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Home My WebLink AboutMiscellaneous - 30 FAULKNER ROAD 4/30/2018 (2)The Commonwealth of Massachusetts Department of Lndustrial Accidents Office of 1nvestigations .600 Washington Street Boston, M4 02111 www.mas&govldia Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers Name (Business/Organizafion/Individual): Address: City/State/Zip: �/P 0 r"> -1 � qss- 3../F�Sphone #: _9Y_ tp)s Are you an employer? Check the appropriate box: 1. 1 am a employer with /_�O 4. 7 1 am a general contractor and I - employees (fiill and/or part-time).* have hired the sub -contractors 2. 0 1 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. D We are a corporation and its required.) officers have exercised their 3. [11 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. F� New construction 7. El Remodeling 8. F� Demolition 9. DBuilding addition 10.El Electrical repairs or additions 11 -0 Plumbing repairs or additions 12.0 Roof repairs 13.[] Other mubL ru,%Q lul UILIL We SeCuor bejo.,y hoj_ th" __ Q Ir Xers compensatior. policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, �Contractors 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, COMpensalion inSarancefor my employees. Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State I /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 c riminal penalties of a fine up to $1,500.00 and/or one-year nnpnsonment, 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 un�derthe �ai�� OE.!��&iurjl that the information provided above is true and correct. �0 S,i ature: 2-na Date: P?1v/ Phone#: 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): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other el Contact Person: Phone#: 0 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apariments 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 coxapliance 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 (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurancepoverage. Also be sure to sign and date the affida-0t. The affidavit should be returned to the city or town the, the applicafion 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 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, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 )ww'"7-mass.gov/dia CER77MED PLOT PLAN PREPA RED FOR: Ji WNCENT GRECO A T NO. 30 FAULKNER ROAD (tN 0 NORTH ANDOVER. MA. NORTH ESSEX REGISTRY OF DEEDS. BK. 8937 PG. 307 ASSESSOR'S MAP: 44, LOT- 16 ZONING: R- 4 MARCH 31, 2009 SCALE- l-40' DA 7E. NO7E.- EXIS77NG SE7BACKS TAKEN TO CORNERBOARD. N07E. EXIS77NG BUILDING COVERAGE = 16X *4 Vfl PREPARED B Y- 0 1�00 01401� JORIf ABAGJS & ASSOCL4TAS, PROFASSIONAL LAND SURVEYORS 9 BARMETT S7REET, NO. 252, ANDOVER, MA. (978)-688-4899 JOB NO. 5650 Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........... has permission to perform .............. plumbing2*Vhe buildings of .................................. North Andover, Mass. Fee.��!-. Lic. -ZA ........... PLUMBINGANWECTOR Check # P) S i.- T/I 14, MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT' TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Loqation 30 Owner V,'O Cr CC New [a Renovation [] �c Replacement [] FTYTTTRIPQ Date Permit # Amount Plans Submitted Yes 0 No 0 (Print or type) Installing Cor Name one: lame Je 0/*'l 7' —j,5 Check Corp. Certificate 0 FlPartner. 4' YC7 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the tVM of iins;urance coverage by checking the appropriate box: Liability insl vance policy Other type of indemnity Bond Ey El Insurance Waiver: L the undersigned, have been made aware that the licensee of tins application does not have any one of the above t1iree insurance Signature I owner F] Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are I true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for tins application will be in compliance with all pertinent provisions of the MqCsa-A-6atts State Plumbing Code and Chapter 142 of the General Laws. lBy: bignatGre -01 Lic Title T ol'Plumbing License City/Town 47 ,APPROVED (oFFjcF usE oNLY QIcZ Im W Master Journeyman .0 I A C- 7- /0 if Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perform . R!eel� wiring in the building of .......... . ................................................. at ............. ...... fe D ....... . North Andover, Mass. Fee..L�j ........... Lic. No..9.!�K.J r.7 ................... Check # FIE��*C* A-L"i N**S* P -E* C-TO"R "q 48 0 0 R C11 0 A d) ff C, --.o P, 0.00,00 E. t5 4� P, 4' 00 o .9 C', 0 ca o 4- bj) cd .41 Q 0 0 �a 0 A - c,,i 'r, 44 -',4, 0,. bob P, bo 0 0 %- 0 - 41 0 P,�.- " 4 . 0 41 'a 0 A 0. -4ff j,' 'g 0 W 4 t5 Cd cli 4-1 0 'F o irp pn tj .86 a 0 C) - C', -0 BE 00 A. C> C) RAA 4, 0 0 C OR OR 0 0 0 �4 0 b4 p, bl) 0 P, bQ -WO 64 0 t; 0 PE A -.g Fol 4ZI 9:k 4) 9 -48 Aq -C-\ Commonwealth of Massachusetts Official Use Only R1 -IT R Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked $v [Rev. 1/07] (i,av,blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORM4 TION) Date: City or Town of. NORTH ANDOVER To the Inspector �f Wires: By this application the undersigned gives notice of his or her intentioAto, perform the electrical work described below. Location (Street & N Owner or Tenant Telephone No. Owner's Address -,�C) zz�e—,4 Is this permit in conjunction with a building permit? Yes [T No E] (Check Appropriate Box) Purpose of Building .9 Utility Authorization No. ExistingService 16,0 Amps Volts Overhead Ell/ Undgrd 0 No. of Meters New Service " Amps Volts Overhead Undgrd 1:1 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 44 Completion of the followim, table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cefl.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei In- grnd. grnd. Wo—.—J Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum p I �NR!0�.r ons 11 ............... ].K.W .......... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local El Connection El Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications W" " No. of Devices or Eg iva 6t OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 6&� Inspictions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the perfort-nance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov�pge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [Er BOND F OTHER El (Specify:) I certify, under the pai th t th ,�!n ry, . icatio i andpenallies q/'per a e information on �ap n is true and complete 77.0 — FIRM NAME: ty '76�w�;I-elk LIC. NO.: Licensee: Signatu LIC. NO.: 71 (If applicabl�, enter "exempt" in the license number line) Bus. Tel. No.! Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner 0 owner's agen . Owner/Agent Signature Telephone No. PERMIT FEE: $ Location No. -3f-U Date .4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 0-,e '/.7- � � 80111 K(W) BuildingIft rector Div. Public Works 7PER'1177tNO. S4r-> MAP +40 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE I INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED ;ISIGNATURE OF OWNER OEVAUTH0_aLUD AGENT zi – 'h—e 1 - 17 E E 0,�e PERMIT GRANTED 19 -Z-r-97 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PEh SQ. FT.' EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. # CONTR. TEL. # LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK :PAGE ZONE SUB DIV. LOT NO. 'A LOCATION ol PURPOSE OF BUILDING OWNER'S NAME Dl�� OWNER'S ADDRES!r NO. OF STORIES SIZE BASEMENT OR SLAB ARCHITECT'S NAME 4 SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 0la4xAtrA<-Q SPAN DISTANCE TO NEARE9T BbILDING DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDIT16N MATER:AL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED ;ISIGNATURE OF OWNER OEVAUTH0_aLUD AGENT zi – 'h—e 1 - 17 E E 0,�e PERMIT GRANTED 19 -Z-r-97 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PEh SQ. FT.' EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. # CONTR. TEL. # CONTR. LIC.# H. 1. C. # - An L/ A BUILDING RECORD OCCUPANCY 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. SINGLE FAMILY I S;oRIES MULTI. FAMILY APARTMENTS I CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY WALL I _UNFIN 3 BASEMENT AREA FULL FIN. B M*T AREA FIN. ATTIC AREA 114 Y2 '/4 NO B M T FIRE PLACES HEAD RgOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING _�ARDVV 0 ASBESTOS SIDING VERT. SIDING COM/,ACN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. BRICK ON FRAME CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR POOR ,�DEQUATE NONE 5 ROOF 10 PLUMBING GABLE 11 HIP BATH 13 FIX.) G_AMBQELI g MANSARD TOILET RM. (2 FIX.) F LAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES— TILE FLOOR TILE DADO 6 FRAMING 11 HEATI;G WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W*T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd 3rd E NO HEATING 0 FM4 t k--� v 0 a 0 m C: . u 0 L2 E In >1 cf) u cn u P -W ri) z z P -W �) 0 -Z cz �2 u —C, x 0 PW &0 04 cz u w to 41 > U) co LL P -W &0 4 oz 04 uw P -W 44 w 6 z cn 0 E V) uj 0 C/) z 0 u U) u 0 co —j < E U— co 0 F- 2 t; CD C.3 z CL 0 Cc Cc CD D L :5 IS Cc CD CA CF CL) Co ca > CD L- 0 G3 �- = C) L) CL CD CD 00 >. co ci cm t� Q cc 0 CL CL ir<m.*: Cc CO2 CD C Cc c cc -0 Co cc 1= CD < CD CD cm u CD g =C3 co) -0 LLJ CL cm C.6 F-- < cm COD w = C42 Le uj ci C.2 0 cm Q CS CD COD CL CO) C4) Cl cc J.. CL4- CO 0 50 0 C/) z 0 u U) u 0 co —j < E U— co 0 F- 2 t; CD cr LLJ z CL 0 CO2 D L F -- a Lu F -- CD CO2 CL) Co ca > CD L- 0 G3 �- = C) L) CL CD >. co Q cc 0 CL CL CM< CO2 C Cc c CO) Z L) < CD a u CL CO) cc LLJ 02 C.6 F-- < cm LU Cl- urri%-.-- %.jr. APPEALS BUILDING CONSERVATION HEALTH PLANNING UNORTH ANDOVER ,74 DIVISION OF PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR North AnCover. Massachusetts 0 1845,6 (617)6854775 11 - 'rsl N. In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number 3 ID is that the dcbris resulting from this work shall be disposed of in a prcperiv liccnscd solid waste disposal facility as defincd by MGL c 111, S 156A. 7le debris will be disposed of in: Signature of Fc,-mii Applicant 00A'�& ", Z�a I e N0T�r�: Demol-it-ion permit from the Tourn of North Andover must be obtaine-d for 41dJng Inspector. tnis project through the off'ice of the Bui I