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Miscellaneous - 32 ASHLAND STREET 4/30/2018 (2)
/ 32 ASHLAND STREET 13 210/017_0.006"0000.0 4 f I E l E E i I II I Date ... 2 .. .. .. .I` WOFTM e F ,ti Up TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION . 9 �9SSACMUSE�t This certifies that . .k ` .f has permission for gas in/allation :5v f—., in the buildings at . . . .-,.N orth over, Mass. / GASI SP CTOR Check# `, 8309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY __ �V ►_ _.._Ta4n ave MA DATEPERMIT# JOBSITE ADDRESS $ ? `37 OWNERS NAME Tq-Sc V, _ V GOWNER ADDRESSTE1 TYPE OR OCCUPANCY TYPE _ COMMERCIALE]I EDUCATIONAL I RESIDENTIAL PRINT CLEARLY NEW: NOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El NOF APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNERT- COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE -=l1 f- -,.( _.T GENERATOR I-.. GRILLE INFRARED HEATER -- LABORATORY COCKS MAKEUP AIR UNIT .. r_(I- .-r-,f I__ ..--f L-.-f�-u L�x���I_.- OVEN L_. _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT . TEST UNIT HEATERJ I---:. f _ UNVENTED ROOM HEATER I WATER HEATER - _ _- OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES { -NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E-11 OTHER TYPE INDEMNITY 0 BOND I _I 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 [_ 1 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 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 wit all Pertinent provision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ - --I LICENSE#3 '- SIGNATLhfE MP MGF JP [ JGF 0 LPGI CORPORATION D# PARTNERSHIP S#F- LLC D# COMPANY NAME: _ ADDRESS ._. . . CITY �- STATE ZIP[—r-30�e7 TEL FAX E::—::-��CELL EMAIL -- - ----- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes *'Zo , Q THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES A 1. 1 The Commonwealth of Massachusetts Department of lndustrlqlAccidents Office of Investigations Uf 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,f Please Print Legib Name(Business/OrganizatiorXndividual): t i�uL 4' Address:_ o11_� (511-ee"? �l City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction 9ployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.El 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 insurance required.]t employees.[No workers' comp.insurance required.] 131J Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they Aire 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. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. �� 01 e-y S 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 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 certify under thepains andpenalties operjugf that the information provided above is true anti correct. Si afore: - ( Date: d"? 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: f 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 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-contractors)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 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 burn 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 ofMassachusetts Department of Industrial Accidents Office ofIavestigations 600 Washington Street Boston,M.02111 Tel,#617-7274900 ext 406 or 1-877 MASSAFE Revised 5-26-05 Fax#617-727;7749 wwwanass.gov/dia / `�► MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE - I _ IMj PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL®-- PRINT CLEARLY NEW: Ell," RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES Eq NO2' FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( ._ _ 1 DEDICATED GAS/OILISANDSYSTEM 4 E 4 ._.__.I _._.__..JI 1 J -__._..._I DEDICATED GREASE SYSTEMI----------4 .____l L_.__._J ._._-( DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER -_! ..--1--_.1 ..--.-_- DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) t _!.,-€ --___.._J KITCHEN SINK € _..__.._.( -.__._...._4 J ___...._..f f € J C € ---__I J _ J LAVATORY _ F ROOF DRAIN SHOWER STALL ! -_.._._l J _[ .._.._._ ) ) .-__..J 4 _I ._ 11F-77 SERVICE I MOP SINK TOILET URINAL ( .......__._I f .._-.-._._.€ ___......_1 _._.._.J ( I � € a ...._....._l WASHING MACHINE CONNECTION I _ ! J J _i _ ...._ I I ( r r WATER HEATER ALL TYPES _€ 4 i i WATER PIPING f € _..- - ( ---J I ( - ( - - ._._... ' J==1 -J _ OTHER —J .__.1 ! _I _._ 4 ._._------ ..._-_.._.! �! .___-._._I _—.J _ ( --I _.) ------.J I ..- -4 -( - ( I - --4 . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ej NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYQ BOND 7] 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 CHECK ONE ONLY: OWNER D AGENT _I 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 provisi of t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � elZ 71— � PLUMBER'S NAME �C v., 1 LICENSE# O� �?' �" SIGNATURE MP Q JP CORPORATION Q# (PARTNERSHIP 0# _-^ f LLC COMPANY NAME ADDRESS CITY In , j STA E ; ZIP c�/��2 0 _—� TEL FAX CELL ��EMAIL kv ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Y No f `L z THIS APPLICATION SERVES AS THE PERMIT J - 0, FEE: $ PERMIT# PLAN REVIEW NOTES n The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyiblv Name (Business/Organization/Individual): f7C2,t S Address: ON rD�eip 1-1 0 2- �Oo City/State/Zip: Phone#: ® Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.['fam a sole proprietor or partner- listed on the attached sheet.t E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 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 12.0 Roof repairs insurance required.]f employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: m e—Y Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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. 1 do hereby certify under the pains and penaltie of erju that the information provided above is trace and correct. Signature: Date: -- ? / Phone#: j 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#: A � 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 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(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 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 burn 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 www.mass.gov/dia Date. . -./. 3��2-- 9562 ".�_�T:��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUSE� This certifies that . .. . . . . ... has permission to perform . . .T . !. . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the bu'ldings of . . . . . . G`//. . .. . . . . . . . . . . . . . . . . . . .. at . . . . . .cZ. . . . . .���. �C : . . . . . . , North Andover, Mass. Fee9? Lic. No..7O�?O. . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 4 Date . . .7./ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . � has permission to perform . . .R,F.we ?i'h•��.!�f 2 Fl-lz ' wiring in the building of . . . . .rorth Andover, Mass. Fee a�f�?. Lic. No. .36.30 . . . . . . . w 4 KR �ELECTRICAL INSPECT Check# 3 y 3 10940 p Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: , �/ ` ;�© t 2- City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigneSOLGOW gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) k+c)'k�/VA Owner or Tenant G-L SOcA kAz c V1 Telephone No. Owner's Address `.� r. e,_-y,4 �- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appro riate Box) Purpose of Building S `^�<<'– ��^� }� Utility Authorization No. 3 P ' Existing Service 100 Amps (to / o� i1 olts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ewe e e X%Sy.`V,0 \nb bn d ve 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 No.of Luminaires Swimmin Pool Above ❑ In- ❑ o.o mergency Lighting g rnd. rnd. Battery Units No.of Receptacle Outlets L( No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches d 5 No.of Gas Burners No. InDetection and Initiatin Devices No.of Ranges 1 No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers I Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other 1 P g Connection No.of Dryers Heating Appliances KW SecNo.o Systems:* 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 No.of Devices or EQ uivalent OTHER: p P Attach additional detail if desired,or as required by the Inspector of fares. Estimated Value of Electrical Work: 6 7 •0© (When required by municipal policy.) Work to Start: �o t!)-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 IN BOND ❑ OTHER ❑ (Specify:) I certify,under the pain andpenalties of perjitry,that tLe information on tis application is true and complete._— �7 FIRM NAME_- G o`�Gc c t– LIC.NO.: �- 3�3�Z5 Licensee: 'r,ek- GO vOa C Signature LIC.NO.: (Ifapplicable,enter "ex mpt'.in the li sle num a li e.) us.Tel.No.: 9 2 Address: ( CQ kce Y ""' �'d� � ccs'��y\ � - 9 kG eC Alt.Tel.No.: * s.57-61 securitywork requires Department of Public Safe "S"License: Lic.No. Per M.G.L c. 147 q P Safety 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. i 4 . F YMEM&AL!.EMT 90 ��sset�•-� ' �'aileB-�[' J �e-zuspeet�oxt�'equixet7($�'O.DQ)�� � 3nspectoxs'coputeoats: �t• (1Cnspecoxs5 zgna -�ofiaYs) Pate Aasse -- C+aiSea-j ) ate-3nseetox�xeo�uixe ( 0.00)-[ �t5�ectoJrS'comm�.ents: pls�e tors'Oz at47, 'als) Slate MAP, -MUOICIXON. 'assert—( iailet7--j ate-zuspeetzo��eruixe[ ( 0.00) [ as,Veetors'comments: (�nspectoxs' zgnatvxe-�oifiaTs) ,+late _• . VE CIAX±,E_n.'A A+OXMI�09-1113. NAM MI :• � !?Sell-[ K +aiI I Re-anspeedo,A required($50.00) !pectbxs9 eoynmefs: 7��' (.t"xtspectoxs',�zgttatuxe�5zaj�nitiaTs) date . e�•,[' � �+'aiSec��-[ )- 'Re�nsp ectzon rer�uized 050.0 D)-•[ � - ectoxs' �w—sp ectoxs' zgnature o xnztials} date ' A'lY1 rr'd A Ayw�'XRn.-n", YnYct'n'e-a.rrrmr.ae•rte[+arr.r,r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 >� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): V�-,'.� Address: City/State/Zip: l-d`� t!\ y �• Wg'Phone#: Q 7� oZ ( �3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction (employees full and/or part-time).* have hired the sub-contractors ( p ) 7. Remodeling �,. am a sole proprietor or partner- listed on the attached sheet. # ❑ g and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. F1 Building addition ` [No workers' comp.insurance 5. ❑ 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 I L❑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' 13.❑ 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. 13 Contractors 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: w Policy#or Self-ins.Lic.#: Expiration Date: Job bite 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 Df 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. 1 do herebyfffy nder the pains andpenalties of perjury that the information provided above is true and correct. Si nature: Date: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M q 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 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(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 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 i 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 burn 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 Fax#617-727-7749 Revised 5-26-05 www.mass,gov/dia Location • No. 6,i5 Date c9' A5 -0411 ti NORTH TOWN OF NORTH ANDOVER A, O f R 9 Certificate of Occupancy $ E<� Building/Frame Permit Fee $ S CMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 17090 11 Building Inspect&r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DAZE ISSUED: SIGNATURE: .� Building Commissioner for of Buildings Date v ;S' -O SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 'of7(�O(o L �610 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R redProvided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record �hsoN At,�ET ort 'u, &1I LAAJ i3 s� Name(1�p' Address for Service v-- otS l Signage Telephone 2.2 owner of Record: Mme Print Address for Service: z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicabl Licensed Construction Supervisor: O License Number 1� Address Expiration Date Signature Telephone - 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name M Registration Number r Address Expiration Date � Signature Telephone G^ 1 SECTION 4-WORKERS COMPENSATION(NLG.L, C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: LAA( I, j RWT bock P61 uP sFl -00< SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be UFF'ICIAL ) D,y Completed by permit applicant 1. Building. (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 �'V Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OW RS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Here y authorize to act on My behal in all matters #to work authorized by this building permit application. Si a f Owner Date b -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 I Signature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH Town of 6 Andover No WWI- C, over, Mass., 0 LA COCHIC HEWICK �ds RATED P"' Cl) U BOARD OF HEALTH Food/Kitchen PER IT T D Septic System BUILDING INSPECTOR .... ........... ........ THIS CERTIFIES THAT........... .. .... ow .......................... ....................................................... Foundation has permission to erect........................................ buildings onap........ao&L*4 . ...04............... Rough to be occupied as.... ..... .. ... Chimney provided that the person acc� ting this permitshaii"in,every' 'term's, application on'file in Final z'! person 1 this office, and to the provis! s of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES N 6 MONTHS UNLESS CONSTRUCTION ELECTRICAL INSPECTOR Rough ................................................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and-,Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE::] Smoke Det. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r �,u€aefr Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542.Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION 3P- A50LAU) 6 Number Street Address Map/lot HOMEOWNER (D17 6s G `33L Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code i II The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned homeowner' assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner'certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and Tuirements. HOMEOWNER'S SIGNATURE K �-� APPROVAL OF BUILDING OFFICIAL Location '2 AS N PK10 No. Date pf Ma oT;�tio TOWN OF NORTH ANDOVER S Certificate of Occupancy $ s • * Building/Frame Permit Fee $ Foundation Permit Fee $ s�cMus Other Permit Feeti� $ _ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ I5� Building Inspector 43107,`955 11s07 15.00 PAID - s 7944 Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. I LOT NO.' Q / 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE — ZONE SUB DIV. LOT NO. CO / , a_�LOCATION CI5LI1 ✓1/ '�n `L ',00 1 p�j PURPOSE OF BUILDING OWNER'S NAME) -�7J�hU�1��1_�2�o/�\,J, lj/Vw�/VV[,(I� - NO. OF STORIES SIIZE + ! OWNER'S ADDRESS {'^v� '" BASEMENT OR SLAB - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �]t'! O, �a ��;� SPAN -- DISTANCE TO NEAREST/ BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET ' POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL 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 INSTRUCTIONry ``y /� , c. 3 PROPERTY INFORMATION lf, I�sV�"r1�E WALL. LAND COST SEE BOTH SIDES QEDA^� SHEF-17�/ EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. �sT -Y- J/ �J UP Y W 1-ILL, EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS �PLANS MUST BE FILE ANP PROVED BY BUILDING INSPECTOR DAT FILED � � / ► 1"4�/ BUILDING INfP[GTOR S ATURE OF OWNER OR AUTHORIZED A NT F E E J!�N► CX3 OWNER TEL.a PERMIT GRANTED CONTR.TEL.N 19 CONTR.LIC.1/. H.I.C.a 4 *-794,+ BUILDING RECORD 1 OCCUPANCY 12 O SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. : CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D —_ —— PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN, B'M'T AREA _ 1/1 1/1 l/, FIN. ATTIC AREA _ NO B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORI� POOR ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBQEL MANSARD TOILET RM. (2 FIX.) _ GAME1.111]LFLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY tQ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING 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 _ ELECTRIC 1st 13rd I NO HEATING NORTH 0VM Of over. No. c>,i 6 A4q_k E!N SS.. 0 d over, Ma _Jqjg' COCHICHEWICK Cl 01'�ATED H BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT.jA�q .....7�.........k.o�;Yti............................................................................................ BUILDING INSPECTOR Foundation has permission to emet.A.L-TV.................. buildings on ..32.....MkA .A�.................................................. Rough 44 .............. .. Chimney to be occupied as U2�r ............................. provided that the person accepting this permit shall In every respect conform to the terms of the application on file In Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough qZ) Aft)^n-. PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONS S S ELECTRICAL INSPECTOR U Rough .......rA' ' 6�1)_G ...... Service �U- IL-Di I.N. CT Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT el Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT Smoke Det. Ti ,+* 4- Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) o TE JOB LOCATION 3� Number ,Street Address Section of town �� t EOWNER" �J �� Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license , provided that the owner acts as supervisor . (State Building Code , Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside , on which there is , or is intended to be, a one to six family dwell- ing , attached or detached structures accessory to such use and/or farm structures . A person who constructs more than one home in a twu-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the building permit . (Section 109 . 1 . 1 ) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements . 4e6h1EOWNER' S SIGNATURE APPROVAL OF BUILDING 1FFICj/A1E)._, Note : Three family dwellings 35 , 000 cubic feet , or larger , will be required to comply with State Building Code Section 127 .0, Construction Control .