HomeMy WebLinkAboutMiscellaneous - 557 SHARPNERS POND ROAD 4/30/2018 (2) _ 1
557 SHARPNERS POND ROAD id Road
210/090.8-0043-0000.0
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TOWN OF NORTH ANDOVER w°RTa
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
Ol 4
s
NORTH ANDOVER MASSACHUSETTS8 5 s�CMU g
978.688.9540—Phone
Susan Y.Sawyer,REHS/RS 978.688.9542—FAX
Public Health Director E-MAIL:healthdept(c_townofnorthandover.com
WEBSITE:http://www.townofnorthandover.com
April 11, 2005
To all Sharpeners Pond Road Residents:
Please note that it has come to the attention of the Health Department that many residents are
leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time.
Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the
roadway is a health hazard. Please be mindful of this, as the Health Department will conduct
periodic inspections of the area to determine who is in violation, and fines will be issued if
protocol is not followed.
The Board of Health follows the State Sanitary Code regarding Human Habitation,
105.CMR.410, Section 1:
410.600
(A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-
fitting covers. Said receptacles and covers shall be of metal or other durable, rodent-proof
material. Rubbish shall be stored in receptacles of metal or other durable, rodent-proof material.
Garbage and rubbish shall be put out for collection no earlier than the day of collection.
(B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a
liner in watertight receptacles with tight-fitting covers as required in 105 CMR 410.600(A),
provided that the plastic bags may be put out for collection except in those places where such
practice is prohibited by local rule or ordinance or except in those cases where the Department of
Public Health determines that such practice constitutes a health problem. For purposes of the
preceding sentence in making its determination the Department shall consider, among other
things, evidence of strewn garbage, torn garbage bags, or evidence of rodents.
.410.602
(A)Land. The owner of any parcel of land,vacant or otherwise, shall be responsible for
maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish
or other refuse. The owner of such parcel of land shall correct any condition caused by or on
such parcel or its appurtenance which affects the health or safe and well-being of th
P pp safety, g e
occupants of any dwelling or of the general public.
(D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way
owned or used in common with other dwellings or which the owner or occupants under his
control have the right to use or are in fact using shall be responsible for maintaining in a clean
and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the
passageway or right-of-way which abuts his property and which he or the occupants under his
control have the right to use, or are in fact using, or which he owns.
' Residents should know the following:
• The Town has a mandatory paper and cardboard recycling ordinance that requires
residents to separate these items from their household trash. Paper and cardboard are
collected every other week on the same day as the household's normal trash. Residents
can call the DPW at 978.685.0950 to get their recycling schedule.
• Residents are responsible for picking up loose trash left at the curb after collection.
Banned Items and Recycling Requirements:
Please refer to the DPW website for a complete list of all the recycling requirements:
http://www.northandoverrecycles.com.
Please contact the Health Department if you have any additional questions. Thank you.
Zan
/ Sawyer, REHS/RS
Public Health Director
File
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557 Sharpners Pond Road
North Andover, MA 01845
August 2, 1989
Mr. Mike Graff
Town of North Andover
Health Inspector
120 Main Street
North Andover, MA 01845
Dear Mr. Graff:
As explained earlier we are in the process of contracting to have the septic
system dug up so an "as built" plan can be drawn and submitted for your files.
I will keep you informed as to our progress on that front.
After speaking with Mr. Wensley of the State Board of Health and explaining
the individual circumstances to him, he has advised me to write a formal
complaint and submit the same to your office for placement in Fuller
Excavation's permanent file. Please except this letter as said complaint.
In October of 1988 Fuller Excavation was contracted to install and deliver a
complete septic system that would work and pass all requirements necessary for
sign off by the Department of Health. Fuller claimed to complete this job in
November of 1988 and was paid in full at that time. He was also paid for
additional site work that was unfinished, but promised to complete in the
Spring.
Upon our seeking final approval from the Department of Health we were informed
that Fuller Excavation failed to file an "as built" plan with the Health
Department. When we tried to contact Fuller his father told us he would speak
to Dave and get back to us. Fuller has failed to call us back despite
numerous attempts to reach him.
We feel that Fuller Excavation has been neglect in their contracted and
professional responsibility by not delivering a complete system and/or
informing us of the necessary requirements of having an "as built" completed
and filed with the Department of Health prior to Fuller burying the system.
We also feel that Fuller is remiss and has jeopardized our warranty of a sound
and working system by failing to follow state and local procedures and
neglecting to respond to our attempts to communicate with him.
Mr. Mike Graff
Health Inspector
August 2, 1989
Page 2
Mr. Graff, we thank you for your help and consideration in this matter. Again
we will keep you informed of any progress.
Sincerely yours,
Barry Eisenberg
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85 MA 01923 PGr�p 6/Z/ Sof - —
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DEEP OBSERVATION &
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Special Notes:
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House Size: a �d
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Ja-By Engineering
PkOF Giabbai, P.E.
(617) 887-2808
0 CIVIL ENGINEERING• CONSULTING• INSPECTION
P.O. Box 319• 18 South Main Street, Room 304
Topsfield, MA 01983
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BOARD OF HEALTH ,
No.Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHECK .LTST R
LOT #
APPROVED - DATES DISAPPROVED DATE
Provided: Reasons:
Title V FAIL OK
Reg 2.5 The submitted plan must show as a mini mun,
a) the lot to be served-area dimensions 1- #..abutters
b -
location and log deep observation hoic distance to ties
c location and results percolation testa. distance to ties
d design calculations & calculations shrn:ing required leaching area
e) location and dimensions of system-incli cling reserve area
f) existing and proposed contours
(g) location any Bret areas within 1001 of csewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within IC,,, of sewage. disposal
system or disclaimer
(i) location any drainage easements within 1.70' of sewage disposal
system or disclaimer-Planning Hoard files
(
Ic known sources of water supply within 2001 of sewage disposal e
system or disclaimer
(k) location of any proposed well to serve, lot-1001 from leaching facility
(1) location of water limes on property-101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage( disposal s) plan must be prepared by a Professional Engineer pawl system
or other
professional authorized by law to preps:•e such plans
Reg 6 Septic Tanks
(a) capacities-150% of flow, water table, t:.es, depth of tees..
access, punping
(b) cleanout
(c) 10f from cellar wall ,or inground sw_' ada.,r pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
g 4 (b} slope greater 0.08 '
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BOARD OF 1111/1LTH i
Town of North An,dover",Mass . ,(,)J-C '
Permit. # 'IDS t.. }vw' ->l' Date
APPLICATION FOR WELL & PUMP. PERMIT . '
Application is hereby made for permit to drilla well ( ::' Application is
made to install ( ) aum stem'.
P P system'.
Location: Address -Lot.)dbq
_
Owner Jj Address '.� e4
�Tel .! �,�—3
Well Contractor t%ddress Tel .
& PUMP SUPPLY CO., INC. & PUMP SUPPLY CO., INC.
Pump ContractorNewton Rt. 108 Address �� Tel .
PLAIRt. 108
STOW, N.H. ( L-Afow, N:M: 09866
WELL CONTRACTOR (To be completed at time of hump •test )
Type of Well WeII used for
Diameter of Well Size of. Casing S
. I.IJ
Depth of Bed Rock Depth casing into Bed Rock
Was Seal Tested?. Yes h,�) No (_) Date. of Testing
Depth ..of--Wel-1 . --'�2 Well Ended in Wha-t. Material Z_Jr6
t
Depth to Water_ 30 Delivers Gals . Per Min. for 4 hours
Drawdown feet after pumping L.� hours' .at _ GPM
Daae of Completion
S.ignature . We Contracto
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PUMP INSTALLER (To be,- filled i.n- before installation)
Size & Name Pump Pump Type Used
Water Pump Delivers GPM Size of Tank
Pipe Material Used in. Well : Cast Iron ( ) G.- l.vnni.zed" Plastic ' (r1
Well Pit (_) or Pitless •Adaptdr (_)
Was sleeve used to protect pipe? Yes (_) NO(_) Type or Name Well Seal
Date
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Date Water. .analysis repor-t 'submitted to Board of }-real'th /1;Z Z �I-� - �
r
Date release given W owner of record & Bldg. Insp
Health Inspector `-�"
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38.Montvale Avenue !p Stoneham, MA 02180 MasEi: (617) 438-6114 Salem; N'.H. (603) 693-3106
,. LABORATORY NUMBER: 171346SALE UTEs
12/8/88 F
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SUBMITTED BY.
i McKinney Artesian Well, tY P11IT11) �.
i " ' 18 Newton Road, Rte:. Wrl()8
j' Plaistow, NH 03865
' € SAMPLE SOURCE: New well/co. .ectedyf.:rom pump'
+ 1 � a
r pp Lot #3' Sharphers .Pond Road,. No. Andover, IKA3
l.. ♦ i e ,
Barry Eisenberg ,
ANALYSIS: Recording to Standard Methods of Water and Wastewater". �sis�
16th
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Ed—
Total
d.Total Col-is,f.o' ra .
w 0 �p.ed LS 100- ms
l
Is
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Chlorides... .... .. 9 Mg/L s...
+ 3a
,d , {.
i.. .•e-r..•.e..•w••. »
a
Hardness... d - -
d � s 66 �
}, x , ` Manganese.... . ...' . 0.03 "in L ` �,
+ r. g/ € d
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r......... ..'........
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5 ' Fb 1
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7 .. less ung
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4 f { 4
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Ti �3. al :.els�;nte.et the �y.
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and state standards for drini«xt wateriowever ''the
qq11 ti
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t sodium`concentration.;sli hfi l: ' y a '
r,krl k �"�, ; ,�'�� ,( Q �' ( . ,. , g y�,:,c�ceeds the recommhnclea
•at ,� t r r �r 'Massachusetts standard of 20 ;pg L.
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Water quality can vary signl.`i_e:,.ntl.y rrottt:.time to •.Cim• .a ;it
due to' various 'local conditix,ki<, . Lr. is advisable to have
i •your•;Water tested in` PP a rOX�.LTld
v iwc�VE' TuCSuit' [ ,r
to•:determine any- change in wYrer.
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1 ,i le
WELL DATABASE
ADDRESS: 1.rce,� cr�,c�
AGE OF WELL: WELL DRILLER:
WELL PERlyIITm: I S WELL LOCATION:
--WEL.L PERiVI T DATE: f.S '
`�O s DEPTH OF WELL: D
-TYPE OF WELL: a:. D b. DUG c. 0WIv-
1
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: 1 —y S' HIGH MANGANESE: Y
HIGH IRON: Y OTHER CONTAMINAN'T'S: CY N
f�
i
Date11/12/98 Complaint Janet stated that she has noticed a septic smell
Complaintit 17 in the area and she thought it was her septic
I:: system so she had it pumped and"no problem"
Complaintant Janet Eisenberg She called her neighbors and took a walk and
notice the smell in the area of 34 Liberty St.-
112 mile away.
Address 557 Sharpnees Pond Road
'North Andover,MA 01845
Action continued:
she is not sure if irs a septic smell or the it is
Owner of Property unknown I corning from the wetlands-the smell comes in
goes. She also questioned dumping. I told her to
notifry Conservation Dept.too.
Owner's Addres
Phone# -
OL Sent ❑
fva� h
TOWN OFA, ANDOVER 1-OWN OF NORTH A,',.-
BOARD OF HEA?
SEPTIC SYSTEM SERVICING �'" "
REPORT DEC g Jc-
Date: ]-i--�
Homeowner:_ Pumper �Gr.
Street _55� Address:
Phone Phone
Nature of S-arvice: Routine ✓
Emergency
i
I '
Observations: Good Condition
Full to Cover
Baffles in Place
Leach'f field Runback
i
Excessive Solids
-- Heavy..Grease__.
-- Roots,.__._.__
Other_._(Explain)
Description of Work: .
Comments
Date F 11/12/981Complaint Janet stated that she has noticed a septic smell
Complaint# in the area and she thought it was her septic
I17 system so she had it pumped and"no problem"
Complaintant Janet EisenbergI She called her neighbors and took a walk and
notice the smell in the area of 34 Liberty St.-
1/2 mile away.
Addresss ,$57-Sharpner's Pond Road
IC-North-Andover,MA 01845
Action continued:
she is not sure if its a septic smell or the it is
Owner of Property unknown I coming from the wetlands-the smell comes in
goes. She also questioned dumping. I told her to
notify Conservation Dept.too.
Owner's Address
Phone#
OL Sent ❑
Date F 11/1-7/981Complaint Apprcodmately 12 stray cats in her
C
omPtaint# 18 neighborhood. Getting into garbage and diging
holes under her house. She has children and it
Complaintant Martha McQuade I is getting to be a health problem.
Addresss 12 Femwood Street
North Andover,MA 01845
Work#978-692-5511 X227
Hone#989-0706
Action
Owner of Property I
Owner's Address
Phone#
OL Sent ❑
Date IJ Complaint Smell in the area. Question of septic.
Complaint# 20
Complaintant Jim Santioanni
Addresss 10 Jared Place Road
North Andover,MA 01845
Action
Owner of Property
Owner's Address
Phone#
OL Sent ❑
BUILDING PERMIT OR "°oT" qti
TOWN OF NORTH ANDOVER o? b`?- �°YL,
APPLICATION FOR PLAN EXAMINATION 70
h
Permit NO: Date Received AO"ArlO h
�SSACHUs�t
Date Issued: 31.x'
IMPORTANT:Applicant must complete all items on this page
G ��j
LOCATION � .1`4 . - � °t,? , . ,'�' /�/o . i +e A(a.Print
PROPERTY OWNER
Print.
"MAP NO:&?02 PARCEL-:1/3 ZONINGbISTRICT; HistoriclDistrict yes 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 - Floodpiain Wetlands Watdrshed=District
Water/Sewer
,DESCRIPTION OF WORK TO BE PREFORMED:
Z.goq/aer GtJt.✓y&— Pue A ,rc e/t X&A.-,
Aylacs IfIuc,4� vL 4g?k . aloe bole Ar a,,lt,. l,eaA
IF
A law ,sir ix,galafe >, Ac v,/ A4- t.,,.4 avae.&44-
dentificatiioon, Please Type or Print Clearly)
OWNER: Name: CArdA/ Phone: -Jcy $
Address: 5-3-7 Ab - A4*VOv�4rAiv
41 T
CONTRACTOR "Name: ' Phone:`
aU.
44
Address.
m
s _
e
Supervisors Construction ticanse r Exp. Date
Home Improvement License: Exp., Dete:
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: $ ��� FEE:
Check No.: 6 /// Receipt No.:
aaa- a
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ur. rt.
$i pa ofi Agerit/Owner Signature of contractor 'a
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
'`}'"^ -.�•�\ ��„ �' -`.+. ...k,. 1. `e `,_ `a•. _ .J+� .psi:'*4 IN
COMMENTS �.
' t
HEALTH. , ri Reviewed on Signature }
.COMMENTS
4 -
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
i� Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Os ood Street
FIRE DEPARTMENT- ;-Tem `DUm `ster on asite
Located at 124 Main StreetA16 _
r
Fire,Department:signature/date TM G
7
'
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
i
s
i
i
❑ 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
L3 Copy Of Contract
o 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 and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o 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
I� 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
�I
Location,5 --�-
No. _ _ Date V " 1
Of MORTN TOWN OF NORTH AMDOVER
t .•o .•,ti0
* Certificate of Occupancy
CHuSE<<' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 2 M \ �--
Building Inspector
x4ORTH
Town of 4 over ,
,o LAKE i dover, Mass., a
COC M ICHEWICK
A0RATE0 JkV -`C
`s BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
/f BUILDING INSPECTOR
THIS CERTIFIES THAT............
...............................................)............................................................................ Foundation
has permission to erect........................................ buildings on...>� ..sAor !�!!�.. ...OK�.......... � Rough
to be occupied as..3 �K.. awl.. ..... ............ x..... ....��'�.... .. tj � Chimney
provided that the person accepting this permit shall in eve respect conform to the terms of the application on iT lFinal
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
i1 ELECTRICAL INSPECTOR
UNLESS CONSTR C START Rough
............. ................. ........................................................ _
Service
BUILDING INSPECTO
Final
Occupancy Permit Required to Ocmpy 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.
The CommosrK;eatth of Massachusetts
i Deparlmerzt of 1ndus&ia1Acd&njs
Hr, 0,Ecce of Investigations .
� d
600 f r=11ington Street
ti�,°�� Boson, MA aZ111
www_nuws gov/dia .
Workers' Compensation Lnsuraace.A$idavit~ Builders/Contractors/Eleetriciaits/PiQmbsrs
A [iiicant aformation
I
Please Print Leeibi
Name (Busin=/cnlwizafion/Individuel): J�+
Adr]ress:
City/StH&ziP A/o . ve,
.Phone#:_97�`�Dy- f�e�--�'
F'Ayoos employer?C'heekithe appropriate bo=a employer with 4. Type of Prejedt(regal❑ 1 am a gemerai rontr:actor and I �:
oy=(full and/or part-time).* have hired the sub-cofactors 6. ❑Newconstructionsoleproprietororpa�ef- listed on'the attached sheets 7.nd have no employees' Thessub-contractors have ❑Remodeling
ng forme in arty ca}rtify, workers' comp.insurance. 8' ❑Derrloiitionorkers'romp, insurance 5. ❑ We are a corporation and its9• ❑But3ding additioned.] officers have exercised their 10.❑Electrical homeowner doing all work right of exein on repairs or additions
Myself [No•workers'co Pti Per MOL 1 I.E]Plumbing repairs or additions
insurance• lied. t
camp, .q L52, §1(4),'and-we have no 12. Roof ..
]. •employee=s:[No workers,
❑ repairs
comp. irmurancx required..] 13.0.pmer
`/iny appficarrt that checks bob#I must also M our the section Wow showing theirworkers'iiompeitsation policy infomtation
t Homeowners who submit this afi'idwit indicating o„y arz an
_ 4Castraetors that check this box roustatmoh sn at}d.�fioasl dhassbow' and H=hire outside conuaetots jurist submit a new affidavit inti'
mg.the name of the sub-corntaotois rind.� � S euclL
.. / <f WoriCet7;�CCT,a Y..i' .
�. ccs er toyer tltaf to ot�ota�Rg tvorls„^'cnr-�serz add" ,m ,irtnmmtion
araraQfaort tcraaee for irry emivlmie q ty ' U_.
as Lfse po,�!'
Insurance Coropany Name:
Policy#or Self-ins.Lie.#: v
Expiration Daft.
Job Site Address:
Attach a copy of the workers' cum asation CitylState/��
pe policy declaration page(showing the policy number and e
Failure to secs a coverage iraEion
erage as required under Section 25A of MCIL c. 152 can l � �'
fine to$1 D4 �d m the im o
UP. ,5 .DO and/or one-year rrrl p srtton of criminal imprisonment,as WC11 � CIViI 'es ' penalties of a
of m the
to$25 Pesti form
up 0.00 a of a STOP W
clay against the violator•. Be advised that a c WORK ORDER�a fine
investigations of the DIA for insurance coverage verin-_ation. of this statement may be forwarded to the(Mice of
I do hereby certify under theaitr sand p en .
ofper�IL7 tYsfir the information Provided above is true and CorreaSi Lure:
/ � Dates o D
Phone#:` 7/ -gyp y
Oj9"acial ase only. Do not write lir this area'riv be cornptelyd or town
�' 3' o$iciaL
City or Town:
Permit/License 4l
Issuing Authority(circle one):
1. Board of Health 2 Snilt#in;Depar'Emeut 3,City/'town Cferk 4 Electrical Inspector 5. Plnmbinb Inspector
(.Other
Contact Person-
Phone#;
Information a. iid Instructions
Massachusetts General Laws chapter 152 requires all emp l oyers to provide workm t' compensation fur their employees.
Pursuant to this statute,an employee is defined as"..:every person in the service of another under any contract ofhire,
express or implied,ora]or written." ` !'
An emplayer is defined as"an individual partnership,association, corporation or other legal entity,or any two or more
of the'foreping engaged in a joint enterprise,and includis-kg the legal representatives of a dowsed employer,or the
receiver ort mstx-of an individual,partnership,associatiain or other legal entity,employing enploym& 'However the
owner.of a dwelling house having not more than three apa-rtmertts and who resides theaerccK or the occupant of the
dwelling house of another who employs persons m do ma iirtance,construction orrepair work an such dwelling house
or on the grounds or building appurtenant thereto shall not Ir..cause of sucb cmpioyment be deemed to be an employer."
j MGL chapter 152,§25C(6)also states that"every state or-local licensing agency shall withhold the issmance.or
renewal of a license or permit to operate a business or to construct bid in the commonwealth far any
appiicaut who has not produced acceptable evideQce.of compliance with the.insurance coverage required."
Additionally, MGL chapter 152, 925C(7)status"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract far the performance of public worse until•accepiabir evidence of compliance with the insmmc e
requn=ncnts.of this chapter have been premed ta.the contracting authority."
Applicants
Please fill out the workers'compensation.affidavit completely,by checking the boxes that apply to.your situation and,if
necessary, suppkysbb-oontractm s)name(s),addrwa(es):acrd 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 rrquir ed,to carry workers'csTripensaiion insurance. Van LLC or UP doeshave
empioyees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidm* for confrrnsation of insurance coverage. Also Ese sure to sign and date the affidavit The affidavit should
be retiarrad to the city or town that the application fol. permit or license is being requested,nott'he Departinem of
Industrial Accidents Should you have arty questions.reps-ding the law or if you are required to obtain a workers'
oompensat on policy,please-call the Department atthe-murtber.listed below. Self-insured ownpanies should enter their l'
self-inmzrance"license number on the approp:ia:'Err..
Chy or Town Officials
Please be sure that the afvdavit is complete and printed legibly. The Department hasprovided a space at the borirnn
of the affidavit for you to fill out in they evert the.Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the perrnit/license number which w-ill be used w a reference number. In addition,an applicant
that must submit multiple permit/iiciai=applications in any given year,need only submit one affidavit indicating-currerrt
poiicy'information(if necessary)and under"Job Site Addr-ess"the appiicant should write"all locations in city or
town)."A copy of-the affidavit that has bean 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 tilled out each
year. where a home owner or citizen is obtaining a liceensu or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves atc.)said person is NOT required to complete this affidavit.
Thr Office;of Investigations would lice to thank you in advance for your cDoperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone ana fax number,
The Commonvmalth of.Mawac3iu,setts
DcpartrnC-Ut of Endusbml Accidents
Office of EnV esti"Altians
600 Washington Street
Basion, RSA 02111
TeL#617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax®r6
17-727-7742
1Lvised -26-US www.m.-=.gov/dia
NORTH TOWN OF NORTH ANDOVER
OFFICE OF
T BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover,Massachusetts 01845
�SSACHUS�S
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please Print
DATE: 71°/09
JOB LOCATION: ��� ���'�" ���lam' NV D^,G A,'- QDe 5/3
Number Street Address Map/Lot
HOMEOWNERZ,4X4--, `�7T65(4
Name Home Ph4ne Work Phone
PRESENT MAILING ADDRESS
/1/b x
City Town State Zip Code
i
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes by-laws,rules an regulations.
pp y d
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535