HomeMy WebLinkAboutMiscellaneous - 281 ANDOVER STREET 4/30/2018N)
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North Andover Board. of As5essors Public Access
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Summary
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Page I of I
I III 1111� 41
MIZ%.,
Zroperty Record Card
Location: 281 ANDOVER STREET
Owner Name: MASCOLA, MARY L
Owner Address: 281 ANDOVER STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 1.02 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2436 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 442,600 415,800
Building Value: 247,100 218,300
Land Value: 195,500 197,500
Market Land Value: 195,500
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=2253097&town=NandoverPubAce 3/26/2013
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
L,P- b,� ..................................................
This certifies that.;=��-:i7,,, . .....................
has permission to perform..'r,-2—A
... .................................................
plumbingin the buildings of ............................................ .............................................
atAtt .... 4�4 W—a ...... ................ )
1. 10 r, Mass.
Fee/.110 ..Lic.-No.k�...j ... ........ e.1
. ...... ......... . . ..................
z 4LU
Check #
TOWN OF NORTH ANDOVER
If
PERMIT FOR PLUMBING
Le
This certifies that.�=&�'�,,
has permission to perform ...
.......................................
plumbingin the buildings of .............................................................................................
at.!;?� ... A") -a -e . ...... . ��./ . ................. IIN orth Andover, Mass.
...........................................
Fee ......... Lic. No. 4
...... ..............
IPLUMBI�G INSPECTOR
Check # eo
wAsHING MACHINE CONNECTION
WAiER HEATER ALL TYPES
WATER
OTHER
_11L�.-.11177 7_71, =1177177[
IL---Jl L_ i J Ill
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2 --NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ea""/ OTHER TYPE OF INDEMNITY D BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
—f—hereby certify that all of the details and information I have submitted or entered regarding th� 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 ap n M b * com fiance with �11P rt�fnent provision of �the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L eSS--e_ Le- Vt e -SI -e _--'LICENSE SIGNATURE
. ]i __j ---- � J, 61
MID pe"*_ ip of CORPORATION j��#L:::::�PARTNERSHIP D! # LLC
COMPANY NAME IP,,,, (ADDRESS
CITYLAL.�:A��' "STATE ZIP 0%94S- TEL
FAX CELL EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY or+h A6 MA DATE Vd-�Alo 11 PERMIT
JOB�ITE ADDRESS
Z"j 7_10 WNER'S NAME
OWNER ADDRESS [.103
A et— TEL FAX
TYPE OR
OCCUPANCYTYPE
COMMERCIAL EDUCATIONAL Erl RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: _R' REPLACEMENT: Ell PLANS SUBMITTED: YES 01 NOR"
FIXTURES -1 FLOOR-
BSM 1 2 3
4 5 6 7 8
9 10 11 12 13 14
BATHTUB
GROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
EA .—J. ____j if -- _J __1 ---I __A
DEDICATED GREASE SYSTEM
AF ---j== I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
I IF___j===
FOOD DISPOSER
-7--f _ — I -_ 11 E
FLOOR / AREA DRAIN
A ------ I —i E -J
INTERCEPTOR (INTERIORT
KITCHEN SINK
LAVATORY
J I I
ROOF PRAIN
------
SHOV�t-R STALL
SERVJ%1".E/ MOP SINK
—j
M_J_
TOILE
_j
URINAL
- I r r __j
EE
wAsHING MACHINE CONNECTION
WAiER HEATER ALL TYPES
WATER
OTHER
_11L�.-.11177 7_71, =1177177[
IL---Jl L_ i J Ill
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2 --NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ea""/ OTHER TYPE OF INDEMNITY D BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
—f—hereby certify that all of the details and information I have submitted or entered regarding th� 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 ap n M b * com fiance with �11P rt�fnent provision of �the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L eSS--e_ Le- Vt e -SI -e _--'LICENSE SIGNATURE
. ]i __j ---- � J, 61
MID pe"*_ ip of CORPORATION j��#L:::::�PARTNERSHIP D! # LLC
COMPANY NAME IP,,,, (ADDRESS
CITYLAL.�:A��' "STATE ZIP 0%94S- TEL
FAX CELL EMAIL
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d The Commonwealth ofMassa chusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, M4 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElQqtricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Applicant Information Please Print Le2rib
NaMe (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Cl;,ik' i&a,ppr,,opriat*e b,ox:
Type of project ()r�quired):
l.FJ I am.a. employer with e-mployees(fuHan&orpart-titne).* 7. []New construction
.2.FJ I am a sole proprietor or partnership and have no employees working for me in 8. E'] Remodeling
any capacity. [No workers' comp. insurance required.]
§. E! Demolition
3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers' compensation insurance or are sole 11, Electrical repairs or additions
proprietors with no employees. 12., E] Plumbing repairs or additions
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13 F1 Ro6f repairs
Thesie sub -contractors liav�'e en�ployce's and have workers' con�p. insurance.:
14. F1 Other
6.FJ we are a corporation and its pffiqers have exercised their right of 'exemption per MGL c.
152, §1(4), and we have nQf, loyep. [No workerS7 Comp. insurance required.]
*Any applicant that checks b6x #1 must also fill out the section below showing their workers' compensation policy informatiom
I Homeowners,;�ho subfiiif 4�s affidavit indicating they are doing all work and then hire outside contractors must s4bmit a new affidavit indicating such.
- fContractors that check this box must -attached an additional sheet showing th� name of the sub -contractors and state whether or not those entities have
employees. If the sub-co'nia cito'r's hav'e�'�'.mploy`e'es, %ey' must provide their workers' comp. policy number.
I am an employer that isproviding workers'compensation insurancefor my emplbyees.' Below is . thepolicy an . dyob site
information.
Insurance Company
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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigati6ns of the DIA for insurance
coverage verification.
I do h ereby certify un der th e pains an dpen alfles ofp erju ry t1z at th e inform ation provided ab ove is tru e an d correct
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one): i
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 . t'i -,
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for the
ii� _�T 1�yees.
# p,
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrd7ati h -'ire,
expres's or implied, oral or written."
An employer is defined as "an individual, partnersWp, 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, employing empl. 6�ees. 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 b6 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."
Addftionally, 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
Plea'se fill- out -the workers' coropensation affidavit completely, by checking �ffie* boxes that apply to your situation and, if
necessary, supply sub-contractof(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employqesother 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. 13 e advised that this affidavit may be submitted to the Depaftment of - Ii1dustrial
Accidents fbi confirmation of insurance coverage. Also be sure to sign and date the atridavit. 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 req*ed* to obtain a Workers'
compensatioil policy, please call the Department. at the number listed below. Self-insur6d 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 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 future permit� 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. 4 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
8/23/2016
ft
Accela Citizen Access
Need Help? For technical assistance in using this web application, please call the
ePLACE Help Desk Team at (844) 733-75220 z.) or (844) 73-ePLAC between the hot
of 7:30 AM -5:00 PM Monday -Friday, with the exception of all Commonwealth and
Federally observed holidays. If you prefer, you can also e-mail us at
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the issuing Agency directly using the links below.
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Translation Information - Click Here
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Home Manage Licenses, Permits & Certificates File & Track Complaints
Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below.
For DPL information, please visit the QPL website.
For ABCC information, please visit the ABCC website.
Information Pertaining To:
.Master Plumber 15423
Licensee Detail
License Number: 15423
Licensing Entity: Board of State Examiners of Plumbers and Gas Fitters
License Type: Master Plumber
Type Class: M
License Issue Date: 06/25/2008
License Expiration Date: 05/01/2018 Status: Current
Current
Discipline:
Other
Discipline:
Name: JESSE D LELIEVRE
Business Name: DBA Name:
https:llelicensing.state.ma.usICitizenAccessIGenera[PropertylLicenseeDetaii.aspx?LjcenseeNumber=15423&LicenseeType=Master%20PIumber
Mark as Read
Date .......
N2 2905
0
4L
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .......... ........ .. ...............
. ... ... ....... .
has permission to perform ....... I ..... C..If c.-f.zf ..................
wiring in the building of ............. 0./rt ...........................................
.. .. .. .. .....
....... .............. North Ando ver, IISS.
0. '/7
Fee....
Lic. N ............. 4, �r...
Check # 7' ELEcrRICAL INSPEcrOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TR E 0 9AMOANIE 4 L TH OFMA M C M EM Office Use only
DL?ARTAiE7VT0FPUBLICSAFM Pennit No. 7 U
UVA BOARD OFF1REPREVEW0NRWUL4TI0AN52701R 12-M Occupancy & Fees Checked
APPUCATION FOR PERW TO PEMORM IiE
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECIRICAL COIDME,27 LC I -00WOn-)
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) D /0(."/0/-`
Fil
Town of North Andover To the Inspector of Wires:
'Me undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) Q 3)
Owner or Tenani AM, -6
Owner's Address (� 14 "-1
Is this pen -nit in conjunction with a building permit: Yes I V1 No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead ED Underground No. of Meters
New Service Amps Volts Overhead 1= Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. ofLighting Outlets
No. of Hot Tubs
No. ofTransformers
Total
KVA
No. ofLighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ground
2round M
No. ofReceptacle Outlets
No. ofOil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. ofDisposals
No. of Heat Total Total
Pumps
Tons
KW
frutiating Devices
No. ofSounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detection/Sounding Devices
Local Municipal
M
Other
No. of Dryers
Heating Devices KW
11
Connections
No. ofWater Heaters KW
No. of No. of
Signs
Bailasis
Vo. Hydro Massage Tubs
No. of Motors
Total HP
.A".
I
lhawawmtljabkhum=Pbhr,ymdxkgCmvideopwAcnsComaWaritsmbswrtdeqivAat YES [Zr NO
Ihaw%hnJftdVAdP=f0f§WX1DtheOffi= YES [D NO r7 ff�uhawdvckedYESpimemdc*tcbWcfwvaaWbydxdmgtc
w4-i*bcx
UsSLRANCE [Z BOND OTHER M (AmSpeffy) L"fIX)4 /OAVA
J EViratiml)*
Eshm&dVakvdUedrJcaIWcik $
WorkiDSW[t hWmficnD*RoVmwd Rao FmW
FIRMNAME
Li=�Lyiill- /,,/CJ06V, t S,9�11- Limmiio '�-3A �,T
Addam AlTel.%
OWNER'S N MWAIV4 Ckned Laws
andditnTys4i&wcntispwnkapphcEdmwm'%csftmW'mneriL
(Please check one) Owner M Agent Telephone No. PERMIT FEE $
0
N2 4740
SA U
This certifies that
Date.d., !�-. �� /.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
...........
has permission to perform ... ' . ) ...............
plumbing in the buildings of .................
at—) ....... North Andover, Mass,
Fee.4/7. Lic. No../ ... ...................
Check # 2 ) , . PLUMBING INSPECfOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
0
. 4
7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTHANDOVER, MASSACHUSETTS
Building L�fion
New 0
2- --- 6 - 0,/
/V Date
2kl ,S�/-- Owners Name —aLmea-A? Permi7#
Amount
Type of Occupancy 0-j 4�e
Renovation El Replacement rl
FIXTURES
Plans Submitted Yes NO
Trint or type) Check one: Certificate
Installing Company Name 4410174,
-- -- _0 -3 W :� __ - ( _&, -MCo
0 Partner.
Firm/Co.
Name of Licensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity El Bond F1
Insurance Waiver L the undersigned, have been made aware that the licensee of this application does not haVe any one of 'the above
three insurance
Signature Owner n Agent
I hereby certify that all of the details and information I mitte
best of my knowledge and that all plumbing work an 1=11atio s TH
S,
compliance with all pertinent provisions of the Mas a hus te P
MS 11' ht
i Lhus
S i
EBy-
Signature oi I Tcensecu-
Type of Plumbing
I-Itle
Ity
City/Town LiceriseNumoer
APPR07VEi]D (OFFICE USE ONLY
(or entered) in abc
Tlication. are true andaccurate to the
ked for this application wUl be in
er 142 of the General Laws.
Master J�f Joumeyman F1
LocationJ�'Jl/
No. Date tj
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Check # 11)62
Foundation Permit Fee $
Other Permit Fee $
TOTAL s
Building Inswbor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT RE R,, N E, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
g -u
" _to
BUILDING PERM[IT NUMBER: DATE ISSUED:
SIGNATURE:
Building CommissiLn��r of Buildings DateA 2 -
—
SECTION I- SITE INFORMATION
1.1 Property Address:
/ � F / ;4�
1.2 Assessors Map and Parcel Number:
41ax - 'A
Map Numb- Parcel Number
V1 21,�e
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provi&d
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone — Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEE[P/AUTHORIZED AGENT
2.1 Owner of Record
M a- /7
N�a ( �,,P- ant) Address for Service
7
"gi'gilfit6re Telephone
2.2 6�;;er of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable o
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
e-4
-) AA Ve C- S I'Ale�-,
Not Applicable 0
Company Name
3 B&AI re A- d -
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § �5c_(6_)__]
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 11 Existing Building Repair(s) ff" Alterations(s) 0— Addition 0
Accessory Bldg. 11 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
1 c�IW +,,1 -ZA15T-411 vew e4r
"'104'e 0 re /V '7L 2� /",-f 1- .4 AL/
C A-0lVeTS -
I SECTION 6 - F.STIMATF.11 rnNQTVTTrT11A1V 9-nQ-rQ I -
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL VSE ONLY. -
1. Building
21. 6o o, r 6
(a) Building Permit Fee
Multiplier
2 Electrical
9- e) d' oo
.
(b) Estimated Total Cost of
Construction
3 Plumbing e00- Cd
Building Permit fee (a) x (b)
4 Mechanical (HVAC) 49
5 Fire Protection
6 Total (1+2+3+4+5) �GC
Check Number
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM[IT
as Owner/Authorized Agent of subject property
Hereby authorize -to act on
My behalf, in all matters relative to work authorized by this building permit application.
4
Signature of Owner &aft_Z7
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
1P
J
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location: 3 8,�I* tu, , 14i n W
Ci Phone
am a homeowner perfon-ning all work myself.
any capacity
F -�farrl a sole proprietor and have no one working 1
am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. Policy #
Compgnv name:
Address
CNI: Phone
Insurance Co. Policy
im -- - .
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DLA for coverage verification.
I do hefty certify under the pains and penalties of petiury that the inthnnation provided above is true and correcit
Signature Date
Print name A vt /V/L- Ala-, Phone # 9 7 ---?(f e F 17
Official use only do not write in this area to be c ' ompleted by city or town official' r-1 Building Dept
[]Check if immediate response is required Building Dept C] Licensing Board
C] Selectman's Office
Contact person., Phone #.- R Health Department
11 Other
FORM WORKMAN'S COMPENSATION
I
k
Town of North Andover t%ORTH
0
0
Building Department 0
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542
fD
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and. a condition of
Building permit # the debris resulting fi7om the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a.
The debris will be disposed of in /at:
A57 -e— 'AAV
(2/� ev- 7—
Facility location
Signature of Applicant
Date
NOTE: A demolition permit fi7orn the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
X
Location '9 —�j
No. 07 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer.Gonnection Fee $
Water Connection Fee $
TOTAL $
-03 Build-IRg inspector
02/13/% 2-49 39.00 PAID
9M Div. Public Works
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