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HomeMy WebLinkAboutMiscellaneous - 62 MOODY STREET 4/30/2018 62 MOODY STREET 210/081.0-OOO4-0000.0 Date.......7��'�.(1..�.................. OF r►ORTH,� o?' , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sSACHU Thiscertifies that .. .. ........................................................................................... has permission for gas installation Q....� � p.. �.JAY, .....-.......,� t�K- inthe buildings of..................................................:.................................................................................. at..�o�.. \ ..... STP q. .......................... ...PNSPECTOR over, Mass. Feo,.7 Lic. No. , ... .... ....... ............................ A Check#P � r i 41) a - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Cj I _ CITY ' MA DATE c 1 / PERMIT# I��I JOBSITE ADDRESS Do' OWNER'S NAME GOWNER ADDRESS TE y^ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:F-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NO —SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 APPLIANCES Z FLOORS- BOILER .-- BOOSTER -- CONVERSION BURNER COOK STOVE ----- DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE s —r---1 I - v GENERATOR GRILLE - - n - _ =�! . - -- _ INFRARED HEATERLABORATORY COCKS COCKS MAKEUP AIR UNIT _ OVEN ,POOL HEATER -1R0-0M/SPACE HEATER ROOFTOP UNIT ) TEST UNIT HEATER — UNVENTED ROOM HEATER I �-- WATER HEATER - - OTHER - - INSURANCE COVERAGE —liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J _ NO E] I have a current Ilab p Y IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER EI AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perl4ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME '`' ___�LICENSE#2i(P SIGNATURE MP El MGF 0 JP E JGF LPGI® CORPORATION�# PARTNERSHIP®#=LLC --�7�� _ COMPANY NAME:I� c, t��}` _...5' - ADDRESS CITY '' ,,C _ — - - - STATE /Y)�A- ZIP G� ��IGI TEL�S "7 - -EMAIL __ �— FAX ' CELL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NQlXS Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02X14-20X7 Wt www mass.gov/dia om ensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. ��• Workers'C p TO BE FILED WITH THE PERMUTING AUTHORITY. Please Print Le ibl A 3licant Information Name(Business/Organization/Individuai): Address: le � 7�,• y� u �� /✓t/� o 1��� Phone#: '�1 City/state/Zip: " Type of project(required): Are you an employer?Check the appropriate box: 7. []New construction ❑ employees(full and/or part-time).* g Remodelhig 1 I a employer with_•_— P for in 2. I am a sole proprietor or partnershipand required]yes working 9. Q.Demolition any capacity.[No workers'comp. 3.❑I am a homeowner doing all work myself[N o workers'comp.insurance required.]t JOE]Building addition I will q.❑I am a homeowner and will be hiring contractors.to conduct all work on my property. 11.❑Electrical repairs or additions 12 + lambing repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 13.0 Roof repairs 5❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 14 ❑Other These sub-contractors have employees and have workers'comp.insurance.' • t of exemption per MGL c. _ o workers'comp.insurance required.] 6.Fl We are a corporation and its officers have exercised their right 152,§1(4),8n4 we have no,employees.[N AnY PP indicating they are doing all work and then hire outside cO contractors and state whethereor nowt those entities have davit indicating h. * a licant that checks box#1 must also fill out the section below showing their workers'bcompensatotrar must policy inforEi mation t Homeowners who sirbrI— this affidavit in the name of the cnumber. $Contractors that check this box must attached an additional sheet showing employees. If the sub-contractors have employees,they must provide their workers'comp policy em l0 ees. Below is the policy and job site I arri an employer that is providing workers'compensation insurance for my p y information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: ity/State/Zip: A"'�tvilt/L lob Site Address: YN O e showing the policy number and expiration date). of the workers'compens tion policy declaration page( punishable by a fine up to$1,500.00 Attach a copy 25A is a criminal violation p Failure to secure coverage as required under MGL c. es i t e Office of Investigations of the DIA for insurance irage as r as well as civil penalties in the form of th TOP WORK ORDER and a fine of up to$250.0 a and/or one-year viola be forwarded to day against the violator.A copy of this statement may coverage verification. peru that the information provided above is true and correct. ,do hereby certify under tlz ains and penal' of p 1 r3' r Date: Si nature: Phone#: write in this area,to be comp leted by city or town official, Official use only. Do not . Permit/License# City or Town: e): r 5.Plumbing Inspector Issuing Authority(circle on 1.B Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspecto 6.other Phone#• + Contact Person• i r Information and Instructions coons 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 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 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)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-ihi ured companies should'enter their self-insurance license liiimber on the appropriate line. _. City or Town Officials Please be sure that the affidavit is complete andprinted 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 Poll' 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date...i .2,. ... . ......... OF 40R TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....C ......... . f ........... ......................................... has permission to perform .......�.. ............................. wiring in the building of........A0 S. -Ale ............................................................... ac .......All .(�J \"P/wA 4.,-1.......................... > orth Andover,Ma s. Fee..0../...7t...-...0../.7..- U i �LE&MCAL INSPECTOR Check# 1.310 Commonwealth of Massachusetts Official Use Only offo Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL)NFORMATIOA9 Date: 7/071/3 City or Town of: NORTH.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) 6'Z /�/6B�y 5frttOf Owner or Tenant Qi sa6/I f Telephone No. Owner's Address �Z /y✓0� Y Jit/C�f" Is this permit in conjunction with a building permit? Yes [R' No ❑ (Check Appropriate Box) Purpose of Building^&Cl/%7 rJ Utility Authorization No. Existing Service /GD Amps 12-0 / Z 9V Volts Overhead Undgrd❑ No.of Meters New Service 20,9 Amps i2o /Z 41a Volts Overhead Undgrd ❑ No.of Meters 2 Number of Feeders and Ampacity C Location,and Nature of Proposed Electrical Work: Sr�jytC C �f'9rU�P_ aAo 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 Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig ting No.of Luminaires Swimming Pool rnd. ❑ rnd. El No' Units i 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 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons J.KW No.of Self-Contained p Totals: ........... "" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: t Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent i OTHER: tN3, Attach additional detail ifdesirect or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0/11 wy (When required by municipal policy.) Work to Start: CTIZ 7 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 cover e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) .I certify,under the painsa d penalties of perjury,that the information on this application is true and complete. FIRM NAME: . ���, j' '117.4re,13oa,�r� ��r �l crri �or� LIC.NO.: /7676,O Licensee: �j,Vjd Signat re LTC.NO.: i?6T6L3 (If applicable,enter "exempt"ina license number line._ Bus.Tel.No.: / 1/ Address: /12 eezw t Ikrec - �vs�US �/¢ Q�9�6 Alt. .Tel.No.: l i 3 S33L *Per M.G.L c. 147,s.57-61,security work requires 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 ❑owner's agent. Owner/Agent PERMIT FEE. $ 211.00 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the pennit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed } on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGA INSPECTION: Pass MyFailed 0 Re-Inspection Required($.) ❑ Inspectors C ents: J Inspectors Signature: U Y Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comment ^ J Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com C The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 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): AG'dtU/ F A�1 .JUv)ysy,>/o E�f'GfdYCi0�1 Address: City/State/Zip: OL� Phone#: 1 SZ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction e loyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. F1 Building addition [No workers' comp.insurance 5. EJ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[J Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees. [No workers' comp.insurance required.] 13.❑Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job 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 requiredunder 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. X do hereby certify under ee p�and penalties of perjury that the information provided above is true and correct. Si ature: G � :/ Date: FIZ ,7VIj5 Phone#: 7ri 5-z 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#: M 5 Information and 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,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 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 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)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. AIso 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 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 F 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 burn 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston?MA 02111 Tel.#617-727_4900 ext 406 or 1-877-MASSABB Revised 5-26-05 Fax##617727-7749 www.mass,govldia 101 24 Date .�h TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . .,. . . . . . Ply , ,, 1 el A� . . . . . . . . . . . . . . . . . has permission to perform ./. +.�. . . �!✓5. f J�ldru/ ,�, ��� plumbing in the buildings of. F .� .� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. 1 Fee,?/.7 . . Lic. No. ./� 7 / �.. . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check #Jam / _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �( MA DATE <c` ) PERMIT# v 12 JOBSITE ADDRESS !na 7` �� OWNER'S NAME POWNER ADDRESS I TEL[::— FAX ` TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: [U/ RENOVATION: REPLACEMENT: D PLANS SUBMITTED: YES® NOQ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ! _ _. { 11 ___ ! .-_.__A DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ( __..._._) ._._._.._ DISHWASHER DRINKING FOUNTAIN �.i ...-.- FOOD DISPOSER FLOOR IAREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I _ 1 l _._� -_-._-_[ .__._� I _-_- .___.J __.__J .__..._._i _.__ .- LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I ! __.._f .—_� 1 .- I J . _J E_-i TOILET SHING MACHINE CONNECTION { { ._ _- _ .1 _ ! ! _. f F-7 ATER HEATER ALL TYPES TATER PIPING INSURANCE COVERAGE: 1 have a current liab- ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LA� OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. S CHECK ONE ONLY: OWNEREJ AGENT O SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SIGNATURE IMP Q JP D CORPORATION MI#©PARTNERSHIP# LLC COMPANY NAME �m�s�j,yw�r�¢ ; ADDRESS I CITY y __.._.._...._i STATE ZIP Qtj J TEL T r --LO - 11 FAX _. -�_ { CELL. J EMAIL _ _.._.-- -- -- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a��-kn 9c� .r> e' � r The Commonwealth oflilassachusetts - Department ofIndusWg1 Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/Organization/Individual): , f�EC`l o9AI A Address: 1A City/State/Zip:- �7a_al. )Al 1114 Phone 4:_ 66- �Zcq(2 Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4. ❑ I an a general contractor and 1 6. ❑New construction r employees(full and/or part-time)." have hired the sub-contractors 2. 1 am a sole proprietor orpartner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. F1Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers'• comp.insurance required] 13J:1 Other *Any applicant that checks box#1 must also fill out the section below showingtheir 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. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job 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 requiredunder Section 25A ofMGL 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. Ido hereby certify under Aepains andpenaldes ofperjury that the information provided above is true andcorrect. - Signature: JQw./-✓s r_wac Date: S—,5p-(0 ` 3 Phone#: ��� — (r1�n r�,9(0 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.CitylTown Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and ffnstrIl ctions 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 ofhire,. 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 ofits political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapterhave been presented to the contracting authority." Applicants Please 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 certificates)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 maybe 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 retumedto the city or town that the application fbr 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 rintecIegiblY. TBI)dpaitinerit has rovided a s ace at the bottom p-- p--- 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn 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: Tho Gonr410awealthofmlassarhusotts - Dopartweiit ofladuadat.accidents Office dIu o igations 600 Washingtoja Street Boston?MA02111, Tel,#617-727-4900 QYd 406 ox 1-877,MASSAFF, Revised 5-26-05 FaY,#617-727-7749 COMMONWEALTH OF MASSACHUSETTS PLUM:I3ERS AND GASFITTERS LICENSED ASA MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: i - m ; !THOMAS. J GAUTHIER 10 SERENITY -CIRN t 1 HUDSON a. N-H 03051-3270 r 1.3274 F 05/01/14 198606 } A Date....0�� ................ OF &ORTA#,� TOWN OF NORTH ANDOVER 4 � 9 PERMIT FOR GAS INSTALLATION �8s.+cHug�t This certifies that ....�...................... �'..`�!.'¢`...:.n. ... ............................. has permission for ga installation .. ....................... ..................... in the buildings of............n ' `�l'?/ . ........................................................................ at........6.2......�d e cY7-i� �� !.�................ North Andover, Mass. / 8� Fee/.f ..--.. Lic. No. ..............7y.. -'................................................. ,412 7e GAS INSPECTOR. Check# p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FFIIITT.TING WORK CIN - ,��5_�, MA DATE I�2�3 II PERMIT# v JOBSITE ADDRESS 0 -t OWNER'S NAME ----ex GOWNERADDRESS �/�r'k� _ _ - TELL-- -.---IIFAX�TYPE OR OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL �,? RESIDENTIAL[fly PRINT CLEARLY NEW: RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES 00 APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER —._..I�.�_ —_,, 1 �. 1.�. -��_ I _� �? _ ? BOOSTER _. __ _.� ._� ,_� C_�_-I __ __ .I __� I_-__- -_---- . --- _= CONVERSION BURNER COOK STOVEI mTM.l �J DIRECT VENT HEATER .! DRYER 1-7-3 F--.1 FIREPLACE FRYOLATOR f FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER —( OTHER `+ i - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES l�]__i NO Ell 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [R' OTHER TYPE INDEMNITY 0 BOND 1__! OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER I_._tl AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with alPertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �- PLUMBER-GASFITTER NAME yu. LICENSE# --_ SIGNATURE MP MGF[ JPF.j JGF LPGI ERP CO # -_- PARTNERSHIP Q# #f-__ 11 COMPANY NAME:-.:r.,- ADDRESS /j ��✓/y2�i,� Irl _ _, _ .. '�, CITY STATE (ZIP TEL 9�� � 7p1 [.s JdhC /� --- - - � � FAX I__-- CELLEMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES fq 44 r r t� 'COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS . ' SED AS A MASTER PLUMBER LICENSED .. ISSUES THE ABOVE LICENSE TO: i ,THOMAS .J GAUTHIER 10 SERENITY CIR (' ,r 4 F- HUDSON N-H 03051-3270 1-3274 05/01/14 198b06 D Lot 2 7 6 Date. 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHUS This certifies that ........... ............................... i // As permission to perform ...................................................."......R,..., ........ ..... ..... m4ring in the building of........ .)....................................................................... at.......�22 ...9.................... . ...... ........... North Andover, _�A .. .. ...... Fee.50-A Lic.No.X-��......... e.1*71 ..... ELECTRICAL MPECTOR Check # Corninonwaa�� Official Use Only 2epart`.inan1 013i. e WC0d Permit No.— BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev. 1 1/99) leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Glcctrical COdc(M•C),5X'7 CMR 13.00 (PLEASE PRINT LV INK OR TYI'L• :4LL/1VFOR6L9 TION)) Dace: biz � �.-- City or Town of: -�l 1 p,v To the Imp -o of 6Yi1 es: By this application the undersigned gives notice of his or her intention to perform the electricai•work described below. Location(Street R Number) teY6716-01� Owner or Tenant _ IAIS. Telephone No. Owner's Address Is this permtit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building_ p t Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ Na,of Meters , New ServIce Amps / Volts Overhead❑ Undgrd ❑ No,of Meters. Number of Feeders and Ampacity Location :ind'Nature of Proposed Electrical York: Com letion ofthe ollotvine table Wrap be�ralvert b the brs'cctor al{Vires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans 0.0 vtat Transformers KVA No.of Lighting Outlets No.of I-lot Tubs Generators KVA No.'of Lighting Fixtures Swimming Pool A ove ❑ n- ❑ o.o mergency tg a ng nid. rnd. Batte Units No.;of Receptacle Outlets No.of Oil Burners FIRE ALAILIIS No.of Zones No.of Switches No.of Gas Burners No.of Detecti—on an x InitiatingDevices No.o.of Ranges No.of Air Cond. Total 'Tons No.of Alerting Devices T eat Pump i Number "Tons_ o.o e - onta ne To.of Waste Disposers Totals: -- - Detectiot>/Atertin Devices . 111�-of Dislnvashers Space/Aren Heating KW Local M unto pa Connection 0 Other No.of Dryers Heating Appliances KW SecuritySystems: No-of Devices or E uivalent. No.of ea KW o.of j o.o Data Wiring: Heaters . Signs Ballasts No.of DeAces or Equivalent No.Hydromassage Bathtubs No.of Motors 'Total HP 1'c ecommutncations ring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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 e:thibited proof of some to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ orrl-IER ❑ (Specify:) y e3 / --�'� (Expiration Date) Estimated Value of Ele rical 1Vork:'G a (When required by municipal policy.) Work to Start: ;; � !t pections to be requested in accordance with MEC Rule 10,and upon completion. I certifj, tntder the pains and pettaltirs of perjttr�;tart t/ie h0ornration oil this application is true and complete. FIPAI NA1%IE: d ,h Gfil/'O /�' LIC.NO.:/9 �!S Licensee: —forZR//a Signature LIC.NO.:4 -"!(%O 7Z (If applicable,ewer -exempt••in the lice►+re number line_) 7r Address•_-O. 6s X .V-5 3— B VA., fir /`� a r �3� Bus.Tel.No.: 1—�4 g°'9 Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware Q t the Licensee docs not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check onc)❑owner ❑owner's agent. Owncr/Agent Signature Telephone No. FPj,,-jn11T F—EEc' `� JUN-26-98 10 :59 AM E K SURVEY 5086880485 P. 02 MORTGAGE PLOD' PLAN EK SURVEY I NC. MORTGAGORL�s'� DEED REP. _y Pa. ADDRESS OF PRINCIPLE BUILDING PIAN REF. _G2 auded a'_ -- DATE OF INSPECTION iy ScrltE:�,�soI 1 ,.CosPEG� «►., fir'' i C .Wfm`x�_o w 5 YY � i A(lac(,d I U f T f NOTE: Thb br fnOAy• inpQ4 P, Uan w= ptvgrw �� 1 FPIiTHEIt SATE~ THAT IN WY PRafE=OONAL ply fw rnortpuQo Putpo[�.as and h not to o� • a opWloN the b. htied upon as a larva)& G}C tLi1tV�Y T. �. �clPf• structurs/s and c"...ory no �Sottslbilty for damages aocepb flu EL -' butbupc�ngs, rslbpce by 01W14 other than the sold moot a F+o.96860 t with the gtbac$ rquhrtnents of Go Ioopi *nd ttz osstyns In connection w" Its propp t x"w'In9 aNlncjnoas, and Umt ho onduvochmwas 9490 Moncinp to sold mortQay,,. •. �,� fCIstof mo* Irnpro ein6nty 4th-w CE tTlilC�Ti4�! TCk ;t��M�t L.0, °�PwtY t$D.c t Gia WUA y QGt�ozis` i Thb 01. Property is hot In a Flood Haznnd Arso. � muncatlon a basad an th• lorutlon of >w�v.y tncric.� E3 2- P�� 1s in 'a Flood } ,V,a, of alh0m, otnd docs not rpxeaont d I�.rty sulvayv thentote C13. IAfWmatioh !a Incufticlont to Atwmfi• Flood Hazard, offsbtY Tlown are not to ba bead for the artobWithm.nt of Flood Haz rd dotetminsd 4,om t� Int radervl Flood fpropstty iihss. U�sararicv Rdte map Po"d f I Location No. U Date f NORTIY TOWN OF NORTH ANDOVER + s Certificate of Occupancy $ Building/Frame Permit Fee $ .q: Ss,u�sE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ fib• a, Check # •.�O�O 8657 Building Inspect r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT 3MIM RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING 7 BUILDING PERMTr NUMBER: DATE ISSUED. 02 7e, M SIGNATURE: Building Commissioner/I o2uildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel'Number: O _22 Nn Map Number Parcel Number I/�J W 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS(ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Reipired Provided v 1.7 Water Supply M.GLL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: _p!� ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No rn 2.1 Owner of Record Name( mint) Address for Service: ( j Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O � Z rn Signare Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: 0 License Number Address Expiration Date ic Signature Telephone �. 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number r Address r Expiration Date Z Signature Telephone G) 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 Descri tion of Proposed Work check all applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descriptionsed Work: o Propo � 0 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE�ONLY Completed by permit applicant 1. Building (a) Building Permit Fee . 0 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)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 OWNERS AGENT``OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Q�h\\ as Owner/Authorized Agent of subject property Hereby authorize to act on My t1f,in all matters relative to orkoriz by this building permit application. Q Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 ti and belief Print Name Signature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DIN ENSIONS OF SELLS DINIENSIONS 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 9 T,)o 5 FORM U - LOT RELEASE FORM Z�p(ac�9►t�e� INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT (1QV0 \(�-e � ��/�, PHONE ,1 g' � — � LOCATION: Assessor's Map Number l PARCEL SUBDIVISIIO'N LOT (S) STREET ` ��`� � ST. NUMBER OFFICIAL USE ONL WA-flo"(JOWN AG - T : CO SERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS &VS ( ,y (OD' TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197I The Commonwealth of Massachusetts Department of Industrial Accidents I„ l Office of Investigations ' / 600 Washington Street Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly t � Name (Business/Organization/Individual): i n /�) )I!)2A_N Address: City/State/Zip: 'hone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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.❑ I 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 me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 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 12.0 Roof repairs insurance required.]t employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box#1 must also till 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. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job 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 c. 152 can lead to the imposition of criminal penalties of a tine 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. I do hereby certify under lite pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: O ficial use only. Do not write in this area,to be completed by city or town(1.1icial 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 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 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 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)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 till 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 burn 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax #617-727-7749 www.mass.gov/dia OCTI-31-2000 14:28 FROM AMERICAN SURVEY It. TO 19709221499 P.01i01 pr 7-R EE "76,x ' I pr.'post l l � I DoT, 4�. " I ��•Q I I 'i � , J STU TLY th! t,l.j til C3 z I I� Si Z 4 :p.; OCATION OF STRUMt' �-� SS: ,�+ BASED ON LIMES OF OCCUPATION 5ONLY. AMORE CURATE LOCATION :i!�r:•?ti.: : e-WILL REQUIRE AW INSTRUM EhM SURVEY. Scale: J" S. IAURETANI ) HEREBY CE LAND SURVEYOR, AMERICAN SURVEYING COMPANY � HEREBY CERTIFY THAT THE :OVE MORTGAGE INSPECTION 1264 Main Street, Waltham, MA 02451 (781) 893-6477 AN WAS PREPARED FQq I. ►o'iIN D IS NOT INTENDED OR REPRE- v I mortgage inspection Plan 'NTED TO BE A LAND OR PROPERTY IE SURVEY. NO CORNERS WERE THE LOCATION OF THE ORIGINAL RECORDED AT SE °jI~ T. IT CANNOT BE USED FOR ES- DWELLING SHOWN HEREON EITHER BOOK COUNTY REGISTRY OF DEEDS BLISHING FENCE, HEDGE OR WAS IN COMPLIANCE WITH THE LOCAL PLAN REFEE�EPAGE�-LC. Cert,s f��.t�9 O, f 3-73 ILDING LINES.THE LAND AS SHOWN APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF :REON IS BASED ON CLIENT FUR- FECT WHEN CONSTRUCTED WITH RE- MAP s ASSESSOR'S ;HED INFORMATION AND MAY BE SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: PARCEL DATED 1BJECT TO FURTHER OUT-SALES, REQUIREMENTS ONLY),OR IS EXEMPT Npp KINGS.EASEMENTS ANDRIGHTSOF FROM VIOLATION ENFORCEMENT AC- BORROWER: L- fY. NQ RESPONSIBILITY IS EX- TION UNDER MASS.G.L.TITLEVII,CHAP. NOEDHEREIN tOTHE LANE)OWNER 40A, SEC. 7, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE t OCCUPANT, IT IS NOT INTENDED NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSURANCE PRQ,GRV,,.f iOOD BE'RECORDED. FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED qyt JE Lo - :;?I - 6� IS ADVISED WHEN STRUCTURES ARE COMMUNITY_PANELr- .IENT G SHOWN TO BE 1. OR LESS FROM --i PROPERTY OR REQUIRED ZONING FIELDED DRAFTED —r—w—;:CK IENT REF.p Q� SETBACK LINES. BY N DATE 1C3.40.31173/m-31 a NORTH TO" of . 4Andover No. _ — - 3 d -- _- dover, Mass., COCMICMEWICK y RATED PPa\ �7 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT C.4....!!.r �,I11J . / � / .......................................................... Foundation ....... ...... ......................... .................... ................ has permission to erect....... .� ........ ..... buildings on � � ................... Rough 7to be occupied as C 3A.4p.44 ............................................ 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. w/9' /9' PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCWOT TS Rough ....................... .. ......... Service . .............................. ........ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det.