HomeMy WebLinkAboutMiscellaneous - 35 CAROLINE WAY 4/30/2018DSA I Dewing & Schmid Architects
30 Monument Square
September 3, 2009
Suite 200B
Concord, MA 01742
Tel 978.371.7500
Edgewood Retirement Community
Fax 978.371.3388
#21 & #35 Caroline Way
Wiggins-Loux (E Units)
280 Elm Street
South Dartmouth, MA 02748 Mr. Gerald A. Brown
Tel 508.999.0440 Inspector of Buildings
Fax 508.999.7709 Town of North Andover
1600 Osgood Street
www.dsarch.com North Andover, MA 01845
Mr. Brown,
We're writing to explain our position regarding the covered entries for #21 & #35 Caroline Way.
Edgewood received a negative determination from the Zoning Board of Appeals for its request to
encroach within the 100 foot CCRC setback. This ruling required Edgewood to explore an
alternate cottage design in order to comply with CCRC (Continuing Care Retirement Center),
bylaw setback of 100 feet and respect the 50 wetlands buffer.
The new design is linear in form, rather than "L" shaped as the other cottages are. In simple
terms, we moved the garage from the front to the side of the main structure, thus lengthening it,
but reducing its depth. This provided a front face (and entry door) that is set very close the
setback and the rear face set very close to the 50 foot wetlands buffer.
We knew cover would be required at the entry door as a practical matter (climate), but more so
for the fact that we are providing a non-traditional on -grade entry, specific to the needs of the end
user, the elderly. We designed the cover to be supported by brackets rather than columns &
footings, specifically to comply with the bylaw. Please note, no other cottages employ bracketed
roof supports.
We believed we were in full compliance with the 100 foot setback until just before we submitted
these cottages to the Town for a permit, when it was brought to our attention that there was
language specific to the CCRC, section 7.3 Yards (setbacks) which states that the setback excludes
eaves and uncovered steps. We don't have steps, so technically we comply, but we didn't feel
confident that this technicality was in keeping with the spirit of the bylaw. Edgewood and the
entire design team didn't want there to be any misunderstanding, so the question was brought to
the Town's attention during permitting. It has been our directive from Edgewood and our intent,
to fully comply with the bylaw. The covered entries are shown on the approved Planning Board
application, though they may not be specifically noted.
Sincerely,
NNER
R. Jeffrey Dearing, AIA
Principal
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Dumber 483 (3/17/09) Date: October 21. 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 35 Caroline Way Unit E
V
MAY BE OCCUPIED AS Single Family Dwelling IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Edgewood Retirement Community
575 Osgood Street
North Andover Ma 01845
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Building Inspector
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Registered Architectural and Engineering Services
Construction Control Affidavit
Project Number: DSA Project #0706.00
Project Title: Edgewood Retirement Community Cottages
Project Location: #35 Caroline Way, North Andover, MA 01845
Scope of Project: 22 Individual Cottages
In accordance with Section 116.0 of the Massachusetts State Building Code I, Allen Dewing Jr., MA
Registration #4301 being a registered professional engineer/architect, hereby certify that I have prepared or
directly supervised the preparation of all design plans, computations and specifications concerning:
Entire Project X Architectural Structural
Mechanical Fire Protection Electrical
Other (Specify)
For the above named project and that, to the best of my knowledge, such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code. All acceptable
engineering practices and all applicable laws for the proposed project.
I further certify that I shall perform the necessary professional services and be present on the construction site
on a regular basis to determine that the work is proceeding in accordance with the documents approved for the
building permit and shall be responsible for the following as specified in Section 116.2.
1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are
submitted by the contractor in accordance with requirements of the construction documents.
2. Review and approval of the quality control procedures for all code -required materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine, in general, if the work is being performed in a
manner consistent with the construction documents.
Upon completion of the Work, I shall submit a fina e ort as to the satisfactory completion and readiness of
the project for occupancy. ED AR�y •.
10�pE wrticTF��
v v
No. 43 cn
0 CO MORD, y A n Dewing Jr.
A
��TF1 OF VRR`''PC
F:\DSA Project Files\Edgewood 0706\05. Project Word Documents\a. Correspondence and Transmittals\vi. Misc
Registered.Cnjneering Services
Structural Construction Control Affidavit at Comnletion of Structural Work
Project Number_ DSA Project #0706.00
Project Title: Edgexvood Retirement Community Cottages
Project Location: #35 Caroline Way, North Andover, NIA 01845'
Scope of Project: Wood Framed Cottage with Concrete Basement and Foundations
Ln accordance with Section 1>16.0 of the Massachusetts State Building Code, I, Geoffrey S. Conway;
MA #32753 being :a registered professional engineer. (structural), hereby certify that I :have prepared
V LL141 1J�Jl.l.11�� _
For the above named.project and that, to the best of my knowledge, such plans, computations and<
specifications meet the applicable provisions of the Massachusetts State 'Building Code, all
acceptable enjineering practices. and all applicable: laws for the proposed project.
I further certify that 1,have performed the necessary professional services and have been present on
the construction site on a xegular basis to determine that the work is proceeding in accordance with
GEOFFREY
Geoffrey S. CoKway, P.E.Date S. cotv�aa�Y
Q. STRUCTURAL
No 327 � to
FSS/CltiAL�t�G
APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
Building Permit # tel' 1
ADDRESS/LOCATION OF PROPERTY: L-35
Map Parcel Lot Number
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION) O
CLOSING DATE ON PROPERTY:-
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE. COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARrUm IF THF -QTD f%'n 10c
DOES NOT MEET ALL APPLICABLE CODES.
Perm IsSued to:
Address
SIGNED '
CONSERVATION
PLANNING
DPW - WATER METER
SEWER/WATER CONNECTION
NOTE
ROUTING
F L.71
l0 2f ®1
Ef/,/bf
Z ?II&It,
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW %4a".
Signature
File: Application for OC form revised Jan 2007
Date.-,!�) ,�
........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
..................................................... . .............................
has permission to perform ...............................................
wiring in the building of .... ..... .........
at,— ......... ............... North Andovq, Mass.
Fee .'�.Zf . . ..... Lic. Ne ............ ...............
S
aLiGRICAL iNS*PE
Check# 14-9149G7-
870
Commonwealth of Massachusetts Official Use Only
Permit No. tf,29 7
Department of Fire Services /���
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code MECJ, 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: —, 4
City or Town of.• A) . /IIJrvwi `e, 12 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) AEQ(a► E ►AA; —
Owner or Tenant -1—`f!iih�d.1'i Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes
No ❑ (Check Appropriate Box)
Purpose of Building �L ► r,} C• Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Apo Amps iz / 24-a—Volts Overhead ❑ Undgrd
No. of Meters
No. of Meters _I
Number of Feeders and Ampacity i— &0 Am J)
Location and Nature of Proposed Electrical Work: LOULE ME K)
Comnlo iinn nfttic fnlinwinv table may be waived by the Inspector of Wires.
Attach additional detail tj desired, or as required by me inecur ul rr dr ".'
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:)
1 certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Interstate Electrical Servi s Corpor.at ' LIC. N .:A-5217
Licensee: Pasquale A. Alibrandi Signature I
(If applicablrater "exe : t" in the license number line.) Bus. Tel. No.:9 7 8 — 6 6 7 — 5 2 0 0
�
Address: Tregie Cove Rd., N'. Billerica, MA 01862 Alt. Tel. No.:
*Security System Contractor License required for this work-, if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's anent.
Owner/Agent I PERMIT FEE: S 9
Signature Telephone No.
-- - - - - - -
No. of Total
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators K -VA
No. of Luminaires
g Pool Above In-
Swimminb rnd. grnd. ❑
o. o Emergency Lighting
Batte Units
No. of Receptacle Outlets d�
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
f Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
!No.]of
Heat Pump Number
Tons
KW
No. of Self -Contained
Waste Disposers
Totals:
Detecti)n/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local Connection ❑Other
Dryers t
No. of D ry 1
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters '
Sims Ballasts
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER:
Attach additional detail tj desired, or as required by me inecur ul rr dr ".'
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:)
1 certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Interstate Electrical Servi s Corpor.at ' LIC. N .:A-5217
Licensee: Pasquale A. Alibrandi Signature I
(If applicablrater "exe : t" in the license number line.) Bus. Tel. No.:9 7 8 — 6 6 7 — 5 2 0 0
�
Address: Tregie Cove Rd., N'. Billerica, MA 01862 Alt. Tel. No.:
*Security System Contractor License required for this work-, if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's anent.
Owner/Agent I PERMIT FEE: S 9
Signature Telephone No.
ok-
4-- ? sw,;rv-,
ev,(6 -,,q19 -k-11
Date ... -..1.9 ... e.Z.
. .. .... .. ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.
........................................................
has permission to perform 2 .:.:. .: , �1.............................................
wiring in the building of ... ..........
at
............. ................................... North Andover, Mass.
Feell Lic. No. ........ . ...........
... .......
I ...........
-�d ELEcrRicAL INSP
Check #
K
,-1\ Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 40
Occupancy and Fee Checked ���
BOARD OF FIRE PREVENTION REGULATIONS v. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL MFORMATIOA9 Date: S --,l y 'tel
City or Town of: NORTH ANDOVER To .the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 3 S r p l i y � e
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building -!Si Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
No. of Laminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
-IFV �1it�y
Com lesion o the ollowin
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑ - ❑
srnd. grad.
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. Total
Tons
No. of Waste Disposers
I Heat Pump
INumber ons
Totals:
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances KW
No. of Wat—er
Heaters KW
No. o o. of
Sims Ballasts
No. Hydromassage Bathtubs
OTHER: .C4vr%/ /
No. of Meters
No. of Meters
table may be waived by the Inspector of Wires.
o.
KVA
ALARMS JNo. of :ones
of Alerting Devices
❑ C'nnnnwfi..n m"m''m 11Other
No of be,
to Wiring:
No. of Dei
'No. of Motors Total HP ITeleco cunimm ab
No of Devices
attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: % j III 0 , d_V (When required by municipal policy.)
Work to Start ,''_ / q- 51 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 covers a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the airs andpenalties o p )
p P ofperjury, that the information on this application is true and complete
FIRM NAME: S✓ VLr /7f1 �► i/y% 19 LIC. NO.: y.SG
Licensee: e4 - ,4 D, J o /h ve?'n Signature��
(If applicable, enter "exempt " in the license number line.) LIC. NO.: .2 2"%!/
Address: , 2 / t eu S 7 l W�f/C�� �� Bus. Tel. No.: V ZY
*Per M.G.L c. 147, s. 57-61, securitywork Alt. Tel. No.:
requires Department o Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement I am the (check one) p owner ❑ owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: ,S
r
rt
tU
"k,Z1111
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 If-ashington Street
Boston, MA 02111
www.mass.gov/dia .
Workers' Compensation Insetrance Affidavit: Builders/Contractors/Electricians/plumbers
AAplicant Information Please Print Legibly
Name (Business/Orp.nization/Individuat): i�%��1y�`� h`nIPn/k;
Address: ,2-
City/State/Zig: Liu ren , /y%j O/�'� / Phone #:. G42 -(f Y -71
AYoIu an employer? Check the appropriate box: Type of project (required):
l .
Are
am a employer with %
4. ❑ 1 am a general contractor and I
6 �, construction
employees (full and/or part-time).*
2. ❑ I am.a:sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet =
7• ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demoiition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
S. ❑ We are a corporation and its
g, ❑ Building addition
required.]
officers have exercised their
10•❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.Q Plumbing repairs or additions
myself [No -workers' comp.
c. 152, § 1(4), and we have no
12.[] Roof repairs
insurance required.] t
employees. [No workers'
I3.0 Other
comp. insurance required.]
^�'r -e+Y��� 111 M=MOCKS Dox n t must also lilt out the section below showing their workers' compensation policy informat m
I
Homeowners who submit this affidavit indicating they arty doing ill work and then hue outside contractors must submit a new affidavit indict* such.
;Contractors that cheek this box mustattached an additional sheet showing• the name of the sub -contractors and their wortoens` co p. po'ic� fi;ra-,atian.
I ant on employer that is prk?"ng:workers' compensation insurawefornw em3ployem Below is the policy aidjob site
information
insurance Company Name: G t'a n i lv % c
Policy # or Self -ins. Lie. #:—W& Z �.�9 ,$-�/ Expiration -nate:
Job Site Address: S r i..c (nJtt City/State2ip: /f/t/J�tJ/' /-jr�
Attach a copy of the workers' compeusatioa.-pone 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 penalties of perjury that the information provvlded above is bw and corned
-/9-17
Phone #: 6 eZ— (o Y 7 y
1
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 ? Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Date. . '-7 ....... .
3? TOWN OF -NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..
has permission for gas installation ............... .
in the buildings of .. .�. t s - . �_.. ?......................
at ............ .. , North Andover, Mass.
Fee../. G u''. Lic. No.) ? ... J� � ... ......
/ GAS INSPECT R
Check # �{ 1
6822
u
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING r
City/Town: I V OI' A &d 11 e r MA. Date- 67 � S a PermiW
Building Location:3f( tea Q / 1 h +�
�h Name- _d a d e �i rem e4i
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New. Alteration: ❑ Renovation: ❑
Replacement: ❑ Plans Submitted: Yes ❑ No ❑
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Installing -Company
Business
Of Licensed PlumbedGas Fitt
Parbieiship
Firm/Company
I have a current IIWMW Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes ® No ❑
If you have checked Ygs please indicate the type of coverage by cdm*ing the appropriabe box below
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAWA- 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 ❑ Agent ❑
'%Y =me=* orbs box u; I nmby cortig► teat all of the detells and information I have sued (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and irslailatlans performed under the permit issued for this application wig be in
compliance with all Pertinent Ww4bton of the Mmachuml State Plumbing Code and Chapter 142 of the General Laws.
Of
BY Plumber
Gas Fitlel
License:
Tine Mases Signature 'j llu Gas Fiber
APPPWVED oFRM USE ONL p Irstal�r Lice nsre Number. a `tet
\1)
Registered Engineering Services
Structural Construction Control Affidavit at Completion of Structural Work
Project Number: DSA Project #0706.00
Project Title: Edgewood Retirement Community Cottages
Project Location: #35 Caroline Way, North Andover, MA 01845
Scope of Project: Wood Framed Cottage with Concrete Basement and Foundations
In accordance with Section 116.0 of the Massachusetts State Building Code, I, Geoffrey S. Conway,
MA #32753 being a registered professional engineer (structural), hereby certify that I have prepared
or directly supervised the preparation of all design plans, computations and specifications
concerning:
Entire Project
Mechanical
Other (Specify)
Architectural
Fire Protection
I Structural
Electrical
For the above named project and that, to the best of my knowledge, such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, all
acceptable engineering practices and all applicable laws for the proposed project.
I further certify that I have performed the necessary professional services and have been present on
the construction site on a regular basis to determine that the work is proceeding in accordance with
the documents approved for the building permit and have been responsible for the following as
specified in Section 116.2.
1. Review for conformance to the design concept, shop drawings, samples, and other
submittals, which are submitted by the contractor in accordance with requirements of the
construction documents.
2. Review and approval of the quality control procedures for all code -required materials.
3. Been present at intervals appropriate to the stage of construction to become generally
familiar with the progress and quality of the work and to determine, in general, that the work
has been performed in a manner consistent with the construction documents.
Geoffrey S!ColTway, P.E. Date
FTt+ OF r,,�ss��
o� GEOFFREY
g S. CONWAY w
O STRUCTURAL
L No.32753 W
ISTEQ�>�`v
S�0NA%
Date'3
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
.....................................
has permission to perform .......... .....................................
wiring in the building of i>
... ! ........ ......
at ........................................ ....... ........ North Andover, Mass.
Fee ..................... Lic. N07;;�3!�4-/
................
E PIICA I�S "�rOi��
Check #
8657
y
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.S-7
Occupancy and Fee Checked Qz_ev
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date:ti+]
City or Town of: NORTH ANDOVER To the Inspector of Wires: -
By this application the undersigned gives notice oofjiis or her intention to perform the electrical work described below.
Location (Street & Number) 3� �UAUh n "1
Owner or Tenant
Owner's Address
Telephone No. qjM
Is this permit in conjunction with a buildi permit? Yes ❑ No Check
_ ( Appropriate Box)
Purpose of Building ��y Q«J�'i�i'�n �� Utility Authorization No.��y_
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
New Service �AL Amps j &0/ Volts Overhead [j2 Undgrd ❑ No. of Meters J
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
u�.uuucetunu[ ueiau if aesirea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to. Start _;t 1�— a 9 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 li;EDE]
'urance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cs in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OTHER ❑ (Specify:)
I certify, under th ains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:'
Licensee: j Signature LIC. NO.:
(If applicable, �e+�ter " empt" in the le ense number line.)
Address: `7 J' QLI �.1� % Tjj� �(i �i �� Bus. Tel. No.: — I — 70D
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I Am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $�'S� °-
The Commonwealth of Massachusetts
Department of .Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
r : www.mass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/organization/Individual):
Address:
City/State/Zip:_ Phone #:_�
Areyou an employer? Check the appropriate box:
LIZ LZ lam
Type of Project '
(required):
a employer with c)-4.
❑ I am a general contractor and I
6. ❑ New construction
employees (fitU.and/or part-time).*
2. ❑ I am a:sole proprietor or partner_
have hired the sub -contractors
listed on the attached sheet. t
7• ❑ Remodeling
ship and have no employees
These suis -contractors have
8. [] Demolition
working for mein any capacity.
[No workers' comp, insurance
workers' comp. insurance.g
5. ❑ We are a corporation and its
❑ Building addition
required.)
3. ❑ I am a homeowner doing
officers have exercised their
MGL
10.❑ Electrical repairs or additions
all work
right of exemption per
11.❑ Plumbing repairs or additions
myself. [No -workers' comp.
c. 152, § 1(4),and we have no
12.0 Roof repairs
insurance required.] t
employees. [No workers'
ME] Other
comp. insurance required.]
r ^ .' uuu cnecrcs oox s t must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of sub -contractors and their workers' camp. p^olici in raroa.
I am an employer that is providing:workers' compensation insurance for my employees: Below is the policy
information. and job site .
Insurance Company Name:
Policy # or Self -ins. Lie.
Expiration Date:
Job Site Address:_ ��� (r� �N gy City/State/Zip:AMMr A.
Attach a copy of the workers' compensation eclaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereliy�.Eertify under thegs{ns and penalties ofperjury that the information provided above is true and eorred
���� r. A 1
Z WW C
Official ase only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector
6. Other 5. Plumbing Inspector
11 Contact Person
Phone #:
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 tnistee 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.oir 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 cant' 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, not1he 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 nurnberlisted below: Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia