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HomeMy WebLinkAboutMiscellaneous - 38 RUSSELL STREET 4/30/2018o� NoarN qti 2 SOL Date .� �tb . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION C. j This certifies that ..... �.v��!M......... Le_ lQw......... . •P has permission for gas installation ..?! .................. in the buildings of ..... e-' ........................ . at .. 3K.. `��?? it.. -'i f�Q.?....... ,North Andover, Mass. 1.1� ;l .. �`,!1.� Fee..... Lic. No. .............. ... GASINSPECTOR Check # -2 � Co 8704 F , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING Ul►OR{S Ii ;' i. 1p 4_; r CITY r'? � MA DATE _ 05 ZZ 1 O / �'J PERMIT # JOBSITE ADDRESS. c c� OWNER'S NAME GOWNER ADDRESS _ _ TEL a-26 820159'5 I FAX PR OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL [� CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: Q� PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES Z FLOORS--8SM 1 2 3 4 5 6 7 8 9 1Q 11 t2 t3 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRI LLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER. � WATER HEATER _ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ 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: OWINER ❑ AGENT ❑ N I hereby certify that all of the delails and information I have submitted or entered regarding this application are true an to to +e t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. 9> ance wi P tie rovision of the PLUMBER-GA;�� ME LICENSE # ,� � [ I�ZCQ`� S GNA U E MP Ea MGF JGF ❑ LPGI ❑ CORPORATION P11 PARTNERSHIP ❑ # LLC ❑ #A� COMPANY NAME ` \--�Z`i�' ADDRESS- CITY DDRESS—CITY �!I STATE `�I� zip CSI TEL _!,77P'-) q-71-5 5q zL FAX - ?Z?� — CELL 4M Pte? -24 ZH EMAIL The Lounnonweakh of jvlassachn eas Department of Indusia icl_Acciden s Of ice of 1lrtrestig atious 600 U17asl in a on ;'tr•eei Boston, A'L$ 02111 iviviv. niass.gov/dia Workers' Compensation Insurance Affidavit: Bnildei-s/Co:azt-ac€oi-s/Electt-icians[Plumbei-s Alp-Dlicant Information Please Print ]Legibly Name (Business/Organization/Individual): Address City/State/Zi Phone #: Are you an employer? Check the appropriate box: . ❑ I am a employer with 4. [] I am a general contractor and I employees (full and/or part-time).* ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance) 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c- 152— 1(4), and we have no employees. [No workers' insurance required.] . lk Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other j try applicant that checks box M must also fill out the section below showing their workers' compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this bo: trust attached an additional sheet showing the name of the sub-comractors and state whedter or not those entities have tployees. If the sub -contractors have employees, they must provide their workers' comp. policy number. `?rg an employer that is providing wot'1(ei's' compens!Ition insurance fog 3nY employees- Beloit, is the policy and job site formation. surance Company Name: )licy 4 or Self -ins. Lic. b: Expiration Date: tb Site Address: City/State/Zip: Rach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dateSz lilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tie 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby cerdfv trader the pains and penalties of pe►jury that the hi orntation provided above is it -tie andcorrect. itanature• Date: one It: Official Erse only. Do not write- in il<is area, io be completed by cite% or frown of -ciaL City or `]town: Permitf--Liceaase 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 #: .t • i The Commonwealth of-1Massachusetts Department of IndustriglAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual):, Address: 0" City/State/Zip: (-?2 ( RM Phone #: A-7 e) Are y9dan employer? Check the appropriate box: Typo of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* 2. ❑ I am a sole proprietor or partner- have nedthe sub -contractors listed on the attached sheet. $ ' 7. Remodeling � ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. 8. ❑ Demolition g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL I I.E[Thimbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.E]Roofrepairs insurance . re uired required.] r employees. [No workers' 13.❑Other comp. insurance required.] 4Any 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 ire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy 4 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 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 tie, violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for iiss*nee coverage verification. X do h*erelLf"cerfiff unde 2e t andpenalties ofperjury that the information provided abov is true an correct. l� 0.�.._�.__. II „atw P Zv t'� 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 4: "o Information and 'Instruction's 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 compliancewith 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 ofpublic 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 maybe 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 (ifnecessary) 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 NOTrequired 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 aMa?aonwealtla of M,9 Depaztment ofladustdal .Accidents Office ofIuvestigatzons 600 Waftgtoa Sired Boston, MA. 02111 TO, # 61.7-727-4900 oxt 406 or 1-877�MASSAF Revised 5-26-05 Bax # 617-727-7749 COMMONWEALTH OF MASSACHUSETT3T`5\, PLUMBERS AND GASFITT,ERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO - PAUL D HO' FI1AN 36 REVERE ',ST BRADFORD MA 01835-77119 r 11764 015/01,/.14 176350; i r / 1 r i f No Date . ............ . TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING This certifies that, ......................... ........... . has permission to perform ... ............................. plumbing in the buildings of .............. ................... . at ............... ................. . North Andover, Mass. Fee-. a .....�... Lic. No... fi". ....f j :............ . F PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR FERMI O DO PLUMBING (Type or print) NORTH ANDOVER, Building S� Owners Name New Renovation F1 Replacement 0 Date CJ v %e,Go Permit # Amount �, �,`� Iry, Plans Submitted Yes M No 11 (Print or type) Installing Company IName of.Licensed Plumber. Insurance Coverage: India Liability insurance policy Insurance Waiver: L three insurance Ohec(one: Certificate Cog ❑ Partner. Firm/Co. type of insurance cover6ge by checking the appropriate box: Other type of indemnity 11 Bond ❑ have been made aware that the licensee of this application does not have any one of the above Signature Owner I hereby certify that all of the details and information I have submitted (or entered) in best of my knowledge and that all plumbing word installations performed under ] compliance with all pertinent provisions of theyassachuset6lstate Plumbing Code VED (OFFICE USE ONLY Agent 11 r%TypePlumbing Licecfse/ - icense Numuer Master ❑ ration are true and accurate to the for this application will be in 42 of the General Laws. Journeyman • Y a ' i it ..--.----�-�--------------. (Print or type) Installing Company IName of.Licensed Plumber. Insurance Coverage: India Liability insurance policy Insurance Waiver: L three insurance Ohec(one: Certificate Cog ❑ Partner. Firm/Co. type of insurance cover6ge by checking the appropriate box: Other type of indemnity 11 Bond ❑ have been made aware that the licensee of this application does not have any one of the above Signature Owner I hereby certify that all of the details and information I have submitted (or entered) in best of my knowledge and that all plumbing word installations performed under ] compliance with all pertinent provisions of theyassachuset6lstate Plumbing Code VED (OFFICE USE ONLY Agent 11 r%TypePlumbing Licecfse/ - icense Numuer Master ❑ ration are true and accurate to the for this application will be in 42 of the General Laws. Journeyman Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............................................ has permission for gas installation .... ..................... . in the buildings of ........ ......:......................... at ................................... . North Andover, Mass. Fee......... Lic. No........... ..............:. :...... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer s > MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS G ype or print) De ` I9 NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New ❑ Renovation ❑ Replacement Permit 9 7 Amount S 1�0 01- Plans jPlans Submitted ❑ (Print or Address ness Telephone Name of Licensed Plumber or Gas Fitter Chec ne: Corp INSURANCE COVERAGE Chs I have a current liability Insurance licy or it's substantial equivalent. Yes If you have checked ves, pl e i icate the type coverage by checking the appropriate be Liability insurance policy Other type of indemnity ❑ Certificate Installing Company ❑ Partner ❑ Firm/Co. No ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the vlass. General Laws, and that my signature on this permit application waives this requirement. Check one: EDSignature of Owner or Owner's Agent Owner F-1Agent 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (oFFICI: USE (W. Y) Signature of 1 ❑ Plurnber — ❑ Gas Fitter ❑ Nlaster Journeyman Fitter f 6T It. FLO R (Print or Address ness Telephone Name of Licensed Plumber or Gas Fitter Chec ne: Corp INSURANCE COVERAGE Chs I have a current liability Insurance licy or it's substantial equivalent. Yes If you have checked ves, pl e i icate the type coverage by checking the appropriate be Liability insurance policy Other type of indemnity ❑ Certificate Installing Company ❑ Partner ❑ Firm/Co. No ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the vlass. General Laws, and that my signature on this permit application waives this requirement. Check one: EDSignature of Owner or Owner's Agent Owner F-1Agent 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (oFFICI: USE (W. Y) Signature of 1 ❑ Plurnber — ❑ Gas Fitter ❑ Nlaster Journeyman Fitter .r r- s.No 2 518 Date... .�,1/. ho TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that kG..l ........ Rj:c mac e ' has permission to perform ....... ...r'.` .............................. wiring in the building of ....... ..................................................... at ..........J... x?'......... lC.�+.55 �. / ....5 I ............................ N h Ando ee ass. 1. F..:.... Lic. No....7.�.............. r.. ............... XRICALI SPECTOR Check # � 7 % . WHITE: Applicant CANARY: Building Dept. PINK: Treasurer II= (-UJ 1"U1VWP-egL.1.ti UP IYLA ;"C,1'ULNE113' uttwe use omy i DEPARTAfEW0FPUBLICS4FMPermit No. A. 1 BOARD 0FFIREPREVE1VH0NREGMTI0A S527CAfR 12.00 Occupancy & Fees Checked APPLICATION FOR PERhIRT TO PERFORM ELECTRICAL 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) a Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant To the Inspector of Wires: Owner's Address . 52 4--e Is this permit in conjunction with a buildi7g permit: Yes MT -go- ® (Check Appropriate Box) Purpose of Building Existing Service 6 6 Amps /� da/ d•Y441ts Overhead r—q-underground New Service Z OU Amps ldo /,-)VO Volts Overhead ®-Underground ,Number of Feeders and Ampacity _ Utility A horiration No. No. of Meters ® No. of Meters ®� Location and Nature of Proposed Electrical Work v we f ci i 7- .777 I'll � Q No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 4iound No. of Receptacle Outlets U 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 Connections ® Other No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis too. Hydro Massage Tubs No. of Motors Total HP OTHER • •. !n:� . r• � •• r �• • :• i - � ira• � � �• • - • :r :. 19• •-rr.,�- : urr i - .•:r l ►r .� i� III i�� .. �.1.:.• AW 1 '• WakIDStart 'L - // - dy InspectionDW-ReWestad Sig w unckrTie Pales ofpajtay. l /� FIRM NAME /i afG ✓/ !/rC 0 1 a_ Valued Watk $ Ra# IL- Lo Final LiomseN . a %YJ /E Li=wm adrsiTei.Nh _ 6L � 7 Hrtrat�c r r i ui , Vivi e AILTeLN0. OWNER'S INSLIRANCEWAIVER, I.ama%=t1theL =dpmEdet�their>staa ecp►e tx�ss lecgrival�gasta�medby }a C�,e � and�mysemtttisp�onwai�esd�sta�tmenaa� / ,l (Please check one) Owner ® Agent ® ( (� Telephone No. PERMIT FEE E) Location No. ��' Date Y- y I-rV NORTF TOWN OF NORTH ANDOVER OL 1- p Certificate of Occupancy $ �ss�cMuSEs� Building/Frame Permit Fee $ fr? Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # %7 l� ---Building Ins0iVt6r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIRENOVAT &; OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 100 DATE ISSUED: 'dir— SIGNATURE: .*0 /W— Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 eRy Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District— Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage (ft) 1.6 WELDING SETBACKS (ft) Front Yard Side Yard Rear Yard ReqWred Provide ReqWred Provided ReqWrcd Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 private 0 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 Gv'rk C'2 -To V'A A ge -,� t I — e, -C11 N!ZU Address for Service - / Signature NIJ Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: ,16*0336 5 /,-2, aob Licensed Construction Supervisor: Address SiTelephone 7natu1J /q 7�- 6 Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Add ss 4-1 Expiration Date Signature Tele one Ma M X Z 0 0 Z M 90 0 Mn ic M rM ro Z G) SECTION 4 - WORKERS COMPENSATION (M.G.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 ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: zc'�doe C o 2 h! tel 0 X 1 L- 1 Ro 0 r%,\ I SECTION 6 - ESTIMATF,D CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Comfeted b permit applicant 0,1110�USEiONLY - 1. Building d 0 U (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) J �� •�' v� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTH RIZATION TO BE COMPLETED WHEN OViNEtIS AG"T ORX$NYRACTOR APP IES FOR BUILDING PERMIT I,A %). (-�'�-c as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, it Hye- &a: /u. 0 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 J efl-C.oU d of `?'_3f 0 Q Date NO. OF STORIES SIZE BASEMENT OR SLAB ST SIZE OF FLOOR TIMBERS 1 2 RD 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone 71 am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for myemployeesworking on this job. ComDanv name: Address Phone #: Co. Jct 1,/ c. ��•�C �r Policv # c Tr o� (2 2 Compgriy name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 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 ce ' un r the p n and /tie of -the information provided above is true and correct. Signature Date 7-31-6() Print name /i�•� Phone # cl ��✓ �� yLl Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate responseis required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover f tAaR=y O ti Building Department o 27 Charles Street North Andover, Massachusetts 0 184 V m �' (978) 688-9545 Fax (978) 688-9542 9 °"�'°-�• A°RA to PPa` 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: CC)�. K c� Facility lo( Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. al V �JJ 0 �•c ,,�a. ea33(-5/ 140 :r• r --% a v t, -",C. — z • L Z3l a,S /00 ocz `d.3�IS� sTe-f T ►(,s9,-) _ (Z:r.�©') �i o K — e."Z "C- 5 -�:,(yw00 �— �' a o vie, _P �02w�L 2 0. G, tjC,t `� C o ') & 1�� I V oW i a J 1 p 6 U 1 Y ce �-,t Doc 5 s l ►tet l ,� NJ�� zVS� c � Ya0ve- o���Z� C/) m 10 U) CD0 m _ r� Cn 10 0, z CD O Q. d =. o p CD t CD o .... ao Ca C4 .p CD 7 0 7 CD O COO) 'C C CA CD 0 CD CD a C. C/! O -• H O Q N no5o m y �m0 m cm) mcm) acm ...0 �a m O m CD 0 p y N � m m m m a > >.0 C cm) O0 C = ,••o. O O -n cc)m ►� C mayCL ': to O"" CD J � m c GEND �. = 0•� N cr'��fy N '1 d C N m �m CO) • m C yCD cy QED i o O q*4 O .� CD o Z �CD o o mC*, D o =CD ' O ls� O CA M CS Er d h d d c "j CD � M I rA v y 0 0 c 1* ':1 W 7O 77 '17 m n O O °'- N r C W b O o 0W. ro z � � ►� ro rA v y 0 0 c