Loading...
HomeMy WebLinkAboutMiscellaneous - 579 CHICKERING ROAD 4/30/2018 (3) 579 HICKERING R g� 2101084.=003.8 I J � Bul .Dl FILE chf � �� �JR7Ii . m4,�gwcu abs f'O - NORTH ANDOVER.BUILDING DEPARTMENT 6 Osgood s-t■,fit f'yA Sti+l1pt �SAC}¢tIS�K North Andover r Tel: 978-688-045 Fax: 978-688-9542 B USMESS FORM F01Z TO ME CLERK DAM. -q ADDU l� Olt 1 TYM OF BUSINESS,, ,AO BUMDINO LAYOUT PROVMM: S ASO �.!!!'.E�.lL.EHICEP.A .€ [fir,ST'.l M5: ZONM0•BYLAW USAGE: NO DUMD)NOr INSPFOTOA SIONATUPIE EUSIM S S FORM POR TO W N CLBRR 2.40 Ronne Occupation(1989132) An accessory use conducted within a dwelling by a resideast who resides in the dwelling as his principal address, which is clearly secondaxy to the use.of the building for Hing piurposes. Homo occupations shalt 'incIucte,"brit not*limited to the following uses; personal services such as fuunished by an artist or instructor, but not occupation involved with.motor vehicle repairs, beauty patiors, animal fennels, or flue conduct of retail business,or the manufadming o£goods,wbich impacts the residential nature of the neighbothood; 4. For use of a dwelling in any residential district or mufti-family district for a Borne occupation, the following conditions shall apply. a. Not more than a total of three (3) people may be employeq-in the home occupation, one of whom shall bethe:owner ofthehome occupation and residing irtsaid di�Uhg; b. The use is carried on strictly witbin.the principal building; c. There shall be no c),-Wrior alterations, accessory buildings, or display which are not customaW W&residential buildings; . d. Not more than twmn five(25) percent of the existing gross floor area,o£;the dwelling Unit. so used, not to exceed one -thousand (1000) square .feet, is devoted to'such use. Sn connection with such use,there is to be kept no dock in trade, commodities or products which occupy space beyond these Jimits; e. There will be no display ofgogds or wares visible from the street; f The building or premises occupied shall not be, rendered objectionable or detrimental to the residential character of the neigh-boyhood due to the exterior appearance, emissioxi of odor, gas, smoke, dust, noise, rlistarbaneo, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Arty such building shall include no features of design.not customary in bindings for residential use. Signa e Date Date..... :.. — i f NORTH 1 3j;.';�`' "�oL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU This certifies that ...&/ �j�.......... has permission to perform .........�.. 4 L��.7`,�..... . .......... wiring in the building of........... G..u em.e ................................. at...... S7.'?:9........ ../.�fz. .r .�.....�� ... .. . ,North Andover,Mass. Fee4t/S-� Lic.No.7� 5;. ............. ....... " ELECTRICAL INSPE.�� �a�63 Check # r 8966 Official Use Only Commonwealth of Massachusetts C� Permit No. L Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT OR TYPE ALL INFORMATION) Date: 1 a b9 City oof: k)Dr4_ Pr)d 0 Uer To the Inspec or of Wires: By this applicati(ioJersigned gives notice of his or her intention t Berfopn the electrical work described below. Location(Street& Number) Owner or Tenant { Telephone No. Owner's Address 6101 e- Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install low voltage security system at above location Completion of the following table may be waived by the Inspector of Wires. � No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of TotalTransformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o. of Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No.of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No. of Alerting Devices g Tons g No. of Waste Disposers Heat Pum Number Tons KW No. of Self-Contained p Totals "' " """""'""""' ............... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local E] unicip Mal Other No. of Dryers Heating Appliances KW Ak*Turity Systems:* 1 No.of Devices or Equivalent No. of Water No.of No. of in . Heaters KW Signs Ballasts No.o eveuivalent Bathtubs No. of Motors Total HP Telecommunications Wiring: No. Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Brinks Home Security LIC. NO.: Licensee: John Holmes Signature t. per_ LIC.NO.: 749C (If applicable, enter "exempt"in the license number line.) Bus.Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington,MA 01887 Alt.Tel.No.: *Per M.G.L. c.147,s. 57-61,security work requires Department of Public Safety"S"License LIC. NO.: SSCO 001163 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ® owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,, f TM CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 47 Date: August 5, 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 579 Chickering Road MAY BE OCCUPIED AS Retail Gift Shop- Rose & Rose & Dove Gourmet, LLC IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: George Gorham Tmst 579 Chickering Rd North Andover MA 01845 Building Inspector Location /7 419 f` �`�`'-•�� a No. 1 /© Date NORTH TOWN OF NORTH ANDOVER f � F 9 Certificate of Occupancy $ Building/Frame Permit Fee $ sAC IM Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # r� Building Insp r r NORT►{ TOWN OF NORTH ANDOVER f C«.Cwwaa * �` i5,1 G N PERM 1 T DATE : July 22, 2009 PERMIT: S01-10 THIS CERTIFIES THAT Margaret Gorham — Rose & Dove Gourmet. LLC has permission to erect. Wall Sign 28" X 120" on 579 Chickering Street provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the ` provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section#6, Voids this Permit. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings SIGN PERMIT APPLICATION 1600 Osgood Street Building 20, Suite 2-36 TOWN OF NORTH ANDOVER Site Owner Applicant t(e Tel Site Address �f�2� Size of Proposed Sign A, 120 May _ Parcel Illumination: (3Not illuminated b) Internally illuminated How attached: a) Against the wall c) Externally illuminated b) Roof c) Ground Materials: Lm l idyl, d) Other Proposed Colors: Background Lettering Cost.of Sign Borders Note: No permanent/temporary sign shall be erected, or enlarged until an Required Attachments: application on the appropriate form furnished by the Sign Office has been Photographs of building filed with the Sign Officer containing such information including Material sample photographs,plans and scale drawings, as he may require, and a permit Color sample for such erection,alteration, or enlargement has been issued by him. Site or Plot Plan (Required for all free-standing signs) Such permit shall be issued only of the Sign Officer determines that the Drawings of proposed sign sign complies or will comply with all applicable provisions of the By- Other, specify Law. Will sign overhang any public road or walkway Yes ( ) No (� If Yes, Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: Receipt# Check# Revised 10.31.2006 Form Sign Permit Application SIGNATURE OF APPLICANT (�(� Option 7-Revised ESTIMATE LAYOUT � 28"x 120" Substrate PLAISTOW, NH Single Sided - Flush Mount To Building ROSE ® DOVE 6" Letter Height DOVE 4 Wilder Drive, Unit 16 Plaistow, NH 03865 603-382-9979 FAx 603-378-0117 S ecia www.sign-guy.com 13.5" Letter Height Name: REVISED 6-29-09 Company: Phone: Fax: E-mail: Comments: y File: Date: NMI llu� Approval: Y Colors: Fonts: PLEASE BE SURE TO CHECK ALL SPELLING This design and drawing submitted for your review and approval is the exclusive property of SIGN*A*RAMA. - It may not be reproduced,copied,exhibited or utilized for any purpose,in part or in whole by any individual inside REVISE or outside without written consent of SIGN*A*RAMA. APPROVED AS IS: x APPROVED WITH CHANGES: x PROOF 0 CapyAgM 2003 f yORTIy 1 Town of North Andover Office of the Planning Department Community Development and Services Division SACHUSE Osgood Landing 1600 Osgood Street Building#20,Suite 2-36 North Andover,Massachusetts 01845 P(978)688-9535 F(978)688-9542 Kellee Twadelle Rose&Dove Gourmet,LLC 181 canal St. Lawrence,MA 01840 June 23, 2009 Dear Ms. Twadelle, According to the North Andover Zoning Bylaw Section 8.3.2.c.i, Waiver of Site Plan.Review,the changes you are proposing to the retail space at 579 Chickering Road St,will not require an application for Site Plan Review. The waiver request is granted based on the following information: • The property will remain in its current use as a retail business, a use which is permitted in the General Business District, according to the Town of North Andover Zoning Bylaw section 4.131(1). • The footprint of the building will remain the same and modifications will be made to the interior. r • There will be no changes to the parking and landscaping areas. The number of parking spaces available in the rear of the building are adequate for this use. • New signage will require a sign permit from the Building Inspector. If there are any questions, please let me know. R ds, udith Tymon,AICP cc: Jerry Brown, Inspector of Buildings v BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Date.... . 3... .... NOR7F, / TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACMUS� ---�This certifies that has permission to perform � � wiring in the building of o� N t'(�'j TALUS T ............................ ... ............ .. ..................... ��� 2 /Ti A .. North Andover,Mass. at............................. ..... . ....... Fee..................... Lic.No...:F ELECTR[CALINSPECTOR Check # / 32-Y 8964 Commonwealth of Massachusetts Official Use only 71-)2 Permit No. , Department of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/29/09 City or Town of. N.Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 579 Chickering Rd#S} Owner or Tenant Gorham Trust Telephone No. 617-899-7051 Owner's Address 11 Tudor Court Bradford,MA 01835 Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Retail Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wire and install lighting. Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 15 Swimming Pool Above ❑ In- ❑ o. of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No. of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I. Detection/Alertina Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* ` No. of Water No. of No. of No.of Devices or Equivalent 1 KW Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $1500.00 (When required by municipal policy.) Work to Start: 7/29/09 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the inform 'on on this application is true and complete. a FIRM NAME: MDP Inc./MOTTI ELECTRIC CO LIC.NO.: 8424 A Licensee: MORDECHAY PUPKIN Signature LIC. NO.: (If applicable, enter "exempt"in the license number line) Bus.Tel.No.:_781-344-8950 Address: 471 PAGE ST.UNIT 2A_STOUGHTON, MA 02072 Alt.Tel.No.: 617-839-1440 *Security System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents ` "mc Office of Investigations �F 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MDP Inc/Motti Electric Co. Address: 471 Page St. #2A City/State/Zip: Stoughton, MA 02072 Phone #: 781-344-8950 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 10 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 sheet. 7. ❑ Remodeling ship and have no*employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. Building addition ❑ We are a corporation required.] 5. oration and its 10.❑X Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself No workers' com right of exemption per MGL y [ p• 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: EMC Insurance Policy#or Self-ins. Lic.#:31-173297 Expiration Date: 05/22/2009 q Job Site Address: 5-7A CAhCAf&AI�2*. 2.j ". "tftst T41—wA City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern under the pains andpenalties ofperjury that the information provided above is true and correct. Si nature: Date: _72cl locl Phone#: 7844-8950 4-8950 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ` Date. 'S �........ J f NORTH� 3?°•t;�`` ,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACNUS� This certifies that ../......2?...... has permission to perform / �G ............... . ............................................................. TL wiring in the building of..... ... ./ ..... at.......5 .7c ,.� !r! l illi ....1� ........:� North And�ovve�r,Mass. Fee..j2.�.� Lic.No.... ............... :.��+ (...��.... 6CTRICAL INspicr R v { / V Check # 896 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07]% (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: - g City or Town of: NORTH ANDOVER TO the—Ipector of Wires: By this application the undersigned gives notice of h' or her intention to erform the electrical work described below. Location(Street&Number) 14 C G Owner or Tenant Owner's Address �� V Telephone No. � Is this permit in conjunction with a building permit? yes ❑ No �� (Check Appropriate Bog) Purpose of Building L o vy 4 0f Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Com lesion Of the folloudn table may he waived bthe Ins actor o Wires. ' No.of Recessed Luminaires No.of Ceil:Susp. (Paddle)Fans No. of Total . Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [IIn- o.o mergency ig g d• d. ❑ Batte Units — No,of Receptacle Outlets No.of Oil Burners FIRE AI_AIMS No.of Zones No.of Switches No.of Gas Burners 0.-of Detection and No.of Ranges No.of Air Cond. Total Wtiating InitiatingDevices Tons No.of Alerting Devices No.of Waste Disposers eat Pump Number Tons KW No.of Self-contained Totals: - _._.__.._..._....._._. - Detection/Alerting Devices No.of Dishwashers space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: ' o.of Water No.ofo. No.of Devices or E uivalent Heaters Imo' Si s Ballasts of Data Wiring: t No.Hydromassage Bathtubs No.of Motors No.of Devices or Equivalent Total HP Telecommunications Wiring: No.of Devices or E uivalent kAF OTHER: 3 vdi cd,* kiss e �c lsi�l' Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Worktt5v When required by municipal policy.) Work to Start: -7 2 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) P �Y:) I certify,under the pains and penalties of per' ?y,that the information on this application is true and complete. FIRM NAME: '7s CI�PSS �s LIC.NO.: Licensee: 3 SevIV&V1Y Signature (If applicable, nter "exem,pgtt in the licenumber line) LIC.NO.: Address: i /t'fQ�/1,q� n�y�r/✓ 5,g/r,y fl/ZO0�rJ' Bus.Tel.No.: *Per M.G.L c 147, .57 61security work requires D Alt.Tel.No.: , Department of Public Safety S License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner [I owner's agent. Owner/Agent Signature Telephone No. PERMITTEE. S ( The Commonwealth of Massachusetts 1~j ! Department of Industrial Accidents Office of Investigations E C I A 600 lashin n Street k, Boston, MA 02111 1 www.nxassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Lembly Name (Business/organ intim/Individual):_ Address: City/state/Zip:_ A111 Q�Iyy' Phone#:_ Q $'j '—l4 Are you an employer?Check the appropriate box: I.❑ I aro a employer with 4. ❑ I am a general contractor and I Type of project(required): 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 sheet._ 7• Z-Re�modeling ship and have no employees These sub-contractors have 8. [1Demolition' working forme.in any capacity, workers' comp.insurance. " [No workers'comp, insurance 5. , e are a corporation and its 9. ❑Building addition rered.) officers have exercised their 10.0 Electrics)repairs or additions 3.7 I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No•workers'comp. c. 1.52, §1(4),'and we have no 12, R insurance required.]t employees. [No workers' ❑ oof repairs comp, insurance required..] I3.❑.Other ;Any applicant that checks bolt#1 must also fill out the section below showing their workers'6ompensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractees must submit a new affidavit indicating such. $Contractors 0,1111 check this box mustatrached an additional sheer showing the name of the sub-conttaetms and their workers'camp•policy i„r t i iaa• I am an employer that is providurg workers'compensation insurance for my.employees: Below inforit the policy mid job site mation Insurance Company Name: ' _�Sk��y t --� /I � Policy 4 or Self-ins.Lie.#: Expiration Date: Job Site Address: C ES . City/State/Zip. 61 S vy ” Attach a copy of the workers'compensation P14iey declaration page(showing the policy number and expi on date)- Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er the pains and enallies of perjury that the information provided above is true and correct Si tore: Date: T� Phone#: Of,r2ciat use only. Do not write in dhis area,to be completed by city ortown.ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions r Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner-of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair 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..oe 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 woric until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants x Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)acrd phone number(s)along with their cenificate;(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,not1he Department of Industrial Accidents. Should you have any.questions regarding the law or if you are requited to obtain a workers' compensation policy,please call the Department at the number.listed below. Self-insured companies should enterthcir self insurance license number on the'appropriate.line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which%will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investiptions would like to thank you in advance for your cooperation and should youhave any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-72.7-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 9 617-727-7744 rwww.mass.gov/dia NORT►y own of 4 L over No. 7 ....w ,. ZoAKE = dover, Mass., 7) . ( (2 . 09 C` i' COCMICHE.C. y1. ADRATE D P'P�\ y `S BOARD OF HEALTH PER IT . T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ....... ...... ............................................................................. Foundation has permission to erect g ....".1. � �� �. g ..................................... buildings ....... ►� ........ ..•.�e. Rough —y. &000110k............... Chimne to be occupied as.... .................. .... ........Q1A.� ............. ........................................................... provided that the person accepting this permit shall in every respect conform tot a terms of the application on file in 6inaal> /- 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. PIAJMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TARTS Rough Service BUILDING INS 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.