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HomeMy WebLinkAboutMiscellaneous - 4 HEATH ROAD 4/30/2018�� A S m D 2 :U O D v Es C O WATERSHED RESIDENTS QUESTIONNAIRE 1. Name V41V7_6_ 6:77 DI6:-1, r_ / /-,, -f: 2. Street Address 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area (connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no - ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? a' washing machine ✓ dishwasher garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub 11. Please state the bran` type (liquid or powder) of detergent you use for: dishwasher clotheswasher ! �- 12. Does your property have a lawn? ql----Y-es ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre Er 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? /ter i2 No. of applications per year ( Seasons) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: 0 Check here if your lawn is maintained by a professional landscape contractor. 2. Street Address 3. flew many members are in your household? 4. ghat type of sewage disposal system do you have? cesspool ❑ septic tank and leaching area IL' connection to municipal. sewer other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of health? ❑ yes ❑ no - ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no ❑ do not know If yes, approximately how long ago? years. What was done? ,.. flog frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes no a:f yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewa�ga disposal system? washing machine ✓ dishwasher ✓ garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub ; 11. 'lease state the brand and type (liquid or powder) of detergent you use for: dishwasher 1�- L L, clotheswasher g _ L 12. Does your property have a lawn? .f yes, approximately what size? ❑ less than 1/4 acre ❑ '/4 acre ❑ more than 1 acre (Specify) 0--y-es ❑ no Er ;/z acre ❑ 3/4 acre ❑ 1 acre acres 13. flow often do you fertilize your lawn? (� No. of applications per year !(% A_! V Season(s) of the year I14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: 0 Check here if your lawn is maintained by a professional landscape contractor. Dante DeLillis fw.•„ ,., APPLICATION FOR SEEPAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT --NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Lot 23 Milk St. _ I will install this system in accordance with all the lays of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches,, and will maintain a minimum grade of 1i until 10 feet preceding the septic tants where the grade shall not exceed 2%. I will install a concrete septic tank of�50gallin size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with open jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a series of trenches, the bottom of which will provide a minimum of 200 lineal (,gam) feet of effective absorption area. The pipes will,be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/411 (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of the will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No pa3..t of the in— stallation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further officer, as provided below, and to :incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. PLAN ATXA DATE 7/22 57 j r, _11�tL Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North .Andover, Massachusetts. DATE ZZ22/57 ignature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Pereolation Test mi ! Soil—clay Garbage Grinder NO J July 15, 1957 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Milk St. building site of Mr. Dante DeLellis. The subsoil was a clay content and a 5 -minute per- colation test was conducted. The land in general is high, but on the side of a hill. The plan as submitted with the application and prepared by Mrs. Kenneth F. Knowlton, Sanitary Engineer is approved with the exception of increasing the septic tank to 750 gallons. It is recommended that a 750 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe in order to take care of an automatic washer. Very truly yours, V vUr��4 William J. iscoll t ; L I BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. T - I iI l lj ;I i q��� �;t;C�// d' DATE �. . 1. NAI: . DRESS '� �� h� LOT N0. 2. AD .i� 3 TEL . 3. N0. OF BEDROOt($ . . . DEN YES . i NO.. . 4. GARBAGE GRIIMI ER YES . . . . . NO.. . 5. SHOW DI},TENSIONS OF HOUSE 6. SHUN DISTA14CES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DTJJEl\SIOlZ OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF VlELL FROr2 SEVVEl GE SYSTEM' 10. SHOW LOCATION OF BROOKS.9 STREAYIlSo DITCHES.. LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FR011 HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. w Kenneth F. Know YL on Sanitary Engineer 74 Conant Street Beverly, Mass. Mr. Tante DeLellis 62 Saratoga Street Lawrence, Mass. Dear Mr. DeLellis, On June 17, 1957 at the intersection I performed certain tests have designed Propose to build on June 25, 1957 I examined with you a pi ec e of Milk and Heath Str*ets in percolation tests and on the a sewage disposal system for the property: of property North Andover. basis of these a home yqu Pervious ground was found on the lower portion of the property and the leaching works are located in this area. on March 30, 1957 I had occassion to examine the same piece of property and at that time found the ground water to be only two feet below the surface. Consequently I have shown an intercepting drain to pick up the ground water as it works down the hillside and divert it around the area to be used as a leaching field. This will tie in with the drainage system for the house foundation and both will discharge to the gutter on either Heath St. or ilk Street as the final grades dictate. This drainage system for ground water should in no case be closer than 25 ft. to the leaching field for the sewage effluent. The water pipe coming into the house should be kept at least ten feet from the sewage leaching field. Data published by the State HealthDDept. gives a cost for sueh leaching works and septic tanks as#350 to 0500. I would anticipate the higher figure at least since this is an extensive field. This figure includes the tank. For tanks alone the 600 gal size is about $80 and the 750gal size about 095. Figures which I have had recently for trench" similar to the intercepting drain have been in the vicinity of #2.00 per linear foot using larger pipe. I would plan on at least #1.50 per foot. The portion around the foundation will, of course be laid in the house excavation and will not need separate trenching. Please feel free to call me if you have further questions on this matter. Very truly yours, enneth Knowlton Date... 2'/'- 6 TOWN OF, NORTH ANDOVER PERMIT FOR PLUMBING TPIs certifies that ................................... has permission to perform ... �Oy-�CUI� ....... 0.( - plumbing in the buildings of .... e ..... V.-) ... I, ... 45. .......................................................... at .......................... North Andover, Mass. Fee2— Lic. No. 4031 . ............................................. ................................ ... ... ..... ChecL' 4, PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,.�t1 MA DATE__ I S ( PERMIT # 1 JOBSITE ADDRESS OWNER'S NAME =47: POWNER ADDRESS TEL[ __::::JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ER EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: Ep RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES Q NO 01 FIXTURES 7. FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM !. _111—A f DEDICATED GREASE SYSTEM J _ _ [ t _ f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I _._.__..1 .._._-_J DISHWASHER _ f DRINKING FOURTAIN I -.-__-_-{ _----__ FOOD DISPOSER I FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK --_-(- LAVATORY __--i..___._J -__.._ _..-.-..-i ROOF DRAIN —_-1 -___j ._ __ _.__ I _-._._J _____ _- ( .__..._j SHOWER STALL _( .__.. ( J �I ( _ 1 1 _ ( 1_1 C_ _j _ SERVICE /MOP SINK _-i _i TOILET ( _I i v_f __. _1 ,_. J= J URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _( i WATER PIP NG OTHER .__.-._.1 ._____ ( i i ___._f _._.___..4 .....___f _.._._I i __► _____( ___.___( I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES10 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY QI BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li ce Vh all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'r'Q- 1-+,(U�vJ �.LICENSE # �� SIGNATURE MPLO JPRJ CORPORATION W# 2 ( PARTNERSHIP �7_,(# G LLC COMPANY NAME Q ✓cS,lriJF ADDRESS `?�`2 w S"V- CITY ( STATE _ ZIP t 6 TEL - -Z - FAX_ _ CELL j 7L-�-t AIL o _._._. .._ _ l.._� H °z 0 H U a w b El El z N ❑ O H � W � W a W O CL Z u _ F a F- aU) LU NLU a a co a p z w a O W Q � U J IL I B � w z w F LL un H O z O H U a z a a, a ' The Commonwealth of Massa.chusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information (�� ,� Please Print Legibly Name (Business/Organization/Individual):--��" " �� �0 -►-.R- Address: AAddress: City/State/Zip: J.) . J .Aj M:A— Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1 I am a employer with.: employees (full and/or part-time).* 7. 0 New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in $.emodeling any capacity. [No workers' comp. insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. JaMlectrical repairs or additions proprietors with no employees. 1 'Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof ROOf repairs These sub -contractors have employees and have workers' comp. insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have nck employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit Us affidavit indicating they are doing 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 the sub -contractors and state whether or not those entities have employees. If the sub-coritractors have employees, ley must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceftify under the pains and penalties of perjury that the information provided above is true and correct. V1 Zn 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date. . ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ?eec �o r ................. has permission for gas installati ................................ in the buildings of 4 . ........................... at .... 45m�F ... f/ ............ 4 ..... h d Fee. Lic. No./,?.? ..... GASINSPECTOR Check # 01-5-d 8275 on 5- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY/l/� t {� �r%� MA DATEPERMIT # JOBSITE ADDRESS I q >�i4 �-�`�c o / OWNER'S NAME OWNER ADDRESS L , TEf, FAX TPYPPTE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL E] RESIDENTIAL CLEARLY NEWT -1 RENOVATION:.__ REPLACEMENT: PLANS SUBMITTED: YES _.- NOLj APPLIANCES -1 FLOORS -- W am BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES l�0 [ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY EA BOND I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT 0 SIGNA RE OF OWNER OKAGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com liancewi all Pert' nt provision oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 1a3aW� SIGNATURE MP M MGF -01 JP D JGFLPGI CORPORATION 0# PARTNERSHIPS#= LLC D# COMPANY NAME: ADDRESS CITY � Qr STATE ZIP S2(o —A TEL FAX --_j CELL(�� EMAIL(�� a- 9 4 a D a t e 9516 + TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SA U TO V1 C This certifies that ....................... has permission to perform ........... plumbing in e b i dings of ....................... at ..... �o Mnidover, Mass. N Fee. ..... Check PLUMBING INS ECTOR Nw- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 19 CITY o2 ti o ti MA DATE PERMIT # JOBSITE ADDRESS k1 Le � OWNER'S NAME ,..a/•f �.. POWNER ADDRESS�4Z�� /!1 4L TEL -,y',x rXFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: ®1 RENOVATION: ® REPLACEMENT: 02" PLANS SUBMITTED: YES ® NO® FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM j DEDICATED GREASE SYSTEM ► _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ► _ __J W_ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _J FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY _ ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _ I TOILET J URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _. J _ __i __j I INSURANCE COVERAGE: &0 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY gAO4"0' OTHER TYPE OF INDEMNITY © BOND ®I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. 6--X?�""/^ CHECK ONE ONLY: OWNER � AGENT 01 SIGNATOME OF OWNER WAGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Jr7� _ LICENSE # ( SIGNATURE MPIA JP[I CORPORATION# PARTNERSHIP 0#LLC COMPANY NAME ADDRESS CITY \ QQ.�„r� STATE) ZIP TEL FAX CELL EMAIL Nw- �j y H °z z o H U W a w N o on z y N ❑! W W O W aLU at z � x � f� Q w 5W O a a O > zz LU V) a O o W� � a U J a a e a N ui x w I-- w W H O z z 0 H U W a �7 a a C�7 a VL ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 , www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address City/State/Zip: Are an employer? Check the appropriate box: 1. am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[9flumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name: t Policy # or Self -ins. Lic. #: 000 J2 C Expiration Date: 3' Job Site Address: Q0&_0 City/State/Zip:'-4A,&aQof e q5 - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is tree and correct. 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia Date This certifies that ....... ...... 61 ......... ........ has perinission to perforni.,.�qx.--!��-�-. wiring in the buildin of . 9 It ... ... . ...... .... at ...... .1 .... 4 . . . . . , Nor th Andolver Mass. F e e . . I f. —5.�O i c. N o. /3. /(f Z4 '.','heck 10 9 3 2 ...... Ao R ELECTRICAL INSPECTO 7 t `,�* Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS W Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMy ATION) Date: 7' — / City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noticeofof hhintention to11 orm the electrical work described below. Location (Street & Number) Owner or Tenant ) r/ AM 641v Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building S(/� �� 1 Y" Utility Authorization No. Existing Service J40 Amps% 9r Volts Overhead IN Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ;6o A,pt/� 0 P 6 fs{� /J r 94 T// Ili /�. 11Aej A1wQs4 °� Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires /J' No. of Ceil:P (Paddle) Fans Suss of Total TransKVA No. of Luminaire Outlets 4(6 No. of Hot Tubs Generators KVA No. of Luminaires �� Swimming Pool Above rnd. ❑ In- ❑ rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets`3U No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches f No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Dis osers P I Heat Pump Totals: Number Tons ............................................... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local -1 0 Other Connection Dryers No. of Dr Y ( Gil- S Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: s Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �pe 66 (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 113 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: 14(;N t ) th/x Signature LIC. NO.: (If applicable enter "exempt" in the license num line.) Bus. Tel. No.: R-7?_ 3<!— ager Address: Co19c% /�% �sPi,���� �L Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent [PERMIT FEE. $ Signature Telephone No. f • A:r.1vJ6JM&F��•LJ(IFQT.I[•-•I(�•�J^-iR�T�R�`��Q}O•��.• p j �i fj•.p-�� y 1.7Jf..•.�1.s34.RV.�.7 J- .G ®J�`� i _ �R•!.L'!V.•-i.`•-11.V.tsr`-f .�41�J..•J<l��.I'1.�.�5' • .. ._ ___. • i k + M(W)cn� ts: 2 3—/Z.+pectore Signature -)ao Initials) -- Pate 2• MAL Tns�eeta mm.ents: . Unsliectoxs° uignatare •-no Wilds) Slate 3. TNI)YRGRODM 3i$S'ECTjOZY: inspetoxs' comments: (axnspectoxs',�ignaimre�aoiniaisj Pate !,t Tri, C assea.-- lspedw (�Cuspectoxs',�ignature � no initials) Date ,sea--jaxIer j atenspecizonxe�uixe� ($50.00) •-[ pactoxs' cozum.entsa � ' • 5 ��, sp eetoxo'ignataxe xzo initials} -- Pate 3Off, TAGN AM TO BE FAINDD PDT AM YZFT OX BITE IF TM.APNEA TO BE INRECT.U+D XN JWOT b ll The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibl Name (Business/Organization/Individual): /✓ G` Address: City/State/Zip: ClelmSre-110 14 Phone#: �%,�`�S �Q G/ 6j Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors 2.P0 I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #:, Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert4o under the pains yndpenaftles of perjury that the information provided above is true and correct. Si afore: Date: -- 3 Phone #: C71 e 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 Information and Instructiolls Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or C town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMossarhusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877, MASSAFB Revised 5-26-05 Fax # 617-727-7749 ww�v.�mass,govl�aia