Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 317 RALEIGH TAVERN LANE 4/30/2018
317 RALEIGH TAVERN LANE 210/107.A-0126-0000.0 J i ����" SFeRBEs JR. f'URsuGA I ,f'L�C WELL Jpu /,e>Se7• `gyp, reeo.r/ cvTe eIWIr`l. /J.rbr e/G SGCVt•.7'e- `6e�Y•'Y n..y f✓.`�C Y�I& JL'...�i' Or' .4a'® I'Cf bl9esiS T�"tlP. oY-r-a' 1 Oy0/Ie �(�.hlaAs 11 A�3j /.,f DR G'Eo geE Al FARR IO��k w� .7 C C6MiS7t`aLe77� r� W�S Jw.�/ + l JG-3/-2SF Re'n�_�Sof. Z.41 2 �yc�o�i I 3•lf.ra Br-,,,;d<e/ by G(a• c e<r�a, w.�.-.. �' sczr� �rw.rs .r- slrc<7' d.k h+ws� � 0 ... .s / ' . Y,F/- MK ,y h"�S /9ST.i0��• .. y4.9 ..%� . t*-✓ Q� Ok �.,. -7-47 .�! s <! *zie d49s snr4s� �e 4-;-X ov co+rrTrwc�art. - ro Fet au..cA •aST�rTi r'*S �dCCor'�°"rCC a'/?""f 7`iL hE94rfl hP uf� yhC7C krc ,fry vc.0 /K / 40 V LoT .z� 6,7�'j2,33 .. auo <�b� �e6 SB-S)E B15 :�.p Z� m BB P°cTs' e.n�..r.n `I'o '3'k ce „-,_ S•.l+°O r.r s �1 -n � °✓'�/e� .Sa6e�r.. �. 0 R`i bC o "moo �-3�0 2z� 3. -f'••\ S �So<r�• y'a' r.'...d r-°ele5 •• rev a.Te..e y; � t �e v T f 0�aiC1 �7Ra. �iG...n.� /�.07 d i _7''e�.- ' 0 4/f,00/.r.F b5 ..I o A ._ 2so./.9 2 5iA X70 W . 4• C.if<S C 4'.c . ^3.`-fzt..-a' u SrlrnS HsurT /e ar7-44ge SQ;4 cw-/xvs /Ts r r• verrr� 6Y a A{e42 iS1.a✓„<.. �a.w.ler./ rt os. a-rr� s�alc r1/'te ro.er✓wm¢S [3`f>;ier 6a f�ts� )' ti V n�z:,x`z!l+ n2ti % B�.L9 -8332 .. de ',. G3o+rE sv./r.r'uPfr/.�mrp6e 6vc.%r.-ee n pcco.s.�S<. br.l.ol,1s..,y ro.• •mer..,s. rvrd/�/.,•, /"6m. rc.<�.a rds � ?e0N?r74 '14, 3Z// b h p Q"'n^�P 9 A/eR � '� sbrre/ '/9zO'rx( ay l�e.rN� .e:���� 9�er?o. ay %� d em/.aY +g>' •<! '�• 11 � ... r +o o� D%� \. � 'n o Nm 5b. w• o R bty°�...' n N '� ? /� !� �C/Y.}adhd A�/-rrl. .0 h.9/K<h2 t..,,i•. •/s �Te Y'7rC fi r•< a�f<♦..•, S9t sTie rr¢ f'\N 4B 52o civ rood•.. ° o� B` p o y�. Dy sti 44s _ �- 35_2ZEb1174e ' { �'• LOT /l0 N\� p >--.-.. TREMA/w NG LAND -� •• or A9 osoo ' /O JF. rrwc .x 0 (D D N V N 1 Erb. 9° 'S 1 D a for 40 \ e v/ ♦p W l ,P Na. 1 �Ah h 467o 7.rc 0 0/ °W // pp o° 2 o 6 "�j �B" N 630�� p° ? p QrEaroT.seY��� Lor 24 .• � oT �3:73 �- S rax' 1 4-SB.ooE B4 sv � Do s�A•a�'r ✓.e. �U'es<A I /,'o�,r �� /ea BB- ',\ h � 4B m o> /6B BB LoT 3.9 pH. .546-os- T� � s \ �• �.,.?� 0 ¢'� Dp �2 o w 046/64 sf4 '/ 7-/3E .789.57 ���a•r N FM ?3 t� yh OJ( \IO o �a p •h O 1'A S w o s ....320/• ...4.00 249.57 ty N IV / (//"- or L 3B �•: N ,>, �:1), r .� �� bf '5 0 1�' LoT 25 p S�692 sF -�N _ 4 Oui� IA,S' p y 44/B f JF 1,' .�' E o'✓ 1, Lor // v` r Lor /2 W N N '�Iv /3 0 lar 1� by � 9� \�� N ° 4S 532 s 1 N ' f r N 3%ZB3s� o ff m LoT W - r 42 /4 �.•_ pp 00 _`/59.o N .A N N ' 4¢996s.F r• r o 0 ,�=_/ W N F�!\' k"• 2 ^\ N N "1 k N p 0' 2i '_ z F�y h oo��:' a;5,5 6Z G=46.201�� � R=zsoo a a j F N Lor/S M \�r ti�D, ft,(1 �1h Lor 37 o pp ry °I 'a� 13 f•i5c.ee.. /97 BSG=32.34 ..;�'° r 4¢B24 s.F- '�. r,,0 Lor 2G �N, 50 >< p4 0p ��`s >� 0 c o. q N by 4'-------------- s;z/_se_oo 96 .. 44/B4sF k r 13 / 4-3 „+ Ip'p Lor i3 p61' w� kypA', 1 - 4• 45,073 sF 3zS s.F 5s 1Ai, oaE. nNA,N ,. e � o Ik' F � ..... ��� ...., ... =.50-/ °a2 •5 o�F 6° ' Lor 36 r 0'00 % "- - Lo> 32 y / 000c/ zsa `�"'E +�- �"�F 9h ob �1p•A ISUJ15 � 247 si' g^ � ?� 02 `1 06E W sy s o: IhP 2,F�B 1,1� ° DZ 47,76B.sF N k o �- /zz.z.ies •a\ Lor 27 Lo .3/ .S yU N 2+ot N .Lor N W / �^ t.4/' h:iZu. A N o6sF x q: &`^ .s 49s.s� 1� Do p ...� 4,e :...ti g J f 10 A, �F N..- � � 45"374 s.F Lor 30 ° I• � 0" � N 0 . h o ,✓RrN .F' o QO rT'a/ a N 4497SsF o for 29 W \Q \Z�p'S �` �I,q• p° 0 02B 0 �� Lor 3S sN� po �0 2 '' azr p. 10 Zv 4, L Bao sF or 0. l to >6• 15 Iye3d' �' 0 Z 96.sq `''9pm o 0. 26 ooF�3r 21� 89. S.x c:,.•r : o 5Z 5o 44 z.oe•._.{..-. _ `poo .� 0 '' ?s' o�� S�a 9 ,ov so��-oo .Q. "o o v 39 .....5/.]0... LoT 34' O o 1 -s %-25-oaE; ...R=sso.00 44 IV <7. 5 e 47,767 sF G e y2. L oT 46 � GA �m �-�� / / _... //4 os 9 -r Fi o�8�•: _ 44 48B SF °0 9� E 23 0. :,• e.�..,"•es�`�L®•�� -.....'.: 00 D0 06, V 00 181,1, \ Iyp..r• ou o' s H rE: r eE ee a mNew \ r1 \\ LoT 33 B"c.L c.L. wA>cR G-� . \Sz�6BS SF ,I 14, o Lor 47 .j $ GEORGE O a / GS... 2 44,304 s.F dam' NwYES 8� GEORGE , Io�ti1 vo"uPa 5pp _ /_rb,l Ws¢jl 9F"ai eao H HnrEs 03 kE I I •+gY.•,tL L T � ro v �D. 3r I x1275' la y, ::;o° Lor 4B 0• �k.p � J 4.5 293 / c / c� <s h�4f E ¢on�m�\�Q 6' IZk1.._. z'r .x L•I kV ' f 'r:,o s'-.��2''-\-•- o°,i55 i5 19 5 Jo�'� � W F t �'L r�IL�'I�i.h7 ll}�Id�'d�1➢Y IL;.�7�i�71�'.�» �d°2+°oo �f �h�o e o 1�®�71�� L➢�d�®IP��,11��f$5�. / If u p 2 A °rt•a Ge tlncau°° N R> : 1pP N ti oo�c \ A, O W � � OGD.tb ANO V RRA<TY T /lArES F G/N6E.ei:vG/G o noY ME c Errs v I� I� -( °' L jA :'5 •3 �P(^ I` Q 2 oto VGcAGE LANE B2B LY N Fc<s PAR.rw.ar ✓ ..7 voJ ol Ck k :ronceo n.,r?:tI Jr v.L lll_u. ='-< o B o N 4000 sf 888�8� �E� q I NRTN AN ERS MASS ROSE/Y/ASSA NUS . P s aoa a naa a°ba soar.°a a,a r°-cr�a et in s e °c H'l� Il h o 0 o N r 14;ne!:any tlzys n•nt z'ter sato ret-i� tl � ?r• t' � O. NaL Ar .......... . E: O /Y YER� N/NG D R-soo I A .•^/`ho.� l ... ... 3-32.00 '.f :.' .3s-2 I!0 5512 � FiH PLAN .:�•La3rS.g�' LL11IllL Q_,%ux.LLv /U OAILt. DIY 0/'h -' � B`c.I.c.G. WATLR Gn,E E _ ,--'- ^� FARNUM ST EG F_V.=/g-¢,J/ -- PLAN'ARFRe�:tGf�ft����b. CONSERVATION DEPARTMENT Community Development Division May 6, 2016 Josh Lobel 316 Raleigh Tavern Lane North Andover, MA 01845 RE: Selective removal of 1 tree located within Bordering Vegetated Wetland. This is a follow up letter pertaining to your request to remove one (1) tree which is uprooting and leaning towards your home at 316 Raleigh Tavern Lane. The tree was identified in a letter with photos received via e-mail on May 5, 2016 from Mr. Lobel and reviewed during a site visit by the Conservation Department on May 5, 2016. The tree which is permitted to be removed is identified in the attached photo. *Determination of property ownership is the responsibility of the homeowner. The tree was observed to be leaning heavily towards the house and in the process of uprooting posing a hazard. Due to the potential danger imposed by the tree, the Conservation Department will permit the removal to prevent possible injury or property damage. These cutting activities shall be limited to the one tree identified and shown in the attached photograph. The approved cutting will be subject to the following conditions: ❖ Machinery shall be staged in the driveway and no machinery shall enter the 25' No ••• Disturbance Zone. No work shall occur in resource areas. ❖ All tree limbs, brush, and other debris materials shall be taken off site and disposed of properly. ❖ The stump of the tree shall not be removed and shall be left in place (stump is not permitted to be ground down). ❖ Care shall be taken to prevent damage to surrounding trees during removal of the approved tree. ❖ Upon completion of the tree removal, all disturbed areas shall be properly stabilized. ❖ The applicant shall notify this department immediately following completion of work for a final site inspection. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web www.townofnorthandover.com ❖ Areas within 100-feet of wetland resource areas shall remain in a natural state and no further vegetation shall be removed without the prior approval of the Conservation Department/Commission. ❖ This permit shall expire six months from the date of issue. Please do not hesitate to contact me should you have any further questions or concerns in this regard. Sincerely, NORTH ANDOVER CONSERVATION COMMISSION Heidi Gaffney Conservation Field Inspector Cc: Jennifer Hughes, Conservation Administrator Please see the attached photo. 1 t 4 Tree permitted .: for removal t . p 1 .wow . r ry Y ''` h• •e. -a--+ems---er 1.w. .....—m.. p , e 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web wwwjownofnorthandover.com +r � Josh Lobel 316 Raleigh Tavern Ln North Andover, MA 01845 917-968-6953 mrjoshlobel@gmail.com May 5, 2016 North Andover Conservation Dept 1600 Osgood St, Suite 2403 North Andover, MA 01845 To Whom It May Concern: I am writing to request review and approval to remove a hazardous tree on our property that is located within what I am assuming is a wetland area. It is a single large tree within 50 feet of our house and driveway which is currently leaning toward the house and appears to be in the process of uprooting. Should the tree fall it will cause significant damage to our house. This tree has us very nervous because it would impact the room regularly occupied by our.three young children as a playroom throughout-the day. should also note that we only moved in to the house at the beginning of the year and are not familiar with the condition of the property beyond the current conditions. We have obtained quotes from a couple different licensed companies for removal by crane from the driveway. Following are photographs showing the tree and its proximity/inclination toward the house. Sincerely, Josh Lobel Enclosure i r ,.$FI OWN� r #4ell, t � yr ,t ,y � jk If R i jwl t � r vw -44 71 •y+e,�"`z�..+;i' `�. "'...; J r w"?JY F YIA��tF't✓c � *� ��v`�� �, '�e+w �[.i.��i�.,s+ ' ,;. �' S 'ice. '� i �'..�•. { t a �,�''"- �►'�*'�G<��x ";��,p *�,4=°�'�I�Y�Y�C.^ta.a3 Jrw a�} �J,��$ ��� `•�`e rEs r ._ �.�,.�� � r'n.�[n x.ftY l�;'t n...`.i(pr ��. vt . �„^. f-:. �a•.. � �..�' tk .�j t�w 1,7k it ,•.- b g7 1 r ac d lift— y ,` "jVS� sa;ss " !! �Z�r::� a '""��,y� ya �� k Y .. r A' "f ... �` :+.,� y•%`i'�j ,�"r'�� :a� a. _� :� � � J• i a✓ I" `�yyi�° �� s�•; (��'�Ft'i 4 ° R �'� ��L-;'� � f•R � ��a ir� { "Alli"", "'"J�. a ikf+lt •r ., j�}�` i� • r` rt°' 7t ` j�`."ir.a'v ,�l�'C, ,t� 1 fy.... vfr.,_a'{'r " ;� -t,�� c "�E ��f..`''� '�° $��b i'�' ' �������;.- ���'`,. �r ,�: 1i3.�•r i � 4��'iSt�u�r,p,�JZ�� ���� �•� . < g r4< asi�� xf " < N jai ti •%�, TV x'� r�. ya ,��' ,"+' x .� aIW 1 M Yjv� �+�«+1 �. k��� � � '��` `s�� .` kA �S •,i F ���� � �M t,'�r� �r ���.. �it Nn t ' s 13.;... r( •1 'tV O OF 46";- � f r•. W, c� w f S, ,ar Y.. iii `` `."•Y�13 3c. "€ "J;i'-r -,-� 'fit` j+_ ....r� `w is Ap �"- +~ '�►--+.�. } =k, >" 'r fCr«'n'<.nr'� � '��.qR ..�� ;�'� �_- °ta•.'. 'S * 'M�. � ✓S ate 4 IAF td : , , :.fes }fP '"-A ,h yr '.•.a ° S, T ,! `�•.-}����'•'�y���i �'ti�y.,w,.. �'`,�f-..'"``��',���' i; xy" `�.'c'�". ' ��1 '1 "i!" .� � `"�",•+-.fir' _L - � ,• t�,'x ` i K'�ra���r$•f,'.r%'r�`.+*I��'o-f�,�"�k. "F j �� �' 'a....+► '4, w= 'Y .�. �d r1� ra. jp. ...�eA�; �'•+Yr ,►�!'t` , •t.�,,Vr� w "�!'" t f t �' r,. "` _ "L#... �+Y+�< ty ilr•'�'•'j, T� / T 1"lw y ,. � _. +. < �� t , a� { Ott �d + � � •.' 3 was.��""�y ra '+� •. .� « �•� � •�~ ;y"t 1 '�I�.r=� -„'�� � r� �^ry� '.'q�. � ��. . "` � ,.,y f h`..�+W/, . leiM'. • �� ���"�T ���`'k• +� w��„ ' L ,t N..T. �<.4' fi� .wT O,��`fr � ��r • „ _^-+ +,e, � � •:`ice,"^,,,yA �X` ,�:,�,k-"^�'� °��"F# ,,,�_ -Yffi •: '�wN .1011* n .� - �r x� r!v € �3�i1��1• ,I� � � ^�a�`+ g �° �� 'i!F'c"�r j �.� `��� r M• d r �q �'W��.4}�dt+.,�.h �,�„�`'�*OiVj{ ��•j f, } �L �� j'A � ..,1+ ^S«, t b � s• t e M' a u 4if?,41�r`}�♦,w��fwM�M,7Rw,n.�1�f 8 ,1 a,w ��.r, � � �i � ` a R ��, `f w a 7' :a �� � ,g„ � .,J'"` �.r�}� �♦i 1lr v» t~ '��' gyp* ' r�e-�� ""'�"'" 'x' � i "� �t � � � �� '• * � r "4�^ 1, V +. �,,;,��t,a^ � '" `� �" '^�. � 'may ft � �w Rr2 .�•�+'° ``i1rµ.� �I �: �' � y '�• ���*�r� r ":.v s 11 �^ ,e - '"�"i`= „� -••'mow, �` • E' �,'k " - � ,'�w ` ��,. i ' .;� � � a f , „ a• + 9 k t" Y: k ' ,,• mow+V a*. a � .:Dv �9 � �°�+f"4.+ '� l+� *+. L L F 4 y ^ fi M . R Y o , � -+a t�lS+=w y.r� ,�w ro,. = v..'a< f�'v t♦ _ 6 ""�, a1�. ,� i -� .: J��{r ��j 5l� � � .�,, i����w „°Z f /::. � Ai'1T-r1 iFi 3'w•�' ��. YY i ♦ i r4 ,s �j 'ate 1 1rt Ine . _ ` 'F • � x.ftt{�v¢ �� yet Y! �`j � .*i � �S''J�' _.,_ ���9 'E � ,3R as.,,;s •' � x �..�-�i.r c'C1�.� ..r�`ix;'i� r H�'Rr ,�n`,s�. �yj.�.��-h �,S�� �'"? "«. 0. �.� �� ,�,,,� ice' ('� t�+.1. �(t��,�,. 8'i�': i t Y.►,� 'x^ � `�+��'� „ Ow _�la - '� • F .♦ 11 T_.'�,' I�Y�ra«i �' •.� 4 ,�,..rani° f.4_ iy�. s x - (�'"1'� �"f+_ t l I.lr��. �"�� Ai`� � _ 'y s y �� xke� �� .. .wr^�.•� � s) �r.' 7r�Y l`�F.{ t . . .+ � �- •` gyp. '..' ''r � '. K ,w-^�. ,,mac• { _ M..,, � f , - a • M , ' tai r fj •� . , �t , M e - s" s 9353 Date. �-- NORTH TOWN OF NORTH ANDOVER , PERMIT FOR PLUMBING ,SSACMUSE� i This certifies that j' . . Le . .� c-v��... has permission to perform .�.fPA . . . �. e-?-�. . .. . . . . . . .` plumbing in the buildings of . . .� YG.�-: . :ti0. . . . . . . . . . . . at . . 5. rth Ando aet, Mass. �(�Fee , . .Lac. No.. . . . . . . . . . . . . . . . . . . . . �.,. . . . . 11 PLUMB N� INSPECTOR Check # �t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYl 4r4i AA&Q-e1 MA DATE [PERMIT9 I JOBSITEADDRESS I3i-j- 41�5t,�'(Av�� IOWNER'SNAME K`,, C'ot'rV\P1a3 OWNER ADDRESS+ �--A'��. TEL,. EL JFAX i TYPE OR OCCUPANCY TYPE COMMERCIAL t EDUCATIONAL �, RESIDENTIAL�. . PRINT CLEARLY NEW.( RENOVATIONA I REPLACEMENT:I PLANS SUBMITTED: YES NO] FIXTURES-1 FLOOR-- BSM 1 2 3 4 5 6 7 a 9 10 11 12 13 14 BATHTUB _ _ .. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ! DEDICATED GASl01USAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM - DISHWASHER I i DRINKING FOUNTAIN FOOD DISPOSER i` - FLOOR/AREA DRAIN l. .. I INTERCEPTOR INTERIOR KITCHEN SINK . .- LAVATORY _ ROOF DRAIN - — SHOWER STALL - SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES. WATER PIPING - .OTHER E - ( E i 7 INSURANCE COVERAGE: oe I have a ctirrent liability iiistiraiice policy.br its substantial equivalent which meets the requirements of MGL Ch.142. YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE000,�PE OF COUERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY f BOND OWNER'S INSURANCE:WAIVER:I ani aware thiat the licensee.does not have the'insurance coverage requited by Chapter-142 of the Massachusetts General Laws,and that my signature on this permit application vialves this requiretitent. - - _ CHECK ONE ONLY:- OWNER AGENT. ( . I SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and Information I have submitted of entered regarding,lhts application ate true and accurate to the best of my knovAedg'e and that all plumbing work and installations performed under the permit issued for this appiicalion will be in conipli nce veithall Pe inent ptovision of the Massachusetts State Plumbing Code and Chapter 142 of llie General Laws. PLUMBER'S NAMEfjS 1`e J LICENSE ff ISy al. ATURE MPI✓ JPI CORPORATION( .1#! ;PARTNERSHIP; 1f{' LLC rff ^� I COMPANY NAMEI�ArA �. .,lptlj( ►& J I ADDRESS CITY ItA n<-\vj<l i STATE I MA-1 ZIP O I e6 l o TEL( cl $ "� - oZ� 17 FAX I CELL I EMAIL . jes5e, 'e—E� -4,p.,,4 6, .LO M i LOUGH PILUIVIB TG WSPLCTIGN NQS' Fs, BELOW FOR©r. + CL us] :ONLY � g'INNAL4INS].rC ONOTFS y. Yes No THIS APPLICATIORI SERVES AS THE PERMIT FEE:I PERMIT 9 PLAN UDV EW.NOTES s i I, F F 1'1► Cpttitio.'1;�(±ecitllr oflVirsrrcti�cs�[ts 1?i�i(rx'�itteit�o�f7tttlirsi'e�talEicedeitfs .. �- llt,,�fe�•oj`rrs'�sfi�n(iatts AN �40.jYrslrtrlgfoir=�SYt�etr Bpstfott;MA02.111 s �'�ttllTtcrs''�ont11eti5:itRnu��tt$jtrrntli:��S;t`ficl�lt'et Bilifiters(G"oufiYt�tos�Ie�[►lcitt�tst�'lutet�el=� { �d111��t3Cl$'utcsi�4rgltiititien7ttifit;idualj: . ._. _. .. .... . . � �tlirf@SSb - Arc r?ell I ��tp'o-bf lnojeclriic�,ideii); l:f]lakilailliplo)•cr Willi _, rt.(�lAlllngCl(Ct'AICUil1CQGI0raltt�� ' ' �. �HC1FC6ilSltt(Gt[Oli isuipto ccsi`fidf(auljorliatt tiiiic):= Ct;it'eltirccf(1(esut►coritrnclors 2<�Xamasolaproprictorot•lin(-{ncr- listecltiiitTieattRclie(isjrge(:1 jlteinotteling f Sjtip Alta Iwo 110 cmplogces VicSC bib-ibOrMors NVO 11 tiiorkrug forillora inycap((ctt}t Wot'kera'com}�.iusinmtce. 1 '� > (]'pul(dingndditioA: [Aatto►kcn�cotitp:insurance �:❑Nvo-ge A coiporatloll and Its, i s1�(lidR(tj otticersLati�cc,�ercfsectli>.cir 10.Q�rjeclrjcaltepair,.orAddi[io(is. � ,I 3.❑I:.ttniitltonieomiculd%1111ixotk 'pill ioltperIv(GL t1;Q1'TuntULtgn�Tair$orA(&litiotT� { f tny�eif-(No work-enecomp. C.I.52i11(•i),�ttcluchaverio t2.[jRoofrepairs ; ! i►isurailccrcgotrecl jfi eliij�loyccs.[i`Iatior�cis' cotnp.lnsiuriucatti(uirecLj O,Q'otur =iSus•}t clittiisrt}1(tuleTixtsbox cl rt++t(ctio fillot+tlT,�sccli�;+i,letti sTw►tutgttreirUrrT,.ri NFiy cF�aiionpolity'fufotluattati ran;au(t;r;lrhasaUmitthfse0ictuitlndir,.liu�(ccyrtctfe?n�rdh�aiF:utdlh:rrhtrcontst6tFcutraai!>mot(supati(niittetstl�uiiid3n�:in�nr�tr_ � ttl:via6iti(iu( tr:.�iTi-�lti+�rtt+;[r�:(aaxdnnra3itioailstarlshatrin�lt-.tun(e�ifl'atstiG•r��itlrt.[�+ri.�rdth;itiii�itcr a,+i:iS.p.FlicrftCairuUiatr�•��� ldnlalteiri�,lvire=rttcntlrliiv(ctrlitrb�rrvnc��s'cvrijrc�rrslrlivirLtsrlrlirlcejar�grerr lvtrr�s Beloit,tsllrepully,allrffobWe, /l�aPluafl0(r. iiris(rraucc.Contl?t+nytl\iTiilt:�.... policy+fForSE[fiits l:ic•il:. �jitiittiiiltate:•. i h.t(nelta co r tol'(It(stro itees'coni tensd1oft i0kgy ttcdartiffeli pap st4Qtttit 6. ricatiailiTittc: i riiiillratest uurattit'e�tigeas reiltuted uuderSecttoii 25R 6f Mdf�.1S2 crfu toad to ilia Itilroskiai Qfcri►iriaatlicuafitesQCa >filo up Co:Si,500.00 andfoi'oiiq}year finpnsoiuuent,.as%icu as aril pedaltics.Lt i11e form oEa STOPAVORK ORI))~~ttBotta fitly tifuli fo5250.00 a da. (tgctlnsi tEio viofator. 13c adviscit(hit ii copy orpus.statem cut imly be fonvar<Ietl to lite—Office—of _ _ _ __— turesligtitionso�tfieAll6forittsumticecoreragelet�iGcatinn: - - - Xtlo�ierc�b�?cerlf�rrrrrle�r•Ihepunrsr�nrf�,a*utrfrlesa: rerrrr(�1art![tlr.=(1(OJ1/1711(oll.'Jrb.Yfilc(lQliolzlsfinF tllffd�ccl, - l?Fioue Qfjr'elirtt�s�=.a(rir:pa flat rt4'!`!.,Ntills-areir,fo N,C4/11111t'It'lFL4'cl nor lelilto,JjlcTal CIO.ol-`i'o tilrv_ .f. 1'(tirittrLSecliserC I Is�tiitig.�liit[(ori�i!(u(zreoi(c}; F iI.ISGat'l1'OIWeARlt2.iT[tltdll(gDelt;ttiinerrt3.GiijllottiiClcilt �.LfsctrlcalTuslrc001'&I'lntuitLigtnsjie�CID 6.Other Jl:llllfolt lLitlltJm.0a and hStr r`diobw fi�fassnchuTe[ts".Generna,Ltt�tis elfapfer X52 rec�(iices alleolplbgersloyiYai•de:�ttbr'�cers'coin�i�tis�.tio'tt foFthelron�pTn�ees:. I'tzsttan[to.-tnlimlatufkkat eri roy�¢.i§(tefiitedas.`..,ei.!eiypersoiiIitDieseruceofanothcrtitiftintycomragto£(iire,, eKui��s ariltiplied,.prnlpf•�tinitten:'.r - A?t JI)PItoyesis!derine$as"44 ilO10111al,pa,i-ftersliipy,as oeiation;cpXpDmtio»QL other le h elitiCyrolrany tAvdjor iiioYe rit;t}tefoLzgoingengagettn>anointe�deprise,aili illLitdiog-the:fegaliiprescntatitros..O a'leceasecFeiupfb}�ei or e •iecei'��erort'iztsfee>ofatfutdiVidtiai,itai'tnEFsLI�L,assoC'tti0tt:ofotllerlegal`enllty;etq��oy,•in;;en�pinyiees Hot�ce1ertnC ounes afadtvelliitglioiiseltaving uoftttbie iliac tiitee;aparttneztts:aud'i olio resictestliereiu;:ortlte oecupa►tf office diffollipghotzseofaiiotlterwlloeinploysltetsoustocloaitaiittenatice,eo»s[nzctfbttorrzpair�York oil Such,citt811ffi-11 iise roc:till;grotiutisobniklfizgoppuriena»ttlteretaslialltnotbecis»seofsuch.entploymentbed e.»tetlfoplo�•er:'= lt.GL cTtaptcr I52;: 23G{6).also'slntes that'`-`aresyR'st:ife o�ioeal ileen3Juo ngattcs*.sltalC iyJtltTioli the�ssuanee or lzetlolfllieca)5Z bt IiErtniffaapeilleaJ�tisnesso2 fo:eonsftiicfbtiildiusinfhcco!»triUittieaffhiointty :ttpp]icanE titi��•J•�as l�ot�itgtlueecl nccepfnblac�I'�l'elLce of'ce»ipliance ivifftfllein`stii•tincecotieritge requicecl'� Add iIioitally,MOLcl181)tor15%§25C(7)states"�leitlter Jnecouintouwealtlznoran'ofits palilicat.subtlfyision sltal! optor into anycontractItor(lzeperformaflce of public ivorl;mitil acceplabTeevidettce ofcotnpliancetvitli fliFinsurance tellii,hmnents of this cltapterizavalzeenpreseatterfto thoco)itractfngauthoiity", ' .�]iplzcltitls • i Please fillouttjt@iptlers'culla aiisationa idxiitCtinipictaly-D)E.tT>.ecldttgfile IlosesihatApply i'4.yo-ticsityatiouttild,if iftO sArj;supply Alb-contracfor(s)matue(s),addkess(es)'andpltone nnthbpt;(s)aiotlg Miifh flteu ceriiGcale(s)p'i' in'stiranc<-.Lf»tlfedLisbilifyt Colnpaflies(LtQ or—MinifedLiabi Gtj€2'RtiiiEiships(LLP)with no en►pfoye?Sotlter'fliatiilm iienthers of parhters;:cre not reoulredto earry+?,vorkers`'c�ntpensation insuranee. Ifan Uc or LLP does have e4tploy'eas,A.policy isrequire d..Bond►isedtltatthisA—Clavitutay6esiiUntittedtofhellepi�ttttientof Industrial Accidents forconfirntafionofinsntttnce.coverage. Alsabesitcefosignaltdclntetltt:►[ticlavlt: ThEtiftidavieshotild be returzted fo the city or town that tltc application for the pettttit or license is being requested,tzot lite Department of Fndt�iria!Accidents. Sitotild yoit ltaez aaty gaestlgns fezarding-lte late ftiry6it ure required to.•ob[aitr a utorkcrs' EOgipz0-Ition policy;please cal!ttte`p;jlaltineac:it the number:fisted belotg.'Self insuieit.cortlpalt'ies_siton)ci enter titch pelf wsurance license numberoF4tlie appropriate line Cita;of Toltiil diticial.s �.'Jeasebvsizretliltt#heaftiilavitiscotitpletealulliriutetl..legibly, filiebepazlttieitfltasptOYlQecla.sliacpattb�hDttolit PoCAN,affidavit fot}roirt6f11ozftinthe-eveatthe Off icOofhtrestigationslzsstocotttncLyoureg1i t iheapplicant, leasebe Surd to fill in the pennifllice»senunzber ivliich tvi I l.be.ttsed as a:referenceaittnzbet:.In adtiition,an npp)ic�tut fiiafmuststtbinitniitlfiplepEznzitTiicense:tpplicatiotrinany*giS�eizyear,treed'allysubnzitone�ffidavitindicatingctnrent � � POTICY Information(ifnece-ssaty)and tuidetUobSieeAdclress"the,applicant'shotzldwrile,1%Hocalionshl . . (cifyor f #bivk}"A cgpy o£tlze attidati�i€thafTias beezt officially stamped or mat-ked by the city o:fowzt uiay be-provided to the aliplicantasproafthaFattatftizfiti(iairitiso!ifitaforAiture-permits or licenses. tieiti'siftidavit lnustbefziledouteach It ye<�r.�l+lzereaJtonzeo►s°zterorcitizett is obfaii�zn,ajicetzseofpermitnotrelated foanj busiitessorcohiniercialraittufe F Oe.a dog.lfceuse or.'pefntitto burn leaves etc)said persolt isNOTrzquiracl to coniplefafitis affidavit. '!'he div-Oflntie t ptions would in, se.do not ltesitafo to gailtra»oe tot yotic Ceo�cz'atio i ltizct s?iot;ld�rotiiz7ir�iii}�o�tiestiozzs, p1€ iva tc5 it cglr 3 T»e bgparf�,iEut'sadctress,teieplzone amc'l faz ntinlTizr - f— UP,Conit�tttt�4c�s►Tdt>;�Z�\�tts$z�.litrsetta - = J3e1iaffiaetzt of,��>ictusttittl �iccidettts u O1'tice o£IitE'et%gloh 600•ZVasititigtbli Sheet os€oil,Am U211:X TO.. . 617-727-000 W 406 of 1-877 IMAs_ SAIrs 1zet�Jsei1�2G-flS F40 617-14-7749' ) �t����.t�tass,gol+lcl�a Date.7/7/ s ........... NOR7/1 TOWN OF NORTH ANDOVER 03� * * PERMIT FOR WIRING 4 S3�CHUSfc This certifies that.;. !. 2 C'..1.G.^............................................... ................................. has permission to perform ..}.A.q.P ....0 wiring in the building of...... ::G. t1��...................................................................... at ........-- :.� ...........P- ti C �? ',�,.,!.)....,North Andover,Mass. ......... ............ Feet 7 Lic.Nd�S,..�.�.C' . � ....... t ELECTRICA L SPECTOR � Check# 2 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 'V Occupancy and Fee Checked •- t BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave 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 INFORMATION) Date: September 23,2015 City or Town of North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 31.7 Raleigh Tavern Lane Owner or Tenant Kim Campion Telephone No. Owner's Address 317 Raleigh Tavern Lane North Andover Is this permit in conjunction with a building permit? Yesi�o x (Check Appropriate Box) Purpose of Building Residential Utility Authorization No. 19949823 Existing Service 200 Amps 120/240 Volts Overhead Undgrd X No.of Meters 1 New Service 200 Amps 120/240 Volts Overhead Undgrd X No.of Meters 1. Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install new ungeround electric service to avoid new septic leaching field. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.ot Emergency Lighting d. gmd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 1 and No.of Switches No.of Gas Burners No. In Detection Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.o Self-Contained Totals: ....................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection Heating Appliances KW Security Systems:* No.of Dryers g f vi r Equivalent No.o Devices o No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 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: 9/24/15 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the,owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certi, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME IDavid W Meehan n LIC.NO.: 81296A Licensee: David W Meehan Signatur dA. LIC.NO.: 8126A (If applicable, enter "exempt"in the license number line.) 7 -BtrS'Tel.No.: 978-587-7518 Address: 4 Mulberry Drive Peabody,MA.01960 ✓-Alt.Tel.No.: 978-535-4022 *Security_..System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally re- quired by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 3 I p . -1.N The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i 600 Washington Street • ti,�= , Boston, MA 02111 www.marss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ _ „ Please Print Legibly Name (Business/Organization/Individual): David W Meehan Address: 4 Mulberry Drive City/State/Zip: Peabody, MA. 01960 phone#: 978-535-4022 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ 1 am a general contractor and I b. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.® I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and have no employees These suit-contractors have 8. ❑Demolition workingfor me in an aci workers' comp. insurance. Y capacity. 9. []Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.®Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]f employees. [No workers' comp. insurance required.] l3.❑Other *Any applicant that checks boz#I 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. !Contractors that check this box mast 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 insurance for my employees. Below is the policy and job site information. 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 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 F 'y under the pains and penalties of perjury that the information provided above is true and correct Signature: /_ `°✓ Date; 9`o?3 ' Phone#: §Tif— 69;1— 2 J! Official use only. Do not write in this area,to be completed by city or town official City or Town: PermidLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector b.Other Contact Person: Phone#: v—' a g:OOMMONWE" OF M t<;C E;C #2 I C�I ANS;,;. ISSUES THE :.FOLLOWING LICENSE AS ! ` AI.C1S ERE1) MAST t:: ELECTR ICIAW.. DAU t Q W ME EHAN 4 MULBE'RR`Y'DR I VEa> <: .0 01960-4648 812Fr:< ::>:<;:: ... 50840 0ORrH 1 oF�t ;6'gyo � 1 b y ` O O coc"Ic"twKw 1\ pA0 *�V ��SSACHU`����y Town of North Andover BUILDING DEPARTMENT CONTRACTOR AFTER HOURS REQUEST FORM CONTRACTORS NAME: I (E)C(1G(UaltI A An CITY/TOWN: &ncl STATE: ZIP: a� BUS.PHONE: 117 `�l '� ��� �� CELL: MA.LIC #: ASTERS: JOURNEYMANS: PERMIT# �2�7 C'j` ti N-GRID SR# REQUESTED DATE: � � { ,�JU TIME: JOB LOCATION: I � ' L��i' / bvj OWNER: dr 4z PHONE: WORKERS CELL: REASON FOR REQUESTED INSPECTION AND JOB DETAILS: CONTRACTOR SIGNATU << NORTH ANDOVER SUPERVISOR SIGNATURE: Contractors requesting INSPECTIONAL SERVICES due to weekend or after hour operations such as service related planned updates or special situations,will be required to provide a four hour minimum charge of$150.00 paid to the.Town of North Andover at that time. Community Development Division, 1600 Osgood Street,North Andover,Massachusetts 01845 i Phone 978.6,88..9545 Fox 978.688.9542 Web www.townofnorthandover.com f 1 Datel......-. !u..-...�`� .... 1 CF NOpT 03?.._ ao TOWN OF NORTH ANDOVER n . PERMIT FOR WIRING *moo - •;:� ss,CHU This certifies that .................... U..?7.L .........` 4&aC....,,,�1`! has permission to perform ....... fl AST.Litre/..fir- ................................... wiring in the building of........!..`.............:...t .!q P '0� .................................................................... at .....3.1...7......kk North Andover,Mass. Fee... — ",.......Lic.No.?J2?I/ ............................................... ... ELECTRICAL INSPE TO�2 Check# ' �3 r Jr � r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. d Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK L OR All work to be performed in accordance with the Massachusetts Electrical Code C),P27 CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL MFOR L4TIOA9 Date: x.()1 City or Town oh NORTH ANDOVER To the Insp ctoY of Wires': By this application the undersigned gives notice of his or her intention two erform the electri al work described below. Location(Street&Number) Owner or Tenant k ( aL Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building j 6L-; F /q Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity a Location and Nature of Proposed Electrical Work: M A(Al6 POA DAM IM 00A ROOK K Rk CW/1411616Y Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: -"................ '""""'..." ' Detection/Alerting Devices • No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No..of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: �/ No.of Devices or Equivalent OTHER: �� 6i"' /vt (op` C�MAN Attach additional detail if desired,or as required b the Inspector of Wires. Estimated ValVe of Ele lcal Work: 15 60 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) Xcertify,under thepains and enaltiLes,of�nern�ury,that theme-i�n. orntation on this application is true and complet .� FIRM NAME: _ A I�' �L�(�A I 4 U LIC.NO.: Licensee: Signature LIC.NO.: (If applicab ent r " xem t"-i the license nu e 1e.) Bus.Tel.No.• Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security wor 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)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance.with the provisions of M.G.L.c. 143,§3L,the t permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extendingthrough August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new,permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M b�_ Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com t ' The Commonwealth ofMassachusetts Massachusetts - Department of lnclus€rial AccMiks Office oflnvesfigations 600 Washington.,S'h'eet .Boston,MA 02121 www.mass.g'ov1dia Workers'Compensation Insurance Affidavit:13uffders/Contractors/Electricians/Pliimberq Apulieant information Please Print Le ibly Name(Businessiorgani'zation&dividual): R/ Address: City/State-[Zip: V Phone V: Are you an.employer?Check the appropriate box: 'type of project(required): 1.0 I am a employer with 4. ❑I am a general contractor and I ` 6. ❑New construction employees(full and/or part-time).* have hiredthe sub-contractors 2.ElI am a sola proprietor or partner listed on the attached sheet. 7• r]Remodeling ship and'have no.employees These sub-contractors have 8. ❑Demolition working forma in any capacity. workers'comp.insurance. 9, Building addition [No workers'comp.insurance $• ❑ We are a corporation and its required.] officers have exercised.their 10 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurancere edemployees.[No workers' �' .a" 13.❑Other comp.insurance required.] xAny a ntthat checks box#t mustalso fill outthe section below showingtheir workers'compensationpolicy information. 'Homeowners who submit this affidavit indicatingthey tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. .I am an employer that h providing workers'compensation insurance for my employees Below is thepoliey and`job site information.InsuranceCompanyName:_ NOM2-K 6 63M� 6AO4 I I(I , Po`h'cy/#or Self ins.Lic.ff:. 1�J 1 J I t I Expiration Date: Job Site Address: 311 7&/W LM5 .City%State/dip• 6i� &Mk5l . 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 o.152 can lead to the imposition of criminal penalties of a flue 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 againstthe violator. Be advised that a copy of this statementmay be forwardedto the Office of Investigations of the DIA.for insurance coverage verification. X do liereby c t olid r Zie Ii ' andpenalties ofperjury tliat the information provided ab ve is tr a anticorrect. - Si afore• Date: r / Phone 4: -0`0 6� Official use ortly. .Do not write in Mis area,to be completed by city or town official. City'or Town: PermiffLicense 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Towns Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuarit to this statute,an eraployee is defied as"...every person is the service of another under any coairact 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 ormore of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trtistee 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,ort 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 bean employes." 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 requi red" 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with uo employees other than the members or partners,are not required to cavy workers'compensation.insurance. If an LLC or LLP does have employees,apolicyis required. Be advised that this affidavit may be submitted to the Department of Iudustrial 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 Towns Officials Please be sure that the affidavit is complete andpriated 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 whichwill be used as a reference number, In addition,an applicant r thatrnust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Job Site Address"the applicant should wxite"all locations in (city or town)."A copy of the affidavit that has b eon officially stamp ed 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 orpermit to burn leaves eta.)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: Tho Go oxawealt�ofW_Q sarhvsPtts - Np.afteut d1ndusWal Accidents Office oT�n� etiagns 6,O0 WashfiWon Sfre�_t Boston, 02111 Tei,#617727,4900 QA406 QT 1-•877•:MA.39 Revised 5-26-05 `ay,0 617"727'77¢9 w�w.�tass,govfctia . I • • 06 • . r aRD. � Is�cT '1:" ANs - E& HE4OLLOWi'NG L1ENSEt ASA �,rF R1= 1STI:1�E© MASTER ELECTRIGIA�fi KUHLMAN ElECTRI CAL SE61i ".-tS INC JSSI: G` KUHLMANI , r t 2 K ITTREVG-E k� ��ABOdY MA 0]96fl 66.2fl E �v r . r COMMONWEAL�H OF MASA►OMUSETTS a o • r ' N :> E'LEtT.- C I A LICENSE ISSUES,:.:THE FOLLOWING" ECsTR;I'C I A fF AS A RI"G" JOURNEYMAN ELi �,. .,, i GAIY�W KUHLMAN J ;Z 3 A.✓�/ W 5 � ' 24 PINE ROAD iw 3 pl Aoo�r M 01960 455460 0 6 '22 0 - . - I i 1 it IwI 17(11 N111t k"I: 1� OF I11 t SETTS= ® e o 0 0 ' fL,1:ETRICIANS= SSUES THE FOLLOWING L DENSE AS A. �x ` R1: IT1:RE1) MASTER A ELECTR I Gl AN"'`: I �CUHLMAN EL€CTR!CAL SERVI CES IE SE G KU.HL K I TtTR� IGE ST, ; 12. AeODY MA 01960 662t> i 21804 A 07°/31/1.6 1936:18 i ,fir COMMONWEALTH OF MASSA►�HI�SETT'S :. BQARp fl EL.ECTR'I C I ANS;: ISSUES .TNE FOLLOWING LI ""EN w. qs {� R`f JOURNEYMAN ,f LECsTR:1'C �� r k FMA AW GAFI-Y ;yl KUHLMAN , N W 24 PINEWOOD ROAD 01 60-4554': ... MA- Y 9 `D RO " >Ap P 60 0 -12 0 t N2 4227 TOWN OF NORTH ANDOVER k' p PERMIT FOR PLUMBING i o ��• Is CHUS This certifies that . . . . . . . . . . . . • • has permission to perform plumbing in_t-h`e buildings of . . . . . . . . . . . . . .-.! .. . . . . . . . . . . . . at ��. ., .. .. . .aI4 -' . . , North Andover, Mass. Fee . . . . . .Lic. No.. �. . . . �. ..;.,.� //// iE._. . . . . . PLUMBING ,vS/ R �701v WHITE: Applicant CANARY: Building Dept. PINK:Treasurer (Type or print) MASSACHUSETTS UNIFORM APPLICATION FOR PE T TO ]DO PLUMBING , NORTH ANDOVER,MASSACHUSETTS / o Dated d Building Locatio d ners N Permit# 1 7 Amount Type of Occupancy Ccs New ® Renovation ❑ Replacement (� Plans Submitted Yes ❑ No FIXTURES w cn xU a Ln 9 W H w E, U a a z g a Cn w a Q w a a a w F w A a d A x A x Ew U o H w x o &��1VII�1T M HJ0M M FLCXR X31 FLCICIR 4IH FLOCK 5IH HJOM 6IFI FI M 7M FLOCK SII3 FL[XI2 (Print or type) Check one: Certificate Installing Company Name ❑ Corp. r Address ❑ Partner. Business Telep ne ff Firm/Co. Name of Licensed Plumber: LULL, d=�P54 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy � Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and' s lations perfo ed underfermit Issued for this application will be in compliance with all pertinent provisions of the Mas s State lu , g C and Chapter neral Laws. By: i 01 LICenSeClum Type of Plumbing License Title C � City/Townicense NumiDer Master Journeyman ❑ APPROVED(OFFICE USE ONLY