HomeMy WebLinkAboutMiscellaneous - 29 PEMBROOK ROAD 4/30/2018C,
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address
Policy Number:
Date/Cause of Loss:
File or Claim Number:
Cindy Catalano
—29 Pembrook Road
BBYSVC
8/15/2012, Water Damage
26619-M
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Mike Peterson
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above -by First Class M
�6T mz,
Signature and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
9524
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. Aknw,5w ... P 4 !7*60AX—
has permission to perform
plumbing in the buildings of .... 1. A� 1"k?R .................
...... North Andover, Yass.
Fee fOS�. Lic. No. .....
PLUMBIN ECT?
Check# //��z
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JE-] NO E]
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAAWIBY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 10' OTHER TYPE INDEMNITY 0 13OND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
[Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER -01 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura e est of y knowledge
and that all plumbing work and installations performed under the permit issued for this appli atjon *111 be in compli wil erti slon of the
Massachusetts State Plumbing Code an apter 142 of the General Laws. CQ -11
j � �-- . 716 XF, % T
PLUMBER- ITTER NAME LICENSE # SIGNATURE
IMP = JPE—J] JGF E] LPGI CORPORATION I PARTNERSHIPE3#= LLC D#
COMPANY NAME: 14K, ADDRESS,
.--A4
_.914
E -3- - 7 --
STATE [AAgzIP TEL
CITY
FAX CELL= EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE fPERMIT #
JOBSITE ADDRE OWNER'S NAME
SS j.=6:&&
. -,Ae
GOWNER
ADDRESS TE FAX
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARILY
NEW:E] RENOVATION: 0J REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES -1
FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
MJ E:j L:::] L.-1 L: --j L:�
BOOSTER
CONVERSION BURNER
COOK STOVE
L�-
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
-411-=1=4
1111--4111'==-L-411
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JE-] NO E]
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAAWIBY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 10' OTHER TYPE INDEMNITY 0 13OND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
[Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER -01 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura e est of y knowledge
and that all plumbing work and installations performed under the permit issued for this appli atjon *111 be in compli wil erti slon of the
Massachusetts State Plumbing Code an apter 142 of the General Laws. CQ -11
j � �-- . 716 XF, % T
PLUMBER- ITTER NAME LICENSE # SIGNATURE
IMP = JPE—J] JGF E] LPGI CORPORATION I PARTNERSHIPE3#= LLC D#
COMPANY NAME: 14K, ADDRESS,
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STATE [AAgzIP TEL
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FAX CELL= EMAIL
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The Commonwealth ofMassachusetis
Department of lndustrialAccidi�ts
Office of Investigations
600 Washington Street
Boston, MA 02111
kvi www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone
Are you an employer? Check the appropriate box:
Type of project (required):
1. El I am a employer with
4. El I am a general contractor and 1
6. _F1 New construction
employees (full and/or part-time).*
2. 0 1 am a sole proprietor or partner-
have hired the siib-contractors
listed on the attached sheet.
7. F1 Remodeling
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
5. El We are a corporation and its
9. F1 Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10. 0 Electrical repairs or additions
3. 0 1 am a homeowner doing all work
right of exemption per MGL
ILEI Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
1211 Roof repairs
insurance required.] t
employees. [No workers'
13F] . Other
comp. insurance required.]
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is theyolicy andjoh site
information.
Insurance Company Name:,
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: Citv/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certlo under the pains andpenalties ofperjury that the information provided above is true and correct.
SigLiature: Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit[License 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract oftire,
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, employing employees. However the
owner oka dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivi . sions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is ' required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also bes U�re to sign and date the affidavit. The affidavit should
be returned to the city or town that the' application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed*legibly i . 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 ity or
_(c
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is'on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or'permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office- of Investigations would like to thank you,in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department ofladustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 It
Tel, # 617-727-4900 oxt 4016 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 i
www-mass,gov1dia
Date. R. ......
IN TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... &q ee� �7. ........
has permission for gas installation .... �.5�4 0..
in the buildings of .... ........................
at ........ . NorthtAndover, Mass.
Fee Lic. No. A ��4. .
GASINSPECTOR
Check # H4.0 2,
8,28-5
A NI-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA D/ PERMIT #
JOBSITE ADDRESS OWNER'S NAME
P
OWNER, S TELI ---_jjFAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL Ell EDUCA NAL D RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES -1 FLOOR- BSIVI 1
2 3 4 5 6 7 8 9 10
11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM I
DEDICATED GREASE SYSTEM I—A I --Al= ...... --'I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM f L—ja-
DISHWASHER --J=======
DRINKING FOUNTAIN ........... 1, F-77
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR) ......... . ...
KITCHEN SINK
LAVATORY
ROOF DRAIN =J =1
SHOWER STALL E -1--i j j
SERVICE / MOP SINK
TOILET
URINAL Z=Inl
WASHING MACHINE CONNECTION -A
::jWATER HEATER ALL TYPES
WATER PIPING
-dT
—ER
H --J I I
--I -D --i --j
F-1 F—f F-1
INSURANCE COVERAGE:
I have a current liabilfty insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
OF YOU CHECKED YES, PL EASE INDICATE THE �TYOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 R—I AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
P L M B _�4 LICENSE # SIGNATURE
ZER j PA� I LLC
MP CORPORATION EAl /#Vj��PARTNERSHIP P-1 #E:.=
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COMPANY NAME P ADDRESS
if\
CITY ZIP TEL 6 rT(J
FAX CELL &MEC6 I
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The Commonwealth of Massachusetts
Department of IndustrialAccidin*ts
F
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizib
NaMe (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:.
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.0 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F1 New construction
7. F] Remodeling
8. 0 Demolition
9. E] Building addition
10.E1 Electrical repairs or additions
ll.E] Plumbing repairs or additions
12. Roof repairs
13F1 Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation polipyinformation.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjoh, site
information.
Insurance Company N
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: Citv/State/ZiD:
r � -
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certio under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone# -
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License N
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson:_ Phone H:
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 employei 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� employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence o i compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivl'. sions shall
enter into any contract for the performance ofpubhc 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, ff
necessary, supply sub-contractor(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 employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is ' required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any! given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" . the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officlaHy stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is* on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture
6
(i.e. a dog license or p* ermit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in adva: nee for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston., D�A 02111
Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE
I
Revised 5-26-05 Fax # 617-727-7749
www.mas's,gov/dia
Date.
9501
TOWN OF NORTH ANDOVER
0 0-
f- % PERMIT FOR PLUMBING
CHUS
This certifies that ... ....................
has permission to 'perform
pl bing in the b ildings of ...................
Pei R -C 1, n. ovpr,
at ... r— w.y. �Or. Nqrth.A . d Mass.
1A 10- ......
Fee XD... Lic. No. -30 � i .....
PLUMBING INSPECTOR
Check ff
&� o e4 (�-i I i z 0�,
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE � PERMIT #
JOBSITE ADDRESS OWNER'S NAME Lm T,
-7
OWNER ADDRESS Il' TELF
RESIDENTIAL �-
OCCUPANCYTYPE COMMERCIAL NAL Ell
NEW: RENOVATION: REPLACEMENT:
PLANS SUBMITTED: YES Eq NO R-1
I FIXTURESl FLOOR- I BSIVI 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 1
W -
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
FP --W F M-- FM- FM- N M- F W-- F M-- FN -K FW- I ON FW- F- MIN M
DEDICATED GRAY WATER SYSTEM F- MOO FM
DEDICATED WATER RECYCLE SYSTEM iF— -F- -F-F-F-F- -FM-FW-FM-FM-
MMMM
F _____F W
__F F PW FM
DRINKING FOUNTAIN F M F W-- M M FW- - FM- M M F W-- FW- FM- F= -
FOOD DISPOSER Imim
FLOOR /AREA DRAIN F F F M- F F�- F�- F�- F�- F F �-- I �-- F r & � I
INTERCEPTOR (INTE
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES
OF YOU CHECKED YES, PLEASE INDICATE T�HE�E OF COVERAGE BY CHECKING THE APPROPRIATE 13OX BELOW
LIABILITY INSURANCE POLICY [2 OTHER TYPE OF INDEMNITY M11 BOND D,
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT
FRI
CHECK ONE ONLY: OWNER [7-11' AGENT 10
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
h4assachusetts State Plumbing Code and Chapter 142 of the General Laws.
4�24
PLUMBER'S NAMELk SIGNATURE
LICENSE # �
MP 0 ip B--"
CORPORATION 0#=PARTNERSHIP 0#=LLC U� ��
IADDRESS
COMPANY NAME Ile
CITY STATE PWJ-0 ZIP TEL
FAX I CELL -111 EMAI
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibby
Name (Business/Organization/Individual):
Address: &I lk.
V -
City/State/Zip: C&\ CC, QA Y? Phone ql�'g
Are you an employer? Check the appropriate box:
LEI I am a employer with
4. El I am a general contractor and I
(full and/or part-time).*
have hired the sub -contractors
demployees
2. 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] 1
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. Remodeling
8. []Demolition,
9. Building addition
10. Electrical repairs or additions
11. E] Plumbing repairs or additions
12.[-] Roof repairs
13.[�KOther 1_00_f,�er
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
f 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 is providing workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fime up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby cpWfp under the pains andpSalfies ofperjury th at th e information provided above is trite and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitALicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in 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 employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth'for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority-,,
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to 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 q uestions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
Date. J . ......
.'NOA TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
"�SACM 5
This certifies that ..................... ..................
has permission for gas installation t IPP. e.AR ........
in the buildingA of . 0-o'�
at V .... .. .......... 6 North Andover-, M�ss.
F -0 .. Lic. No.�00'.J�-... Ivr
ee3DZ fi., c i.P..
Check # GASINSPECTOR
8265
1z,
VV J
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE I PERMIT#
JOBSITE ADDRESS �OWNER'S NAME zo J
GOWNER
- _QLAc
ADDRESS TEL[7
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL E] EDUCATIONAL RESIDENT
CLEARLY
I
NEW: El RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YESF-11 NOR -1
APPLIANCES -1 FLOORS— BSM 1 2 3
4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN L__ __j
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
_15THER F I
.......... ' .... .... . .. . - .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES IR 0 El
I IF YOU CHE CKED YES, PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE -BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER n— AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinent !on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME E# NATURE
LICENS
LLC
IMP El MGF JP' JGFE] LPGI [j CORPORATION n#E= PARTNERSHIP D#L:-= ---I#=
COMPANY NAME:Ift-\. ADDRESS ------
CITY STATE JjE] ZIP EL
FAX CELL����MAIL
IN
VV J
LLI
CL
1
40>
iL
The Commonwealth of Massachusetts
Department of Industrial Accidents
rn Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (B
q -N
Address: a�
V
City/State/Zip: C CVI\ eel Q& D Phone #: IM 093
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. 1 am a general contractor and I
(full and/or part-time).*
have hired the sub -contractors
2. V(employees
l am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. F1 We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
E]
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F1 New construction
7. E] Remodeling
8. F1 Demolition
9. F1 Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12.[] Roof repairs
5
13TRIOther f�p'j,�Cr
*Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below is thepolicy andjob site
fnformation. I
Insurance Company N
Policy # or Self -ins. Lic.
Job Site Address:
Expiration Date:
City/State/Zip:
&ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGI, c. 152 can lead to the imposition of criminal penalties of a
fmc 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
c)f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Tdo hereby csj*Xv underthepaMs andp aftles ofperjury that the information provided above is true and correct.
/, < — ,-, 1,2 'N
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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Location � A".1 Llwo A�e
No. .5-1-37
Date / D -/"Z) �
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
C -/O
Check #
/b/j, —
4237 Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
0
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/I!�REtor of BuildiII2 Date
SECTION I- SITE INFORMATION
1.1 Proped Addr
�7,css- � 1, 0 0 �,Q
1.2 Assessors Map and Parcel Number:
Map Number Parcel Numbef
1.3 Zoning Information:
Zoning Di;tr �ct Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (11)
1.6 BUILDING SETBACKS Qft)
Front Yard Side Yard
Rear Yard
Required frovide Required Provided
Required Provided
1.7Water Supply M.G.L.C.40.1 54) 1.5. Flood Zone Information:
Public 0 Private D Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Address for Service:
z
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Sp?ervisor:
(� i� �Z- V�, C^ -C// �tz—
Licensed Construction Supervisor:
/,/ /�
Addreh
Signature Telephone
Not Applicable EJ
License Number
Expiration Date
3.2 Register ome I provement Contractor
p
7,6
Not Applicable 0
Company Name
Registration' Number
Address
Expiration Date
Signature Telephone
0
z
M
00
0
N
"%W
I SECTION 4 - WORXERS COMPENSATION (MG.L. C 152 § 25c(6) I
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 appUcable)
New Construction 0
Existing Building 0
Repair(s)
0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 11
Other 0 Specify
Brief Description of Proposed Work:
47
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Itern
Estimated Cost (Dollar) to be
Completed by permit applicant
it,
C
INTIR
USE' 014L,
17
1. Building
(a) Building Permit Fee
Multiplie
2 Electrical
(b) Estimated Total Cost of
. Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
Total (1+2+3+4+5)
Check Number
.6
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
7 as Owner/ (utholrized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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
Print Name
Signature of Owner/Agent
1111111, 11111111 --mm
NO. OF STORIES
Date
R
SIZE
BASENIENT OR SLAB
SIZE OF FLOOR TINIBERS I
2RD 3w
SPAN
DEMENSIONS OF SILLS
DRvENSIONS OF POSTS
DIWNSIONS OF GIRDERS
HE, IGHT OF FOUNDATION
TTUCKNESS
SIZE OF FOOTING
X
MATERIAL OF CHEVINEY
IS BUELDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
9x,
-BOARD OF BUILDING- REGULATIONS
_17�!,Jkv License: CONSTRUCTION. SUPERVISOR
w
Numb -et;',. Cs- 035152
BiAdate: M/31/1948
2025
Ex�ires':,08/31/2001 Tr. no:
ed,To-. 00
GLENN C COTE'
11 KOPER LN
Administrator
PELHAM, NH 03076
HOM 10PRO.MENTCH
Re'istration' .
9 114134
Tyk: ODA
sale# viny-1, Siding, t ViA
GLENN COTE
-te 0��W 11 KOPER LN
::_�NIST�RATOR PELHAM
MR, 03074
4
.4,
Town of North Andover tkORTH
Building Department 0
27 Charles Street -W
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542 & 0 0,10v
ACHU
DEBRIS DISPOSAL FORM
0
In accordance with the provisions of MGL c 40 s 54, and. a condition of
Building permit # the debris resulting from 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:
X,
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
I fit' L.�U11i111U11VVVCf1U1 U/ 1111d,�i0dWiLl,�iUJI-S
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affida Vit
Please Print
Name:
am a nomeowner perrorming au WOUK My5eff.
I am a sole proprietor and have no one working in any capacity
F-7 I am an employer providing workers' compensation for my employees working on this iob.
City: Phone #:
I nci irnnrp rn P,01icv.** 9.,?
Company name:
Address
City: Phone
Insurance Co. Policy # 1.
= to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties a fine up to $1,500.00
andtqr 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 herby certify under the pains anoenalties of
Print
the information provided above is true and correcL
#
— el;:�)
Official use only do not write . in this area to be c * ompleted by city or town official' E]' Bbilding Dept
E]Check if immediate response is required Building Dept 0 Licensing Board
Fj S�lectman`s Office
Contact person.,— Phone A 0 Heafth Department
0 Other
I FORM WORKMAN'S COMPENSATION
ol*�
IN
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No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
- )BUndation Permit Fee, $
-F
rm Fee $ C-)
it
r 1'^nn +;^n t
.41oll VwVV V%, Ulu $ ---------
Water Connection Fee
$ C)
X /J/j
Bulldin6 inspector
6 7 2 2 Div. Public Works
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Location
No. Date
4001Tjj
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
18593
C-/ Building Inspector
1.1 Property Address:
(%I LJI�V IL;L.- TeS —NO
1.2 Assessors Map and Parcel
z(
Map Number
Number:
-Fq
Parcel Number
CUiPiE
Name Print Address for Service:
(& I - ��t _
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
I -A
1.6 WELDING SETBACKS (ft)
Service:
Front Yard
Side Yard
Rear Yard
ReqWred Pmide
ReqWred Provicw
Provi&d
Not Applicable 0
I Am �E�
Licensed Construction Supemsor:
1.7 Waw Supply NLG.LC.40. 54) 1.5. Flood Zone Infonnation: 1.9
Public 0 Private Zone Outride Flood Zone 0 Municipal
Serwerage Disposal Systcur
0 On Site Disposal System 0
- . --. --. . -11 %IFMLLI��
(%I LJI�V IL;L.- TeS —NO
2.1 Own" of Record
CUiPiE
Name Print Address for Service:
(& I - ��t _
Sigiiiture Telephone
2.2 Owner of Record:
Name Print Address for
Service:
Signature Telephone
,SECTION 3 - CONSTRUCTION SERVICES
193.1 License Construction Supervisor:
Not Applicable 0
I Am �E�
Licensed Construction Supemsor:
0
— S66_S&'2q
2?,'
License Number
Address 0,!s2. 3-733
Signature Telephone
S - zs - goo(,,
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
&I —Z � _,�
Address
I V
EViration Date
Signature Telephone
I -.1p.rTION-T WORKERS COMPENSATION MG.L C 152 & 2506) 1
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 Mescifliption Proposed Work (chweck
ap;kable)
New Construction J9
Existing Building R
Repair(s) a
I Alterations(s)
tion 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
REP44L A-tj D P-9-PL-PdC- 0 f ST�o (Z
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
C14, NLY"'
1. Building
13,soo
(a) Building Permit Fee
Multiplier
2 Electrical
/300
(b) Estimated Total Cost of
Construction
3 Plumbing q610
Building Permit fee (a) x (�b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Niunber
SECTION 7a OWNER AUTHORIZATION TOBECO I TED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, �-R-A,--'A, as Owner/Authorized Agent of subject property
Hereby authorize ol # X", to act on
My behalf, in all matters relative to work authorized by this building pemiit application.
Signature of Owner Date
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
u I 1 1
Print,Name
q
Signature of Owner/ALnt, Date
�M
NO. OF STORIES SIZE
BASENENT OR SLAB
FF ND RD
SIZE OF FLOOR MMERS 2 3
SPAN
DWENSIONS OF SILLS cp
DMENSIONS OF POSTS Zw&
DMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS eoCL -P
SIZE OF FOOTING X
MATERIAL OF CHRvMY (U.A.
IS BUILDING ON SOLID OR FELLED LAND 5C)LI D
IS BUILDING CONNECTED TO NATURAL GAS LINE Yf>
Department of IndustrW Accidents
Office of Investigations
600 Washington Street
Boston, M4 02111
lip www-mas&gov1d1e
I Workers' Compensadon Insurance Affldavit: Buflders/Contractors/ElectridanOlumbers
AvyUcant Information Please Print Legibly
Name (Business/orpnization4ndividiw): bt),Lri- -To
Address: 2 -St R , yn.
City/State/Zip: 'Sim, ��.@.uszy 0 (qG2_ Thone 1?22�- 255z-
Are you in employer? Check the, appropriate box:
1. 0 1 am a employa with 2- 4. ED I am a general coutractDT and I
employeei (fall and/or part-time).* have hired the sub -contractors
2.[:] 1 am a sole proprietor or partna- listed on the attached sheeL
ship and have no employees These sub -contractors have
working for me in any capacity. workerst comp. insurauce.
[No worken'conip. insurance 5. We are a corporation and its
required.] officers have exercised their
3. 0 1 am a homeowner doing all work right Of MIMPtion per MGL
myself. [No worken' comp. c. 152, 11(41 and we have no
iiu� required.] t employees. [No workers,
cww. insurance require&]
7),W of project (required):
6. New construction
7. Remodeling
S. Demlition
9. Building addition
10.11 Electrical repairs or additions
I I.F—] Plumbing repairs or additions
12.[0 Roof repairs
13.[] O&er QEpF�(O_ 5,C-pRp1
-Any ww"UM& UM11 G� OUR M A nmw am Mi ow me Mccuou Delow MowM8 S& WO&WocnVantion polmy m&mubm
t Homeowners wbo submit Gas affidavit indicstims they am dozq an wwk aad gm bm ou"WIC contson mud submit a new affidavit iadic�g Vack
tcontrwom dw cbeck d& box =0 allmbed = additmW sheat obDwk* aw � of&g wbcon�
so fibeir wolkew comp Policy informatiolL
I am an employer d&w h providing xwrkers'compensadon Insm -
rancefor my employe" k the pWA7 andjob ske
Insurance Company Name: . A i
- JRgrar _ILzAg44__jq,
Policy # or Self -ins. Lic. M 0:�) (2 G Expiration Date: I - Zt( - 6
Job Site Address: M F, Q city/statecip:_ /V. A"D:�V� 064 rt,
Attach a copy of the workers' compensation policy declaration Page (showing the Policy number and expiration date).
Failure to secure coverage as requiref under Section 25A of MGL c. 152 can lead 10 the fiWsitiou of criminal penalties of a
fine up to$ 1,500.00 and/or one-year Imprisonment, aswell. as civil Penalties in the form of a STOP WORK ORDER mW a fine
of up to $250. 00 a day against the violator. Be advised that a copy of this statement may be forwarded ID the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerdo under the pW= andpenakin ofpedury a& &e blfwm
A h A P adonprovWd above to frue md cwreft
OffleAd use o*. Do not wr*e In this area, to be comyWaed by c4 or gown opkkL
City or Town: PWmlMcense
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
3. CRY/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
Contact Person: Phone 0:
Massachusetts General Laws chapter 152 requires all eniployers to provide workers' COMPM260111 for tbe ariployem
Pursuant to this statute, an employee is defined as "...every person in the service of 2xiotber under any contract of hiie,
express or implied, oral or writtm"
An empWar is defined as "an individual, partnership, association, oDiporation or other legal entity, or any two or mot
of the foregoing engaged in a joint enterprise, and including the legal tep, entativesof adeceased cinployer,or the
receiver or trustee of ali individual, partnership, association or other legal entity, employing employees. However *0
owner of a dwelling house having not more dm three apartments and wbo resides therein, or the occupant Of the
house of another who employs persons to do maintenance, construction or repair work on such dwelling bouw
dwelling I
Or on the grounds Or building appurtenant thmm shall not because of such enVloyment be dmmcd to be an en1plOYef-1
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal Of & license Or permit to o"rate.a business or to construct buildings In the conumawe&M for any
applicant who has not produced acceptable evidence d compliance witb the insuramee -coverage required."
Additionally, MGL chapter 152, §25C(7) states "Ncidier the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance wilh the inSWEXC
requiremen ts of this chapter have, ben presented to the contracting authority."
Applicants
please fill out the workers' cotniicsisation affidavit completely, by checking the boxes that apply tD yaw situation and, if
necessary, supply snb_contractoAs) name(s), address(es) and phone uninber(a) along with their certificate(s) of
insurance. Lunad Liability Companies (LLQ or LmnW Lubility Partnerships W) with no employees other than the
members Or Partners, an not required 10 carry woTken' compensation insurance. If an LLC or UP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of ladusUW
Accidentl for c4nfirmation of insurance coverap Also be am to sip and date the affidavit. 11ic affidavit should,
be returned to the city Or town that on application for the permit or license is being requested, not the Department of
Indusuiai Accidents. Should you have any questions regarding the law or if you are required to obtain a worken'- -
compensation policy, please call the Department at the munber listed below. Seff-insured companies should enter dkeir
self-insumce license.umnlier on the approp S-Flbr�
City or Town Officials
Please be . sure diat 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 die event the Office of Investigations has to contact you regarding the applicanL
please be sue to fin in die permiVficense number which will be used as a reference munber. In addition, an aPPlicant
that must submit multililt perinitlicciise applications in any given year, need,only submit one affidavit indicating current
policy inftwnistion (if necessary) and under "Job Site Address- the applicant should write "all locations in -(city Or
town)." A copy of the 316112vit dist has been officially sumWed or marked by the city or town may be provided to die
applicant 0 proof that a valid afdavit is on file for future permits or licenses. A new affidavit must be filled Out each
yew. Where a home owner or citizen is obtaining a license or permit not related tD any business or commercial venture
(i.c. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidaviL
The office ofinvesdgations would like to diank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us 2 cWL
The DepartineNt's address, telephone and f2K m=ber
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 wwwmass.gov/dia
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-689-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: that the debris resulting from this work shall be
disposed of in a property licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
(Location of Facft)
Fire Department Sign off-.
Dumpster Pennit
Signaiure of Permit Applicant
Date
I
LU
-.1- -1--;--- - -- ". ! -,-- - -- -
AC -0-80, CERTIFICATE OF LIABILITY INSURANCE 0? ID KNI
FIERRY112
-Te';;'2 DIYYYY)
0 3404
PROO.JC&A
'THIS CERTIFICATI 19 1 ED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
T. A. Sullivan Ins. Agcy, Inc.
344 S. Union St.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-&-e x -0 Au I I Om -
F-
Lawrence, MA 01943
Phone: 978-683-4'700
SURER$ AFFORDING CO'ARAGE
NAIC #
FerxIs
Da"'iff to Last Construction
F.tx— Kt.al "Our-OmO-CQ-.----
14923
Cozp.A�,.,�.ned
-
231 N End Blvd
sali6b4xy mh 01952
INSLRF:� D
D ExP 'Am, ye pe. SC.ji S 5,000
s 1,000000
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RECIAPEMENT,TERM OR CONDITION OF ANY CON7RACT CR OTHER DOCUPAENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY —RTA!N, 7HE INSURANCE AFFORDED SY THE POLICIES; DESCRIBED HEREIN IS SJBJECT TO 4,LL THE TERMS EACLUSiONS AND COII OF SUCH
!'O� I CiFS AGGRESATE LIMITS smom IvAY HAVE BEEN REDuQeD DY PAID Cualf,45
IS 6�06[
-&-e x -0 Au I I Om -
F-
t.TR 4RD! TYPSOF INSURANCE
POLICY NUM,�-,—T-
DA-.6,MW0C1YV)
I LIMITS
"NIMMI J."ILITY
I.-FENCIE. 1,000000
i F:i-
A I
-
CTR0001303 11/12/03 11/12/04 7"1:
-
�7 S 100,000
CUO:S MADE )c
D ExP 'Am, ye pe. SC.ji S 5,000
s 1,000000
s 2,000000
I IN- A,GPE-:;'TE 01" AP-L.-ES� PEP
S J'()00000
EVIP(, -
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AWTOMOEI LWSILITY
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Carpentry
112-1--iAmdUff-111-4
IIJ4I I S40LILD ANY Of THE ANCIVS DFSCRtSF'J Pfj- ICES 91 CANCELLED RIFFORE THE EXPIRATION .
DATE THEREOF, TKE ISSUINQ 114SVRER WL. 21106AVOR 10 MAIL 10 DANSWRITIEN
TO �HIE 0 9TIFICA�fi �C�DIER NAMED T. C THE LEFT OJT FAIL�RV TO DO SO SHALL
IMPOSE NO OQUGAT-ON OR LIAWLITY OF ANI XWO UP014 THE INSURER. ITS AQSN-% OR
REPRESENTATIVES
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