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Miscellaneous - 33 ELM STREET 4/30/2018 (3)
I THEMOR OLM MEEDHAP&GROUPo September 10, 2014 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 36 Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1479641 Insured: CHRISTOPHER BOWE DIANE BOWE Address: 33 ELM STREET, NORTH ANDOVER, MA Policy No.: F0102850 Loss Date: 09/06/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, ��/ 40-�-O- Marie J. Landers Property Claim Examiner 1-800-688-1825 x1136 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 7 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. j Fax: (781) 329-1818 Check # • _ ' ' .Z ' Building Inspectors' l)cation NQ. Date t` % 4/ MOR7q TOWN OF NORTH ANDOVER f �,y � 9 41 Certificate Occupancy $ of +,,s°°''••°' JACMUS *' Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # • _ ' ' .Z ' Building Inspectors' ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING - BUILDING PERMIT NUMBER: 410 DATE ISSUED: 17-16,6w SIGNATURE: Building Commission dln for of Buildings Date SECTION i- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Fronta e fl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 3 / t A •s'% ame (P ' t) Address for Service /3ignature Telephone 54:AA L 2.2 of Record: z Owner I / Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor:,___ License Number AW -7 Addre ra ya Exp;y6tion ate Si ature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Id 3 � j Co in panyName Registration Number ,� �r �l �r1�1�). �e'�f,� /1/�JC _ Address G7�' _ S nature Telephone fn. v E. 'ration Date �f ou M z C IN �0 C z rn QC C OT0 r 9-- r r 5 SECTION 4 - WORKERS COMPENSATION (M -GL C 152 § V Workers Compensation Insurance affidavit must be completed and submitted in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction Existing Building ❑ 1 Repair(s) ❑ application. Failure to provide this Alterations(s) 0 1 Addition Accessory Bldg. 0 , I Demolition 0 1 Other ❑ Specify Brief Description of ProposedWork: -7 'c)AV lsuy ;ta X i�/ R s t� ^AS, Cke t r - 1 .. •_�Vlvni fl-T=l1aJ r rlcTQ t will result Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building >a 5 n (a) Building Permit Fee Multiplier 2 Electrical e o (b) Estimated Total Cost of Construction TJ 3 3 q'3.3&o, 3 PlumbingD00.00 Building Permit fee (a) X (b) Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) 1,9 i -a o 6 Check Number SECTION 7a OWNER AU'lHOKIZAHU1V tU ISL (UlYlYLLiLU wnri� OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I cilg" < (. j�; daJl j" i�e L.J i✓ , as Omer/Authorized Agent of subject property f lereby authorize tAo 1 b}= L+ X �.e� qP to act on My be ; in all matters relative to work authorized by this building permit application. ,--2g�oJ signature of A%&r Date rr.rmarmu -n, d,%%uw D/A=1VUnD17Vn A!_CNT MPVT ARATInN as Omer/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief r ^ Prin e Si, ture of Omer/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB ST M RD SIZE OF FLOOR T MBERS 1 2 3 SPAN DIMENSIONS OF SILLS DME-NSIONS OF POSTS DIMENSIONS OF GIRDERS IiEIG1I7' OF FOUNDATION THICKNESS SIZE OF FOO'EWG X MATERIAI.OF Cl IIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS 13UU DING CONNECTED TO NATURAL GAS LINE P Wx UU U a A� aA Od UW �w� �0 3 �U z� rp U V z `YD N w � a F �F � 2 IL W Q > U U o H Oa z od = W W 19 O Z v LL E..., Z` 1— a~ V W a, C P Wx UU U a A� aA Od UW �w� �0 3 �U z� rp U z �I N w � �xW F �F � 2 fr � \v o � d � U a O A da 2w� � �w� dp0 U Ua� WFR+ �xW m 0 z �J �, pG UW 71 0 ° . ° ° ° ° 0cA Cl) cn U6 O 0 �i O Z O H O E L O c O v _cc m COD O Q. COD O C cc CL CO) O is co CL. CO) C O CM C o -o m m 0 CD �o co C L L C. 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O a C 4 � C O G3 Z ts CDCLCO3 C 0 U) U) Cc w cc w CO ER* 'o Y .^ Z y Qu W Q �2 H (J u Q � w � O.L if 3 H q O z W am W a O T a) C c m rn a, Ln C: � o cu r u L ami to a rn u O n D E� a aia C O �n � E O al n An O aj a u v c L L- D al U1 L in o CL M � k U 0 — am o" a c-0 G'� Q c: 0 a �'� � '3N ` `� 3.2 o 1-5 �. ��. 0 0 N vs c u �: Q)CJL O 0 U -j `i in L OO V) mt CL � ` O 0 C O = QO c. °-6 'C o 0 �.�' �� t .0-�� O C z .O H O W a O T a) C c m rn a, Ln C: � o cu r u L ami to a rn u O n D E� a aia C O �n � E O al n An O aj a u v c L L- D al U1 L in v 0 b 6 z c •� : W O � C N VJ CC3 C.) •nom : O. c O to m c to � o �. E TU co CO o a E s Z v� j e m O Z 3 cM. QC E h ea co F --a C •�//'�►►' H 3 Y/• CT m C9� N 2:�coco w U -c o Kcj CR cm r- -r—, oQ W R� ti C) y O .. �.. 0 .- Z o Mai cm c c c3 44 a1 0 06 W C � =(D NQ �.. •N LZZ � C Z ,o oc E coy CD 0 ti c� ( l W oma N m 0O 5 O- _ ao 5 0 L fl I O 0 1411 co O 0 O C N coN .co L CL co O Co w CO) O V C. CO) C O O C. N r—� 0 CO .0 3� co L C. o a, as Q E �p� C J O .O O CO Z Z CLN c 0 LLJ Irw w crw U) u ri a chi o o w o r4 ECIS U w w o u: Cd x O W U W o G F U U o c w w Z o n c •� : W O � C N VJ CC3 C.) •nom : O. c O to m c to � o �. E TU co CO o a E s Z v� j e m O Z 3 cM. QC E h ea co F --a C •�//'�►►' H 3 Y/• CT m C9� N 2:�coco w U -c o Kcj CR cm r- -r—, oQ W R� ti C) y O .. �.. 0 .- Z o Mai cm c c c3 44 a1 0 06 W C � =(D NQ �.. •N LZZ � C Z ,o oc E coy CD 0 ti c� ( l W oma N m 0O 5 O- _ ao 5 0 L fl I O 0 1411 co O 0 O C N coN .co L CL co O Co w CO) O V C. CO) C O O C. N r—� 0 CO .0 3� co L C. o a, as Q E �p� C J O .O O CO Z Z CLN c 0 LLJ Irw w crw U) The Commonwealth of Massachusetts Department of Industria! Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone aam a homeowner performing all work myself. oI am a sole proprietor and have no one working in any capacity 2I am an employer providing workers' compensation for my employees working on this job. Company name: ��i�cJ J3v\ 1 n—& 1,>g e a AJ �- L• �` . Address 7� l�r�.a i�T �cl bc)c� L/ City:.- AAJ �Lo �; cvi� Phone # Insurance Cb. Policy* Comoanv name: City: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGI.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certifyunj der pat and/penn�affii`yes of penury that the information provided above is true and correct Print name �� ��•r>� r �J+D�-�l n Phone #�d��:� Official use only do not write in this area to be completed by city or town official' C]Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other M WORKMAN'S COMPENSATION Town of North Andover of Na 07" qti 6, o Building Department 0 27 Charles Street North Andover, Massachusetts 01845 978 688-9545 Fax 978 688-9542 '1s4sS,4 CNUs���h DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 9 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Si nature of Applicant 6-•-a1 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. r 4 BOARD OF BUILQiNG REGULATION~ License: CONSTRUCTION SUPERVISL:R ` Number. C; 0531;3 _ Birthdate: 01/21/1968 Expires: 01/21=02 Tr. no: 15558 Restricted To: 00 FREDERICK A PAPPALARDO _ 71 ERIGHTVMD AVE N ?.NDOVER, MA 01845 L•�•,•� '� f =,• Aiim.'^='stator Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 123349 Expiration: 02/03/2003 Type: DBA PrO. BUILDERS &,DESIGN 00 [ FREDRICK PAPPALARDO 73 BRiGHTWOODAVE`�—;�,��'rw, N ANDOVER, MA 01845 Aftic:stratvr Y �29 LdA FORM U - LOT RELEASE FORM INSTRUCTIONS: .This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. _- *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT 1-/¢. Ili' XV-+lPHONE�n-6-�0'3�1.s",) LOCATION: Assessor's Map Number PARCEL SUBDIVISION OA LOT (S) Ir, 7a 0 STREET ST. NUMBER_? FICIAL USE ONLY TOWN AGENTS: ADMINISTRATOR DATE APPROVED 7 11,51 U l DATE REJECTED COMMENTS /V v -%gZ-- V, TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm ,AORTA 3? �� .r . ,. '• OC h p ,sSACNUSE� Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING i This certifies that ......!.il.............................. . has permission to perform ............ .................... . plumbing in the buildings of .................................. at ...............- ................. ,North Andover, Mass. Fee..,— Lic. No.....�."' .. .......... �.�,: r- L .......... . PLUMB1NGASPECTOR Check # y/ 5171 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MA Building New P tiM HEM 7II3)EIOOR t gIH)HLOClit Name of Renovation 0 Replacement FIXTURES (Print or type) Installing Company Name Address ' h Date ---,I Permit # > Amount k-4— r Plans Submitted 0 No El Check one: Certificate 0 Corp. 0 Partner. DFinn/Co. Name of Licensed Plumber."4type—,'Ai-.�mrance �� Insurance Coverage Indicate me coverage by checking the appropriate box: Liability insurance policy n 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 El I hereby certify that all of the details and information I have submitteMW cation are true and accurate to the best of my knowledge and that all plumbing work and installatio for this application will be in compliance with all pertinent provisions of e a achusettta�perfo of the General Laws. By: dna g2,42cense own ZOVED (OFFICE USE ONLY of Plumbing License Master ❑ Journeyman 19 Town of North Andover RECEIVED JOYCE BRADSQfoar ¢ice of the Zoning Board of App eals a TOW' Development and Services Division NORTH A William J. Scott, Division Director 1001 MAR 2 q 9: 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner J,R_3 '4 l^ 1U.1,6! 11.3 '- 1=1 Telephone (978) 6888-9541 Fax (978) 688-9542 This is to certify that twenty (20) days have elapsed from date of derision, filed Any appeal shall be .filed Notice of Decision rithout filing of an pea pU/ within (20) days after the Y' nr "!1133 Da Joyce A Bradahaus .••�...._ date of filing of this notice Town Clerk in the office of the Town Clerk. Property at: Diane & Chris Bowe NAME: Diane & Chris Bowe DATE: 3/13/2001 ADDRESS: 33 Elm Street PETITION: 006-2001 North Andover, MA 01845 HEARING: 3/13/2001 The North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday, March 13, H;, 2001 at 7:30 PM upon the application of Diane & Chris Bowe, 33 Elm Street, North Andover MA r7 n requesting dimensional Variance from Section 7, Paragraph 7.3 of Table 2, for relief of a side setback �Q and for a Special Permit from Section 9, Paragraph 9.2 in order to add a proposed family room, deck, and breakfast area and to extend a pre-existing, non -conforming structure greater than 25% of the existing (7 structure on a non -conforming lot within the R-4 zoning district. N The following members were present: Walter F. Soule, Raymond Vivenzio, John Pallone, Scott Karpinski, Ellen McIntyre. Upon a motion made by Walter F. Soule and 2na al by John Pallone the Board voted to GRANT a �� R" dimensional Variance for relief of a side (North) setback of 6' and relief of a side (South) setback of 8' and to GRANT a Special Permit in order to allow for the addition of a family room, deck and breakfast area and to extend a pre-existing, non-confomung structure greater than 25% of the existing structure. In accordance with the Plan of Land by: Scott L. Giles, PLS, #13972, 50 Deermeadow Road, North Andover, MA dated: 6/14/2000 and 1/26/ 2001. Voting in favor: WFS/RV/JP/SK/EM. The Board finds that the petitioner has satisfied the provisions of Section 10, paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the zoning Bylaw. The Board finds that the applicant has satisfied the provisions of Section 9 Paragraph 9.2 of the zoning bylaw and that such change, extension or alteration shall not be substantially more detrimental than the e,,dsting structure to the neighborhood Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit grunted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial *use or construction has commenced, it shall lapse and may be re-established only after notice, and a new hearing.—� Town of North Andover It— / Board of Appeals 1 / / MI/Decisions211:fi 1/8 lia;mond Viten..zio. acting Chairman ATTEST: A True Copy S U y,z Registry of Deeds Northern District of Essex County Lawrence. MA 01040 04123/01 � 34 Rec: Tre PLAN 36. 00 los+ 1��Z7 A }' Coyies 3'00 # 35 Rer: Type N0TC 30.00 copies, 0.75 " Tofal. 69-75 # 36 Pavmpnt Check 70.00 V 25 # 37 Chanop . THAW YOU/ Thrm's J,BlIrkP ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accozdance-with thepzovisions of MG.L. G. 143,'§.3L, the permit application form to provide notice of installation of wiring shall be uniforin throughoutthe Commonwealth, and applications shall be filed bn the prescribed form. Atter a permit application has been accepted by an Inspector of Wiresappointed pursuant tom. G.L o. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the pewit 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 maybe.,deemed bythe.Inspector_of_Wires abandoned_and.invalidMe____. • or she -has determined that the aufhorized 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 A-/ 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 certairrpemmits -and licenses concerning the use or development of real property. With limited exceptions, the Act automatically dxteuds, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effector existence' during the qualifying period beginning on August 15, 2008_and extending1hroughAugust 15, 2012. JMule 8—Permit/Date Closed: j �Z- '� Note: ply for new permit it Extension Act—Permit/Date Closed: n Date........... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............................. .:..' ��................ .. ................... has permission to perform....:.:..:........ " . ..... ^.:................................. wiring in the building of ..... +ar''`..................................................... at -.-............ ....................... ....................... .North Andover, Mass. Fet � �. 0........ Lic. No. G..2.'............... ......... ELECTRICAL INSP R Check # S � VJ( LV/ LV VJ iL, LL JI VJI'�L..lV, i/t l,.11 `VI iVl lrl�. ,..ILIA. iVV I rIVL VL/ VL Cornmoawaat°!Ji o� �la�eacltuaelts ,1 ec77 ENo. :i:►1 Use Only 2.parbnerd o/„ `ire �anricai S: Checked 1 °iBOARD OF FIRE PREVENTION REGULATIONS blank} APPLICATION. FOR PERMIT TO PERFORM ELECTR]CAL All work to be perrormed in accordauce with the Mass.:drusctts Clactrical Code (NIEC), 527 CpR 12.()o WORK (Pl- &I-YEPIUIVT IX INK OR TyP,� AZ L 11VF0 LI. 1770/9 � City Of. o rile Inspector of F;%ir BY this application elle undersigned eivcs notice o his or her iTuieatiou to perform the Locatlont (Street &Nutuber) �` electrical work described below, Owner or Tenan t /,� - Owner's Address �,[' :r _s Telephone 110. Is this permit in conjunction with,a 1}uildinh,,,pn:rmit? y� Purpose of I3uildin No ❑ (Check \Itpraprtatc Box) AJ,, �/,J �� �i�%^. `r UtilityAuthorizatiott No, Existing Service \tirhs _ I;Volts Otierhead CDUudgrti 11 No, of itileters . Nett• Setw•fce •Amps / Volts Overhead ❑ Undgrd Q No. of Meters. Number of feeders and Ampacity Location and Nature br Proposed Electrical worlt: • "" � rye +�" / •���.'✓'��/ _ Con"pledon of the 4311 ....... a No. of Recessed Fixtures d No, of Lighting Outlets No. of Lighting Fixtures No, of Receptacle Outlets No. of Switcltes No. of Ranges No. of Waste Disposers No. of Dlsh�rasliers No. of Dryers b tvo, of Water Heaters KW No. Hydromassage BatIttubs ' IOTHER: of Cell,-Susp. Middle) fates of Clot Tubs Pool fwvTe All- Prud. ❑ Qrnd_ ❑ of Op Burners 0. of Gas Burners No. of Air Conti. Generators R'VA, E ALARj,j.3iYofZoues Dcttooeen3` Itlldnt9my Devices of Alerting Devices o f _els Con tamed rea Heating I{tiY Loca Appliances Ktiy Secu 1 o. of Data s Ballasts No. ofllotors Total HP - Conn,ecp on C1 Other ty`,�e�.s.—�---� dtradi additional detailif desired, or as t er uirtd by rile huFector of Wires. INSURsuNCE COVEIIAGE: Unless waived by the owner, no permit for the performance of electrical work niay issue unless the licensee provides proof ol'liability insurance including "completed operation" coverage or its substzntial equivalent. The undersigned certifies that such coverage is in force, and has =hibited proof of same to lite permit issuing office. CRECK ONE: INSUIL\NCE BOND ❑ OTI3ER. ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with IVIEC Rule 10, and u-3on completion. r ccn•rifj•► un►ler t/— a Pains a,►d penarlias ofrerfur�; NraC Ute itrfortrrQtiotr are rlrfs applicRtfoit is trite and coirrpigge !'IIu�I NAME- �y� /�/�` �, ! I,iC, AN 0.: Licensee:;nature LIC. i`i0.: �' ' u— L (lfapplica /r, enter ' �,} u�Ft" irr the /it ise �t ntbtr e.) Address: / R '% .iii'/ ,�— 0 } �•� ,. / ✓ Bus. Tel. ZNo.:.9' -YS-1 - S/ `70 OWNER'S l NSLI:LANCE W.&UVER. I am awatte that the Licensee dors not have the lability lls'arsee cot era2e normally required by law, 13ymy signature below, l hereby waive this requirement. 12111 die (cheek one Owner/Agent❑ owner [3o\yncr's agent. Signature Telephone No. =Pj;-R11-1rTT FEE- : ,s � a Date ........'%...... ...... e�tio` TOWN OF NORTH ANDOVER FO 9 PERMIT FOR GAS INSTALLATION This certifies that ............................................ has permission for gas installation ........................... . in the buildings of ........................................... a at . ............................... . North Andover, Mass. `,Fee......... Lic. No........'... .......................... GAS INSPECTOR Check #- • , / MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date , NORTH ANDOVER, MASSACHUSETTS q Buildi Locations J2= I Permit # 2 ` Amount $ Owner's Name �4 New 0 Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print tor type) t �+ /►� n f7� r r one: Certificate Installing Company U �/ ` Jlj 4-fi— Corp. Li Address 1 Name of Licensed Plumber or Gas Fitter 1M C L . ❑ Panner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I nereay certify tnat all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work endostallations perf°Ve under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma ach efts State Z gnd-GhapteQ 42 of the General Laws. `!ED (OFFICE USE ONLY) Siglature of Licensed Plumber Or Gas Fitter Plu bei %7 �---- FittericL nseumRTer- Master Journeyman ATH. FLOOR (Print tor type) t �+ /►� n f7� r r one: Certificate Installing Company U �/ ` Jlj 4-fi— Corp. Li Address 1 Name of Licensed Plumber or Gas Fitter 1M C L . ❑ Panner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I nereay certify tnat all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work endostallations perf°Ve under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma ach efts State Z gnd-GhapteQ 42 of the General Laws. `!ED (OFFICE USE ONLY) Siglature of Licensed Plumber Or Gas Fitter Plu bei %7 �---- FittericL nseumRTer- Master Journeyman ti e4 O:i icc Usr Only UV The Commonwealth of Massachusetts -72"JS� Pr rriC Xo: ✓ -- Department of Public Safety Occupancy 6 Fee Checked {� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 heave blank) t APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -0-- /"z — City or Town of s 6ZO �,�, ^/,� �r�To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address LSC/ Is this permit in conjunction with a building permit: Yes ❑ No Check Ap ropriate Box) Purpose of Building Utility Authorization N X60 " COisting Service (7 Amps�- Volts Overhead �dgrd ❑ No. of Meters_ New Service 14g_0 _Amps W" 4�olts Overhead G40 Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures No. Swimming Pool Above ❑ In - grnd. Generators KVA No, of Receptacle Outlets No. of Oil Burners No. of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices of Sounding Devices No. of Self Contained Detection/Sounding Devices Local Municipal ❑Other D Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No. of pumps Total Total Tons KWNo. No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. o Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: urruant to the requirements of Massachusetts General Laws I have a current i lily Insurance Policy including Completed Operations Coverage or it substantial equivalent. YES NO � .I have submitted valid proof of same to this office. YES NO If you have ch ed YES ,.please indicate the type of verage by checking the appropriate box. Ot INSURANCE BOND ❑ OTHER ❑ (Please Specify) / ify► V° t Expiration�X�te� Estimated Value of Electrical Work $ Work to Start ��j�-- 9� Inspection Date Requested: Rough Final Signed under the pe es of perjury: FIRM NAME r Il� f CO JLC— LIC. NO. Licensee f ignature LIC. NO. Address /'7 ` Bus. Tel. No. €�2 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S 316-- C>— Signature of Owner or Agen r ._ REMARKS BY ELECTRICIAN: Z ry- O Z O N E E u O N L O in Z w N a V REMARKS BY ELECTRICIAN: v . Date. .,,..............�.,...... NORTN TOWN OF NORTH ANDOVER p PERMIT FOR WIRING $A US Thiscertifies that.........e.....:.,.....................I..................................................r i has permission to perform ....................:.. �. ...:..... ../.. r....... �.... �.................. wiring in the building of .......,. ......................................................... at ..........:..... ............./............:.1 ............................... . North Andover, Mass. Fee.....,.....:...... Lic.No...r.....fC?...........................................................ti. ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File i NoDate .................................. This certifies that TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform ............................................................................... wiring in the building of.................................:................................................ at ....................:............... .:....................................... ,North Andover, Mass. Fee. .............. Lic. No.............. ............... ........ ! . s ............ .............. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THECOMUONR U71OFMASS4Q-II1SE77'S Office Use only DEPARTMFVTOFPUBLICSAFM Permit No. 3 BOARD OFFIREPREVEWONRWULATIOAN5270WR12-M Occupancy & Fees Checked � UVAPPUCATIONFOR PERMIT TO PUFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dates 9e -;l 3,1,,� l -L11 Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Owner's Address To the Inspector of Wires: JJ Is this permit in conjunction with a building permit: / Yes j No (Check Appropriate Box) Purpose of Building de P77 / f ,,� Utility Authorization No. Existing Service Amps / Volts Overhead 1:3 Underground No. of Meters New Service Amps / Volts Overhead r -"l Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work' E ) 17 � No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures J Swimming Pool Above Below Generators KVA igroundg1:1round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets �. No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• Ir>su-=Co,a� PusuantY�lhetegtmat�alts�C�a�a'aIL _ _ Iha,,ea=ftLdokh-&==Pc[LynidffgCar4)kt2Er&nCmaWcritssi a9mlat YES NO IlimesihntledmWptodof=netotheOffi= YES U NO 1 If}puha%edia WYFS,pkmei�lheNxofo bydeckirglhe INSURANCE BOND OTIiR ftweSpecffy) Die '( Expi�an Fstm*d V*edHec tical Wcik $ WdkbShxt h>Spe rnDt>meRegt>estad sigtiedtaider7iePervitiesofp0jtayf�"� 1,✓ ��rRilr%G- �T FIRM NAME Licatsae-' rr lcl Sigl� • 17' 1 (.y • • M and@tatmysigt>ahseonthispanitapphctm theresp tint. (Please check one) Owner M Agent Roi# FmW L;o meNa /. TJ —/Y'# amiess Tel Na — AkTel. Na instra> oecaerd@e ori l egtrivaietttas tegtmed bye Genital Laws Telephone No. PERMIT FEE $ Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........�... r'�......1.7f.."� ............. . has permission to perform ....J..: , ..G.:.•.'............'.... `' plumbing in the buildings of .................................. at ............... r...................... , North Andover, Mass. Fee... �.:.. Lic. No.. �.... ..................... . ......... Pi-UMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHU ETTS Date 0/ Building Location Owners Name Permit # Amount Type of Occupancy N • New Renovation ® Replacement Plans Submitted Yes 13 No Mal ►' 1 ' i 1" :kvjlmmmmmmmmmmmmmmmmmmmmmmmmmmm i �. ------------------------- (Print or type) Check one: Certificate Installing Company Name 1, ❑ Corp. Address �✓ �P%CPa C �h e 'PdV2- 0;?0 Partner. Business Telephone Firm/Co. Name of Licensed Plumber: —D Il v\ 1 -�-si fqn s Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0 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 threeinsurance Signature Owner F1 Agent El 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 installations p rformed under Permit Issued for this application will be in compliance with all pertinent provisions of the assachusetts t e lu in Code and Chapter 142 of the General Laws. By: ure o Icense um er Ty Title pe of Plumbing License — 2715 Cit own icense um er Master ❑ Journeyman APPROVED (OFFICE USE ONLY �1 A z/ SIGNATURE: //� lvf Building Commissioner/Inspector of Buildings Date //- G - d SECTION 1- SITE INFORMATION 1 A Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number V, � y� J ! 1/ / e ,iD � I/Zoning 1.3 Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUH DING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R aired Provided 1.7 Water Supply M.G1—C.40. 54) Public ❑ Private ❑ ZOIIe 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT 2.1 Owner of Rec d N' (Print) L 6 Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 e sed Construction Supervisor: License Number Address 'ignature ;.2 Registered Home Improvement Contractor :ompany Name address Telephone Expiration Date Not Applicable ❑ Registration Number Expiration Date 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 .......0 No ....... ❑ SECTION 5 Descri tion of Proposed Work (check all applicable) New Construction Existing Building, fd Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ . Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - FSTI MATim rnNCTRTTf TTnN rnQTC tem Estimated Cost (Dollar) to be 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 Check Number OWNERSAGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT I as Owner/Authorized Agent of subject property IHereby authorize IMy behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date to act on 4k 1> vT.ti as Owner/Authorized Agent of subject �iroperty , 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 of Owner/. Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3Ru SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DRAENSIONS 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 0 0 Aj 1 O d Z4 rA W as w x w d CG aL 'U V. u c cn 0O H P-iU � z a ° -o C w° me U u. a � (r 'oo O a: w a W v, U W W moo O a cn G is. O � w O w G w H W w C w 0 u cn Q O cn g O O p U 0 z O U 9 n `\ - f R O O E L Z aL CL O CO) C cm I C3.— 0O2 0 yO .O .coF `� CD 0 co = cc CD 0 c -vv o a C C Cc C3 J� CD .c Z CD CL V CO) C C •� CO) cm LL C U LLU u i a u U . c o me c w O ` C H O A OC wv p, C O W C O 160- 60-Ea E CC In c o a y O m ~ O w$ M m c l CL= mm In3 cco CM m Cc =10 y y In y m � :Me O :cam¢ :acs O V y w '� Z C O CL a ca _ o a" O rH 00�... yyj C Or=.-.'Ot �c y C C �E w w y U o omc COP) a. 0. 50,0 = (A = .0 � a4m g O O p U 0 z O U 9 n `\ - f R O O E L Z aL CL O CO) C cm I C3.— 0O2 0 yO .O .coF `� CD 0 co = cc CD 0 c -vv o a C C Cc C3 J� CD .c Z CD CL V CO) C C •� CO) cm LL C U LLU u i a u U TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . �' S�ect�o�i far +Eift�`�ial U�c 4}rii . BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I ctor of Buildings Date IQ— a—SECTION SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Lr z a 3 Map Number Parcel Number 1.3 Zoning Information: i7-4- Zoning District Proposed Use 1.4 Property Dimensions: /5- 7`s2 Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public V Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record c 1, —; -�1 lam;- l—� . 6 0 �, 3 3 I ,�. , 5 �Vc,, -�, a w vv► Name ( 'tnt),<' �� fh . �/c - - (3 a l�J L Address for Service tgnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (RG.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 au applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 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 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on y behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of ONvner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 s 2ND 3RD SPAN DIN>ENSIONS OF SILLS DIMENSIONS OF POSTS DIEWNSIONS 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 OF 4��ec 61ti0 . °p Town of North Andover 4 Machine Shop'VHLW Neighborhood Conservation District Commission 1600 Osgood � North Andover, MA 01845 SSACHUSE Certificate t© Alter Date: � 1 ZP-00 Contact Name & Address: ProjectAddress: � E /0-� Project Description (attach additional pages, if needed): rf*-r)OVC_ et 5�lnq W1, vin 5,0 d�-h 5 I d e F Lr) v -'e a," d" r Commisssiion Vote: Voted J to toff *hy Certificate to Alter on d072 Comments (attach additional pages, if needed): Signed: Q Machine Shop 7 R z District Commission MSV NCDC Page 1 Date...-� . .��. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • o a ,SSACMUSE� This certifies that has permission to perform ..... ...'. %-" *'' plumbing in the buildings of . at-:....:� ,�- .............. North Andover, Mass. Fe6l/'l... Lic. No.�� V. ............... � PLUMBING INSPECTOR Check .N -3 2? 0152 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS a /j Date 7 Building Location 3 3 EAW S1 Owners Name �i^i'.� l��d Perm 777 7137 Amount Type of Occupancy New Renovation u Replacement Plans Submitted Yes 11No (Print or type) l Pl C Check one: Certificate Installing Company Name , , corp. LL Addressho 2 l F� 6/�3 j _0 Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate t e 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 M 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 installatio erfo d unde�a�r d for this application will be in compliance with all pertinent provisions of the Massachusetts St ng 142 of the G ral Laws. By:. i u Licen—sea rIUMDer ype of PI bin License Title / City/Town 777cense ilumuer Master n 3ourneyman j,G APPROVED (OFFICE (OF-FICE USE ONLY • MMM MMMMMMMMMM NM W -M-01110010 OMMMMMMMM MWWMWWMMMMMM WM nonnOMMMMMMMMMMOOMMMM 6'MMWWWMMMNMMMMWMMMMMWMM_MWM MWMMMWMMWMMMMMMWMMWNWMMMM0 (Print or type) l Pl C Check one: Certificate Installing Company Name , , corp. LL Addressho 2 l F� 6/�3 j _0 Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate t e 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 M 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 installatio erfo d unde�a�r d for this application will be in compliance with all pertinent provisions of the Massachusetts St ng 142 of the G ral Laws. By:. i u Licen—sea rIUMDer ype of PI bin License Title / City/Town 777cense ilumuer Master n 3ourneyman j,G APPROVED (OFFICE (OF-FICE USE ONLY tilde �� a � rz The Common wea th of Massachusetts Department of Jrndustrial Accidents Office of Investigations 600 Mrashington Street Boston, MA 02111 ww-massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plambers 3 iicant Information NaMe (Busines0orpoiza6on/lndividual): Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I dm a employer with 4. ❑ I am a general contractor and T Type °f Prelim (required): ,� 1100Yem (full and/or part-time).* have hired the sub -eon ractors 6. ❑ New construction 2•!�I I am.a.soie proprietor or partner_ ship and have no employees listed on the attached sheet x These suis -contractors have 7• ❑ Remodeling S. ❑ Demolition workingforme in an y capacity, [No workers' comp. insurance workers comp. insurance. 5. ❑ We are a corporation and its 9. Building addition 3. ❑requnred.] 1 aim a homeowner doing officers have dxercised their 1Q•❑ Electrical repairs or additions all work myself [No -workers' comp, right of exemption per MGL c. 152, § 1(4), and we have no 1117 Plumbing repairs or additions insurance required.] _t .employees. [NO workers' 12.0 Roof repairs COMP. insurance required..] 13•7_0ther *Any eVplitr' That checks bo)t#t mutt also fm out the section below shoin wg theirworkers' oompensatioo policy information. i Homeowners who submit this affidavit indi.calint they ars doing e11 work and then hire outside contractors must'submit a new affidavit indi ' #Contractors that check this box Myst attached an addhiousl ahear Showh. g. trhe name of the sub -contractors and their woricem, s . cfliug such c*r.- Volt^.trfo..Ujor.. I an an employer tinct is pro,Vidr rworkers' t cotnpensaiiarr rrsrtrance of a VPC. Below is the O infarrnatfon. f mY nF!o Y P hry aadjob site Insurance Company Name- - wr ame:olicy # or Self -ins. LIC. #: Job Site Address: Expiration Date: — Attach Attach a copy of the workers' compensation policy declaration pag Failure to e (showing the policy number and expiration date secure coverage as required. under Section 25A of MGL c. 152 can Iead 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 WORT{ 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 Investigations of the DlA for insurance coverage verification. the Office of I do hereby that the infornwtion provided above is true and convect Official ase only. Do not write in lits area, m he completed by city or own— c- City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.OtheT Contact Person: Phone #: Information a i1d Instructions Massachusetts General Laws chapter 152 requires all emp 1 oyers 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 includir ag 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 mai-ntenance, 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 fcensing agency shall withhold the issuance or renewal of a license or permit to operate a business or tro construct buildings in the commonwealth for any applicant who has not produced acceptable evideuce.of compliance with the insurance 'coverage required" Additionally, MOL chapter 152, §25C(7) states "Neither tree commonwealth nor any of its polWcal subdivisions shall enter into any contract for the performance of public work until accept able 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 compiertely, 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 requiraiito carry workers' compensation insurance. Ifan LLC or LLP does have empioyees, 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 cityor town that the .application for the permit or license is being requested, nofthe 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 nue rrber listed below. Self i*+.surec] cn„zp"�i ehrn�;d enter tc,e;T 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 aff'idsvit.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 a -ill be used as a reference numbe7. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating -current poiicy'infonnation (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy ofihe 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 fide 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 Investigptions 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 Strect Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSA.FE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia