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Home My WebLink AboutMiscellaneous - 56 BEVERLY STREET 4/30/2018 56 BEVERLY STREET 210/009.0-0033-0000.0 I NORTty Town of E 1jAndover 0 �*a t No. b 22- 2ol �� h , ver, Mass, C0C"1C"t WICK ' P � 1 V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ......... :.. ..`= .�.i:r:: .:.......y' ..�.... :.�'..'..e-:_ ............ v INSPECTOR BUILDING has permission to erect ................. ,7,;^ Foundation ; p ......... buildings on .... . ............................. ...,............................... -- 1. I 110-1, Rough to be occupied as .........�,...�: .::L=�: ............: '.. ...4.... :'.......` ;Y�-� ►;.. ........ .. . .. provided that the person accepting this permit shall in every respect conform to the terms of the application en on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Cr Construction of Buildings in the Town of North Andover. PLUMBING INSPECT R VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT4ION)STARTS Rough Service . C . - BUILDING INSPECTOR Final ' GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. I Gel ina5 %mdural �ncjineerinq L. C Phone 978.465.6436 Daniel L. Gelinas, P.E. Fax 978.465.5160 579A North End Blvd. Salisbury, MA 01952-1738 email danlgelinas@comcast.net Oct 30, 2015 Steve Derocher 56 Beverly St North Andover MA, 01845 SUBJECT: Observation and Recommendations, at 56 Beverly St North Andover, MA Dear Mr. Derocher: Per your request Gelinas Structural Engineering LLC (GSE or Gelinas) met you at the above site on 10-29-15. The purpose of trip to site was for structural observations and to advise if a 28'x45' metal garage building is constructed per manufacturer's recommendations and meets Mass State Structural Codes Executive Summary: Site observations indicate the structure appears substantially complete and per manufacturers drawings Discussion: 1. Manufacturers design criteria is consistent with the Mass State Building Code 8`1' Edition 2. 3 bents /frames in field match drawings 3. Bent lateral brace points match drawings 4. Rafters/purlins observed match drawings 5. Girts side wall framing observed match drawings 6. Box wood headers match drawings 7. Summary, see Executive Summary above Please call with any questions Very Truly Yours, L Daniel L. Gelinas, RE D Letter_15289.doc �'�" s 4 Job 1528 Nov 1, 2015 HEC=OVAYM TAX MAP 8 LOT 15 ASSESSOR MAP 9, LOT 33: X59 MARBLEHEAD STREET STEVEN & PATRICIA DEROCHER N/F ASK REALTY TRUST 56 BEVERLY STREET NORTH ANDOVER, MA 01845 SO1.04'QO"E - DEED BOOK 8712, PAGE No. 247 9.0' 47.00' 6.2' i 45.0' GRAPHIC SCALE SCALE.l --20' FEET 20 0 10 20 o EX. CONCRETE n n FOUNDATION 1.0' 45.0' ZONM TAKE FOUNDATION z ZONING DISTRICT: R4 REQUIRED PROVIDED MIN. LOT AREA 12,500 S.F. 9,385 S.F. LOT AREA= C Com»-4 ' 9,385 S.F. A w xMAX.MAHEIGHT 35 FEET 20 FEET \ z rn<v MIN. FRONT SE78ACK 30 FT 157.2 FT to -q MIN. SIDE SETBACK 15 FT 1.0 FT Z x r� MIN. REAR SETBACK 30 FT 8.2 FT m m m {rn(A P<>v W 1 in s, -i rn�' * A VARIANCE WAS GRANTED BY THE ZBA y{co o N o N� (SEE PETITION 2015-002A) N 00 _ w _m m�j--I r*i z�o0 157.2' 6.7' EwsnNG 1.5 STY WOOD STRUCTURE 1 CERTIFY THAT THE FOUNDATION SHOWN WAS LOCATED BY AN INSTRUMENT SURVEY AND EXISTS ON THE GROUND AS SHOWN. 17.2' _ g � 2 17.3' 17.3' O r ?- NO]'30.00"W 1 j X415 / 50.00' 150.00'S W/ I PIN Ic FOUND En Iw BEVERLY (40' WIDE) STREET w � IZ m 56 BEVERLY STREET 1 eDH FOUNDATION AS--BUILT FOUND LOCATED IN NORTH ANDOVER, MASS. (ESSEX COUNTY) PREPARED FOR STEVEN & PATRICIA DEROCRER SCALE: I,,= 20' DATE. JULY 17, 2015 PREPARED BY SULLIVAN ENGINEERING GROUP, LLC P.O. BOX 2004 WOBUIM MA 01888 (781) 854-8844 TAX MAP 8 LOT 15 MCM OWNER #59 MARBLEHEAD STREET ASSESSOR MAP 9, LOT 33.- N/F ASK REALTY TRUST STEVEN & PA7RICIA DEROCHER 56 BEVERLY STREET NORTH ANDOVER, MA 01845 S01'04'00"E - DEED BOOK 8712, PAGE No. 247 9.0' 47.00' a2' k 45•0' GRAPHIC SCALE SCALE-1"20' FEET20 O 10 20 o EX. CONCRETE N FOUNDATION I 45.0' �k 4 ZOlIfM TABLE FOUNDA77ON F z ZONING DISTRICT R4 REQUIRED PROVIDED MIN. LOT AREA 12,500 S F. 9,385 S.F. LOT AREA= C tin- 9.3x5 S.F. °°x MAX. HEIGHT 35 FEET 20 FEETuj f Z z A> MN. FRONT SETBACK 30 FT 157.2 FT m G° M1N. SIDE SETBACK 15 FT 1.0 FT * x0D DSO Z X z -i MIN. REAR SETBACK 30 FT 8.2 FT * rriK OD w m to to °i --y mt N * A VARIANCE WAS GRANTED BY THE ZBA . N OD °° c (SEE PETITION 2015-002A) �- o W � � r m -a En rn C4 Zm°° 157.2' 6.7' EVVING 1.5 STY WOOD STRUCTURE I CERTIFY THAT THE FOUNDATION SHOW?! WAS LOCATED BY AN INSTRUMENT SURVEY AND EXISTS ON THE GROUND AS SHOWN. ' #58 6.2'[%%. %�' 17.2' J- SB 17.3' 17.3' PAMWN01'30'00"W — 150.00' 150.00'S W PIN FOUND 1� FOUND "o BEVERLY (40' WIDE) STREET ^?oft m I 56 BERMLY SMEET FOUMM"M AS-BURT SBDH FOUND LOCATED IN NORTH ANDOVER, MASS. (ESSEX COUNTY) PREPARED FOR STEVEN & PATRICIA DEROMER SCALE: 1 "= 20' DATE.• JULY 17, 2015 PREPARED BY SULLIVAN ENGINEERING GROUP, LLQ' P.a BOX 2004 WrOBURN, MA 01888 (781) 854-8644 i Date.. .. .. ..... .... 4 �r10Rrry TOWN OF NORTH ANDOVER t , PERMIT FOR WIRING ss�cHU This certifies that ... CA ....................................................................................................... has permission to perform ....,,�J ...,.40.41. e6s/' wiring in the building of.......�, C vf.� at .. Jr ....... ...... ... ... .. .........t"r' . ................, rth Andover,Mass. Fee. d„�........Lic. No. pY� .... . LECTRICAL ECTO Check# .` �atsssnnwa�t o� asiass Official Use Only Permit No. Occupancy and fee Check BOARD OF FIRE PREVEhlTIO#�RC-GULATtaP�S ,�Ip7J 16.,r blank) APPLICATION PCT PERMIT TO PERFORM ELECTRICAL WORK All wmrk to be pez%rmed in wcordance,ids the Mmacbusetts Ebcftica1 Code OAM M CMR 120Q L F"PA W DV AW OR ME,4Z.L NFORWTJOAq Date: Cityor'Towutil. AIMTN A tVD oV E--t� To tblt=lnspeotorof lune By ffis application the understood gives notice of his or her intention to perform the electrical wtmi-de.scribed below. Laca€kn(Street&Number) 9-6 3 E V t=/LL Y E77Z tF' _ Owner orTettaut S 7z-V t---j 3 'D E/LU C M e'A Telepkt ne No.-7 7y-218'5078 Owner's Address SG EVE/'G t"i="'i Is this permit in conjunction,with a bid1ding permit Y No ❑ (Check Appropriate Bbx) Purpose of Building tT Arll -e C 9 .V(^e d Utility Authorization No. EAWmgService-200 Amps /20 1 Z,111017olis Oierhead Undgrd❑ No.of Meters ,New Service Amps / Velts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity 12-a/ele /,$�57— Location and Nature of Proposed Electrical Work: Com kdon of$x1agowing table mny be ir-aived the Lector o Ares. No..of Tota! Aio..ofRecessed Lrsm`snaires No.4f Ceti.-Soso,(paddle)F= Transforrmers KVA go.of Lummaire 60dets No.of not Tubs Generators KVA NO,of..Lulminhirees Swimming Pool Above ❑ In- ❑ k,o mergenacy g trsrg. Md. d. Bafle. Uit fs Na` of Receptaclo Outlets No.of Oil Burners PM ALARMS No.of sones o€Switches No.of Gas Burners No,of Detection.and Inifiatin Devices No.'of Ranges NO,ofAir.Cond. Total No.of Ajertigg Devices Tons Na.o€�'4'asteDisposers Heontained okump l�Iumbor Tons Kt'4" tecUon/AIerEiaaDevices N&•of Dishwashers SpacdArea Heating k'%' Local❑Muirici at ❑ Other Conn6cttidn l*iq.oI'Dryers HeatingAppl'casseeyt Security Systems:* l�to.of Devices ar trivalent e..of'4'i!ater R, ; Pio.of o;of Data'Wiring: tleatexs Signs Ballasts Nb.of Devices orMent eat No.Hydromassage Bathtubs No.of Motors Total HP Telecammnntcations :: No,of Devices or vT1E - ';0 A-M P Attach addi owl de 09 ifdesired,oros;-O uTdred bX the rmpactor q( Estruisted Value of Electrical Work (Wben required by municipal policy.) Work to SUrt: Inspections to be requested in accordance with 1C Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit fer the performance of electrical work may issue unless the licensee provides proof of fiability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has C ibited proofof same to the permit issuing office. CHECK ONE; INSURANCE ❑ BOND ❑ OMM ❑ (Specify.-) I cep,colder the pains olid penaltirs'°fPedWY'that the hz ormadon on this applic Wan is.trtie and complete: >±IRM 1 AME: �cl v'AJ�ci Ce c_ LIC.NO 2-S�7Z Licensem C�6u Aoe4 Signature LIC NO.: M'aPp enter- nr the ItCeli9e rrllftrber line) Bus TeI,i�`o.• 'r7/38 Address: /f tT/-e h W GSL'Ll $7" �'�+"'� NY *Per M.G.I..c.147,s.57-61,security work requires Department of Public Safety"S"Lic3w= Alt Lir.No.: ' j- 9-9 r Y s�7 C OWNER'S INSURANCE WAIVER: I ars aware that the Iacensee doesnat have the liabil'riy insurance coverage normally required by law. By my sign clow I hereby waive this requirement. I am the(check:one) owner ❑owner's agent. Ownen'Agent S"rabna€ure TetephoneNs.77Y-Aief-9-078 PEMWTFEE.$ �yZO• I � ,� v. �� s� - z z � G� �O .�n' 4 Y a,� 4nid e r n p f � rl. i Location No. "� /2 Date 10Zli 4 1 NaRTM TOWN OF NORTH ANDOVER 3 O Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ 2` &0 s kMU 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ p Check # 7f 20 s C tt[4 F r, Build' tj} spector 2467 �. `t TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 2 Date Received Date Issued: zo—Aizo IMPORTANT:A licant must complete all items on this page LOCATION f� C t/-� A �+ Print PROPERTY OWNER J l� y-e I?&G c-� Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ^ne family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial /Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well 0 Floodplain 0 Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: � (P 6d r (Identification Please Type or Print Clearly) OWNER: Name: S''F c� e 1J '22uc-14 N2 Phone: Address:_ v -0-0 VL y ` CONTRACTOR Name: -Z 0 Phone: �-- Address: �`- Supervisor's Construction License: U f 1 'Z Exp. Date: 2 v 12, Home Improvement License: ► Z g Ce I Z Exp. Date: Z v I `3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ ("Roo Oo d J FEE: $ . ��- Q° Check No.: 1 -2 0 Receipt No.: 71 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner .. .. � signature_-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 T'eiitp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS TOWN OF NORTH ANDOVER NORTH BUILDING DEPARTMENT °�<t'`° '6'6 1600 Osgood Street, Suite 2-36, North Andover Ma 01845 0 NOTICE OF VIOLATIONArgo �9SSACHUe Date: Addre"sem- Buildi g ❑ Zoning BylawStop Work Order 13Certificate of inspections Electrical Plumbing Gas r i - Violation observed: x ��_� _") Failure on yo r part to comply with this notice within 10 days may subject you to penalties prescribed by Massachusetts Law 780CMR or North Andover's Zoning By law. Please contact the Building Departmep for further information at 978-688-9545 Inspector Home Owner Contractor NORT�y Town of over o No. Lo , '� dover, Mass., O L E 'pA COC MIC HEW 00 TED P?p1�C 77 ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIE&THAT.............. y.................................... Foundation has permission to erect........................................ buildings on ...�6....,). c�' r^�r,...��., ,..,..... Rough to be-occupied as Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough ............... ......... .. Service BUIL ING INSPECTOR Final Occupancy Permit Required to Occupy Building . GAS INSPECTOR gh Display in a Conspicuous Place on the Premises — Do Not Remove F nal 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. Propozat "°a Of Free Estimates 8 West Street Fully Insured Thomas Doyle D.B.A. Salem, NH 03079 THOMPSON'S ROOFING (978)691-1355 Shingles - Slate - Rubber Roof Single Ply - Copper Work PROPOSAL SUBMnM TO PHONE DATE Steven STREET JOB NAME 56 Beverly Road CITY.STATE AND ZIP CODE JOB LOCATION North Andover MA 01.845 ARCHITECT DATE OF PLANS JOSPHONE We hereby submit spetdficatians and estimates for: Strip cuff x.11 roof shi.n_^l_es on entire house Renai_1_ all _loose boards and if any needs to be replaced .it will cost $3 . 00 a lineal ft. Install . 024 white aluminum drip edge Apply ice and water shield 6 ft. up all along edge and in valley Apply 151b. felt paper on rest of roof area Reshingle with a GAF 30 year Architect shingle .Install new flange around soil pipe ( Install new ridge vent Remove all_ work related debris �� gyp/ C14 f of 30 year warranty on material 606 �l 5 year guarantee on labor (, construction 1_i_c. #060112 improvement ;128612 UP *rg05t hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: Six thousand eight hundred dolam(S 6x800 . 00 Payment to be made as fokms: $37000 .00 start of job balance upon completion All material ay"arttaw to be as spwftd.M work to be oompbted in a worlunwillts star-w Authoriod e�s wii =ectM or y upon vA ltttw orders,and wo beoortb an�wp over and above the estiffoe.All aQeernertb oontin0errt upon strias aoGdants or deWsd bepid o r .trot.Owner to carry fm torrsdo and other necessary trwirartos.Otr workers ars fuky NOW This proposal may be Covered by YYbiatlen's Campernation houranca Not liable for occuring problems caused by withdrawn by us tl rM accspyd wM—. dam, snow sitting on rooftop- Z1UtPMMt Of Jr0pWar—The above prices,epecificabom and o �� crmc5tions are satisfactory and are hereby accepted.You aro authorized tD do the work as sptertified.Payment win be made as outlined above. Date of Acceptance: 9/`C /z 5 i ACORDrr CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM'YY)05/13/2011 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Pelham Insurance Services, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 122 Bridge Street Pelham NH 03076 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Northfield Insurance Co Thomas Doyle dba Thompsons INSURER B:AIM "onstruction and Roofing INSURER C: iv 16 -West Street INSURER D: Salem NH 03079 INSURER E: COVERAGES 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD(YY) DATE(MM/DDM') LIMITS A GENERAL LIABILITY WS10659 04/15/2011 04/15/2012 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED S 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS MADE FX OCCUR MED EXP(Arry one person) S 5,OOC PERSONAL 8 ADV INJURY $ 1,000,00C GENERAL AGGREGATE $ 2,000,OOC GFN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,00 C PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) S SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR F1 CLAIMS MADE AGGRRGATE $ $ DEDUCTIBLE $ RETENTION S STATS L TORY IMff B WORKERS COMPENSATION AND AWC 7012214012011 04/21/2011 4/21/2012 ORYIMU- OR S ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,00( ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ 100,00( If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,00( OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Roofing jobs CERTIFICATE HOLDER CANCELLATION Fax:978-623-8320 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 LIABIU OF KIND UPON THE Town of Andover Mass INSURER,ITS AGENTS 90 Us$ESENTATIV 36 Bartlet Street AUTHORQEDREPRE Andover Ma 01810 U. ACORD 25(2001/08) (Z)AcoRnNORPORATION 198 A MC VMP Mortgage Solutions,Inc.(800)327-0545 Page I o' The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintLe1=lbly Name(Business/organization/Individual): yN„ Do Yi r Address: (J.0- —E- 5_4 City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 1• am a employer with Type of project(required): Z 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2•❑ I am a sole proprietor or partner- listed on the attached sh&et.s 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp,insurance. . ❑Demolition [No workers'comp,insurance 5. ❑ We are a corporation and its 9' El Building addition required.] .officers have exercised their 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions Myself. [No workers'comp. c. 152,§1(4),and we have no insurance required.]t employees.[No workers 12•J�Moofrepairs comp,insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill 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. i an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ /Y) Policy#or Self-ins.Lic.#: �, Q/` Z f `(0.) Z U t Expiration Date: ICj/ Job Site Address: rf -e Al tin City/State/Zip-X, &s. _L Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required Wider 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 maybe forwarded to the Office of Investigations of the DIA-for insurance coverage verification. ado Izereby certify uIlder the pains andpenalties ofP erJ'urY that the information provided above is true and correct. .i nature: r Date: hone#: -- Offrcial 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): . I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: ' Phone#! Information and Instructions uctions 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 j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance-or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PIease fill out the workers',compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy.;please call the Department at the number listed below. Self-insured companies should enter their ,self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permithicense number which will be used as a referencd number. In addition,an applicant that must submit multiple permit/licerise 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 shouldou have an please do not hesitate to give us a call. Y y questions, The Department's address,telephone and fax number: The CO�.�Ukormealtl o'lNfjassac'o setts Department of Industrial Accidents Of ce 0 1UVestigat�iouS _ 400 Washington Street Boston;MA 02111 Tel.#617-727-4900 ext 406 ox 1.-877-MASSAFE Revised 5-26-05 Fax#617.727-7749 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 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 1 OA. The debris will be disposed of in: S w-eR- �<.c C c �• 1'L M (Location of Facility) Signature of Permit Applicant la � Date ` D R� r 5S a e- Pe rS 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 i ❑ Notified for pickup - Date I Doc:.Building Permit Revised 2011 June/mi 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 and Two Family) ❑ 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: Doc.Building Permit Revised 2008mi