts No. of Motors Tota u . n t ble ma be waived b the M2,ector o Wires. 4 0 yy Total KLA Transformers Generators KVA 0. mergency ig ing Batte Units FIRE ALARMS No. of Zones No. f Detection and Initiatin Devices No. of Alerting Devices No. of Self -Contained .......... Detection/Alerting Devices Local EjMunicipal Other Connection See rity stems:* 0.0 Data Wiring: No. of Devicej_RK19— �kvalent 1'elecommunications Wiring: No. of Devices or —Equivalent LO :TH:E R: Z t-T1q6-e- j2ek&L 4 t- 0 " 5,/,5 7-C-- J7 : :-�- :t> �0C 10 Attach aaamonal detail if desireTo—ras required by the Inspector oJ wires. Estimated Value of Electrical Work: 254*f1!tM0 (When required by municipal policy.) WorktoStart: ested in accordance with MEC Rule 10, and upon completion. Inspections to be requ 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 En BONDE] OTHER [I (Specify:) on is true and complete. I certify, under the pains and penalti hat the information on this applicati FIRM NAME: 154n LIC. NO.: -/1-9 —9C— L,C. NO.: ign Licensee:_/Z :Ii5h 17-/+ Signature Bus. Tel. No. (Ifapplicable, enter "exempt" in the license number lijs� �5—� el;11,99-3 Alt. Tel. No.: Address: iequires Department of Public Safety "S" License: Lic. No. *Per M.G.L. c. 147, s. 57-61, secu. ty wor 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) 0 owner [] owner's agent. Owner/Agent Telephone No. PERMIT FEE: $ Signature Date. liklY ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that -5-po Z/;v 04V .7 ............. 1� .................... has permission for gas installation J. W. . X�k�-� .... in the buildings of T .6VZ. &.)2e �le 42 el�, ........ at ..7-2 Q. . XM ... /� .......... North Mdovery.A�ss. Fee.A��qh? Lic. Check# ��- 3 �,3 GASINSPECTOR 79'1 1 A IT TO DO GAS FITTING Cityl'rown;&,r 4LhOl) le -At- MA. Date: Ap Iff 776 / — Permit# Building Location. 'Imf 4!:�'eeo�'-Pnuv fey Owners Name: /P� Type of Occupancy: Commercial El Educational El Industrial E] Institutional Residential New: �Alteratlon: El Renovation: [:1 Replacement: E] Plans Submitted: Yes[] No F] FIXTURES bo W W C6 Lu W 0) I= z Lu �4 I- C6 co (0 Q W M Lu 0 co co 6i M X 0 LLI LU L) ca 0 1W LLI zI-- I-- a -i>- ac wonww Z UJI W 0 1-- 5 0 z 9 2) Lu COLU gmo wbogF- co Lu IL > z Ix L< Lu U) CO 0 < Lij LL >UWZ -IF--I--0Z-J0LLCn=zWWW z W 5- W W =� < < M 111 0 z 0 F- W I.- W W 025wn<WWW550go CnI-->Z'-X�V' W 2 z W 1 -- ba. wl�-=)=> SUB BSMT. BASEMENT - — — — — — -isr—FLOOR 2 NL)FLOOR 3�u FLOOR T'FLOOR 6'"R FLO—OR 6T'r—FLOOR 7 "' FLOOR 44 Ehecko�neO—nly—i de�i—ficate4— Installing Company Name: &C—Orporation Ze Address.13-6-tf&,)�A t�el city/Town: /S If -910 Business Tel: zzr-"Z- -31�= Fax: le. /S t7 El Partnership Name of Licensed Plumber/Gas Fitter: &4epe El Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or I . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [9�-Nb El 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 El Bond r-1 OWNER'S INSURANCE WAIVER: I am aware that the licensee ELoes 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 Signature of Owner or Owner's Agent Owner E] Agent By checking this box 1-1; 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application w HI be In compliance with all Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By P-Mumber El Gas Fitter - Title [a*laster Signature 61 Licensed P—lu er/GasF!tftter Cityrrown Eliourneyman ca APPROVED OFFICE SE ONLY El LP Installer License Number: The Commonwealth ofMassachusetes Department ofIndustrialAccidents Office of In-vestigations 600 Washington Street Boston, M,4 02111 Www-mass.govIdia Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians[Plumbers mlicantInformotin-n Natl2c (Business/Organizationffndividual): Address: City/State/Zip; Phone Are YOU an employer? Check the appropriate box: I-ElIamaemployerwith-2A 4. El I am a general c ontractor and I employees (fall aud/or- part-time).* 2. El I am a sole Proprietor or have hired the sub -contractors listed partner- on the attached sh9et I ship and have no employees These sub -contractors have working for mein any capacity. [No workers, comp. insurance Workers' comp. insurance. 5. El We aie a corporation and its required.] 3. E] I am a homeowner doing all officers have exercised their work right Of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we haveno insurance requiredJ t employees. [No workers' COMP, insurance re ;-7 Type of project (required): 6. Pq-<�w construction 7. D Remodeling 8. Elliemblition 9. El Building addition 10. D Electrical repairs or additions I El L Plumbing repairs or additions 12.E]Roofrepairs 13.El other 11- J I L !Any applicant that checks box #1 must also fill out the section below I ... i Mug their workers, compensation policy inform�tion. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidav d cat g suc -contractors and their workers' cOMP. Policy information. tCOntractors that check this box must attached an additional sheet showing the name Of the sub it in i in IL lam a7l emplOyer that 1sproviding w0TkeTs'COMpensation insurancefor Iny inforination. MPIOYees. Below is thepolicy andjob site Insurance Company Name: Policy # Or Self -ins. Lic. M ExpirationDate' Job Site Address. 4-tw-eie- 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 Wider Section 25A of MGL c. 152 can lead to the julposition of criminal pen fine up to $1,500-00 and/or one-year imprison e P alties of a In nt, as well as civil eRalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Beadvise'd that a copy of this statement may be forwarded to the Office ok Investigations of the D9 for insurance coverage verification. r do h ereby certify un der th ep ains an dp en aftles OfP erjury t1i at th e infornzation pro vided ah o ve is true an d coTrect. P11, Qffi"cial use only. Do not writefn this area, to he CoMpletedby cIV or town off,-cial City or Town: PermitUcense Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CitYlTown Clerk 4. Electric 6. Other al Inspector 5. Plumbing Inspector ContactPerson: 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 i;defuied 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 ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employ-mig employees. However the owner of a dwelling house having not more than three apartiments and who resides therein, or the occupant of the dwelling house of anot6r 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 shaIlwithhold 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 insurancd 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 ofpublic work until acceptable evidence of com�liance 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 riecessary� supply sub-contractor(s) narne(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. D e advised that this affidavit may be submitted to the Department of In'dustrial Accidents for confirmatiortof *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 orlic s isb g req sted t Dep ent of Industrial Accidents. Should you have any qyestions rega�ding the la ell B cin ue no the artin w or if you are required to obtain a workers' compensation policy;please call the Depa�tment 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 fin out in the event the Office of hrvesLtigatiolls has to contact you regarding the applicant.' Please be sure to fill in the Permit/license number which will be used s a r f r c b r. ad tio app ca t ni ise applications in any given year, need only submit one affidavit indicqing current that must submit multiple pen Mica, ft e e OR 6 man e In di n, an E n Policy information (ifnecessary) and under - Job Site Address" the applicant should write "all locations in ty town)." A copy of the affidavit that has been _(ci or 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 mustb'e filled out each year. Where a home owner or citizen is obtaining a license or permit not related tor any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) s id perso is NOTreq ed to compi t is af d vit. a 11 uir e eth f! d The Offilce of Investigations would Eke to thank you*iu 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 Conimomean-, of1djassachuse-tts Department of Industriall Accidents Offlc-e of Investigations 600 Washington Steet Boston; M. -A 02111 TO. # 617-727-4900 ext 406 or 1-877-M-ASSAFJ3 Revised 5-26-'05 Fay, # 617,727-7749 Wwvv-mass.g-Qv/dia NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 B USMESS FO" FOR TOWN CLERK DATE: 'S. I 1 ?4 -,? 0 1 Lf ADDRESS: Lt (CL Le vid- t�t ml �7c) ZONING DISTRICT: - TYPE OF 13USINESS-:, F4t+e y -1 scs . . V—q t 41A a -55e VV -b BUILDING LAYOUT PROVIDED: tl� cs� NO A7VAFLABLE PARKMG SPACES: ZONING BY LAW USAGE: YE NO 13USINESS FORM FORTOWN CLERK 2.40 Home Occupation (1989/32) An accessonr use conducted within a dwelling by a resident who resides in the, dwelling as his princi pal .address, which is cleariy 8econdary 'to the use. -of the, -building. for �ving ptuposes. Home. occupations shall 'ifickide, -b6t not'limited to the following uses; personal services such as flunished by an artist or instructor, but not occupation involved with motor vehicle ppairs, bea�4, paxlors, animal kennels, or the. conduct of retail business, or the mmiufacturitig o�goods, Wbich impacts tb� residential nature. of the neighborhood, 4. For use of a dwelling in 4ny residential district or multi-fhmily district for a home occup6tion, the Bollowirg conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the 0WRiff of thd h6mc 0mupation and residing M- said di w,11ing., b. The use is carried on strictly within the principal building; c. 'Ihere shall be no exterior alterations, accessory buildings, or display which are -not customary -with residential buildings; - d. Not more than (25) por=t of the existing gross floor area of the, dwelling upit. so used, not to exceed one thousand (1000) square f4 is devoted to *such use. In connection with such use, there, is to be kept no stock in trade, commodities or products which occupy space. beyond these Emits; 0. There will be. no display ofgo6ds or wares -visible from the street; f The building or promises occupied shall not be rmdered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas., smoke, dust, noise, disturbancc� or in any other way become objectionable, or detrimental to any residential use wiffik the neighborhood; g. Any such buildim shall include no features of design not customary buff s for residential in ding use. Signature DaW September 21, 2012 Gerald Brown Building Commissioner Building Department Community Development Division Town of North Andover 1600 Osgood Street North Andover, MA 01845 Re: 270 Great Pond Road (Assessors Map 37A, Lot 56) Dear Mr. Brown: As you know, I am the owner of 270 Great Pond Road on which we just built a new home. Also located on the property is an existing barn structure. I am requesting your confirmation that the proposed uses of the existing barn structure described below would be permitted under the North Andover Zoning Bylaws. The barn on the property is approximately 1,600 square feet in size and was constructed in the n -Lid -1980's. The barn has been used intermittently since that time for overnight guests and extended visits. The barn structure includes two stories, with the 2nd story finished with a full bath and 2 bedrooms, and the first floor finished and left as an open concept space with a half bathroom. In total, the barn includes three rooms with 1.5 baths. I would like to have the ability to lease each of the three rooms to up to 3 unrelated persons although I do not envision leasing all three rooms to more than one or two individuals. The property is zoned Residence 1 and it would appear to me that this proposed use would be considered an accessory use permitted by right in the Residence 1 District. I am requesting that you confirm that the proposed use would be permitted. Please let me know if you have any further questions. Thank you. Sincerely, N a n �cy e IU4n� MAOIZAIAA-I ) i� �0// o .1. I^A 1. TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 Gerald Brown, inspector of Buildings September 24, 2012 Ms. Nancy Leland 270 Great Pond Road North Andover, MA 01845 Re: 270 Great Pond Road (Assessors Map 37A, Lot 56) Zoning Determination Dear Ms. Leland: I have reviewed your letter, dated September 20, 2012. The property is located within the Residence 1 (R-1) Zoning District. Uses allowed by right within the R -I Zoning District are defined under Section 4.121 of the Zoning Bylaw. These uses include "Rooming house, renting rooms for dwelling purposes or furnishing table board to not more than four (4) persons or members of the family resident in a dwelling so used, provided there be no display or advertising on such dwelling or its lot other than a name place or sign not to exceed six (6) inches by twenty-four (24) inches in size, and further provided that no dwelling shall be erected or altered primarily for such use." (Section 4.121.3 ), as well as "Any accessory use customarily incident to any of the above permitted uses, provided that such accessory use shall not be injurious, noxious, or offensive to the neighborhood." (Section 4.121.16). 1 have determined that your proposed use of three individual rooms for purposes of leasing them to less that four persons would be considered an allowed accessory use customarily incident to the single family residential use of the property permitted by right under Section 4.121.3 of the Zoning Bylaws. Whi le it is possible that one could consider the proposed use to be one which is a "Rooming House" as broadly defined under Section 2.63 of the Zoning Bylaws, the provisions of Section 4.121.3 require the persons leasing or letting the premises be "...persons or members of the family resident in a dwelling" which is not the case in this situation. Additionally, since the proposed leasing or subletting of the rooms is not to "four or more persons not within the second degree of kindred to the person compensated, "the use of the barn as you have described would not be regulated as a "rooming house" as defined under the State Sanitary Code (105 CMR 410.000, 410.020), nor would the barn need to be licensed as a "lodging house" as defined under Section 22 of Chapter 140 of the Massachusetts General Laws. (See MGL c. 140, section 22-31). Please let me know if you have any questions regarding this determination. Sincerely, Gerald Brown Building Commissioner CC: Building File 0 Ms. Nancy Leland 270 Great Pond Road North Andover, MA 01845 Re: 270 Great Pond Road (Assessors Map 37A, Lot 56) Zoning Determination Dear Ms. Leland: I have reviewed your letter, dated September 20, 2012. The property is located within the Residence 1 (R-1) Zoning District. Uses allowed by right within the R-1 Zoning District are defined under Section 4.121 of the Zoning Bylaw. These uses include "Rooming house, renting rooms for dwelling purposes or furnishing table board to not more than four (4) persons or members of the family resident in a dwelling so used, provided there be no display or advertising on such dwelling or its lot other than a name place or sign not to exceed six (6) inches by twenty-four (24) inches in size, and further provided that no dwelling shall be erected or altered primarily for such use." (Section 4.121.3 ), as well as "Any accessory use customarily incident to any of the above permitted uses, provided that such accessory use shall not be injurious, noxious, or offensive to the neighborhood." (Section 4.121.16). 1 have determined that your proposed use of three individual rooms for purposes of leasing them to less that four persons would be considered an allowed accessory use customarily incident to the single family residential use of the property permitted by right under Section 4.121.3 of the Zoning Bylaws. Whi le it is possible that one could consider the proposed use to be one which is a "Rooming House" as broadly defined under Section 2.63 of the Zoning Bylaws, the provisions of Section 4.121.3 require the persons leasing or letting the premises be "...persons or members of the family resident in a dwelling" which is not the case in this situation. Additionally, since the proposed leasing or subletting of the rooms is not to "four or more persons not within the second degree of kindred to the person compensated, "the use of the barn as you have described would not be regulated as a "rooming house" as defined under the State Sanitary Code (105 CMR 410.000, 410.020), nor would the barn need to be licensed as a "lodging house" as defined under Section 22 of Chapter 140 of the Massachusetts General Laws. (See MGL c. 140, section 22-31). Please let me know if you have any questions regarding this determination. Sincerely, 011 Gerald Brown Building Commissioner CC: Building File TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 A A Gerald Brown, Inspector of Buildings September 24, 2012 Ms. Nancy Leland 270 Great Pond Road North Andover, MA 01845 Re: 270 Great Pond Road (Assessors Map 37A, Lot 56) Zoning Determination Dear Ms. Leland: I have reviewed your letter, dated September 20, 2012. The property is located within the Residence 1 (R-1) Zoning District. Uses allowed by right within the R-1 Zoning District are defined under Section 4.121 of the Zoning Bylaw. These uses include "Rooming house, renting rooms for dwelling purposes or furnishing table board to not more than four (4) persons or members of the family resident in a dwelling so used, provided there be no display or advertising on such dwelling or its lot other than a name place or sign not to exceed six (6) inches by twenty-four (24) inches in size, and further provided that no dwelling shall be erected or altered primarily for such use." (Section 4.121.3 ), as well as "Any accessory use customarily incident to any of the above permitted uses, provided that such accessory use shall not be injurious, noxious, or offensive to the neighborhood." (Section 4.121.16). 1 have determined that your proposed use of three individual rooms for purposes of leasing them to less that four persons would be considered an allowed accessory use customarily incident to the single family residential use of the property permitted by right under Section 4.121.3 of the Zoning Bylaws. Whi le it is possible that one could consider the proposed use to be one which is a "Rooming House" as broadly defined under Section 2.63 of the Zoning Bylaws, the provisions of Section 4.121.3 require the persons leasing or letting the premises be "...persons or members of the family resident in a dwelling" which is not the case in this situation. Additionally, since the proposed leasing or subletting of the rooms is not to "four or more persons not within the second degree of kindred to the person compensated, "the use of the barn as you have described would not be regulated as a "rooming house" as defined under the State Sanitary Code (105 CMR 410.000, 410.020), nor would the barn need to be licensed as a "lodging house" as defined under Section 22 of Chapter 140 of the Massachusetts General Laws. (See MGL c. 140, section 22-31). Please let me know if you have any questions regarding this determination. 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