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HomeMy WebLinkAboutMiscellaneous - 443 BEAR HILL ROAD 4/30/2018 443 BEAR HILL ROAD 210/064.0 0112-0000.0 r i Location / Y,3 ec� No. 3 58 Date 1 q NORTH TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ cNusEt� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector i34U` 9 ,p Div. Public Works i { / { XXXX]iC ' �t�c f f PERMIT NO. �S� APPLICATION FOR PERMIT TO BUILD' ' ' ' NORTH ANDOVER, MA NIAP NO. LOT NO. // 2. RECORDOFOIVNERSIl1J DATE BO OK PAGE ' ZONE SUB DIV. LOT NO. LOCATION 1._ PLL A\ - — (') PURI'OSEOFBUILDING Q Q� ` e�� OIVNER'S NAME �i`1` I T V NO.OF STORIES , v\- SIZE v�Q OWNER'SADDRESS J /� BASEMENT OR SLAB ro �I,An ARCHITECT'S NAME SIZE OF FLOOR TIMBER$" 1 // 2NO It). BUILDER'S NAMESPAN \ 1'\ w DISTANCE TO NEAREST BUILDING DIMENSIONS OFSILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR } DIIIIENSIONS70FGIRDERS r AREA OF LOT �._ FRONTAGE v IIEIGIITOF FOUNDATION h� THICKNESS .� IS BUILDING NEW SIZE OF FOOTING /� �� 5'�I d T(�l�os r I. _ IS BUILDING ADDITION LAMATERIAL OF CHIMNEY p ,Ov^ IS BUILDING ALTERATION JC IS BUILDING ON SOLID OR FILLED LAND �( WILL BUILDING CONFORM TO REQUIRIENIENTS OF CODE e S 1S BUILDING CONNECTEp TO TOWN WATER ` BOARD OF APPEALS ACTION, IF ANY ti t.V IS BUILDING CONNECTED TO TOWN SEWER 5 i IS BUILDING CONNECTED TO NATURAL GAS LINE }ij�,o INSTUCTIONb 3. PROPERTY INF016L T[ON LAND COST EST.BLDG. COST 43005 PAGE I FILL OU'}SECTIONS 1-3 EST.BLDG. COST PER SQ. FT. EST.BLDG. COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERAIII NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: G PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING 1N ECTOit DATE FILED OWNERS TEEN — 3 `J � CONTR.TELH to Q - S CQ 'j J 0 CONTR.LICl1 SIGNATURE OF-OWNER OR AUTHORIZED AGENT ,I FEE $ / �/' ✓ ILLC•# PERMIT GRANTED ll 19 Revised 5/5/99 J111 s ." FORM-U ­LOT' RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from- Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. "*,�I✓ 'L1CANT FILLS OUT THIS SECTION******* APPLICANT " t-4- P� PHONE &81 ' -3 �O- � LOCATION: Assessor's Map Number ULA PARCEL SUBDIVISION LOT (S) STREET A ° ST. NUMBER__�/(/ USE RECOMMENDAT IONS OF TOWN AGENTS: J14'�'��L� c LA 511 R 0NSERVATION ADMINISTRATOR DATE APPROVED 7 ry DATE REJECTED COMMENTS NO , , f TOWN P NNER DATE APPROVED DATE REJECTF� COMMENTS l Q1Z-P.t` hAX:h A P L p �"Gi int IIIQ��;1 ) L Q o 4 ZC t FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWER/WA T ER CONNECTIONS DRIVEWAY PERMIT agFIRE DEPARTMENT RECEIVED SY EUILDING 1,NSPECTOR OCT 2 5 INGI Revised 919;jm - „ .- la LDING DIEPAR i 61 ENT� Town of North Andover F AORTM OFFICE OF 3�O c' baa COMMUNITY DEVELOPMENT AND SERVICES p * - 27 Charles Street 116 c�9 WII.LIAM J. SCOTT North Andover, Massachusetts 01845 "SsgcFHus���y Director (978)688-9531 Fax(978)688-9542 :FAX TRANSMISSION DATE: f I- 3 9Q TIME: l0 ' 00 Qm # OF PAGES: _2 INCLUDING COVER PAGE FROM: Arnq Sc(omoiL , Planni1-,- A55 S*anq' SUBJECT: BUILDING DEPT FAX#: 978-688-9542 SEND TO FAX #: 961 - 2666 REMARKS: Please ca[I c soh aaq c uesHonS. 0''7 6- (A6 - g 535 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 wY�r�ny / � itt C., 3 i•it'� t a y. r E e I r 4��Jam'^�_�_ � • �» ���,_ . S . . / ���y� � ��-»�,,.��,��\ . �� �\» {� � *� \/ \� y �� . \ ri / \y % | ._��_��..»v:; �y � . ! \ | \ 1 yy % I ���_� . � _ . � ~ . ; ] �, . _� y > 2 � . � \ � ; � �« . ! z | « � !7 ! � ® ; -_����x. _ � » , , �� � ~ �` �� � �r | i p �| ��. ;�� 3 }_ . . «� � . � � ` ` { \ /. } : � P . � � { ( \ � : { * . ) / ���-- � ��....(���` � , | � . � . . . . _ _ } ` } � � . ^�\ ( � } ]_. . . _. . . . � . y � \ ` � . � ^ � �\ . � ( � . � { � � � � :2 z . \ � ~ .�� \ �� . ` � ` / � . ( � . --��.�. � . \ � ` / x - { z z � . \ : x� > y . ® ( y/� � . , . \ . �_����. .y�_§� / �/z'�� , . r ���_�. . � �-© /- {�� . . t � ..,e ` ,! 5A C 'r t [ Ea S ..._..._.n—,,,,._....�......e,.. _,.�,.�.._--_-._�--._,_---- .... . __ �' -�� ";f.-. , a .,+...y` ��`t 'Ir �s.�_... .. ....� .n. m:: s' .._ f.�.. - -. �.... ._ .. - � _ - j� �V' r __,......_._.._._.�........�....,-� �R __ _ _ F' ems-ter+—+. .�..m�u� �� / _ t `s. ' I j( f e £�_. q �--� 1 • J u The Commonwealth of Massachusetts Department of Industrial Accidents r d • Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name:—�_ C Location: �� �' y �1 ly l�/l1�✓►� �Y- CityO S`. �(2" -IX- Phone �(63 J am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers''compensation for my employees working on this job. Company name: l /T/-= ©G l i SCS Address City: S M � 6�3c):2 3 Phone#•(06 (?79 (� � Insurance Co. v fLv Policy# W C,-f Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify u der the pains and penalties of perjury that the information provided above is true and correct. C� Signature C, P Date Q l Print name 1 l ; 61,c121 ( ��� C �:jf'l, Phone# &63-M Ll'3?k Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept Lincensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other AC ORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y_Y) COPID ICD LLI-2 10/18/99 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Catalano Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 251 Broadway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Methuen MA 01844 COMPANIES AFFORDING COVERAGE William Corcoran (Renewal) COMPANY Phone No. 978-688-4667 Fax No. 978-682-9037 A COMMERCIAL UNION INSURED COMPANY B Liberty Mutual Insurance Group The Collins Company COMPANY Mike Collins D/B/A C Box 281 COMPANY No Salem NH 03073 D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $3 0 0 0 0 0 A X COMMERCIAL GENERAL LIABILITY CBR115624 05/25/99 05/25/00 PRODUCTS-COMP/OPAGG $300000 CLAIMS MADE rX]OCCUR PERSONAL BADV INJURY $300000 OWNER'S BCONTRACTOR'S PROT EACH OCCURRENCE $300000 FIRE DAMAGE(Any one tire) $100000 MED EXP(Any one person) $5000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND VJC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS ER EL EACH ACCIDENT $ 100000 B THE PROPRIETOR/ INCL WC131S227489029 06/13/99 06/13/00 EL DISEASE-POLICY LIMIT $ 500000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 100000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Operations usual to the named insured. CERTIFICATE HOLDER CANCELLATION CAPTVIL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Captain's Village Development P O Box 514 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Salem NH 01079 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R ESENT TIVE 1(��� William e43ACORD CORPO�'"" ACORD 25-S(1/95) RATION 1988 ' fa; y 3 , 1 r .ts-?r ! <dra _ li - . i ""-t ,} a r -.4,. 1 .4•`hti� 1 :x }.; r. L t,.F. > :7'. yF:: 'Z fd Y9'{ }'MP,j( i r Y ,£..f{ k .t } 1 S J , ".r ,..^ -#' '...1 t;c,.,ro.:y-?F a , ,� FF -}�',' a2 f :r4' 9 ]. .b.. t 't 'r. t „5.:"^ .t:. ry lis ylrr tri 3b"t f 4.{ l,r ', rt., 1 Ailr I,C.:. i f p 3 i. _ f ry.d ,• ;3 } 1. a r x it11 ,.a,�,a , 3` }t)ls zx• c ,r•­fz >,, `c• 1. :-, a t i a �. l s ;'. 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BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with.the provisions of MGL c 40 S 54,a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: kb� �g +e a haw G I Location of Facility (-�AA A A �J Signature of Permit Applicant Date .3 NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r - f . / � I • gym. j � a d ell /1�r>;�� �Ratlow,tYs �JVG?ohCK PLO Wor a i 31F $ Fi�[R ODiD 'prZt;lE- ti1i J� !ter ' r�3�vivdcvm�Tr �' CARTER 434301 : VAI L R o d 40g p scare• 1 A PROFESSIONAL LAND SURVEYOR, AMERICAN SURVEYING COMPANY DO HEREBY CERTIFY;THAT THE ABOVE MORTGAGE INSPECTION 77 Rumford Avenue, Waltham,MA 02154 (617)893-6477 PLAN WAS PREPARED FOR 41uuieM&a FuNriiNv Gca RJN CONNECTION WrrHANEW MORTGAGEMortgage inspection Plan 4ND IS NOT INTENDED OR REPRE- SENTED TO BE A LAND OR PROPERTYTHE LOCATION OF THE ORIGINAL RECORDED Al. COUNTY REGISTRY OF DEEDS LINE SURVEY. NO CORNERS WERE . DWELLING SHOWN HEREON ETHER BOOK Z~-( _PAGE _S_ I __LG. Cert# SET; R CANNOT BE USED FOR ES- WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: 4MI11Z TABLISNING FENCE, HEDGE OR APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN 01= ASSESSORS 3UILDINGLJNES.T}1ELANDASSHOWN FELT WHEN CONSTRUCTED WITH RE- MAP PARCEL: DATED HEREON IS BASED ON CLIENT FUR- PTE x LL V_o o p NISHEb INFORMATION AND MAY BE SPECT TOIIORIZONTALDIMENSIOP1Al ADDRESS: NISH ECT TO FURTHER OUT SALES, REQUIREMENTS ONLY),OR IS EXEMPT A L�uC� M 4,SUB . FROM VIOLATION ENFORCEMENT AC- BORROWER: P&U TAKINGS,EASEMENTS AND RIGHTS OF NAY. )`{Q RESPONSIBILITY IS EX- TIONUNDER MASS.G_LTITLFVII,CHAP. G TENDEDHEREINTOTHELANDOWNER 40A, SEC. 7, UNLESS OTHERWISE SUBJECT DWELIJNG UES IN FLOOD ZONE DR OCCUPANT, IT 15 NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS,SHOWN ON NATIONAL FLOOD INSURANCE PROGRAM FLOOD 01 BE CUPANT,RECORDED, FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED ��ur I. 19 V3 IS ADVISED WHEN STRUCTURES ARE COMMUNITY-PANEL 0 I� DATE 4 J I, - q3 SHOWN TO BE V OR LESS FROM CLIENT Ca�ilt_I�AtJ PROPERTY OR REQUIRED ZONING 9Y FIELDED DRAFTED CHECKED CLIENT REF.# SETBACK LINES. nATF c.4-u. 4 t L�_ r .st-t 'd 0_q:A F R PrF. i NORT1y Town ® ` OL dover 0 No COCCr1l E dover, Mass., / �$ 2 ORATED P9 C1 5` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT...., .R.............V r p A 1, �� BUILDING INSPECTOR • ......... .... . .... .......... Foundation has permission to erec �........ ..�..... buildin son ..... .� '...... e01 /Y/I/ "Al .......... Rough to be occupied as......svo ro 0 0 c N .b E ��, . . . . .. . . ......... ................... ....................................................................... 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 to 1 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRJC N T ELECTRICAL INSPECTOR L• & Rough 1 q, ,r .......... ............... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. r ' Ate Date. ........................... kORTN °���``°:•�"� TOWN OF NORTH ANDOVER 3? �•,r ..,.._,. OL p PERMIT FOR WIRING �,SSACMuS This certifies that r' has permission to perform � ... ........................ wiring in the building of-:.: ...... y.. ..........North Andover,Mass. 1�Fee. ............. Lic.No/ y� j . . . .. . ELECTRIC L INS CTOR� ` Check # /G t 7755 �} Commonwealth of Massachusetts Official Use Only ~ Department of Fire Services Permit No. /1S' UV Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 :MR 12.00 (PLEASE PRINT LN INK OR TYPE ALL INFORMATION) Date: l) S p City or Town of: NORTH ANDOVER To the Inspector of tVire, By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ?j g LsPR �,U b Owner or Tenant Nie - IVB (�5.A D f-\ Telephone No. Owner's Address Sp,M L Is this permit in conjunction with a building permit? Yes 2 No ❑ (Check Appropriate Box) Purpose of Building ` Utility Authorization No. Existing Service Amps / olts Overhead ❑ 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: R�► J uta SGy��w 5 jZ} ]�i11--`fZ Svc �[ J-7St2 1�,✓T�t) t®- Completion ►Com letion of thefollowing 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 ❑ In- ❑ o.o Emergency Lighting rnd, rnd. Battery-Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners o.of Detection and InitiatingTotDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons KW No.of Self-Contained Totals: -� Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Municipal P g Local❑ Connection ❑ Other No.of Dryers Heating Appliances , Security Systems:* No.of Devices or Equivalent No.of Water aaeaters KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP ' Telecommunications Wiring: Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: 1��`������( - t��+�, Signature LIC.NO.: J 3 Ybd 14 (If applicable, enter"exempt"in the license numbb lrine. Bus.Tel.No.: S ze 6(29G�9 3 Address: 1) CA -S� �, I > V612 10 (3-1 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 10 r (W `Y t y The Commonwealth of Massachusetts Department of Industrial Accidents 1j Office of Investigations 600 Washington Street Boston, MA 02111 i www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers A licant Information Please Print Leaibl Name(Busines1s/Organization/Individual): Address:_ ( sr /Zi /Stat Cityep:_ } �:S�i1 c J N4 Phone#:� ? Ad ��3 1 _� Are you an employer?Check the appropriate box: Type of project(requires: 1-❑ I am a employer with 4. ❑ I am a general contractor and 1 6 Q New construction _ etnoloyees(full and/or part-time).* have hired the sub-contractors 2. am.a sole proprietor or partner- listed on the attached sheet._ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q 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.G- lectrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself.[No-workers'comp. c. 152, §1(4),'and we have no 12.[] Roof repairs insurance required.]t employees. [No workers' comp. insurance required..] ME]Other 'Any applicant that checks bo)t#I must also fill outthe 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 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 u d r the ins d realties of perjury that the information provided above ' true anil correct Si afore: Date: Phone#: OMial 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#: I I n and Instructions ` Information � 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 wank 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 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-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,nottthe 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 600 Washington Street Boston, MA 42111 Tel. #617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 . 4vww.mass.gov<dia so 11'6). - 2t� 51 Date... t „ORTM 1 "o TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41 This certifies that .......[.!.!. �'..V2 pbi a C �� t V J� .................. ............. .................... has permission to perform ..... ..t..f.�...�E:�}.......... // ......... wiring in the building of r f 61 �G It at.... .. ...../J.fs,2....! :.�(.... �'L............. .North Andover, ass" w Fels vv Lic.Noka..:./? EGECTRICALINSPECTOR (a�-7 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer TBEO!)AMO1 WE-4LTHOFM S 4CHUSETIS _ office use only DEPARTMENTOFPUBLICSAFETY - Permit_No. - �co M f BOARDOFMEPREVEONRWULATIOMR7CM IZ-W _- VA Occupancyy&Fees Checked PLICATION FOR PERAff TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. MAP Location(Street&Number) 3 /Glr Owner or Tenant h U PARCEL Owner's Address a,9'5 d Flf R H/L-/- R D Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building 1)k yL IN 6L Utility Authorization No. Existing Service Amps / Volts Overhead F7 Underground M No.of Meters New Service Amps / Volts Overhead [=] Underground No.of Meters --� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work'. K 7 C-a—A-Al 4 P D /T(0'Al No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators- KVA and ound No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of-Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local a Municipala Other Connections No.of Water Heaters KW No.of No.of Si Bailasis rNo.Hydro Massage Tubs No.of Motors Total HP ,OTHER IrnxanwCotiaage.RasuatttlDftmgtmarX lsafM%mdnse!$GmaalLam Iha,,eaanatLnbt7dyhmra=PcbyatdukgCaT#At CovwdWcriissisharidegttivakrrt YES © NO a Charestrbrn&dvalJdprtx bfmnemtheOfce YES rJ NU If}puha%edxdWYES,pi=mdc*it M3ecfwmaWbydcdcrgthe bcx 1NSURANICE © BOND ® oT ER ftaseSPey) L / /G T Y /IV S c//y,4 Ar C F Expiratirn Dai EtmEdod Vahreo(E]earizi Work$ WedctD Statt LVadm D*RegtxsW Rough Final � 1 y�q Sigm d u ndxTie Rmities Ofpetjuey. FIRM NAME AA ,C X e%slit /t C k A U LioatseNa M /2 Lioa>see l G f/,� 14 D ilrC,a/li/r�y�, Sigm"e �,� �•� �-�� L+censeNo Br6IItea"'STe.Na Addte,5 ti d.IL/a 7)RfyF S ILf.�j ...A/> � AIL TeLN). OWNER'S 1r�LJRANCE WAIVtR;l.anawatethattheI�oers9edocs trr�t4>�etheiri5uarneoD�etrilsst�ar>bales;uivatentas regtrrtadbyMassadas�ts Galeal Laws aDdfl�atmysecxtllaspermitappfic�ttwai�ttuste�utaatrlt. (Please check one) Owner Agent Telephone No. PERMIT FEE$ t MORTF � NORTH ANDOVER BUILDING DEPARTMENT �,wc 400 Osgood Street s� s Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: / 2/ .Z//2 o U NAME: A2 h ee, � 11417 JO v e I- ADDRESS: 3 12�� �71i`/l LQ ell ZONING DISTRICT: TYPE OF BUSINESS: Z�7-1c 01 BUILDING LAYOUT PROVIDED: YES �NV AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE U� L Y Revised 11.5.04 BLISMSS FORM FOR TOWN CLERK � •A December 21,2004 Mr.Michael McGuire Local Building Inspector Town of North Andover Building Department Dear ML McGuire, SUBJECT:DBA I run an Internet-based business selling collectible coins. In order to accept credit card transactions I need to open a bank account under a DBA. Because this business is internet-based,it is run from my laptop on a desk in my basement. Total amount of space dedicated to this business is less than 10 square feet. All mailings received through the business are delivered to a Post Office box in Andover.No office dwelling is necessary. Sincerely, Andrew Scoppa i 443 BEAR HILL ROAD NORTH ANDOVER, MA 01845 /41 1 Date.... ..............0......... 0- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......................... ................................................................ has permission to perform ................................................................ wiring in the building of ......................................... at.... .... . ......... orth Andover,Mass. ud 0. ...... Fee,— ........... Lic.N ....................... 44 ELECTRICAL INSPECTOR Check # e) 5472 The Commonwealth of Massachusetts °"'�' °"'y I Department of Public Safety Pamn No. r r � rs� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy 8 Fes Chock 3/90 thaw Conk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Maasachusett's Electrical Code,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date The undersigned applies for a permit to perform the electrical work de ib below. To the Inspector of Wires: Location (Street & Number) 3 Owner or Tenant Owner's Address '/9"M r Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building 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 Electrical Work No.of Lighting Outlets No.of Hot Tubs Total No.of Transformers KVA No.of Lighting Fixtures Swimming Pool Above In rnd. ❑ )md, ❑ Generators KVq No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Batte Units No.of Switch Outlets No.of Gas burners FIRE ALARMS No.of Zones No.of Ranges No.of Air Cond. Total No.of Detection and tons Initiating Devices ,No.of Disposals Heat Total Total No.of Pumps Tons KW No.of Sounding Devices No of Dishwashers Space/Area Heating KW No.of Self Contained Detection/Sounding Devices ANO.of Dryers Heating Devices KWMunicipal LErin ❑ Connection[]Other No.of Water Heaters KW No.of No.of oltage Signs Ballasts No Hydro Massage Tubs No.of Motors Total HP OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws �-- I nave a current Liability Insurance Policy including Completed 0 ions Coverage or its substantial equivalent. YES LJ NO ❑ I nave suommed valid proof of same to this office. YES LT NO ❑, It you nave checked YES,please indicate the type of coverage by Checking the appropriate box. INSURANCE ❑ BOND ❑pTHER❑ (Please Specity) AP'( / A. T,, / a Est maied Value of Electrical yvOrk$ 67i r— (Expiration Date) Work to Start j b Signed under the penalties of perjury: / FIRM NAME \ N LIC.NO. O Q� Licensee LIC.(' 1/ars Signature LIC. N0. Aooress_ /Yh /R /,�/ �'i 7—(.L,/X Y 1 v/� u, Bus.Tel.No. moi_ 7 Y7 AII.Tel,No. `I O d ^ -.t"/ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage or its substantial equivalent as required by Massachusens General Laws,and that my signature on this permit application waives this requirement. Owner•❑ Agent ❑ (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) /�j N2 37 - 70 Date......... AACMVI VAORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ........ ...........r.................... ......................... has permission to perform ........................... ................................... wiring in the building of .?. ... ,r ?................. at........I...j.../2)....A�/....................... North Andover-,Mass-t--,"- Fee... Lic.NoA7 T,2(................. ......................m,........ �ECE Check # C�R I&AL INSPE6l"OR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of MassachusettsFd Official Use Onl Department of Fire Services 7 �.... BOARD OF FIRE PREVENTION REGULATIONS Fee Checked . (]eaee blank;) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All,work to be performed in accordance u ith the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) D a te: City or Town of: �Q • J�'�t �d V'eC" To the Inspector of Wires: By this application the undersigned gives notice of his or her ntenuon perform the electrical work described below. Location(Street&N tuber) ' Owner or Tenant rt Our a Telephone No. q� � �•J�� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 56 (Check Appropriate Box) Purpose of Building Utility Authorization Na Existing Sen�ice Amps / Volts Overhead❑ Undgrd❑ No. of Meters New Ser%ice Amps / Volts Ovcrhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work md., Yl Yo L Completion o0he followinz table may be waived by the Inspector o(j ires. No. of Recessed Fixtures No. of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA Iv'a of Lighting Outlets INo. of Hot Tubs Generators KV A No. of Lighting Fixtures IS�`•imAbove Pool ❑ !n- o.o mcracnc ming ❑ b y Lighting 11g tina II grnd. �rnd. Battcry Units No.of Receptacle Outlets INo. of Oil Burners FIRE ALARMS INo. of Zones No,of Switches INo.of Gas Burners INo.of Detection and Tnitiating Devices - . No.of Ranges 1.No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers (Heat Pump Number Tons KW INo. of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers ISpace/Areaffeating KW . (Local ❑ Municipal ❑ Other Connection No.of Divers Heating Appliances KW Security Systems: / 11 No.o Water K,W No.o o.o Na of Devices or Eauivaient 6 Heaters Data Wiring: Signs Ballasts Na of Devices or Eouivalent No.H}•dromassage Bathtubs INo. of Motors Total IiP Telecommunications Wiring: Na of DeN ices or E ui%alent OTHER: Attach additional detail if desired,or as required by the Inspector of II'ires. 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:) / ' (Expiration Date) Estimated Value of Electrical Work. q LN (When required by municipal policy.) Work to Start 61 Inspections to be requested in accordance with NEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this°application is true and complete. FTRi1'I NAME: ADT Security Sen•ices 111 Morse Street,Non o(l.MA 02062 LIC. NO.: 1333C Licensee: John S. Bassett Signatur LIC. NO.: 1S33C (If applicable,enter"esempt•'in the license number line.) Bus. Tel. No.: 7M——l1 Address: Alt. Tel. No.:603-594759 resi OW'NER'S INSURkNCE WAIVER: 1 am aware that the Linnsee floes not have the liability insurance coverage normally ONLY required by law. By my signature below, I hereby waive this requirement. 1 am the(check one)❑ owner ❑ owner's agent. OwnerlALTnt I — __ __ I IV.ONon I