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HomeMy WebLinkAboutMiscellaneous - 66 CHADWICK STREET 4/30/2018 66 CHADWICK STREET 210/066.0-0050 0000.0 TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING ss�caus�t This certifies that.............I. .h..0. �.....................J ....................................................... has permission to perform..... ! .�-°:.) ✓e,p . ...................................................... plumbing in the buildings oL1j-t..A24 at... ..(.p...... .:Y1(a r w... ..�4... 1� . ........ North Andover, Mass. Fee,, ..........Lic. No3zeo.. ........................ . .. G.. .. . T.0...................... PLUMBIN... . .G IN.SPEC. TOR Check# ,, 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK JJ CITY MA DATE 2Z. PERMIT# JOBSITE ADDRESS OWNER'S NAME� pMY _ sqa; �JI P OWNER ADDRESS TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL EN PRINT CLEARLY NEW: RENOVATION:DD REPLACEMENT:Q PLANS SUBMITTED: YES EO NOL FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( __. _ ( _ t _ _ I _ __—j===== DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ I ..__._I -_--� i .-._._._I k ---_-__f _._..__l .____ .__.__f _........ _.. ._.. ._...._1 _� ....._...� FOOD DISPOSER l -.._ _t I 1 ( ( _ _._.1 J -_.___-_{ _---_-j FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ! ._!._.{ I . __i LAVATORY ROOF DRAIN l � . __—I I 1 ! _ 1 J __.._J -___—_! __.--.-! m.--A I SHOWER STALL -1 1 � -1 .____ _..___1 __.t _._._..d SERVICF-/MOP SINK ..l C _[ I _. ! [ ...__._._ ___l TOILET URINAL. I L__j _._. _ _._.. _i ._- .---( WASHAG MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ C NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY D BOND Q 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 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I 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 —_�,I LICENSE# SIG MP 01 JP tq CORPORATION # PARTNERSHIP D#�LLC� COMPANY NAME ADDRESS E CITY `_---....._..._._..STATE �/( _� ZIP (� ( TEL — FAX CELL �EMAIL y�,` _- - q4mal ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL VSP +CTION ES Yes No JZ(f 4(l THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date..._, .....t ..r.. t................... "ORTAt TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CH ES�9 This certifies that V ''��' r?) has permission for gas installation .. :, ;,,:.�-- ............ ...................................................... in the buildings of...,......�,,..�.�„�,.�, ............................................................................. at.... ..................:: t 3� North Andover Mass. Fee.....:ei' .. .... Lic. No. ......................... c �� GAS INSPECTOR Check# � CJ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Y U�bI r7J � MA DATE PERMIT# V - JOBSITE ADDRESS ( �� W��(C { ( � 'OWNER'S NAME - � GOWNER ADDRESS TE - AX r - - r TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST ® RESIDENTIAL CLEARLY NEW:E3 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM 1. 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BOILER - .. l _ �, .I. _ I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE (t FRYOLATOR _ FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT r ! ( OVEN I POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST - UNIT HEATER ! U VENTED ROOM HEATER i WATER HEATER (� .......... .............. . INSURANCE COVERAGE have a current liability 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 V OTHER TYPE INDEMNITY L] BOND Ell 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 Q 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.. PLUMB ER-GASFITTER NAME II LICENSE# SIGNATURE MP 0 MGF 0 JP ( JGF LPGI© CORPORATION Q# PARTNERSHIP®#=LLC E]# __ . -j COMPANYNAME:=-- ADDRESS CITYVLG� _ STATE h ZIP TELX& FAX ) CELL EMAIL_a U 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 � e � S COMMONWEALTH OF MASS SETTS 901:20-.Te PLUMBERS ANIS GASEITTERS:4Fi IS5UE5T:HE F0LLOWIt:G LfCENSE L I Ct NSl O q5 A JOUR NEYMAN,,P%--UMBER X, N t AQG:A I ZENG 105 C 0 6iA`)A S Y : UINCY `1J MA 02t6g 7553 215952 J The Commonwealth of Massachusetts M Department of IndustrialAccidents u = 1 Congress Street, Suite 100 'f Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): AU h Address:_I l) �_g IM 0&j A_ z � City/State/Zip: D.Lwvv AAA Phone#: 7V 6��O Are you an employer?Check the ppropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2Q1 am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. 1-1 Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submif 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 state whether or not those entities have employees. If the sub-contraciors have employees,they must provide their workers'comp.policy number. I am an employer Mat is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: I 0 `i" N nd(/1.1 it, 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 the pains and penalties yury that the information provided above is true and correct Signature: V12"t el., Date: 'Z—ZZ— ?,016 . Phone#: — 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): ; L[.6 Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board ontact 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, o 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 foi•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 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 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 .tal .. .�. ....... OF r10R7F/,� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING r wk= gs'�CHUS� This certifies that . �. �`� . has permission to perform . ..�-, .... ......... `A�U.t1! wiring in the building of..,....PG i S V . / Aldi,g ........................................ at ..CE'..9.....C�"`°'..`^' (L................................................North Andover,Mass. .................�L....... Fee..............................Lic. No. ....... . ..............................v..................................... ELECTRICALINSPECTOR Check# . Commonwealth of Massachusetts Official Use Only i Permit No. 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 ININK OR TYPE ALL MFORMATIOA9 Date: ;)- a 9 - 2-V 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 (, C ,�A LLq si Owner or Tenant ( t$ Telephone No. q 8 - 69-1 Owner's Address Sf 0J. Ign�Lje_�- n'l A 01 fitd C Is this permit in conjunction with a building ermit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building e- V1 Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Location and Nature of Proposed Electrical Work: C Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires a 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 Lighting No.of Luminaires Swimming Pool rnd. grnd. F1 Battery Units No.of Receptacle Outlets GC7 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 No.of Waste Disposers Heat Pump Number..Tons..........KW.......... No.of Self-Contained 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: Heaters Signs - Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: 13aA, Attach additional detail if desired,or as required by the Inspector of Wires. Estimated'Value of Electrical Wo4?-M O (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 Ili epains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: - Licensee: 40,11A Signature ( j LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.•_L5-SU- Address: (a A n,o(d( S'fi QuI r,24 M 19 oaI 6 q Alt.Tel.No.: *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 V / Signature Telephone No. 1P__P_P_M7,T FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed 6 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 1 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 0 Failed IN Re-Inspection Required($.)❑ Inspectors Comments: i Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPY4 TION: Pass IN LZ Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: 41 X Inspectors Signature: ". Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com � dv• a • The Commonwealth of Massachusetts Department of IndustrialAccidents - d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant Information Please Print Lel4ibly Name(Business/Orgw&ation/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction .2.FI am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.# 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no,employees.[No workers'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. *Contractors 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-conliactors 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: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 thepains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: 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-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 Iiudustrial 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 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 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 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 1 pom'm,omvealth of Mas usetts Di'vigior(of Registrati RciaF�oi'Eleetri a al t SAI THi„ 847 MET 4 1� i HYDE PA J Joumeyma 5^857-B 07/31/2016 , S e 0092-78 { License No. Expiration Date. Serial No... _ J a BUTTERWORTH & O'TOOLE, INC. ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY P.O.BOX 8294 SALEM,MA 01971-8294 TEL. (978)741-5731 FAX (978)740-9109 claims@butterworthotoole.com 08/04/2014 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS . GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall City/Town Hall ADDRESSES North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Genia Kmiec Address : 66 Chadwick Street North Andover, MA 01845 Policy No. : 3058104 Loss of : 08/04/2014 Water / Overflow File or Claim No . : 44-0898 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000 . 00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Patrick Tobin Adjuster i�rr'k Member of National Association of Independent Insurance Adjusters Location No. Al/7,/ Date O cYJ 1 p NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 'Ss�cNust` Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ _ TOTAL $ -5� ' Building Inspector X0123/98 08:58 25.00 PAID Div. Public Works Location No. f / Date NORTH TOWN OF NORTH ANDOVER `p Certificate of Occupancy $ i ♦ i Building/Frame Permit Fee $ # Foundation Permit Fee $ MUSE Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector ' Div. Public Works PERMIT NO. ' / _APPLICATION FOR PERMIT TO BUILD********NOIZTII ANDOVER, MA NI(1'NO. I0[.NO. 2. RE('URi)OFOWNLRSIIIP DATE BOOK PAGE ZONE SUB DIV. ►.c FF No . — /1( G t LO( AIION /� PURPOSE()F BUII DING ()WNER'SN,AME�4J �,� f ��q�/ NO.OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ST ARCI11TEI'S NAME SIZE OF FLOOR TIMBERS 1 2 ND 3 C Will DER'S NAME /tiy /� t SPAN DISI ANCE I O NEAREST BUILDING DIMENSIONS(Y SILLS DIS I ANCE FROM SI REI F DIMLNSIONJS(lF POSIS DIS I'ANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF I.OF FRONTAGE HEIGIFF(N:FC)INDATION THICKNESS IS BUILDING NEW SIZEOF I(XYIING X IS BUILDING ADDI 1-1014 MATERIAL OF CHIMNEY IS BUILDING ALI ERATI(NI IS BUILDING ON SOLIDOR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED I OTOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CCNJNECI'ED TO I OWN SEWER IS BUILDING C(NNNECI ED TO NATURAL GAS LINE INSTUCTIONS 3. PROPER[NINFORNIATION LAND COSI' EST. BLDG.COS T Q PAGE I FILL CX J I_SECI1 NNIS 1-3 EST. BLDG. COS I PER SQ. FT. ESI. BLIX i.Coo I PER R(X)thl EI FCTRIC MEI ERS MUST BE ON 02ITSIDE OF BUILDING SEPTIC PERMIT NO. AI-IACFIEDGARAGESMUST C(NJFORMTOSTATEFIRE RE(A)LA'TI(NJS 4. APPROVED BI- // ( � Q� PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECT(Ili 6xB111L )ING INSPECTOR DA FL 1111:1) ' / //l OWNERSIEI.4 �= C(NJTRAE14 1/1� 66 C(N1TR.I.ICN O 3110 41 ? 11GNA I 1 IRL l)P UN'NI:R l N2 AILD It)RIZEI)AGLNT //' /� Ili-RMI-IGIiANIlI> 1) (/ t The Commonwealth of Af4ssachusetts - ( Department of Industrial Accidents — Office o//nrest/gaUons _ 600 Washington Street } Boston,Mass 02111 Workers' Compensation Insurance Affidavit name: locations j city phone# rl I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity rl I am an employer providing workers' compensation for my employees working on this job. comoaev ranee:. address:..... city phone#: ItliRrAtllXS CO: policy# C3 I am a-sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comoanv name& .. address•: f .. Sill:' Qh one# inaurttnce co: Qoliry# comQany.name: _ ` I _ address.. - ei phone i Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a flue up to S1,500.00 and/or One years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerci under the pains andpenalties of perjury that the information provided above is true and arced Signature Date Print name���Q t �i U' Phone# 1 foL official use only do not write in this area to be completed by city or town official C or town: permit/license# Bu:ngepartment❑LicBoardcheck it immediate response is required Sels OfficeC3Heartmentcontact person: phonea; r7Ot (revucd 7/95 PJA) Town of North Andover ,ORTH OFFICE OF F °�; •��o A COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street * i • r North Andover, Massachusetts 01845 �,'•�:;:,;::•`s5 WILLIAM J. SCOTT 'SSACHUSE� Director In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number 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 1 11, S 150A. The debris will be disposed of in: (Location of Facility) All Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for tills project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 � r10RT Town of over No. s17/ * l dover, Mass., 14909 19918 0 Z LAKE '9"CO CXICXEWICK S E BOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT...7'rNboi....K..............K.m..'.Q.L. BUILDING INSPECTOR .............. ................ ..................... .. .... Foundation has permission to e�.Re.r . . buildings on........... ....�... . .... �C .. Rough occupied as ` N u a .............................. Chimney to be .......... N ................... ........... ........ ... ...............V............ 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 vopo_E G i PER1viIT EXPIRES IN 6 MO S Final ELECTRICAL INSPECTOR UNLESS CONSTRU NaT/ c Rough .. .............. Service ... ... ... ..... ... ........................ ... ........ .... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough F nal No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.