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HomeMy WebLinkAboutMiscellaneous - 465 STEVENS STREET 4/30/2018 / 465 STEVENS STREET J 210/096.0-0015-0000.0 I ' I I I I JI Location ��� �r •-✓� No. t ocj Dateof MART" TOWN OF NORTH ANDOVER 0 s Certificate of Occupancy $ s orb+,���`�• � �,SSACMUSEt� Building/Frame Permit Fee,$ 4 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3171 17 2- 9 5 // --Building Inspector t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONZftUCT WAM MOVATL OR DEMOLISH A ONE OR TWO FAMMY DWEU ING V BUILDING PERMIT NUIviBERDATE ISSUED: SIGNATURE: Building COmmisslO Dale SECTION 1-SM INFORMATION— . Z 1.1 ftgMty Ad _ 1.2 Asm=Mair and'Paroel Number. Q On )al vel— D/U 7 I'Nw ��� puool Nwnbar 1.3 Zonieglafamution: IA PiopatyDimmiacs: Ionia Aistrict Use Lot Area Froma g 1.6 BIJIMING SETBACKS ft Froul Yard .Side Yard Rear Yard Rtqtiued Provide Regitired Provided Provided Q 1.1 WAW SepptylvLtkt..G40.I S4) I.S. Flood Zoo Infmm fm— I.t: Seward mpow Syswm: PW& ❑ Ytitata ❑ Zoo t)awkFloodZeao ❑ Maoicipsl n Onssai .i System 0 SECTION 2-PROPEM OWNERSHMAUTHORIZED AGENT M 2.1 Owner f Reco L/ / Name{ t) Address for Service eL -G SS 73�� v i��c�ouPl X19 G�/ Signature Tfthone 2.2 Owner of Record: Name Print Address for Service: , Signature Tel hone m SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor / Not Applicable a ` Licensed Construction Supervisor. rS OU 7 0 J 0 /, 6,y 1//� � f 0.�7A so Number � PL� Qiti Address 2,zz 9 6w 4Vz , /""-U 3- Vey �-51� it Henn Signature/ Telephone �' r 3.2 Registered Home Impmvm=t Contractor Not Applicable n a Company Name Regi ration Number r..r Add= r Si re Tele hone Expiration Dau ' 1 SECTION 4.WORKERS COMPENSATION O QL C ISI § 73c(6) Workers Compensation Insumaceaffidavit must be,ootnpkted and submitted,widr this application. Failure to provide this affidavit will result in the denial of the issuanoe of the buildiQZ Permit. Signed affidavit Attached Yes.......0 No...... SECTIONS Dfterri tiown Pro ©sedWorn ai"i"It Y New Consttuctimt'0 - Existmg Building 0 Repair(s) Qom' Alterations(s) `0PAddition 'a Accessory Bldg. 0 Demolition ° 0 Other 0 Specify BriefDescrriptio``n ofProposed Wale 'EX If /1/, V- } SECTION 6 RST'IMMATED CONSTRUCTION COSTS Item EstJmated Cost(Dollar)to be " C ided b t applicant a _ I.° Building (a)o o (a) Building PeunitFee !/ Multiplier 2 Electrical Z (b) Estimated Total-iCostof Construction 3 Plumb' Building Permit fee:(,)u.(b) 4 Mechanical IVAC` 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7e OWNER AMNORIZATION TO BE COMPLETED WHEN OWNERS AUNT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Herebyauthotize / 00 / G to act on M ,in all ers rellatve to work authorized by this building permit appticatia� ) Si tore of er Date SECTION 7bb OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print N ne Signaf&eof er/ nt Date 140,OF STORIES SIZE BASEMM OR SLAB SIZE OF FLOOR TIMBERS l 2ND 3 SPAN D54ENSIONSOF-SILLS OIIvIFNSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS: SIZE OF FOOTING x MATERIAL of CiHll MY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS.LINE t . . . . r i BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR n Number: CS 064798 t Birthdate: 09/19/1963 jExpires:09/19/2004 Tr.no: 9109 __. Restricted:!60 . WILLIAM A MCDQNAL.D ' PO BOX 448 "h j PELHAM, NH 03076 Administrator j i North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: // (Location of Facilit ) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ' �.10RTfy Town of Andover 0 , No. _ ` LAK lover, Mass., ;- COCKICKEwICK y1. ORATED U BOARD OF HEALTH PERMIT T. D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... ..................... ....................................... Foundation has permission to erect........................................ build' son ..��.�.... ..... ..................................... Rough to be occupied as. Chimney ...................................................................................................................................... . provided that the person accepVfig this permit shall in every respect conform to the terms of the application on file..In.. Final this office, and to the provisio 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 y��g �T ELECTRICAL INSPECTOR V!V LESS COl V ST UCTIOI*�V S T %� Rough .............................................................................................................::..: . Service BUILDING;INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and-,Approved by the Building Inspector. Burner ' Street No. SEE REVERSE SIDE' - Smoke Det. '<e%�"VwnJ�wJ .ASI Location__`. /� -- No. ��f Date elf?Date �ORTM TOWN OF NORTH ANDOVER O 4L I F A A °>>i Certificate of Occupancy $ Building/Frame Permit Fee $ s�►cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ U• Check # 17647 —Building InspectortV TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 5,4 D _ 5 Ma AW0ver MA, Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage tl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided R red Provided s iff ©. 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ it SECTION 2-PROPERTY OWNERSEIPIAUTHORIZED AGENT • Y6S rn 2.1 Owner of Recor c Name(Print) Address for Service J1 tR Signature go, Telephone 2.2 Owner of Record: Name Print Address for Service: o . z rn Signature Tele hone Aw SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Q Licensed Construction Supervisor:/ (S D�y� / U O r 1-` D �o,4, / ��/ Gly /V/ 3U7 License Number Address 9119 Expiration Date Signature 4VTelephone 3.2 RegisteredHomeImprovement Contactor Not Applicable ❑ 0 OdI70 �� /JU11W�f Company Name / / V,2 /W O rn Q 701,, �7 9 / /�IQnI /1//" D 70 7 6 Registration Number r Address r &0 3 yU� ySsb Expi ration Date zz Signature Telephone V/ ov .Norwf w,po4r. Survey ,Svemices ' 19949 Iyer S'JJ'�'>F+ i fvaierhig j" 018.70 58' GARAGE -n �v ` 58' J STEVENS STREET QwGmy L BOWDEN #34$10 A PLEASE CALL 978-372--0835 PRIOR TO USING THIS PLAN FOR ANY OTHER REASONS THAN MORTGAGE PURPOSES �,�F�GACIE INSKCTIDN WAS CLIENT: PHILIP A PARRY.P.0 SORROW: ROBERT F. DURNEY & HUNNEMAN MORTGAGE DATE: 07 31—Oi JESSICA M. DURNEY OORPORA71ON SCALE: I" = 7& ADDRESS: 465 STEVENS, STREET AM IS HOT INTEIOED OR REPRESENTED TQ JOB NO.: 3443.00, NORTH ANDOVER. MA. N A LAW 00w SES LINENO CommRDED AT NO ESSEX REGISTRY OF DEEDS NERS WERE SET. !'T CANNOT KUSED TO THE BEST ac MY PROF£SSiOMAL FOR MTAULMNG FOKF- HEDGE OR KNOWLEDGE AND BELIEF BOOK: 3938 PAGE:198 L.C. CERT.# OIALOW LINES. THE LAND SHOWN IS BASED IA LOCATION OF TmE PRIMARY ON CLIENT FUMtSHED WORLJATION AND MAY S RUC URE SHOWN WAS ESHER IN PLAN REFERENCE: N/A BE TAWI(rh LA ANDTO FURTHER �Rl%t OF WAYS. ���� LOCAL CT 101E N DRAWN PER TOWN OF NORTH ANDOVER ASSESSORS ZONING BY—LAWS N EFFECT WN+£N NO RESPONSIBILITY IS MENDED TO CONSTRUCTED(WITH RESPECT TO MAP# BLOCK PARCEL. 15 THE LAND OWNERS OR OCCUPANT. IT IS HORIZONTAL DIUENSIONAL NOT INTENDED FOR THIS DOd1YENT TO BE REQUIREMENTS ONLY) OR IS SUBJECT DWELLING LIES IN FLOOD ZONE C RECORDED. EMOT FROM UOLATION ENFMCDANT ACTION UNDER M.G.L. 7171E v& AS SHOWN ON NATIONAL FLOOD INSURANCE CHAPTER 40A' SEC' 7• UN= RATE MAP DATED: JUNE 2. 1993 _ OTHERWISE NOTED OR SHOWN. NOW -p il COAWNITY 2500898 PANEL #00OW ZO'd TT:TT V006 TT End 9900-9V2-816-T:xPJ .0'd`,kNNUd dITHd v r The Commonwealth of Massachusetts Department of Industrial Accidents a � d Office of investigations .4 Boston, Mass. 02111 Sy1b Workers'Compensation Insurance Affidavit Name Please Print G Name: Location: J Citi IVO O ���d!%` �� Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City_ Phone#: Insurance.Co. Policy# Company name: Address City: Phone#: Insurance Co. Policv# 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_wcell_as_civitpenattiesin.the farm nf-aSTOP WORK_ORDPR..and_afine of.(.$100.0.0)_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 hereby certify under the pains and penal' s f perjury that the information provided above is true and correct. Signature Date 6 Print name `Z 11.1e--in G Oritr /�Q Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing E] Building Dept ❑Check if immediate response is required Licensing Board F-1 Selectman's Office Contact persona Phone#: F-1 Health Department Other ✓die �omvneaouuvcz Aam'clauaem BOARD OF BUILDING REGULATION-i, N License: CONSTRUCTION SUPERVISOR Number: CS 064798 B irthdate:.09/19/.1963 Expires: 09/19/2004 Tr.no: 9109 i Restricted: 00 WILLIAM A MCDONALD PO BOX 448 PELHAM, NH 03076 Administrator I ✓fie Ui a7x7no7uvea� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 142720 Expiration 5/14/2006 _ Type.`�;I`3BA McDONALD BUILDERS WILLIAM McDONALD 20 LONGVIEW CIR.1 r„ , �.✓ PELHAM,NH 03076 Administrator /615)s . -5 3 2 X2 3 - 0 _ r 02/15/2008 16:02 19786871215 JOHN PAGE 02 DgpWmmt of POW ifvWW Dgw*uftf Of' door tit Werk%m MMOPMOt NOTIMATION OF DEIJUDING WORK f 1!� r M retie d d&Com n1w be cmpk d in oNa re oft*wMb qte wdgcoom r gatmente of NLGL4 C.111110. 4"CMA 2LO ate 19S C-MR dam,a"am tee.n0y aeaea" co" a7,r N*oafn�pro�.er ahn 11 �►CG1u�^-�=- N of - l* law Pabst iogeeler�l[1�L^Dole of wpwdm ^o ,�f .-_t�owie 11 ,3 �E=F Dade ARAM OF FVAMCT Stan Addrerr_tj(f f -- Apt Nueber --• --^... Cit''----- •�---��'� xap O ��pis-_ _. Ptvpab Ownie .�' Adetsw► yrs r S',�r,�AnS.-!"� .1/�►� oc�i- Tdephone msbet .'7�• 61'- 7307 DdodbV Me"- AatGN+ LYtAM EecwMula►t.) DerteMtloee Comb Coming Odor IMW Wood,&M axpleia Clewes ow: Dwa%q is aalti•b"Y SowMeq -a 0 - Cif Cmpk m Doe--L When wo wart be dens: AM-,Z,t PM.-12U (Spft 600 41 db) projed Swpmiew Nee ucaaae 0--Exp.Does Wertar'e CMPMOWM Pdk7 lYttoebor Corder be erre of mergtrtq Bowan !'eCr� LjrA awd oNM d ,qW beleise Aoa rad Doti wtdenlead dw Ceoraahm"at Zee sas0er.l0sed teenb eaee.►ando•rrs pbte pw N�r9 tte atm 14e CMR 3100,and tlee Lead pabioreM=pravangan aeN Control Repetagone, 105C MR 460.000,and Mewe�aae Deh�Reed deo the t6hfMMlew eentdned in oh nook"M Isom and eoeroo r dee bat ddf WWkw io. wWV end Wet Daee r a-4 Mand c j c, . CaeerapNaewe �1�.�" (' mn ru _�►C)n Addw_ j"(L Ue �+ �p r e r_ l D 3 r.bpiahe Nebar lel 7 OVER- North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Fa " ity) Signature of Permit Applicant -7 Z 2"f Z,/) Y Date NOTE: Demolition permit from the Town of North Andover must be obtained.for this project through the Office of the Building Inspector NORTH 0 o fAndover O No. o�A co `Q,, dower, Mass., ORATED P'\1 .qs BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System op oeBUILDING INSPECTOR THISCERTIFIES THAT...... ... .0.. ...............................P.a.ro!k*y................................................. ............ Foundation has permission to erect....g.........., .......... buildings on 4..4. S�.��.N........�.......... ...... Rough .... ..... to be occupied aS....O fN D tc k ........ ................ ....... Chimney, ..... ...................................... . .. .............. .... .................. �.... ..... ... provided that the person accepting this permit shall in every respect conform to the terms of the application on111e in Final this office, and to the provisions of the Codes and By-Laws rela ing to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 01 (D 15ao, PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI N TAR S ELECTRICAL INSPECTOR Rough ............ . Service UIL G 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. 469 STEVENS STREET 210/096.0-0014-0000.0 \ I Location V6 No. Date M�RTM TOWN OF NORTH ANDOVER 9 t Certificate of Occupancy $ ;�s•'^U Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ Check # vo 22262 Building Inspector BUILDING PERMIToNo oT 6'�a �. ,,• e o TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION 4 Permit NO: Date Received Date Issued: '� 4ssgc►+uSE� IMPORTANT:Applicant must complete all items on this page LOCATION Gf / i7 eaj -T4, Pc nt PROPERTY OWNER—& ef/0. u y Print MAP NO: PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 22,OAC/ FEE: $ � Check No.: b Receipt No.: d-�-- NOTE: Persons contractin/ v t,registered ontractors do not have access the guaranty fund Signature of Agent/Owne _x _ , ignature Of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: "ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166,Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use VV e%A ❑ Notified for pickup - Date Doc.Building Permit Revised 2009 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single andTwoFamily) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2008 FORTH ® of { over, Mass., 7) , -to 'O COC HIC HE WICK y1. ADRATE D P'Pa\ �CC7 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES L..V.r..l....... ""' Foundation as has petTnission to erect...... buildings on .... .� .........�... I�.......S...- ................... Rough .............................. to be occupied as . lh. ��!!.�.5�.... ......... ��A.�MM�.�i..... ........�r .1./'...QChimney provided that the arson accepting this permit shall in every respect conform to the to s 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 i ELECTRICAL INSPECTOR 1 UNLESS CONSTRU ARTS Rough .......qL ................................................... ............. Service BUILDING IN TOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No �.athing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. o+ MO"*M TOWN OF NORTH ANDOVER •`-,' �� OFFICE OF BUILDING DEPARTMENT 4'w , , 1600 Osgood Street Building 20, Suite 2-36 . North Andover, Massachusetts 01845 GeralInspector of Bulldiings Brown Telephone(978)688-9545 Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: - /S- p _ JOB LOCATION: s-1kee 7- /V- Number V.Number Street Address Map nn HOMEOWNER Name Home Phone work Phone - PRESENT MAILING ADDRESS v City Town State zip Code The current exemption,for"homeowners"was Wended to include aww,,-oCcu-pied dwellmp to two urns or leas and to allow such homeowners to engage an individual for hire who does not possess a Iicense,prnvid�that the owner acts as supervisor). State Building (Code Section 208.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which helshe resides or intends to to be,a one or two family strvatrnes. A ode,on which then is,or is imended person who oonsrructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsbilit3,for comptiauces with the State Buil Applicable codes,by- rules and �g Code and other laws, regulations. The undowigned"homeowner"certifies that he/she understands the Town minimum• of North Andover Bail mon and Department procedures and � re4us that he/she wrll comply with said pmoedm,es and � r HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revimd 10.20o5 Form Homoowmn Fxmmptkm i TIOARD OF \-PPEALS 699-9541 C0N',gERN'.j:I'10\688-9530 1fE.\L jjj 08-9540 PL.L\tifVG(,gg-9535 I The Con► nwealth ofMassachusetts r f Department of Industrial Accidents OJfce of Investigations . 606 Nlashington Street Boston, MA 02111 www nzassgov/dia , Workers' Compensation Insurance Affidavit: Builders/ContractorsMiectricians/Plumbers A p licant Information Please Print Le_ghl NV aMe (Business/Organiration/(ndividual): 1�/v 70171JD ?Ice A Address: y� ' City/State/Zip: /'YyY / i��el . Phone .�'o � .. 7reyouemployer?Cheek.the aPpropnooz: employer with 4. 1 am a general contractor and IF7O y(�°1�'ees(full and/or part-time).* have hired the sub-contractors []-New construction . 2. I am.a.sole proprietor or partner- listed on the attached sheet.3 odeling Ship and have no employees These st6-contractors have working for me in any capacity. workers' comp.insurance. lition o workers'comp,insurance. 5. ❑ We are a corporation and its ing addition aired] officers have exercised their ical repairs or additions 3• 1 a homeowner doing ail workright of exemption per MOL ing repairs or additions ysel£ [No workers'corrtp, c. 152, §1(4)�'and we have no insurance required.]t .employees.[No workers' 12•❑Roof repairs comp• insurance required] 13.❑.Other l Ho apptasrct that checks bo>_'!�r must also fill out the section blow showing their workers'iiom t HomeownC"who submit this affidavit indicslting they ars dein ah p°" i°^policy information _ ZCarrtntcmrs that chick this box musre�ohrd as add.�tions]Shea show end��hire outside contraetets must submit a new afridavit indicsfiss such. ► ttee name of the sut:�and their wo t'iers'ccrcp.per:..,,,irtnrtnetion. I am.an errrployerthat ispronidarworkets'compensation insuranceformy e infornzadort nrployees: Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lir.9: Expiration Date: ------------ Job Site Address- City/state/Zip: Attach a copy of the workers'compensation policy declaration page(showing-,the policy Dumber and expiration date}, . Failure to secure coverage as required under Section 25A of MOL 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 forward Investigations of the DIA for insurance coverage verification. ed to the Otiiee of I do hereby c nder the and peri o .e ,• .lP rjury,�that the information Provided above is Ince and enured Si tore: � Phone#: EoMealth only. Do not write in this area m be corapletad b or town.o Y ff n; Permit/License# ority(circle one Health Z Building Department 3.City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector on• Phone#: Information and Instructions s. Massachusetts General Laws chapter 152 requires all emp Ioyers 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 sary two or more of the'fomguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver ortrustee-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 maimte:nanee,construction or repair work an 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 ors-local licensing agency shelf withhold the issuance or renewal of license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance'c overage required" Additionally, MOL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public worse until-acceptableevidence of compliance with the insurance requirements of this chapter have been presented to the coTTb acting authority," Applicants Please fill out the workers'compensation^affidavit compie✓tely,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 retluiredito carry workers'carnpensation insurance. Ifan LLC or LLP does have employees,a policy is required. Be advised that this of a-&may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also lase sure to sign and date the affidavit. The affidavit should be returned to the city or town that the.application for the pin 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 nur nber.listed below. Self.-insured eornpanim should enter their self insurance'iicensc number on the'appropriaie line. City or Town Ofru ials 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 perm/license nrmiber which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating-current policy'infbnnation(if necessary)and under"Job Site Add-ess"the applicant should write"all locations in (city or town)."A copy of'the affidavit that has been officiaily stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for futum permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a Iicense or permit not related to any business or commercial vwture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affrdavit. The Office of Investigations would lice 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 Fzidustrial Aaeideats Office of Lnvestistions " 600 Washington Street Boston, MA 02111 TeL#617-7274900 ext 406 or 1-8.77-MA.SSAF;E Fax 4 617-727-774 Revised 5-26-45 Www-mass.gov/dia