HomeMy WebLinkAboutMiscellaneous - 290 STEVENS STREET 4/30/20187690
Date. .,V/. . 7 —. // ...
0 -
TOWN OF NORTH ANDOVER
k�L
PERMIT FOR GAS INSTALLATION
This certifies that .... /Vx ..... 7.�C ...................
has permission for gas installation . /� ........
in the buildings of /-� ...................
....... orth An/dov Mass
at
Fee. Lic. No.��M,4:33. .
GAS
q INSPEC R
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: &644 A/Zt�4. Date: 4�1;71111 Permit#
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Building Location: OwnersName:- Z#-�611,ftf
Type of Occupancy: CommerciaIE] EducationaIR Industrial 0 Institutional El Residential-E]--
New:e- Alteration: E] Renovation: Replacement: El Plans Submitted: Yes El No F1
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SU§--BSMT.
BASEMENT
J' FLOOR
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—e"-F—LOOR
4TW--F—LOOR
�FLOO�R
5
-61H FLOOR
7 TH FLOOR
:4111
6T"--F—LOOR
Installing Company Name:
Check One Only Certificate #
,AddressL� City/Town:.
141
AWWLA4
State:
El Corporation
I-BusinessTel:
Fax:
El Partnership
11
Name Licensed Plumber/Gas
ej--&—c
llllelt7io
El Firm/Company
of Fitter:
INSURANCE COVERAGE:
I have a current liabliLty_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes F-1 No R
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy jz Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and �tat my signature on this permit application waives this requirement.
Check One Only
Owner Agent El
Si natu' 0 Ow 6'0 0 ne" s A ent L -j
B c r i
�yhe ingfth box Whe eb ce that all'of the de al.is and irif mat o.n �havpe ub ed entered) regrsduin this applipca�t!one �tr�anid
ccu 0 i I y rt fy t or 1 s mitt (or g 'r
st , 'w�.�� ,
� 1. �� , i � t 0 r , P rmit i�
ra be n e an b n rk a d �inll �ij n erf�. �ned nde th e s d fo this , PI.ction w. 11 be n�
— I t". .—V I IV I &I IV IVJU**dLf I UbUL15 QUIL0 NUITIDing Code a na Chapter 142 of the General Laws
Type of License:
By 171 Plumber
Title 0 Gas Fitter Signatu(e of L)ffensed Plumber/Gas Fitter
El Master
City[Town Eliourneyman License Number: c,2X�FS�;—
APPROVED (OFFICE USE NLY) F-1 LP Installer
Fri
Date. 91 J -
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUNIBIZ�
40
'2SACHUS
This certifies that rr ......................................
has permission to perform ... R" ................
plumbing in the buildings of
at 2 5 P 1 r ................ North'Andover, Mass.
Fee. . Lic. No.. /40.) 6
PLUMBING INSP CTOR
Check
7694
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Lo 4 Owners Name
Type of Occupancy
New ri Renovation Replacement ' 1:3
FIXTURF.P.
)� V
*V
I -V
Date ./-/ -1 V
Permit #
Amount
Plans Submitted Yes No
(Print or type) Check one: Certificate
Installing Company Name I t h/ Corp.
Address X- N- Partner.
NO, 6�:� - vi'l
busme I ss Telephone O'�Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate theppe of insurance coverage by checking the appropriate box:
Liability insurance policy r--Y--�- Other type of indemnity Bond
JW n F1
Insurance Waiv : I, the undersigned, have been made aware that the licensee of this applicatiori does not have any one of the above
three insurance
I hereby certify that all of the details and in(Ormation I have submitte
best of my knowledge and that all plumbing'w&&AaLi-n=Uatj-c,ns P,
compliance with all pertinent provisions of the Massachusetts P
By:
Signature oi Lic-M-s-ecT
Title Type of Plumbing
City/Town / 6'3 0 1
1APPROVED (OFFICE USE ONLY License I-quintier
01
or entered) j
and accurate to the
ation will be in
�ral Laws.
Master 9 Journeyman M
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KAREN H.P. NELSON Town of 120 Main Street, 01845
Dimctor (508) 682-6483
NORTH ANDOVER
BUILDING
CONSERVATION DIVISION OF
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
.1
DEMOLITION OF BUILDING AFFIDAVIT
DATE . � n'
OWNER'S NAME & ADDRESS
c�P,90 r7.— /E4 X.�vvevr,
LOCATION OF PROPERTY TO DEMOLISH f,7:- A",
DESCRIPTION JI'Ale-L t- 1710of 6r
CONTRACTOR'S NAME & ADDRESS
DEPARTMENT PIpN—,FFNS'
WATER: SEWER: JJt) SQ -V -)-o
DEPT. OF_gUBLIC WORKS
GAS �41'tzl
ELECTRI
TELEPHONE
-7 12"
F I R E A/ a' y � / -7 , fi 1 4 4^ r -c- d r c fJ Z r-
6 C2�4e -I a 1-4 77 1-%
�0
DUMPSTER - ON/OFF STREET
DIG SAFE NUMBER
DATE RECID BLDG. INSPECTOR
06/08/14 SUN 04:50 FAX 1 508 681 5796 ANDOVER HHC
1-000-070-9999
06-0&96
(5c6 &�CN
Account No.
Dear ; f
-To whoo �'+ ()^C�
C1 ce
Very Truly Yours,
Michael Banks
Service Representative
E'31 E
06/06/96 THU 16:10 FAX 15086573885 CONTINENTAL CABLEVISION
Continen,
Cablevis!
FAX COVER SHEET'
TO: Ll 8 U D13 ES2 I
FROM:
DA 71 E --
Number orpnits including this coYcrsfiec,C,,—j2
ConrideniWitv No(c
The infermati6n coritz;nctl in 110s (zesirnfle mclsitt iS Pfivilcgcd 3nd COANdential inrormition intended only
N�r thr wc of (Inc ind' Tr cmr.Uy nzm,:.j !b,�yc. If 1�,: rta-ler oro,;s -rssnte is not (be adcnka ,
li�ati�n, 64(r1bution or copy or jj,fj$ t2csimile mcssaCe is
rccipicrl, you are licrOy rotiried th21 Iny Oisseml
strictly prohibifed. lryou hive rectivcd Ow racximilc ;n crror, ple2se no(j(y us immedia(cly by 10cphonc
Lznd return this mcss2ze to us u the 2ddrcsi Wow vil 11,C1Jni1Cd Stiles Poshl Service. Th. -ink you.
COMMENTS: -
-Trj -RvalAE
TTI)
ze
Tryou havc .2nY diffilcullY receiving 014 rntssW, P)cA$c call file numb4r listed bcic%Y.'
ThoNWASystem r2,c number jis (503) 6S7-388$.
06/06/96 THU 16:10 FAX 15086573885 CONTINENTAL CABLEVISION 0002
01/23/1991 06:04
KAREN H.P. VELSON
Dimew
RL'ILDLNIG
CONSEWATION
HEALTH
PL.ANMG
w
5U9752063
THOMAS LAUDANI
Town of
NORTH ANDOVER
DmsmN or
PLANNING & COMMUNITY DEVELOP-NEENT
W:; F —K� �- , A E, i � ), - I -,
PAGE 02
220 Main Sbftr. 01 W
(508) 682-6483
PTO
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LOQ&TION Or Sn-v.-Nd -rz- Ae, 'O�.,,e
M3ZM=l AUMSS
0.- r!t 040�0-9- 0�ol'e Mir O_f 7.ff.P -,oW7f. 73- f;VC0-V A.,OXO'
DEPARTMEHT
F.rzc=
?:1REjeL,qL,—A!Lrl) -4 —4') r 1 t)�Vwv,-&C afaq—� 9// Alfj� P .4� 0!;�P—J,FC 74—
4 IP �74 9 O'n 6 1-1 r 1-9 Wl- 4-:� 6-A6147 f.
DU"STER - ONIOFF STRZ=—&--v40'&-_- /7 lv, �/,-/ -�rof"
DIG BA=
1 "90810 MAIN OFFICE:
NA' -0N ' ft P.O. BOX 5, BRADFORD STATION
... TA
I.N HAVERHILL, MASS. 01835
PEST & TERMITE CC
%6. sk�� /VW
June 6, 1996
Mr. Brian Lawlor
290 Stevens Street
North Andover, MA 01845
RE: Rodent Control Prior to Demolition
Dear Mr. Lawlor:
This is to verify that on June 6, 1996, our personnel carried
out professional rodent control services at *290 Stevens
Street, North Andover, MA, prior to demolition of the building.
All of the work was in conformity with accepted practices.
Please do not hesitate to have any interested parties contact
us if there are any questions which we might answer.
Cordially,
Richard P. Magu>/e, General Manager
RPM: lag
Encl
HAVERHILL LAWRENCE EXETER, NH NEWBURYPORT BEVERLY
(508) 374-7061 (508) 681-0390 (603) 772-3311 (508) 462-9282 (508) 887-0177
9 10 12 2
Date .... ... ... 3..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... /?.�,� .............. 117 ............ .............
has permission to perform ......... 11--..7 ....................... : ............
.......... .. .. ....... ..
wiring in the building of ... ......... ,f .- , X, .......................
......... ....... :� ....... . North dover,
Fee..Y ....... Lic. N ......... . ............... .........
RICA NSPECTOR
Check j
Commonwealth Of Massachusetts Official Use Only
Pepartment of Fire Services Permit No. Z—
e
Occupancy and Fee Checked
1/0 1
BOARD OF FIRE PREVENTION REGULATIONS Mev. FI/O7 -------
kleave blank
APPLICATION FOR PERMIT'TO PERFORM ELECTRICAL WORK
All work to be perforrned in accordance with the Massachusetts Electrical Code (ME 5 7 CMR 12.00
(PLEASE PRWflVINK OR YYTEaL NFORMA Tjoh) Date: ��- 3 -
City or Town ofi NORTH ANDOVER
By this application the undersigned gives noti To the Inspector of Wires:'
Location (Street & Number) ce of his or her intention to perfofm the electri ; cal work described below.
0
Owner or Tenant L:k- F -
Owner's Address /I
Is this nermit,.
-juncuonwitna buff ngperniLit? Yes El' N
Purpose of Building 0 (Check Appropriate Box)
Existing Service Amps Utility Authorization No.
volts Overhead UndgrdE] No. of Meters
'w Service
�L— — Amps Overhead Undgrd No. of . Meters
Number of Feeders and-Ampacity
Location and Natu ---
. re of Proposed Electrical Work:
No. of -Recessed Luminaires
R
No. of Lumillaire Outlets
ai
u-cs
No. of Luminail
0 P c utlets
No. of Recep
tacle Outlets
�NO- of Switches
No. of Ranges
NO- Of Waste Disposers
ishw
No- of Dishw=ashers
FNo. of Dryers
Heaters KW
No. Hydromassage �Bat�h�tls
-�t OTHER:
om . n of the
0- of Ceil--SuSp- (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above
d. El
No. of Oil Burners
go. of Gas Burners
go- Of Air Cond. io
7— -ril
m2nm,t%blo MaY be waived by the ELecto, 0
0. 05 f WireT.
TO�al
Transformers KVA
lGeneratons KVA
0- O-.!ngency ig g
11 'D I., -
ALARMS jNo.- of Zones
0. Of Alerting Devices -
Totaij:
No. of Self-C—ontain(
Space/Area JHleating KW
etection/Alertin I
ocai (I Municipal
g pph n
Heaiting Appliances KW
Connectioi
Securi Systems:*
No. of No. of
No. of D -r; --
Si
jData Wlrig—:
____Ballasts.
'TO. Of Motors Total HP
No. of Devices or
Tele !-CFnU-n-u�nicaGi�s
ces or
EJ Other
Estimated Value of Electncal Work: d-,0-0, o 1� Attach a11511,16 1''! :1,11 11 or as reguired by the InsPector of Wires.
------ -- (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,
INSURANCf —C and upon completion.
0� LRA�(GEV: U;nless waived by the owner, no Permit for the Performance of electrical work may issue unless
the licensee provides Proof of liability insuran e in luding "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.
c c
CHECK ONE: INSURANCEEI BOND [] OTHER . El .(Specify:)
Icerdfy, under thePains andpenalties ofperjuryy thatthe inform
FIRM NAME: 1-1r, adon on this aPPlicadon is true and complete.
Licensee:
Ir E
IF41e LIC. NO.:
(If applicab e, enter "exempt 11 - en- Signat
Address: in the hcensern-u�mberlin—e) LIC. NO.:
Bu
Bus. Tel. No.:190io-2- I
Alt Tel. No.:
*Per M.G-L c. 147, s. 57-61, security work requires Dep�r�ent of �pubjj�c --,D 7
OWNER'S INSURANCE WAI-VER: Safety �11�se: Lic. No.
I SSS" License- 40-�
required by law am aware that the Licensee does not have the liability in ----------
, yrsi below, I hereby waive this requirern surance coverage normally
Owner/Agelit ent. I am the (check one)Elowner
Signature Telephone No 11 owner's agent
ELECTRICAL PERMT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - D_ OUG SMALL
I YT
�J_t Jwqox Xj%�JLJAL"pj;
ID-
00� — L j xaued—
Inspectors, comments:
Signature - no
17 'VTWT A T
ection required ($50.00)
�S)
Date
_L j Pte -inspection -required ($50.00)
Inspectors' comments:
3. UNDER GR21!��W INSPECTION:
Pa sed — Failed
Inspectors, comments:
(fiasEpectors' Signature - . no initials)
4. EINSPECTION — SFRVICF,:
' ' Sp -"Cl
_ D T 'CAL
ATE CALLED NATIONAL GRID:
0 L
P P _
ss
_ _ f ]
assed — f ] Failed — f i
I sp ctors, c
Inspecto& comments:
(Inspectors' Signature - -no initials)
5. INSPEcTioN - oTHER:
Passed — f I Failed —
Inspectors, comments:
-no
($50.00) -
uired Wo.ofn -
Date
Date
Date
Date
DOOR TAGS ARE TO BE LD_0_TJT AND LEFT ON SHE IF THE AREA TO DE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPEcTION OF $50.00 IS TO BE CHARGED.
The Commonwealth Of Massachusetts
Department Of r"dustrial Accidents
Office Of rnvesfigations
..600 Washington Street
Boston, AL4 02111
www-mass.gov1dia
Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers
Appficant Information
Name (Business/organization/Individual):-
Address: '42-7
Y(O
City/State/Zip: YM &,f-7 PVk(
Phone #: 07' -0 / 7 Z2
Are you an employer? Check the appropriate box.,
LEJ I am a employer with
4- EJ I am a general contractor
�employees (fiffl and/or part-time).*
and I
have hired the' sub -contractors
2. I am a sOle Proprietor or partner-
listed on the attached sheet. I
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.]
3. 1 am a homeowner doing
officers have exercised their
all work
myself [No workers, comp.
right of exemption per MGL
c. 152, § 44), and we have
insurance required.] f
-no
employees. [No *orkers'
;A -Y aPPlicaUt that checks box *1 must also 0 out . the section Comp. insurance required]
Homeown— — — belo"F Showing their W01-e1S' CC, -4
Type of project (required):
6. New construction
7. Remodeling
8 - Demolition
9. Building addition
10 Electrical repairs or additions
ILEI Plumbing repairs or additions
12.0 Roof repairs
13.R Other
os U this aindavit indicating th _r 0;1 Pul-Y 1n1or=at-on.
CY 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. po icy 0 a on.
I inf rM ti
am an employer that isproviding workers I Compensation insnrancefor HZY employees.
informadom Below is the policy andjob site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration.Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation Policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of M-GL c. 152 can lead to the imposition of c . riminal 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 c:ey�t�&�er the
"dpenalties ofpeijury that the information provided above is true and correct
Official use only.. Do not write in this area, to be completed by city or town officid
City or Town:
Permit/r.if-pnea ny
-0-//
JLSSumg 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 #:
.A.
16
(07� 6�1�
er
Wl 'O-F�. RA A 00 A" Ail..
i
10 1912 Date ......
TOWN OF NORTH ANDOVER
0 -
PERMIT FOR WIRING
'�SACMUS
This certifies that ............. .........
has permission to perform .3.v.-ov.�
'Xve�-
.................................
wiring in the building of .... CkQ55�..
ftIP15 as
at ......... �7 6.21 ------ - North Andover, M s.
........ OM76 ...........
Fee.3.00. Lic. No.,,) �AL S
/ELECTRIC N PE R
Check #
Common -wealth of Massachusetts �y
Department of Fire Services P -72� �
ermit NO.
'm
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS V. 1/0
EPe . IF
/071 (leave blanK
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be Performed in accordance with the Massachu. ,
setts Electrical Code (MEC), 527 CMR 12.00
(PLE-4 SE PRWN EVK OR YTPEALL WORMA
TIOA9 Date:
City or Town of: -NORTH ANDOVER
By this application the undersil:! i� f To -the Inspe0or of Wires:
:: 0 his or her intention to pedotm the electrical work described below.
Location (Street & Number)
U
Owner or Tenant
Owner's Address Telephone No.
Is this permit in conjunction with a building perniLit? Yes No E]
Purpose of Building P"A-0 477, a/Z-/ (Check Appropriate Box)
Existing Service 3 P Olt Utility Authorization No. _ULZ_
"2 A— s OverheadEJ * Undgrd Eff No. of Meters
E-70 Ainps 2&1—�
Hew Service 4V-0 Amps
T_ -L—Volts Overhead R M
Number of Feeders and-Ampacity CC I-) Und9rd ly No. of' eters
Location and Nature of Proposed I -
Electrical Work:
No. of -Recessed Lumma;res; Com letion of thefo owin table may he waived by the ector qf Wires.
No. of Ceff.-Susp. (Paddle) Fans Nn_ of Total
No. of LUminaire Outlets No. Of Hot Tubs nsformers
No. of Luminai Generators XVA
tres Swimmingpool Abov [],Jn- 0. 0 mergency
No. of Receptacle Ouhets d. d. -0 Ba e Units 9
No. of oil Burners
N f M_F
0. 0 Switches 111i9aE 1111 No.'OfZaanes
No. of Gas Burners No. -of Detection and
0. of Ranges .60 tin' -Devices
No. of Air Cond. Total
Tons No. of Alerting Devices
Rea: 11riv :;:
No. of Waste Disposers liumber Tons No. of Selff-Contain
Totals: . ...... ..... . .........
No. of Dishwashers Detection/Alertin cr Devices
No. of. D Space/Area Heating KW Localo C unicipal Other
ryers onnection
Heating Appliances Security Systems:*
No. of Water KW
Heaters No.,. 0 No. of - No. of Devices or E uivalent
1i Ballasts. Data Wiring:
S
No. Hydromassage Bathtubs N No. of Devices or 1Equivalent
0- Of Motors 11''E, 'I
Total M, Telecommuni I I 1111! 1111! ii!� 'I , * g:
OTHER: No. of Devil�ces orl�f111iVn1d-"+
p Ce,)Attach ]:� � I .
Estimated Value of Electrical Work: 12� !ie I in!''I 1 5 enred
, or as required by the Inspector of wirey.
Work to Start: (When required by municipal policy.)
ThsPecRo'ns to _b, rrq..
uested in ac
URANCE COVERAGE: 'Unless waived by the owner, no permit for the performance of electrical work May issue unless
INS cordance with MEC Rule 10, and upon completion.
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 issu go
CHECK ONE: INSURANCEE, BONDE] OTHEP, 0 .(S in ffice.
ce?W pecify:)
0Y, under theP_ains andpenalties o
FIRM NAME: erju , that the information on this application is true and complete
At'
fWAVIX Licensee: LIC. NO.:
gr Signal
aPplicahfel ente LU�r _:&22'�_2 _60
r exempt in PISIlicense her line) LIC. NO.:
Address: ""goe /, I
%: OL) A 0-1 co I? Bus. Tel. No.-_DjE�
M.G.L c. 147, s. 57- — ............
OWNER'S INSL 61, securi work require Alt. Tel. No.:
TRAN s Department of p u1blic Safet
Y,,S" License:
required bylaw. By myCE WAVER: I am aware that the Licensee does not have the liability ins Lic. No.
signature below, I hereby waive this requirement. urance coverage normally
Owner/Agent I am the (check one) 0 owner
Signature Telephone No. 0 owner's agent
ELECTRICAL PEPMT No.
ELECTRICAL INSPECTION REPORT:
INSPECTOR- DOUG SMALL
I - ROUGII INSPF' CTION:
Passed - Failed-[ Re-inspectiojirequirecT(s5o.00)-f I
Inspectors' comments -
f2 712A S
(Inspectors Signature no initial
Date
2. FINAL INSPECTION, -
Passed - f j . . Failed Re-inspectionrequired($50.00
Inspectors, comments:
-Ot=
ell
(Inspectors' gnature-n Utials) 7 -
Date
3. UNDER GROUND INSPECTION.
.Passed - Failed - i requi . red ($50.00)
Inspectors, comments:
I 1�-Luquvtaw b- aignaLure - no It
L4. INSPE CTION - SF
,.RVICF
"I"'SPEC'
DATE CAILIALD IVATIONAL G-RI01
) I -E
P p s
assed Failed - r I
s
I sp ctors, C
nspectors, comments:
(Inspectors' Signature - no
5. INSPECTION - OTBER:
Passed - f I Failed -
NAMM
Date
Date
Inspectors, ents:
u
( rus )ectors,
fasplectors' Sign re - no initials) Dafe
DOOR TAGs ARF, TO 13E 0-0—UT AND LEFT ON SITE IF TM ARFA TO BE INSPECTED IS NOT
ACCESSIBM AND A RE -INSPECTION OF $59.00 IS TO'"�. CHARGED.
The Commonwealth of Massachusetts
Department of Mdustrial Accidents
Office Of LnVeshgations
..600 Washington Street
Boston, AM 02111
www mass go v1dia
Workers' Compensation 'nurance Af"davit:.Bv_uders/Contractors/Electricians/Plumbers
Applicant Informatian
NaMe (Business/Organizafioa/fildividual):
Address: d A N
A I -
�K
IQ . 20, 1
0 MOM M 41A
re you an employer? Check the appropriate box!
I. El I am a employer with
�part-time).*
4- am'a general contractor
2eRemployees (full and/or
I am a sole Proprietor or
and I
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet, I
These sub�cOntractors have
working for me in any capacity.
[No workers' comp. insurance
workers 5 MP- insurance.
5. E] We are co
a cOrPOration
required.]
EDI am a homeowner doing all
and its
officers have exercised their
work
myself [No workers, comp.
right of exemption per MGL
c. 152, § 1(4), wrld we have
in . sllrcwce requixed.] f
no
employees. [No -,iiorkers,
cornp i11121—
Type of project (required):
6. El New construction
7. [] Remodeling
8. E] Demolition
9- El Building addition
10. [1 Electrical repairs or additions
.11-0 Plumbing repairs o r additions
12.F1 Roof repairs
13 M r -W.
*Auy applicmt that —ce, requirecIJ
'Contractors that check this box must atta"'dcat"'g they a
CLe�,s box *1 Must also a out the section bellow showing their V
compm
t Ho e-o-wners who submit this affidavit 'on
-coELtractors and their workers' comp. policy 0 a on
ched an additional sheet showing the name of the sub tOrs "It submit a new affidavit indicating such.
doing all work and then hire outside contrar p6icy
i I'am a" e'"Ployer that isprovid'ng workers'MnPensadon '. inf; rm ti
nfOrmadoyL Ins"raneefor my eMP16yees. Below is thepolicy andjob site
Insurance Company Name:_
Policy # or Self -ins. Lie. #
Expiration.Date: 2—
Job Site Address: id�
City/State/Zip:
Attach a COPY Of the Workers' cOnipensation Policy declaratiOn page (sho
Failure to secure coverage as required under Section 25A of' - wing the Policy number and expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as MGL c. 152 can lead to the, imposition Of criminal penalties of a
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
Investigations of the DIA for insurance cov �"cation. statement may be forwarded to the Office of
erage verill
I do hereby certify.under Pains andpenalties OfPeriurV that the 'nformation Provided above is ftwe and correct.
Si ature:
Date:
Phone #�
OffIcial use only. Do not write
in this area, to be completed hy city or town officiaL
City or Town:
Permit/License #
0
f1clal u
se on y
I
r Wn.
r y ce
Si a re:
un
D
d
0
flu ev rfttv. er
__g tu
t pain
s andpenalties oiperju
not write
f f"c
(C CIL
OL
uthor-ty ir e) -
B (. c
C ty
i 0 To
Issuing Authority (circle one):
m
r
L Board of Health 2. Building Department 3. City/Town Clerk
r
6. Other 4. Electrical hInspector 5. PIMwnbing Inspector
rso
1: n
Contact Per
[E son: ----------------- Phone