Loading...
HomeMy WebLinkAboutMiscellaneous - 44 CIDERPRESS WAY 4/30/2018 BUILDING FILE Date. . !641111: . 9455 R'M TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING 40 ,SSACMUS� This certifies that . . . . . . . . . . . . . . . + has permission to perform plumbing in the buildings of . . . u?/rif'�sif, at . . ,1�T -xl. �Sf. . . . . . . . . . ,�. .... . . ,/North ndover ass. Fee.� c Y.Lu. No...�. 7/57 . tt/.1�,�✓r'4�! :V-�,�i�. . . PLUMBING INSPECTOR Check # Date.. MONTM 6 o� °� TOWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION , h SACHUSEtS / r This certifies that . llke. Xelle!�. . . . . . . . . has permission for gas installation ° ./� . . . . . in the buildings of . . I*J,4hh' ovle Cv�'h�ior�1 at . . . y7. . . ! ? .'P1J. . . . . . . . . . . . , Northamo der, Mps. Fee. Lic. No. . . ... . . . . . . . . ,�'r GAS INSPECTOR Check# /7 7�✓ 8205 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY - �Vg-1 -� MA DATE PERMIT# I�,pa JOBSITE ADDRESS _ ,SS __ OWNER'S NAME --- '�_ OWNER ADDRESS TEL[ � — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0-I RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:E] REPLACEMENT:[t- PLANS SUBMITTED: YES0__f NO 01 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _,, w: CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _--J I- L-1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER .. LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT ('— TEST _f II .--J L ! ! ! _f . _I I _A UNIT HEATER UNVENTED ROOM HEATER 1-71 r. i !_ WATER HEATER OTHER qj 111-1 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES Jd0 [3 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [2"*' OTHER TYPE INDEMNITY EA 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 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 compliance with all Pertinent prov' ion the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. lei PLUMBER-GASFITTER NAME ¢ ( LICENSE# �` SIGNAT RE MP[dMGF JP JGF 0 LP—G]�M! CORPORATION 0# PARTNERSHIP D#=,;'LLC 0(# COMPANY NAME: ADDRESS _ !�.. _._ l------- CITY _ ____CITY _ STATE /W" ZIP _ITEL LU f P/ AJ FAX E==CELL MAIL ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes .No �. // THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /� /� FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations UT 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/fndividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I 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.El am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[J Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *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 a're 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 and job site information. Insurance Company Name:, 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 DTA for insurance coverage verification. I do hereby certto under the pains and penalties ofperjury that the information provided above is true and correct. Siamature: Date: 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.EIectrical 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 ofhire,• 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 eommonwealth 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-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 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 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 Department of Industrial Accidents Office QUA-Vestigations 600 Washington.Street Boston.,MA.02111 Tel,#617-727-4900 at.406 or 1-877,7MASSAFB Revised 5-26-05 Fax#617.727-7749 WVVVt-MasS,goV/dja MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ — _I MA DATE _/ PERMIT# JOBSITE ADDRESS i >u e S S OWNER'S NAME L POWNER ADDRESSTEL , off S FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL Q RESIDENTIAL d PRINT CLEARLY NEW: ©( RENOVATION:© REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO© FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB € __ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN -1 _.._-_-J ___J INTERCEPTOR(INTERIOR) ..._,_._( _ KITCHEN SINK I ---__.I _._-1 � J � I _.___1 ...._.___._I _...-..-__i __._...._� J _ ..,....__.__1 LAVATORY _ i _..-__► ._ ._ .-._._ I .----_-._i .-_._-.� ____...( _.____.J __.___-� .---_....J _._i ._.._-.- —€ _ _I ____-! ROOF DRAIN ,-j F-7-3 SHOWER STALL _f � ..._€ .------ ______.I SERVICE/MOP SINK E _-...._..__► _. ____€ __..___.,I __.__f .____! _.____._I ._._J _! .._...._.-_i ____ ._____1 ..__ ( . _.__� _( TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ; WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VNO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND Q 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: OWNER 0 AGENT _( I 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 compliance with all Pertinent pr vi f the Massachusetts State Plumbing Code and Chapter 142 oj the General Laws. t PLUMBER'S NAME LICENSE# - �/ SIGNATURE MP d JP CORPORATION©#=PARTNERSHIP D# LLC E COMPANY NAME _ f _ ' ADDRESS CITY[W I STATE ZIP dZ-07 6 j TEL FAX _ CELL 1p MAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes,, THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 7iG �z FEE: $ PERMIT# PLAN REVIEW NOTES P ALN\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit:Dodders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly j Name(Business/Organizafion/Individual): i I - - - -. Address: _--- -- - - -- ----- -- - -- — I City/State/Zip: Phone#: r2. you an employer?Check the appropriate box; I am a employer with ¢• F ect(required):' ❑ I am a general contractor and I employees(full and/or part-time).*' have hired the sub-contractors onstruction I am a sole proprietor or partner- listed on the attached sheet,t deling ship and have no employees These sub_contractors have tionworking for me in any capacity. workers' comp.insurance[No workers'comp.insurance 5. ❑ We are a corporation anditsng additionrequired.] officers have exercised their cal repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself: [No workers'comp. C. 152,§1(4),and we have no insurance required.]t 12.[]Roof repairs q ] employees. [No workers' comp.insurance required.] I3.0 Other aITEM=that chec:.s bo Yl m st also t11i cut F'uesection bel =to�� ,,��, .,mg E„eir workers:s,compms:-ion pol:cy info.-ma ion. 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 workerscompensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#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 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 true and correct. Sienature: Date. Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# 1 Issuing Authority(circle one): 1 I.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical InsL75. 6.Other Contact Person; Phone#• 1 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-houseor 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 colmpliance 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 Vatil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasefill 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 certificates)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 rota-iced to the c---,f or town thai the aolica-for the pe=�7is o�1rYeYlSe iS bung r�q'aeS*w d,not the D=per ter ent 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 (Le.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 Commonweal& of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel. #617-727-4900 ext 406 or 1-8.77-M. ASSA-FE Fax#617-727-7749 Revised 5-26-05 I NxrUnwr"ac V Date A/.vv............ 4,, .3. TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SSACINU This certifies that ............................................ ....... has permission to perfo 12 ...^.... ....r 1 ......................................... wiri, mth building of.....reel." ...L -!............ at. ... .. .................. .�orth Andover,Mass. Fee 39.�...... Lic.No. .I�OR ...MO....... .. .... . . . ..... ..... l ��CAL INSPECTOR Check 'ff (yo- 10890 Commonwealth of Massachusetts official Use Only a , Department of Fire Services PermtNo. %Pa BOARD OF FIRE PREVENTION REGULATIONS 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 C),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL.INFORMATI0A9 Date: L<'( t 7�— City or Town of. NORTH ANDOVER To theIn pec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ,t �S S C.v Owner or Tenant M P__1_) (>_G c:�tJ 5 e M, N 5 Telephone No. 6,j Owner's Address Gt.�. �. t�� .� , _ A� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building_ Es Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters ew Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letfon o the oliowintable m be waived b the Inspector o Wires. 4Dryers Recessed Luminaires L No.of Cell:Susp.(Paddle)Fans No.R Total Transformers KVA. Luminaire Outlets t L No.of Hot Tubs Generators KVA Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting Md. rnd. Batter Units Receptacle Outlets ') fl No.of Oil Burners FIRE ALARti3S No.of Zones Switches p No.of Gas Burners ( No.of Detection and Initiatin Devices anges ( No.of Air Cond. TonaTotal-3 No.of Alerting Devices • aste Disposers I Heat Pump Number Tons ' KW...... No.of Self-Contained otals: "'"""""' Detection/Alertin Devices ishwashers t Space/Area Heating KW Local❑Municipal ❑ Other Connection ryers Heating Appliances KW Security Sys ems:*. No.of Water Heaters KW 81 No.of Devices or Equivalent No. Bal as Data Wiring: Si Ballasts ts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices Or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lec rical Work: I lE� sJ (When required by municipal policy.) Work to Start-__,b < <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 cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [,BOND ❑ OTHER ❑ (Specify:) I certify,under th�1'ains and penalties ofpedilry,that the information on this application is true and cor:pl'Ete. FIRM NAME: Z.-A-n,.4-L LIC.NO.: Licensee: o t i t,�G �>��C,/,� gnature LIC.NO.: t o (Ifapplicab ,en r`exempt"in the11cenenumberline.) k0 Address: c u,s6. n S �� ;Ct,± -o Bus.Tel.No.: 3 L-Z c !7° *PerM.G.L c. 147,s.57-61,sec rity work requires Department ofPublic Safety"S"License: Alt. Lie.No. 6 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/Agent ❑owner's agent. Signature Telephone No. PERMIT REE. $ P ` _. ._ • MELI.iAA&ALPE TNO. .+..{FJJI.J=J`UJIJ.O' J.ei��.a•..J.� I �tJtJ.L.1CI?R.4CWJ-f 1NF5.R.ICip'yt '7'�CTOR••—• _ I'�ssei +'ailed- j Re-xnspectiozl repked($50.00) h8pectors'Comments: {.tr t 1 R•, (nsp ctoxs7 5ignatur zootiaT _ Pate 2.NWA LI�m9.'xc tlow; Passe$- aiTed�rte#�uspectio�xeruixec�($50.00) [ I Jn _etors'co eats; (Cnspectors'Pignatare•u ' 'als) Pate � 3,CJ T R CRODM I'NSI'EC7C'fOZY: _ 3'assed--j 1 p+'ailed--j I ' Re-inspection required($60.00)-'[ J -Inspectors,comments: . (Inspectors}Signature-no Initials) Date 4.INSPACIjON—SEW VjCW`: Passed.--[ ) Failed--[ ] �e-:nspectionxeq�red($50.00)�( � hnspectbrs'wmmeph: (fuse ectors,signature-io Wtials) bate 'assed- [ Iaiied--[ _ 'Re-InspectionregWed($50.00)•-[ � asp actors'coanboents: a spactors' ignatuxe no initials} bate D C)OP,TAQ9 AU r'O EE MLED OTQT.AO XEP'T OX RITE IF TM.AREA TO DE INSPECTED IS NOT .A.CCESSEM AND.A.EE SPECTZON OP`$50,0 010 TO 15CAA C-M- . The Commonwealth of Massachusetts fa Department of IndustriqlAccidints Office of Investigations UT 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):, A-1-ALA C e4 ,L 41 L__ Address: 3 f s B City/State/Zip: g g Phone#: `� 7Tf 37 t -0s'(6 Z— Are y an employer?Check the appropriate box: Type of roject(required): 1. I 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.# ?. ❑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. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. d 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. U`t-4n./OU��- t.N S ' Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 'I -L CZG—P-4-e5 S City/State/Zip:._ -(,/V v 4-Fry 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 DTA for insurance coverage verification. I do hereby certiry under thepains andpenalties ofperjury that the information provided above is true and correct. Si ature: q Date: b GS' t L_ 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#• 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 ofhire, express or implied,oral or written." An employeiis 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." r Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if t 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 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 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 Dopartment of Industrial Accidents Office of Investigations 600 Washiugton Street Boston,MA 02111 TO.#617-727-4900 ext 406 or 1-877,TMASS.AFB Revised 5-26-05 Fax#617-727-7749 wwwanass.gov1dia O.NORTH f� •r ,SS.IC/N5E4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 840-12 on 5/24/2012 Date: July 13, 2012 THIS CERTIFIES THAT Meetinghouse Commons LLC THE BUILDING LOCATED ON 44 Ciderpress Way MAY BE OCCUPIED AS a single family home_IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meetinghouse Commons LLC 115 Carter Field Road North Andover,MA 01845 Building Insp,ctor Fee: Prepaid Receipt: 25330 Check :2987 AORTFi T0 o ower 0 No. o o dover, Mass., /� COCHICHEWICK 7�s RATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System tq A BWDING INSPECTOR THIS CERTIFIES THAT........ ...nc..4"�' `?.c? ''/............................................................ Fou daition \ i O has permission to erect........................................ buildings on �� .....f .f' '.:ff..��.. .............................. ou >- �f� C/�/; �� `.ice "VA V Osr- hi y to be occupied as chi provided that the person accepting this permit shall in every respect conform to the terms of the application on file in n this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoningor Building Regulations Voids this Permit. `Rough �� �i �2 . 9 9 Final PERI✓ 7 EXPIIMES IN 6 MONTHS G / ELECTRICAL INSPECTOR UNLESS OONSTRUC 'IO "I' TS -Ug P�7 1, ................................ .. Service .. ....... BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final(,// No Lathing or Dry Wall To Be Done FIR_E-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner ' - Street No. SEE REVERSE SIDE Smoke Det. NORrH O SLED 16 qti o to _• APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION �9SSaCHu5BUILDING PERMIT # ADDRESS/LOCATION OF PROPERTY: 7 7 �-1 Arrwtv Map Parcell Lot Number y� r SUBDIVISION: LLG DATE REQUESTED FILED/READY FOR INSPECTION: Xllz frallL CLOSING DATE ON PROPERTY: FIVE 5 DAYS NOTICE PRIOR TO CLOSI ATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE CO P TED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLL S $20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL AP ICABLE C APPLICANT SIGNATURE Permit Issued to: l LLC C Address:11 5 AerK60p, . AA Ja' ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW ❑ ►J�p �`J��l" . CONSERVATION 40 b&Z qZ -111 9- 9 PLANNING ❑ N �,� oA. 4;e DPW-WATER METER lall SEWER CONNECTION ❑� DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW K6A SIGNATURE File:Application for OC form revised Jan 2007/2011 NORTH TO" Of _: Andover . No. mil -- � 0 o , dover, Mass., I�0 COCMIC1II Y ICK ✓�s RATED �' ,��� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ � i?P/�'. .. ..�� '!�...4.C��L !�/v f .... ........................................................................ Foundation has permission to erect........................................ buildings on ...���%. ss.. .............................. Rough to be occupied as Chimney �. <� provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS T ^ c ELECTRICAL INSPECTOR lJ i of LESS COg�I STRtT 7 J Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises -Do Not Remove Final No Lathing or Dry. Wall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer X Tanning/MassageMody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS_ N ,_Z gA cj . �-)09 Cha j�Inv)A-)U JV[) CONSERVATION Reviewed on Si nature .0 , COMMENTS MA DEP '2�jZ— b114 «a r� arae, t�DG ar Q AJlJ cu ir�nS HEALTH Reviewed on Signature COMMENTS_ L�6 cSY\ u\34 -ec Sewer Zoning Board of Appeals:Variance, Petition No: —' Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision:_Z y 2- i l l y Comme Water & Sewer Connection/Stqnature&Da Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -Temp Dumps r ite yes Located 384 Osgood Street ✓ _ no Located at 124 Main Street Fire Department signature/date /b� 12,,l lr COMMENTS The Commonwealth of Massachusetts Deparbnent of rndustrW Accidents Office ofrnveszi." ons ;600 Washinetsn Street Boslora, M4 02111 Workers' Compensation Insurance Affidavit- .� B��a Ao Iicant Information dens/Contraetors/Electridans/plumb- ers PIease Print 1, ably Name Business/o "z ` Address: City/state/Zip: A Phone#: Are you an employer?Check the appropriate box I•❑ I am a employer with 4. ❑ I am a Type of project(required): ire employees(full and/or * general contractor and I part-time). have hired the sub-co 6' New construction _.® I am a sole proprietor or partner- listed on the attached ship and have no employeessheet$ 7• ❑Remodeling Throe subcontractors have 8. ❑Demolition woz for me in any capacity workers, comp. [No workers'cep•ins ranm 5. ❑ We are a corporation and its 9• Burl ❑ dmg addition 3.E3req' ) officers have exercised thea. I0•❑Electrical 1 ain a homeowner doing all work repairs or additions rft s l£ o workers of�e i°m per MGL 11.❑Phmr � 'comp. c. 152,§1(4)s�we have no ���°i additions Insurance required.)fi cmPIWees- [No workers' I2•❑Roofrepairs COMP.insurance rte) 13.[]other `-- 1:ro�f that chi bus,t z ,n'II out the S=ia. FIomeownas who submit this at�dn it i t� ��,ata dsria€alt wa •C°�"""`°""" -''=�moa 'Coattacooia that t oris lrox must attached ao additi tuefl hire GnWde coamaco�s sabmit a mew affidavit iudi—wn -- - — - - ° -sheetahowinglbr-M2=-of&e cii- t3►—-— - I am art employer that is , boas and thea wtrrlaas•comp-t �i�ormarion informalio2 D1 wor&ers �n ;an mance fm,my employe= Below is the poficy and job site Ince Company Name: Policy#or Self-ins.Lie. Expiration Date: Job Site Address: Attach a copy of the workers'compensationC / : policy deelaraiz�p��( Fashne to secure coverage Section 25A la M shQR'in the policy number and expiration date fine up to$I,500.00 and/or one-year imprisormCTL C. 152 can lead to imposition of crimiBat Phi of a Of up to 5250.00 a da SII as civil penalties is the form of a STOP WORK O' and a fire y against the violator. Be that a,co Investigations of the DIA for migW ance cov "P9 of Eris sent may be forwarded to the Office of as Jr do herefiy cartify ceder pairs and ofP�?7my Sias&e infordwiion Sio.,at,,, V&rte and correct Offxid use may- Do not write to dl&mT,7, to be completed by city or town officiaL City or Town: Inding Authority PermitfUcense# rity(circle one): - L Board of Health 2.Burp Department 3_C' /Town 6. Other n3' Clerk 4.Elecical Spector 5.Plmnb' ms Inspector Contact-person Phone I - i I Nlassachusetts-Department of Public Saferi- Board of Building Re�,ula#ions and Standard's COnstruction Supervisor License License: CS 55417 Restricted.to .00,...- THOMAS.D ZAHORUiKO y 5 115 CART "ELD D N ANDOVE.R;MA 01845- s c Expiration: 44512012 �`+tmmi+sinner Tri€: 21090 MAP 104C1 LOT 30 ✓ ' ~�� I / I NOTES: 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A / MAP 104C LOT 29 PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT N/F ESSEX COUNTY SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, '.� GREENBELT ASSOC., INC. MASSACHUSETTS"; SCALE: 1" = 80'; DATE: JULY 20, 2001 BY THIS �• OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY 14.09' NORTH DISTRICT REGISTRY OF DEEDS. 2) THE INTENT OF THIS PLAN IS TO SHOW THE AS-BUILT LOCATION 1464, OF THE FOUNDATION ONLY. Ajp 13'24 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR FLOOD TAKEN FROM THE FLOOD RATE MAP 7Sp3B Tp�S/T U FOR TTHEONE TOWNSOF NORTH ANDOVER MASSACHUSETTSINSURANCE COMM COMMUNITY MAP 104C �Syp� �N�> / �`� PANEL NUMBER 250098 0007 C, MAP REVISED: 6/2/83. LOT 28 TOp4 < � /� �S?3 /� f 4) 11iE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED ______7 yry / Lo��sg7 1 SUBSTANTIALLY IN ACCORDANCE WITH THE 408 SITE PLAN AS yy / / h�hgl-q r`✓ APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. (13.11' �@�� \� // \ I HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT / NUMBERS 24-26 FOUNDATION SHOWN HEREON IS THE RESULT OF A ZN� FIELD SURVEY BY THIS OFFICE MADE ON APRIL 23, 2012. OF G� J ------ CHRISTOPHER � �` I -- \ \ $ FRANMER >• �� NO 36118 AL LICENSED LAND SURVEYOR DATE AL - CERTIFIED FOUNDATION PLAN / ^ MEETINGHOUSE COMMONS TOWNHOUSE UNITS 20-23 '�� A AL GRAPHIC SCALE CIDERPRESS LANE p a za 50 100 NORTH ANDOVER, MASSACHUSETTS -p d PREPARED FOR i q y�G�s I ''I'` MEETINGHOUSE COMMONS, LLC CD (IN FEET) 121 CARTER FIELD ROAD 1 inch 50 ft NORTH ANDOVER, MASSACHUSETTS / A / / // M SBM Road,SuBo One p / _ Salem,Now Hampohln 03079 Z _ i (603)893-0720 AnNGINEERS•PLANNERS•SURVEYORS �It / ` `_/ \ MHF Design Co-,Cttanb, Ane. SCALE: 1" = 50*1 DATE: APRIL 24, 2012 DRAWING NO. DESCRIPTION BY DATE DRAWN BY: CHECKED BY: PROJECT N0. NAME AL �jeOpl�F REVISIONS ___ CMF 250508 1 2505CFP.DWG 1