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HomeMy WebLinkAboutMiscellaneous - 42 BAY STATE ROAD 4/30/2018 -42 BAY STATE ROAD , 210/058.A-0019.0000.0 BUILDING FILE 12/4/2017 Community Software Consortium of Nor+rH^h _;. ti cr• ' •� o� � { tf r T #: No. h Andover Board of Assessors - 7 :IP Back to Results I Search for Parcels I Search for Sales ViewiPrir l Record Card Parcel ID: 210/058.A-0019-0000.0 FY: 2017 Community: North Andover Photo(Click on Photo to Enlarg Vie Summary Location: 42 BAY STATE ROAD Property Card Owner Name: TAMAGNINE,JAMES E Residence Owner Name2: MARIE J TAMAGNINE Map View Owner Address: 42 BAY STATE ROAD = Land City: NORTH ANDOVER State: MA Zip: 01845 View Abutters segments Neighborhood: 5 Land Area: 0.31 acres Properties Use Code: 104-TWO-FAM-RES Total Finished Area: 3120 sgft Detached Tax Class: T Pct-Exempt-Land: 0 Structure Pct-Exempt-Bldg: 0 42 L54-BAY STATE ROAD Sewer. Road Type: T Sales Sketch(Click on Sketch t0 Enlarg ) History Water: Road Condition: P Value Assessments Current Year Previous Year History Total Value: 424,500 405,400 Building Value: 242,900 227,300 Condo Land Value: 181,600 178,100 Market Land Value: 181,600 COIS�merci�.i Chapter Land Value: Latest Sale Sale Price: 0 Sale Date: 01/01/1980 Arms Length Sale Code: N-NO-OTHER Grantor. Cert Doc: Book: 01475 Page: 0111 Copyright©2015 Community Software Consortium.All Rights Reserved http://epas.csc-ma.us/PublicAccess/PagesiParcelSummary.aspx?MenuID=3&LinkiD=193091&Commcode=210 111 Residential Property Record Card Parcel ID: 210/058.A-0019-0000.0 MAP: 058.A BLOCK: 0019 LOT. 0000.0 Parcel Address: 42 BAY STATE ROAD FY; 2017 PARCEL INFORMATION Use-Code: 104 Sale Price: 0 Book. 01475 Road Type: T Inspect Date: 03/27/2015 Owner: Tax Class: T Sale Date: 01/01/1980 Page: 0111 Rd Condition: P Meas Date: 03/27/2015 TAMAGNINE,JAMES E Tot Fin Area: 3120 Sale Type: Cert/Doc: Traffic: M Entrance: X Address: Tot Land Area: 0.31D Sale Valid: N Water: Collect Id: RB 42 BAY STATE ROAD Sewer: Grantor: Sewer: Inspect Reas: C NORTH ANDOVER MA 01845 Exempt-B/L% 0/0 Resid-B/L% 100/100 Comm-B/L% 0/0 Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: DK Tot Rooms: 12 Main Fn Area: 1468 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 Story Height: 2.35 Bedrooms: 5 Up Fn Area: 1632 Bsmt Area: 1212 Seg Type Code Method_ Sq-Ft Acres Influ-YIN_ Value Class Roof: G Full Baths: 3 Add Fn Area: Fn Bsmt Area: 1 P 104 S 13700 0.310 N 181,559 Ext Wall: AB Half Baths: Unfin Area: Bsmt Grade: DETACHED STRUCTURE INFORMATION Masonry Trim: Ext Bath Fix: Tot Fin Area: Foundation: CN Str unit _Msr-1 Msr-2 E-YR-Blt Grade Cond %Good P/F/E/R Cost Class Bath Qual: T RCNLD: 241393 Kitch Qual: T Eff Yr Built: 1970 PA S 150 1988 A A /50//42 1,500 1 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1906 VALUATION INFORMATION Sound Value: Fuel Type: G Grade: A Cost Bldg: 241,400 Current Total: 424,50D Bldg: 242,900 Land: 181,600 MktLnd: 181,600 Fireplace:. I Bsmt Gar_Cap: Condition: A Att Str Val 1: Prior Total: 405,40D Bldg: 227,300 Lard: 178,100 MktLnd: 178,100 Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: /1001173 Porch Type Porch Area Porch Grade Factor p 216 Sketch Photo 12 24 FL I 19R 276 411 12 1212 SI-R 17 ; 48 6 7 G 6 42 L-54- BAY STATE ROAD Date.. . . ..... . TOWN OF NORTH ANDOVER PERMIT FOR GAAJtLtTALLATION �9SSACHUSES This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . t t . has permission for gas installation . . in the buildings of . `.. .. . . . . . . . . . . . . . . . . . .. . . . . at . . . .1.: —V. .. // . . ! .�. . . . ., North Andover, Mass. Fee. .`� .�. . . . Lic. No. 3 ? . ... . Qs . . . ... .. . . . . . . GAS INSPECTOR Check# 5587 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) AIJ0 >(EL, Mass. Date 6 Permit# Building Location RAS( 5-TATE KID Owner's NameJA AFS TA MAG N I NE WO H A 1,32mck ) IA 01$�,j Type of Occupancy_ LE S 1 DW 1"M L New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ � o Y W N N N r� Z V! 0 0 J Uf W O U z x F- s >. z z O F- ¢ ` W O N 0 W d to = = H N y C tri \ W .4 O. > 1' Q W J Q Z F. H N Q 4 }- U A N W ��7 m 2 O Z W O fV�l X Yt > OC W � 2, � rt S oC '.x O 0 Y u. 3 a 0 _j v ¢ > G CL O SUB-8SMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET �C) Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone q 7 5-6 87=110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and accur4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will�In mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j � T e of License: Title Plumber Signature of Licensed Plumber or Gas _ Gasfitter City/Town Master License Number_374'5 APPRCaVED O FILE SF ONLY Journeyman i BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING ' LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE .19 GAS INSPECTOR I Date... .... .......................... j'�NORTM,hOp TOWN.OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .� gCMU This certifies that �L- P�" ...................................................................................................... has permission for gas installation .......... ag in the buildin soft v�°�-�!" t ............................................ .................................................................... at....4z.......-� `..... .e--........12 X North Andover, Mass. '� .. Fee3. ..a.... Lic. No. ..4;5b ....................................................... GASINSPECTOR Check# 4ui Z 91 03 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE - -I PERMIT# JOBSITE ADDRESS _� OWNER'SNAME InIPS1'YIAG/I�n GOWNER ADDRESS _ TELA FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT Q- CLEARLY NEW:[Q RENOVATION:D REPLACEMENT:13 PLANS SUBMITTED: YES NO® 1 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =J=j ___.l _._ BOOSTER I I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I I [— DRYER FIREPLACE _ FRYOLATOR _ .� J _ (--[-- FURNACEI __- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _ Si ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER E WATER HEATER OTHER II.. - - - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES 10 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z7 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. CHECK ONE ONLY: OWNER (moi AGENT SIGNATURE OF OWNER OR AGENT S 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 1 and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision 9f the Massachusetts State Plumbing Code and Chapter 142 of the General L Ws. A PLUM BER-GASFITTER NAME - ---' � ,;� _ LICENSE# _ ( SIGNATURE MP© MGF 0 JP® JGF LPGI© CORPORATION©#=PARTNERSHIP®I# _ LLC®# COMPANY NAME: ADDRESS CITY �l _ STATEZIP TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES No THIS APPLICATION SERVES AS THE PERMIT Yes El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � y The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly I/ 1 Name(Business/Organization/Individual): Address: City/State/Zip: ziorlrl�dolll Phone#:. Are you employer?Check the appropriate box: Type of project(required): 1. am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.I 7• ❑Remodeling - ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 [J Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself o workers'comp. c. 152, 1 4),and we have no Y [N P § ( 12. Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 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 anew affidavit indicating such. tContractors that cheAthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Al"nsurance Company Name:- L., �/ ► r Policy#or Self-ins.Lic.#: Expiration Date: --� Gtr Job Site Address: Ai C ty /State/Zip:: Attach a copy of the workers'co pensation-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 certo under the pains and penalti ,f perjury that the information pro v! a ove is true and correc4 Simature: I;eData / Phone#: O' U�—�i )3 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 orimplied,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 producedacceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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(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 6.00 Washington.Street Boston,MA 02111 Tel#617-727-4900 at 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 wWW.MAss,gQVMa NwEAL,- 6F..MAS$ACNt1SETiS� � �° "PL'�1!JIBERS��ND'GASFITTEKS �' w LIGEn ED JOIHE riNEYMAN GASFITTER , + ISSUES TA90VE LIOENSE TO ' s YR r MARK TA`s NARD.'. ti 210 G R E N BL 9 L0'ND0NDER NH :03053 2364 150310, Date.2.16114 T TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......�.Onk......... .................. ............. ............. ... .... ... .. ...... ... has permission to perform ................................ ..... ......... ................................ wiring in the building of...................4.4::....... 7, ► at .....A....... ...J.qwf ............................ orth Andover,Mass. Lic.No. Fee .......... .. ... . ............................ cT�� ELFcnmcAL"INspEcrOR Check# Z-- 12147 Commonwealth of Massachusetts Official Use Only Permit No. e Department of Fire Services Occupancy and Fee Checked s BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT rN NK OR TYPEALL INFORMATION) Date: 2_- (.-k4 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) 42- 3ra� S- � i -L Owner or Tenant ,�q,tic5 '1.4 Telephone No. Owner's Address 4 2- S 1 Is this permit in conjunction,,with a building permit? Yes ❑ No 0 (Check Appropriate]Box) 7' Purpose of Building hAiMt.-, Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters (` Number of Feeders and Ampacity Location and Nature of Proposed ElectricalWoPrk: - ✓IS i'm � r-'j S�v��,, C Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ( KVA No.of Luminaires Swimming Pool Above El ❑ o.o mergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No,of Zones No.of Switches No.of Gas Burners No.of Detection and -�- Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons g No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained p Totals: " ' ".......""....""... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Ky Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No,of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent �G OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5�O'9 (When required by municipal policy.) Work to Start: 2.-(m�k L[ 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:) Icertify,under the pains and penalties ofperjury,that the information on this application is true and complete.FIRM NAME: _ r� c S-e r,J l d�r LIC.NO.: J4 IS 5 Z-cj Licensee: PZ d,.,,,-Z c&,,,o Signature LIC.NO.: 4/6oi1- afapplicable,ente "exemp"in the li eVse number line.) Bus.Tel.No.: 103-5 K2--Yri Address: ���( �X- �.., IJP L13o?� Alt.Tel.No.: 603-233- *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: 1 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the 4 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Ed Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Id Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F?] Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: PassV,M Failed Re-Inspection Required($.) ❑ Inspectors Commen -1 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com J The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information �+ Please Print Legibly Name(3usiness/Organization4ndividual): 41,,,,L– Address: 71 �)�k al &.�. City/State/Zip: S �,, t QJ k- Phone#: O 30- Are you an employer?Check the appropriate box: Type of project(required): 1.V9 I am a employer with -3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.t �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.( I Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i-Homeowners who submit this affidavit indioating the$are doing all work and then hire outside contractors must submit anew 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. .1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#:_ U Q® 2 -1 Expiration Date: '7 14 Job Site Address: <{ 1_ 3AB S — City/State/Zip:_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine .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 Investigations of the DIA for insurance coverage verification. Ido hereby cerpunderth p ' s and penalties ofperjury that the information provided above is true and correct Signature: Date: 2--6 -i Phone#: Go 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 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 producedacceptable 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 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,arc not required to carry workers'compensation insurance. If anLLC 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(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. Anew 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: ` ho CQMMOzkweaith of 114assaclausetts Department of Industrial,Accidents Office ofInvestigat7iom 600 Washington Street Boston,NMA.02111 TeX.#617-727-4900 ext 406 or 1-87MA.SS.AFE Fax#617-727-7749 Revised 5-26-05 wwwauass,govma COMMONWEALTH OF MASSACHUSETTS UQARD(3F Wk!CIANS ISSUE5 THE FOLLOWING L10ENE 'AS A REGISTERED MASTER. FE-LEC TRI"CtAN ALi'INE ELECTRICAL`' SERVICE I;NCa ` s� R I CHARD F Df LVECCH 10 I 7 DEERF.I;�L-D S U-M rJ 1 03079 15929 A OT 31/16 < 36133 1 . North Andover MIMAP February 6,2014 i r °w Staten °a Bays: ik i 3 € a: I i. H, Interstates —I SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, -- Roads Meters Data Sources:The data farlhis map was produced by Merrimack 1401111 Valley Planning Commission(MVPC)using data provided by the Town of r Easements Of North Andover.Additional data provided by the Executive Office of O MVPC Boundary 2.e'�s� r�.e 00 Environmental Affairs/MassGIS.The information depicted on this map is ❑Parcels 3' L far planning purposes only.It may not be adequate for legal boundary F p defnilion or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING i ► THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Ri ;, # OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT #r, �� M ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ty THIS INFORMATION �1SSACMUSet 1"=32ft GENERATOR APPLICATION DATE: 2-t.-1, LOCATION: OWNERS NAME: Jests -4c � GENERATOR kw �3 NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: 6-o3 - 4 <- ELECTRICAL GAS � NaT RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: a *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVALe"-" I v