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Home My WebLink AboutMiscellaneous - 55 PARK STREET 4/30/2018 I 55 PARK STREET f/ 2101070-0046_-0000.0 \ i I TOWN OF NORTH ANDOVER NLILD q O �ft,•!D �6y•�A OL O M Building Department "D «° 1600 Osgood Street �4�DRw Building 2-'Suite 2-36 Building Dept �SSAilDTED CH North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: y/��/l TEL#: q 7JC' NAME OF COMPLAINTANT: ,��,�i°�. ADDRESS.-,:--..56' 11'4,eor ��f COMPLAINT TYPE: ��P�7 Electrical: Plumbing: Gas: Building: Property Owner: Pr/�NS `7 �Fl R ST2 2 T' Address: S a o el e f' lo- /e S � e 1'lGU f3 ,ted JrpzPel Signed: '¢Fr Complaint Form-Revised 6.2007 , (9r '0d1 6 /al Location No. Date ,-/? X x- r 1 , �aR,h TOWN OF NORTH ANDOVER ►°. 41 D Certificate of Occupancy $ cwUstt� Building/Frame Permit Fee $ 'S/47 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 18037 /Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RLP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMPf NUMBER: DATE ISSUED: �j SIGNATURE: Building Commissioner/lEspMr of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O o � Map Number Parcel Numbei 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District. Proposed Use Lot Area Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required —+ Provided Required Provided v 1.7 Wow Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No M 2.1 Owner of Record C qPS � v s z 3-3' Pakk Name(Print) t I Address for Service: —� Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 ho r/11-C, L`censed Construction Supervisor. O /0,5-- / e�( ( c Nn � License Number Address / O D Expiration Date Signature Telephone (... 3.2 Registered Home Improvement Contractor Not Applicable ❑ v r Company Name m Registration Number r Address `2 t( l 0 r Expiration Date G) Si slurs Tel hone i SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: — ZE;7 /` ��-( �0� l /V SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of a Construction lJ 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN Air IAU7 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 77bOWNER/AUTHORIZED AGENT DECLARATION 1, 2&n,7 d s Y�?� 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 1� - *C YY/ C'S Print Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DIN ENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town NORTIy o �r. over _ o . :.. ........ No. ]( z dover, Mass., T 0 LA E 1. 40 COCHICHEWICK ORATED PPG �5 1 ` BOARD OF H ALTH Food/Kitchen Septic System PERMV kn BUILDING INSPECTOR THISCERTIFIES THAT........ ......`............... iA.. ........................ ............ ..... ........................................ Foundation a permission to erect........ ........... b ilding .... has w Rough to be occupied as.......................................................................... Chimney provided that the person accepting this permit shall in every respect con rm 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 ELECTRICAL INSPECTOR UNLESS CONSTRU N STARTS Rough ..... .... . . . . Service UILDIN S C Final Occupancy Permit Required to Occicpy 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. Bumer Street No. SEE REVERSE SIDE Smoke Det. AC0RA- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMlYY) PRODUCER 06/20/2005 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pelham Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 960 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 122 Bridge Street Pelham NH 03076 INSURED INSURERS AFFORDING COVERAGE NAIC# Thomas Doyle dba INSURERA:Nauti1US Thompson's Construction & INSURER B:Associated Industries 8 West St INSURER C: Salem NH 03079 INSURER D: COVERAGES INSURER E: 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RvSR AiiLr'L- - LTR INSRD ' TYPE OF INSURANCE - _ Y Pnt..{C.Y€FFFCTIVE-*nt 1rV PY.PIRAT{nN POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DDM() A GENERAL LIABILITY NC 330576 LIMITS - 04/15/2005 04/15/2006 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CI-AIMS MADE �OCCUR PREMISES EaTO oocurrence $ 50,000 MED EXP(An one arson $ 1,000, PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 i AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT ( ALL OWNED AUTOS Ea accident) $ SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (Per person) $ NON-OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE GARAGE LIABILITY (Per accident) $ ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC S EXCESS/UMBRELLAAUTO ONLY:LIABILITY AGG $ OCCUR ?'•qo NI ACE EACH OCCURRENCE sc�ascA-� . DEDUCTIBLE g RETENTION $ $ B WORKERS COMPENSATION AND AWC7012214012005 04/21/2005 04/21/2006 $ EMPLOYERS'LIABILITY WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE X TORY LIMITS ER OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-EA EMPLOYEE s 100,000 OTHER E.L.DISEASE-POLICY LIMIT s 500,000 )ESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS rob: Various roofing and construction %t_RTi1=iCAi"c rivLvcic" _ . _ fynwood Associates CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 19 Basswood Lane AUTHORIZ Kt:SENTATIVE Andover MA 01810 !`// �c ti L"/• S�, S :ORD 26(2001/08) n A rnon r+nnnn...�,.,.. ....._ �ro�oga�X Page of Free Estimates 105 Haverhill Street Fully Insured AT j�T�`� Methuen, MA 01844 T�iOMI ►Jl.�l,�S ROOFING (978) 691-1355 j Shingles - Slate - Rubber Roof Single Ply - Copper Work PROPOSAL SUBMITTED TO PHONE � �� DATE Carrie Psz b sz 5-23-05 STREET JOB NAME 55 Park Street CITY,STATE AND ZIP CODE JOB LOCATION North Andover MA 01845 ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Strip of r 4.1 1 l �f �?i:.ns3'. e Renail all loose boards Install aluminum drip edge around roof line Apply ice and water shield 6 ft. up all along edge Apply 151b. felt paper on rest of roof area Reshi_ngle with a ' 30 year Architect shingle Install new flanges around soil pipe Install a new ridge vent lOn back dormer fasten down i inch insulation Apply . 060 Manville rubber fully :adhered Install metal around edge Glue and caulk all seams Remove all work related debris 30 year warranty on material 5 year guarantee on labor I construction lic. #060112 improvement #128612 If you decide to have the back addition done it will be $2 , 400 . 00 more** Y We PrOpOge hereby to fumish material and labor—complete in accordance with above specifications,for the sum of: Four thousand dollars($ 4 ,900 . 00 }. Payment to be made as follows: on completion All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving Authoriz p °> _ extra costs will be executed only upon written orders,and will become an extra charge over and Signattme above the estimate.All agreemems contingent upon strikes,accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.Our workers are fully Note:This proposal may be covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. 2Creptance Of PrOPOgal—The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature work as specified.Payment will be made as outlined above. —49� • mad Board of Building Regulations and Standards ` HOME IMPROVEMENT CONTRACTOR Registration: 12802 , I Xpiration: 412812007 Type; DBA -- --- - --- THOMPSON'S ROOFING THOMAS DOYLE � "� -- w 8 WEST ST Administrator 03079 SALEM,NH - I I V The Commonwealth of Massachusetts Department of Industrial Accidents ' ��" Office of Investigations ;I r `� / ' 600 Washington Street Boston ,VIA 02111 ivww.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,applicant Information Please Print Legibly Name Il�usincss/lhganiration/Individual): ,SdK S OZJ� Address: 1 Q /`r` c, ,4c CityiStaterZip: �A" Phone _------- .Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. + 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for the in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12g. '[Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box#f must also till out the section below showing their workers'compensation policy information. +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. am an employer tliat is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_-� _ Policy ,4 or Self-ins. Lic. #: v1 �/C 2 Z� Zt�dS— Expiration Date: 114�_l— Job Site Address: �crr(,.k / City/State/Zip: 4d 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 ofcr�urinal 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 tine 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. l do herebycerci ,u ler the mins and penalties o ' era that the in iwination rovided above is true and correct. , .r l P I P J r1' I P Ci mature: h_ nate: 72– Q S� Phone 011icial use only. Do not write in this arca,to he completed by city or town ollicial. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws:.Chapter 148 Section 10A. The debris will be disposed of in: LL-.& ,5 b (Location of Facility Signature of Perm' Applicant Fire Department Sign off: Dumpster Permit ZS— • Date Date. . . . .�.�...-..� MORTN ?�.<��•°„•�4, TOW N OF NORTH ANDOVER PLUMBING SSACMUS� ` This certifies that . . . .L L-4u /` has permission to perform . . . ..�.8� jlJf� f�I • i%h ,B.� t�xv plumbing in the buildings of . . ./>. . .'zy:/ . . . . . . . . . . . at . . . . . r .��'¢!? . . S ... . . . . . . . . . . ., North Andover, Mass. Fee.3 . . . . .Lie N �4�0 PLUMBING INSPECTOR Check # 2713 u 8'167 !r r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS _ L Date Building Location � rj PAP I .� Owners Name � Z� �%�Z Permit# /� Type of Occupancy Amount New 0 Renovation Replacement . Plans Submitted Yes No ❑ FIXTURES F ww U co O W x WO a U W h F 3 � co Z p F' z 1.- W O & a M A H C7 A d SZB. • BASEVINf M H-OCIR �FII�it M H—OCII2 Jill 4M)FIAOCIt SIH MOM 6IH)NL" - 7M HLOOR Ll STH HIM (Print or type) / Check one: C rtificate Installing Company Name lA�,l-/�.4L, Cr f 14 (j Corp. Address �L��- s� Partner. WU ❑usmqess Telephone '7 Firm/Co. Name of Licensed Plumber: CFF tV e Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I ha e bmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing wo;Massacand in ons rformed under Permit Issued for this application will be in compliance with all pertinent provisions of the s S in Code and Chapter 142 of the General Laws. Byn icense um er y e of Plumbing License Title iCity/Town tenseum eT�r Master urneyman El(OFFICE USE ONLY 111��iii The Commonwealth of Massachusetts kj a� Deivartnnent of.1ndustrial Accidents or at � ! Office o Invests ations ..�u fg 600 Nrashington Street Boston, MA 0.2111 e� www.massgov/din Applicant Information Workers, Compensation Imitrance Affidavit: Builders/Contractors/Electricaans/Plumbers • Please Print Legibly Narni (Business/oTpnirafion/individual): Address: Citystate/Zip: Phone#: . --------------------------- Are you an employer?Cheek.the appropriate box: - l.❑ 11 am a employer with 4. ❑ I am a general contractor and I Type of prelim(repaired). employees(full and/or part-time).* have Dred the sub-contractors 6. ❑New construction 2.❑ I am.a.so}e proprietor.or partner- listed on the attached sheet$ 7. ❑Remodeling ship and have no employees "Phase su}i-contractors have working for me in an ty, g (]Demolition y capaci workers' comp.insurance. Building[No workers'comp. insurance 5. ❑ We are a corporation and its ❑ ng addition required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LD Plumbing repairs or additions myself[No-workers'comp, c, 152, §1(4),and we have no }nsurance required.].t 12.❑ Roof repairs nq �. .employees. [No workers' COMP. insurance required..] 13•D Other 'Any applicant that checks bmell t must wso fiat out the section below showing their workers'compensation policy mImrmation. t fiomeownan who submit this affidavit indicating they ars doing an work and then hoe outside con 4Condactone that check this box must attadxd an add tiooat sheet showing.the nam of the sulrcon �musf submit a new affidavit indiaetiag such tractors and their work= Corr., oa',,;' !ant an enrployer altar is ro � , r F �^: mtonnation. p g:workerr compensation insurancefor my employem Below is&e information, o'P ECJ'and joh site . Insurance Company Name: Policy#or Self-int:.Lic.#: Expiration Date: .lob 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 e. 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. !do hereby certify under the pains and penalties of perjury that the information provided above is one and eoneet Si tura: Date: Phone#: E only. Do not write in this area,in be cnrtmleted by citj,or town.officio[ n: Permit/License# thority(circle one): Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector son- Phone#: Information a nd 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,assaoiation,corporation or other iegal entity,or any two ormOre of the'foregoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associations or other legal entity,empioying 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 os-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 pmformmsee of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented t D the contracting 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 ` insumce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the " members or partners,arc not required to carry workers'co rnperrsation 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 Acciderrts 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 arc required to obtain a workers' as .pensation policy,please-call the Department at the numberlisted below. Self ws zured Sf+!npaniac shrs�!ld ens+Pr fhCr 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 hes provided a space at the bottom of the affidavit for you to fill out in tlu event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which A-ilI be used as a reference number. In addition,an applicant that must submit multiple permit/licanse applications in any given year,need only submit one affidavit indicating-current policy'infonnation(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 fidmm 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 Massachu' setts Department of Ind stsiai Accidents Office of Investigations 600 Washington StrL=t Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-977-MA.SSAFE Revised 5-26-05 Fax 4 617-727-7744 www.mass.gov/&a Date.. . .Jam.. ..ir... . .. . . 1 V ORT1y a° TOWN OFA TH ANDOVER • PERMIT FOR GAS INSTALLATION S^CHUSEt This certifies that . . .6141 :AKIW& . . . . .A. . . . . . . . . . . . . . . has permission for gas installation . .�a!4 esz. . . . . . . . . . . . . . . . l' in the buildings of . . . . .I.Zwys.2. . . . . . . . . . . . . . . . . . . at . . . . ..� �. � (�. . .5!-. . . . . . . . ., North Andover, Mass. Fee. J P. . . . Lic. No..;D�91�,?. . . . . . . . . . . . . . . . . . . . . . . . . .. GASINSPECTOR Check# 2-7 2- 6 6 8'/ MASSAMUSE. UNIFORM APPLUCA MN FOR PERM( TO DO GAS (Type or print) NORTH ANDOVER, MASSACHUSETTS Date d . Building Loqations Permit# ' Owner's Name � l /3 /-� Amount$ New❑ Renovation r Replacement plans Submitted ❑ u Y Z , x o ° N w o z o UD a x a W o a > w Z d W F w W C7 w �"' rq x S .'Zr > O Z p z W C W SUB -BASEM ENT _ BASEMENT O C IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR TH . FLOOR 6TH . FLOOR 7TH . FLOOR. BTH . FLOOR. (Print or tvpe)C Name A /.} Check one: Certi-calA Ins ta,4jing Company Address —L vrp• u / Partner. usmess a ep one n Name of Licensed Plumber'or Gas Fitter E.� FiCo. � � INSURANCE COVERAGE 1 have a current liability insuran=policy or it's substantial equivalent Check one, If you have checked ves.please indi the type coverage by checking the appropriate box Yes Liability insurance policy N°❑ Other type of indemnity u Bond Owner's insurance Waiver 1 am aware that the licensee does nOt hie the Insurance coverage Mass. General Laws,and that my signature on this.perrnit application waives this requirement. required by Chapter 142 of the Signature of Owner or Owner's Agent Check one: t hereby certify that all of the details and information I have submitted(or entered)in>Owner 1 aAgentttionD best of my knowledge and that all plumbing work and installations rm compliance with all pertinent provisions of the Massachusetts S under Permit issued for this applicatioare true and ncwil be in curate to the Co a and Chapter.142 of the General Laws. By: Title Sig Licensed Plumber Or Gas Fitter Title �t' 'Plu bet City/Tovm; -❑ Gas Fitter icense um er _ APPROED(OFFICE USE ONLY) Journeyman man t , •••..witrVCQLt�1 OJ Massachnscay /W6 Departmerrl of jndustr' tal Accidents. a of b"Irtiaatiorts tiDU W e Washing ton e Street r Boston M4 U.2111 Workers, Com enRation Insurance wH�_�s�.°ov/din P davit: guilders/ContMctors/Elecirician%'ZtZ A Iicanf Iaformafion Name ganization/tndividua(); Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 1.❑ I an a employer with (� em to ees 4. I a° a 'erneml contractor and I Type of project.(required): P Y (full and/or part-time).* have hired the sub-contractors '6• ❑ New construction 2.❑ I am a sole praprietor ar ariner- ship and have no employeeslisted 01't the attached sheet I 7. .❑ Remodeling. a These sub-contractors have working forme in any capacity work g• ❑ Demolition [No workers'. comp. insurance 5. ❑ We re.a comp. insurance, required.] area corporation and it 9' ❑ Building addition 3.❑ 1 am a homeowner doing all work rift a have ex I0: ercised.then• ❑Electrical r--pairs or additions Myself [No.workers' exemption per MGL 11. °OTnP c. 152, § 1 4 ❑ Piumbing repairs or additions insurance required.] t � ),and we have no �emploYees. [No.workers' 12,0 Roof repairs 'Any appiieattt.that cheeks box#i.must also fiil out the section below hoinsurance required] 13•❑Other 'M' whu subnut:tltis aiidauit indicating vie,,are,oir.-,t`Esc r!t ��ng their workers'con xConuacmts ffim checi:this box must attathed an additional sheet showi Paasation poiicy information, t"` hire r,=ide eontracimi rnust aubmii n new amriav the name.of.fhe stk"ont=tona and th mP p ft indi �a ch. t om art.erttpla}�e Yh�is proviatr cit workers'w 4?rwepoc�.C�tz % o c3 imomtation. iq orrnabon, s err nce fop PM,employe= Below is the o ' , Insurance Company Name: P and job site Policy#or Self.ins. Lic.#: Expiration Date: � Job Site Address: Attach a copy of the workers' compettsafion policy decia Cita'/St /Zip: ration page(ShowiR;the oii Failure to-s-- coverage as required under Section 25A of P cY number and e fine up to $1,500.00 and/or one-year imprisonment MGL c. 152 expiration date). Prisanm,nt as well can l t0 the nnPosition of criminal penalties of a Of up to Z2S0.00 a day against the vio}ator. Be advised that aascCivil penalties in the form of a STOP WORK ORDER and a fine Investigations Of the DIA for insurance coverage verification °f this statement ma be forwarded to the Office of Ido hereby,certify under the pauac and penalties of perjurj =hat the irr orna Si�rtature: f tion provided above is true and correct Phone#: Dat : DcurL use oV. Dn not write in this area tobe corrrp[eted.by city or town° cut( City or Towu: Issuitte,Authority(circle one): Permit/L,icense 1. Board of Health 2. Building Department 3. City/Tawn 6. Other Clerk 4. Eiectrical inspector 5. Plum Q btnb inspector Contact Person: Phone#r 1.1 kvi LuaLIVU +a [tU 111St UCr1OnS Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for thea employees. Pursuant to this statute,an employee is defined.as"._eveT-y pion 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 includiirsg the legal representatives of a deceased employer,or the receives or trustee of an individual,partnership, associati<:>n or other legal entity,employing employees. However th-e owner of a dwelling house having not more than.three ap,artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do ma intrnance,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 o r local licensing aeency shall withhold the issuance or renewal of a license or permit.to operates 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"Nerther *he commonwealth nor any of its political subdivisions shall eater into any contract for the perf6rrimm of public worl< umtil 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 com?Vetely,by checking the boxes that apply to your situation.and,if necessary,supply sub-contractor(s)naine(s),address(es) and phone nwriber(s)along with their certificate(s)of insurimcc. Limited Liability Companies (LLC) or Limite=d Liability Partnerships(LLP)with no employees other than the members or.partners,are not required.to cazry.workers'compensation insurance. if an LLC or LLP does have.. employees, a policy is required. Be advisedthat this afficLa.vit may.be submitted to the Department of. Industrial Accidents for confirmation of insurance coverage. Also be sure to sien and date the.affidavit. Theaffidavitshou}d 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 reser-ding the late if you am required to obtain a worl:crs' rompznsation policy,please call the Depwlanent at the m><anber,listed below. Self-insured companies should enter the, self-insurance license number on the appropriate line. City or Town Officials Please be sure that tele zffidavitits compiwx and printed leHrbly. The Department has provid=ed a space at the bottom • of the.affidavit foryou to fill out in the event the Office of'Investigations has to contact you regarding the appii=L Please be su=re to fill in the permMicense number which will be used as a reference number. In addition, an applicant that must submit multiple pwinittlicense applications in arzy given year,need only submit one affidavit indicating current policy information(if necessary) and undar"Job Site Add_-r_ss"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially sternped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future per mils or licenses. Anew affidavit must be filled out each year. Vrrlrere a home owner or citizen is obtaining a Iicens� or permit not related to any business or commercial venture (i.e. a dog license or permit to burnleaves etc.) said pessor-n is NOT required to complete this affidavit. The Office of investigations would like to-thank you.in ad=vance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and far, number. The Commonwealth of?Massachusetts Department oflmdustrial Accidents. Office of Lnvesfi.gafioas 600 Washdngton Strewt Boston; MA G2111 Tel # 617-727-4900 wrt 406 or 1-87/7 MASSAFE Revised 5-26=05 Far,4 61 7-72.7-7749 WW'.Meass.gov/diff