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HomeMy WebLinkAboutMiscellaneous - 66 CIDERPRESS WAY 4/30/2018 BUILDINGFILE 09840 l 113 Date.5!�� . . . . . .�stixAa ' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Vl f� This certifies that . . ! ._.�.C�-�. . . . . ilex. . . . . . . . . . . . . . . . . . . has permission to perform . I�.e j 6 ��'6S e- : . . . . plumbing in the buildings of.M Q e. �"fl� .1 h . . . . . . . . . at .(I nn P' p. !.._. 0(Z,�?(�.r� � . . . . . . .J. . . . . .North Andover, Mass. Fee S(�ch-7 . Lic. No. . . . . . . . . . /l�r . . . . . . PLUMBING INSPECTOR Check#_�'� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY v1Aj MA DATE PERMIT# JOBSITE ADDRESS �S OWNER'S NAME POWNER ADDRESS I TEL��-- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: © RENOVATION: REPLACEMENT:© PLANS SUBMITTED: YES NOD FIXTURES-1 FLOOR BSM 1 2 3 4 5 6 7 8 1 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ^� DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _f _..... ( ..__.__! _.-____._( ___..._l [ I ...._._._( _- ._......_.._€ .-----! ..__....1 . JI .___._f ......_..( FOOD DISPOSER __..I .. .__I __-__( _.-----( FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ _( 1 _----.__€ __.___( TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING f ¢ OTHER IF INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[y/NO M IF YOU CHECKED YES,PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW a LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY f BOND -1 R 4 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 R-1 AGENT 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 Pert*n n of the Massachusetts State Plumbing Code and Chapter 1 of General Laws. PLUMBER'S NAME - LICENSE# S7 E SIGNATURE IVIP d' JP Q CORPORATION[](# PARTNERSHIP P# i LLC COMPANY NAMEW=j rADDRESS o2 G e 10/1 � 19 -- CITY +STATE ZIP �30�G--� T L FAX s CELL 3-1R EMAIL j i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES { Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# i PLAN REVIEW NOTES ti OLIS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kv600 Washington Street Boston,MA 02111 V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep:ibly Name (Business/Organization/Individual): X Address: n City/State/Zip: `�X44 6' �C_ Phone g#: — 03 /JS J Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. El am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 E]New construction 2.❑ 1 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. [No workers' comp. insurance 5. El We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.E] 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.E]Roof repairsinsurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the p ins and penalties of per �Ihhe information provided above is true and correct. i nature: Date: hone#: -Z ,5 3 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#: a r J 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 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 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 1 COMMONWEALTH OF,,MASSACHUSETTS PLUMBERS AND GASFI'TTERS LICENSED.AS A MASTER PLUMBER; ISSUES.THE ABOVE LICENSE TO - IITCf-IAEL: bJ KELL' EK 20 KENNEDY ,Di2.• �, ' PFLNAhf `. ~P4, G30 7 G <2G05` 15157 G 5/0-1/.T.4,;. 61: i Date .3. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ti This certifies that . . . I ' has permission for gas installation . . . P. ��►�!l�.v�.�-J�, , in the buildings of. . �?�,,�� LU. . . . . . . . . . . . . at . II l-�• •+•cP e ,(? P. S. . . . . . . . , North Ando er, Mass. Fee . M( e.. Lic. No. . . . . . . . . . ?* ! --�' GAS INSPECTO Check 8617 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Y MA DATE--.,., / PERMIT# I JOBSITE ADDRESS _ OWNER'S NAME GOWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[' RENOVATION:® REPLACEMENT:E( PLANS SUBMITTED: YESE] NO JJ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER �- __ _ ri - - _ - -_. LABORATORY COCKS _ f - MAKEUP AIR UNIT >� �f L._- C I --I __ OVEN POOL HEATER ROOM/SPACE HEATER _., I _ _ ._-JL L ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER - r ,J . TI L..' --111 OTHER rJ 4 INSURANCE COVERAGE N have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES .._ NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF C7BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY 0 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 L—] 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 Wl Pertinent pro isio the Massachusetts State Plumbing Code and ChaIpter. 142'of the General Laws. PLUMBER-GASFITTER NAME1�'— - . _ \ LICENSE# S/S�.� SIGNATURE \ MP YMGF F-JI JP D JGF LPGI 0 CORPORATIONnJ# PARTNERSHIP 0#=LLC[ # COMPANY NAME:-- ADDRESS CITY % STATEZIP �- TEL .�_ .. FAX CELL EMAIL 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 t�L� The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations VV 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le0b �Lly Name(Business/Organization/Individual): �LL� Z / r Address: 02 O 'zip? d/^ City/State/Zip: AZI�� � Phone#: 663 _e5 3-" 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 employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑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 ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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 a-re 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. Iain 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. Ido hereby cert under th pains and penal ' s o jury that the information provided above is true and correct. Si ature: Date: Phone#: in G 3 ` 5' ? —/-? 9/ 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 Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the 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 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 ofMossachusetts Department of Industrial Accidents Office of Investigations 6.00 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1.-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 w-mass.govfdia y ` i i i .. C.OMMONINE TH'OF,MASSACHUSETTS PLUMBERS AND GASEITTERS LICENSED AS A MASTER PLUMBER.... , ISSUES.THE ABOVE LICENSE TO "l7CRAE L: W KELLEK I= 220, KENNEDY , R-,. F'ELHAM' 15157 CFS/01 '14 :7G].Gi I Date — • ............................ NORTH °�• ',� TOWN OF NORTH ANDOVER a PERMIT FOR WIRING q•O•,�w� ,(l MUgE This certifies that ............... 'hl`.� ,, ............. ....................... ............................................ has permission to perform ..(IN,).C:)...................................... .......................... vyiring in the building of........ ...7 ...0 ..................L L. -........................................ at ....� ... ..(. f1-Ufa.S....... .......................North Andover,Mass. Pee......3�-..J.o"'-�,ic.No. ..M����?.................���..E.��! ........... ELECTRICAL IAISPEOR Check# I f l � f. J / Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.�, IA?_ Occupancy and Fee Checked a 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 rCt 527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL I1VFORAMTIOA9 Date: 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) 426, Ct6 wL c S !1 Owner or Tenant �?t�"Com✓ Cp elephone No. (,ir -7- Owner's Owner's Address (L ( -L -J). it/O Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building !'(,A,,--s 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: L4-,,La C,0 e, } Completion of the following table may be waived by the Inspector of Wires. Y No.of Recessed Luminaires Q,,._, 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 ❑ In- ❑ o.of Emergency.Ligbting 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 Tot No.of Ranges ( No.of Air Cond. ` Tons No.of Alerting Devices No.of Waste Disposers l Heat Pump Number Tons KW No.of Self-Contained .......................................................... Totals: Detection/Alerting Devices 1,0 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 Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail i desired,or as required b the Inspector o 97res. o� f 4 Y P .f Estimated Value o Electrical Work: IQ,00 d ..• (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ET BOND ❑ OTHER ❑ (Specify:) I certify,tinder the a' and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.: 'Z- Licensee: A-t-LCA( p,,,,q�,�Signature LIC.NO.: ,) frO (Ifapplicable,e r "exempt"in the license nz�mber line. Bus.Tel. No.: 14n Address: i17.�,L, n. :b� Alt.Tel.No.• �O L� *Per M.G. c. 147,s.57-61,se urity work requires Department of Public Safety"S" icense: 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. wrier gent PERMIT FEE: $ Signature Telephone No. 0 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the A permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed fU 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 M Failed Re-Inspection Required Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: s Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Commen Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: V Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r ' The Commonwealth of Massachusetts Department of Industrittl Accidents Office of Investigations 600 Washington Street Boston,MA 021H Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: P t/•cj Ty Ka City/State/Zip: Aa,Q Phone#: t>tS Are you an employer?Check the appropriate box: Type of pr ' t(required): 1.Lam'I am a employer with 4 4. ❑ I am a general contractor and 16. ew construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they a're 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: 6D 6 C.,(� SS k,✓ City/State/Zip: lib. •AA 0tv-e Attach a copy of the workers'compensation policy deciiration 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. I do hereby cert! nder thepains andpenalties ofperjury that the information providedbove is true and correct. Si ature: Date: Phone#: 7 S—p iqg 7— 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.PIumbing Inspector 6.Other - - Contact Person: Phone#: i 1 ' 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 ofpublic 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 Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the 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 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 est 406 or 1-877-MASSAFE Revised 5-26-05 Fax##617-727-7749 www,mass,gov/dia °, ,ORY.1� w i r ��SS1CHU5 t� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 570-13 on 2/21/2013 Date: April 10, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 66 Ciderpress Way MAY BE OCCUPIED AS a single family home_IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meetinghouse Commons,LLC 115 Carter Field Road North Andover,MA 01845 Building Inspector Fee: Pre Paid Receipt: 26167 Check : 3583 NORTI, Tlown ® _ ._--. r O to No. 15io-- IlaY LAN. h ver, Mass, �h C OCNICHIWKK A0,?A r E o - � S U BOARD OF HEALTH PERM I- T T LD Food/Kitchen Septic System ,-� THIS CERTIFIES THAT ` P`l.�? . ......i�,SC : �7�!l���?^�C. .....`.f!� ............... IN -� ILDIG ECT Fo ndation� %�` has permission to erect .......................... buildings on . ...... ..1.. . .... 1_d .••��..�f••••••••••••• � / Rough to be occupied as Cf:`�/..r�.�..:. G� lsl�(.' {............ ..... Chimney- provided that the person accepting this permit shall in every respect conform to the terms of the application ,nal / on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and 1 Construction of Buildings in the Town of North Andover. P uN�`I TOR L� Rough /� VIOLATION of the Zoning or Building Regulations Voids this Permit. Final v' PERMIT EXPIRES IN 6 MONTHS ELECTRICAL IN ECTOR A� UNLESS CONSTRUCTIO STARTS ough � � �' " Service .... .. .. .uG:*�:'. .......................... .... ............... ... . .. BUILDING. .INSPECTOR.. GAS INSPECTOR117 Occupancy Permit Required to Occupy Building Rougl V;?- ' h Premises — Do Not Remove Final `��/� Display in a�Conspicuous Place on the No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. <} ----'�— Smoke Det SEE REVERSE SIDE f�' �� NORT1i T%own of � _ �T ®ver No. 15io-- h _ ver, Mass, � �/X-Y coc"IcHfwrc« AERATED S U BOARD OF HEALTH PERM ..1- T T LD Food/Kitchen 14 Septic System A, L INSPECTOR THIS CERTIFIES THAT % P'f �~ c'- ar C:....'.......... U . . .. .....����. —.B DING NSPECT ........................ ........... Yo K" ; Foundation has permission to erect . buildin s on .. ...... .. g Ug to be occupied as .:. .J " .c.^J..flt�.................................. .............................. Chimney / provided that the person accepting this permit shall in every respect conform to the terms of the application anal on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and 1 Construction of Buildings in the Town of North Andover. POM ; INSP TOR Rough P" VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL Mf ECTOR UNLESS CONSTRUCTIO STARTS ugh.- � `� 3 A r Service �r��+. 7 / ....... ..... . . ... ................................................... �Final BUILDING ��— INSPECTOR ' 114' "GAS INSPECTOR C Occupancy Permit Required to Occupy Building Rough ail r Final �� � Display in a.Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. ...... Smoke Det SEE REVER=SIDE Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 257,625.00 m $ - $ 3,091.50 Plumbing Fee $ 386.44 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 386.44 Total fees collected $ 3,964.38 66 Ciderpress Way 570-13 on 2/21/13 New Townhouse I � NO R Tt•� own oAndover No. 1 — - � h , ICOR COCNIC IWIC 7 RATE0 '9S U BOARD OF HEALTH PERM ..IT T LD Food/Kitchen Septic System ,..•.,.,.,...•..,,. BUILDING INSPECTOR THIS CERTIFIES THAT ......_w ......... ......i>.,5. ............................5....... Foundation has permission to erect ............ buildings on .. . . .1.. ....%�.� •� &/,Y j Rough • �,re� Y CCJ t� Chimney c" tobe occupied as ......... ... ..... .... .....................:�.................................................. .............. provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough Service ....... ..... . .............................................• Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE tans Subml d Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL blic Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS $ N CONSERVATION Reviewed on Signature LU COMMENTS hr b6P Z�Q,, i jji aC�arYQc�1cR wl00 '04 KLS ,Molyj_ HEALTH Reviewed on Signature COMMENTS I r Zoning Board of Appeals:Variance, Petition No: — Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision:_ Comments Water& Sewer Connection/sl nature&Date 19e� Drivewa Permit DPW Town Engineer: Signature: Located 3.84 Osgood Street :FIRE.DEPARTMENT.=Temp Du ter:on site es - no Located at 124 Main Street Fire Depaitment signature/date j COMMENTS i NOTES: ��^<> 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT ky�uyaQa�T �� SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, MASSACHUSETTS SCALE: 1" 80'; DATE: JULY 20, 2001 BY THIS i C41, Y>e; / < �, / MAP 1040 LOT 29 OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY N/F ESSEX COUNTY NORTH DISTRICT REGISTRY OF DEEDS. GREENBELT 4^ acn�r S ASSOC., INC. 2) THEINTENT OF THIS PLAN IS TO SHOW THE AS-BUILT LOCATION \ /``` � ?oy' ,fit ✓�` 11 21' OF THE FOUNDATION ONLY. 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR L�y 6 FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP / r`74, i ��9r FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY PANEL NUMBER 230098 0007 C, MAP REVISED: 6/2/83. 4) THE CONCRETE FOUNOATION SHOWN HEREON HAVE BEEN-INSTALLED SUBSTANTIALLY IN ACCORDANCE WITH THE 408 SITE PLAN AS APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. I :HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT NUMBERS 16-19 FOUNDATION SHOWN HEREON IS THE RESULT OF A FIELD SURVEY BY THIS OFFICE MADE ON NOVEMBER 8, 2012. • ( 1)t. � dI4, \ b,S ` �w J/ �yitt oP 114SC ' MAP 104C �� -off 25'NO4EIIR1310PNEA M ,IL LOT 28 ..--OlszawnNEE AL �' ;+Ee" AL AL AL LICENSED LAND SURVEYOR DATE CERTIFIED FOUNDATION PLAN MEETINGHOUSE COMMONS TOWNHOUSE UNITS 16-19 t — GRAPHIC SCALE CIDERPRESS LANE 0 2e e0 loo NORTH ANDOVER, MASSACHUSETTS 1 6m sh ad PREPARED FOR I MEETINGHOUSE COMMONS, LLC (IN FEET) 121 CARTER FIELD ROAD I inch - 50 ft. NORTH ANDOVER, MASSACHUSETTS 44 Sill..Rood,9.119 Ono Salem,Now fl—pfhlro 03079 (803)893-0720 AIHF benign Coneullenle,Ine. ENGINEERS•PLANNERS.SURVEYORS • SCALE: 1" - 50' DATE: NOVEMBER 12, 2012 DRAWING NO, DESCRIPTION E.IDAII DRAWN BY: I CHECKED BY: I PROJECT NO. NAME REVISIONS CMF 250508 2SO5CFP.DWC i --- I Massachusetts -Department of Public Safety Board of Building Regulations and Standards i Construction Supen.isor License: CS-055417 t THOMAS D ZAH4YtUIICOf: 115 CARTERFIEiLD RD t "Z7 N ANDOVER Mf 0184$ Expiration Commissioner 04105/2014 Boffin, M4 62,711 . WorkersCo •�eov�i&a _ - ic� O o on asurance At�da II!Ude GDMt act0r MectIidmsftu�mbesa Name(Bss�organizati � - - - Ptease Print Iv Address l city/sukmp 40) Phone#.- Are you an employer?Q,eg the aPPmpriate b= 1.0I am aOWIOYervpft 4. 0 I am a Pnecai Type ofProlet( ): - 2.0 emplwem(f&amUorpart-timek* have hied*e�. 6actm - New I am a so}e pcopriarpaa�er Hsard an The wed shert 1 7. ship endbmnD cm lion - �� fiat ma m, anY eat Y. worT�as' kava 8- 0 Deanofi&m qu' '�- s. ❑We arca a a dim 9- C7 n 3.�] I all - �fi oc em hava emir 10-0 E ar mymx[so �,C P.w°rk nLt Of cxemqgion per MQ, I1-0 Phubing rVaim oraddhions >nsnneaxae -]t a M$1(41 and wehavano L.0 Roofer _ LNo a►o&s, .sem Hca �m �ca� x ,) 13-008= �l god tsmLua --'�oalLatst�tbabmcmn�tatt�dan � �;�-nf. rataaat �igP gw r&ers, °odfiarwadn='=Mp.�y- ,..� fbr m`empIoy. Adow is&ePv&y andj4 site buUn ace co mpdny Names Policy#or Serf ins.Iar : Job Site Adcim Attach a copy of the wokeCatY/SEatelTp: Faihme in °fin P�9 mon pap( the Poky amber and mon date sevum �P �. a A as c p can Ind ID�e mon of P ofa 00 a day a �e violata� Be _the�ofa STOP WORK ORDER and a fins ons of 8a;DIA farms�;a ibaf a copy�ft mqbi�fmv arded tothe Office of Ido hoaeLyp&Mdw Pab!s and ofpi WA Si�elure: G mon ���co�sect Phone: arew�to he cvnpfi*t_.. - byar aL City or Tower Inning A' y(ch-de om)t; . P L Booed of Heaft LBml&wgmeat 3_ 6.Chher Cit9/Tawn C3erk 4.Membri bVector S.p1m1bba.jpsP Contact 1'e['SOIC . Phone a: