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HomeMy WebLinkAboutMiscellaneous - 66 HERRICK ROAD 4/30/2018 / 66 HERRICK ROAD 210/015.0-0019-0000.0 � 1 I i I Date...«.. /.i ................... 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... .....P.1 r .s,Ke has permission for gas installation ... 7:*4..r........................................ inthe buildings of.......................................V....................................................................... at.../,.. L W f . .......... North Andover, Mass. Fee, '. ... Lic. No. .�D.j ................................... GA:6 INSPE6TOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYrblZ4'a r j MA DATE /�� /SJ1 PERMIT# JOBSITE ADDRESS T_ ., OWNER'S NAME GOWNER ADDRESS TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES E] NO Q 11, APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ._. T-.::j[ L:.,.,( J L EQ _ EQ ZQ 1. .. . L:Q LQ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ -� DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR I I I GRILLE INFRARED HEATER [ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER n OF TOP UNIT UNIT HEATER LINVENTED ROOM HEATER w. WATER HEATER OTHER ......... . ......... . ........... ..... - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND F] 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 [r.�IJ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 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 the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFTTER NAME w / LICENSE# .3rI SIGNATURE MP W] MGF L—ji JP 0 JGF© LPGI CORPORATION WJ# 3 3 y PARTNERSHIP 0# _ (�LLC[ # COMPANY NAME: -4� _ ADDRESS CITY +54✓1 aVYA STATE e,4 ZIP ]TEL 7a FAX CELLL. 73,�G EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No .S �� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES s Date.. ... OF NOprN,4, , TOWN OF NORTH ANDOVER o * * PERMIT FOR WIRING CHUS��� *b61. This certifies that .........................F............................... ................................................................... has permission to perform ..,if,,,�.. „` �?:.............. 0�`�� wiring in the building of....�...,i,�=„......... ( � jj ......................................................................... at ... `f'5*-""* t-0 '01 �f�— ,North Andover,Mass. � Fee.............................Lic.No.V...L,2 ...................................................................................... ELECTRICAL INSPECTOR Check# 2 r 3 I T S 3 5 f©die ® C� \,3 e• N¢. �r3cS o ket..,C W f rC Official Use Only Commonwealth of Massachusetts 1 Permit No. p De artment 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),5�7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: _74 /l I 5 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) H r;-r C_k P_ Owner or Tenant 0 c,r i �� C AJ n,ir- Telephone No. Owner's Address C "�c;� IzaIs this permit in conjunction with a building permit? Yes ❑ No [ (Check Appropriate Boz) Purpose of Building S i C L Utility Authorization No. Existing Service 20 0 Amps / Volts Overhead ® Undgrd❑ No.of Meters New Service 1 Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �1h1 es Completion of the ollowin table m be waived by the Inspector of Wires. t No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.o Total M Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. Elrud. � Battery Units No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etection an Initiating Devices No.of Ranges No.of Air Cond. TotalTonsNo.of Alerting Devices No.of Waste Disposers Heat Pump um_er ns o.oSelf-Contained Totals: o "- �'" -"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ MunicipalEl Other Connection No.of Dryers Heating Appliances KW Security stems:* No.of Devices or Equivalent o.o ater KW o.o o.o Data Wiring: 1 Heaters signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HTelecommunications Wiring: P No.of Devices or E uivalent OTHER: i!� tC7� Swv�e� X7)2 Ex E sA t-�rr,zE S i�F tr4C�� ��/CaCEw f� Attach additional detail if desired,or as required by the Inspector of fres. Estimated Value of Electrical Work: JO (When required by municipal policy.) Work to Start: /2-,5--/5' Inspections to be requested in accordance with MEC Rule 10,and upon completion. M INSURANCE COVERAGE: Unless waived ed 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 roof of same to the permit issuing office. g P P g CHECK ONE: INSURANCE-M BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ,lJiV,-1/v �Zc tv�,,2 L �� LIC.NO.: Licensee: rZTt9ty Signatu e 2t 'Ir LIC.NO.: S2 z/5-ff (If applicable,enter "exempt"in the license humber line) Bus.Tel.No.; Address: Alt.Tel.No.: `Per M.G.L c. 147,s.57-61,security 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)E]owner owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. s s i The Commonwealth of Massachusetts Department of IndustrlalAccidents 1 Congress Street,Saute 100 Boston,MA 02114-2017 www.mass.gov/dia Sy Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbexs. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��?►4!a! T—i2zo u Address: 1541 Gv wviEM L i2b City/State/Zip: M A(bav�2 iul a o 15z 4-5 Phone#: 761 Are you an employer?Chec'mlie appropriate box: Type of project(Iequired): IQ I am a employerwith employees(full and/or part-time).- 7. []New construction 2.®Tam a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.FJ I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure That all contiacfors either have workers'compensation insurance or are sole 11.XElectrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14 [J Other 6.Q We are a corporation and its offngers have exercised their right o£exemption per MGL C. 152,§1(4),and we have na erjloyees.[No workers'comp.insurance required.] `Any applicant that cheeks box 41 must also fill out the section below showing their workers'compensation policy information. i 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 state whether or not those entities have employees. If the sub-cbi6c6s have employees,ley must provide their workers'comp.policy number. I am an employer that is pr•6vidir2g workers'compensation insurance for my employees'Below is the policy and lob site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: r Job Site Address__ % 1 t°�� City/State/Zip: �; �c ' i / O l V Attach a copy of the workers' compensation policy declaration page(showing the policynumber 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 he:eby cern under tlae pains enal les of perjury that the information provided above is true and cof rect. Date: Signature. Phone#: 78/ -,39'7- VY117 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation£or their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of lure, express or implied,oral or written." ' An employer is defined as"an individual,partnershjp,association,corporation or other legal entity,ox 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 cant'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 affiidavit. The affidavitshould 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 yo'u'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"rob 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-NUSSAFE Fax##617-727-7749 Revised 02-23-15 www.mass.gov/dia 3� +C}IVIItI*iA it EALTH QFMAS' CM1.� ABOARD OF Ett Tt 'I C IANS t SUES,'THE FOLLOWING LKENS` 'RFU'JOURII,x''F":N ELECTRICIA e AIs P. FROSURC y c'� lJA14.�I.'t RO 3.. 4;,3 AiMw.UYkR. 018-6-35 z» -:07131116 °79806 CONTROL# J 0 0 4 v IMPORTANT if your license Is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the propermailing of your Renewal Application and any other correspondence. This lieense is subject to Massacriusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law.Keep this license on your person or posted as requirad by law and/or # regulations. ' I k a`c R CERTIFICATE OF LIABILITY INSURANCE °07/24 015""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Bridge Insurance Assoc. CONTACT 80 Langley Road PHONE (617)965-1777 FAX (617)9641888 2nd Floor E-MAIL Newton Centre MA 02459 INSURERfSl AFFORDING COVERAGE NAIC INSURER :Travelers INSURED INSURER B BrlanFroburg, INSURERC: 159 Wavedey,Road INSURER D: North Andover MA 01845- INsuRER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICYMBE POLICY EFF POLICY EXP LIMITS A GENERALLIABILITY 680-008E474619 7/08/2015 7/08/2016 EACH OCCURRENCE 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 (Fa occAirre CLAIMS-MADE F-1. OCCUR MED EXP(Any oneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIESPER: I PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO- F-1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per acddent) $ AUTOSNON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS a UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESSLIAB HCLAIMS-MADE AGGREGATE $ DED RET $ WORKERS COMPENSATION 77T WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N FR ANY PROPRIETOR/PARTNERIEXECUTWE� NIA E.L.EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ KDrs S,describeunder E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Al 002163 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©-19884010 ACORD-CORPORATION—All-rights-reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i � ������ � � � i 1 I 1 i i M� � i�l. I�' ��I � � ����.� �S ��`� ��ra.�-�.�,.-e� _� ., Town of North Andover a,;�: ;-217 -4�6`5`�, AIL ,s=,„°,• BUILDING DEPARTMENT ...3... Q r } y, COMMUNITY DEVELOPMENT AND SERVICES . , Street,Bldg.20 Suite 2035 �C ' "` 1600 Osgood S g '� ZIP 01845 North Andover,Massachusetts 01845 ��% ��@/�/ 0411-10235393 Vt J-0k V - t 01 NIXIE 276 SC 1RETURN SENDER e0@$/1Ci/2 I 1 NOT DELIVERABLOE AS ADDRESSED ; UNABLE TO FORWARD i -3 C; -01-0 "s5104oa9 -0-6-69-1-9161-23-3'3 tA TOWN OF NORTH ANDOVER t NORTy 1 Office of the Building Department a2°•`t``D�`y��� Community Development and Services � 1600 Osgood Street North Andover Massachusetts 01845 °°•— -�• SSACHUs�t Jerry Brown Telephone(978)688-9545 Inspector of Buildings FAX(978)688-9542 July 16, 2014 Daryl and Tara Macnair 509 Commons Walk Circle Cary,NC 27519 RE: 66 Herrick Road,N. Andover MA 01845 Dear Mr. and Mrs. Macnair, Please be advised that upon a visual inspection of the dwelling unit at 66 Herrick Road on July 15, 2014 it has been deemed that the structure is in unsafe condition and abandoned with the electrical service damaged due to storm activity. This may result in injury to abutters or abutting property, local children or anyone utilizing the structure. Please accept this letter as official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions: Whoever violates any provision of 780 CMR, except any specialized code referenced herein, shall be punishable by a fine of not more than$1000.00. Each day that a violation exists shall constitute a separate offense. You have thirty(30) days to contact this office so that we may begin the process to remedy this in a timely fashion. If you do not contact me within the thirty (30) day time frame we will need to initiate court proceedings. I may be reached between the hours of 8:00— 10:00 AM at 978-688- 9545. Respectfully, Gerald Brown Inspector of Buildings rl v p • 1 Je. . 1 �iiiLFFVii- � � dS �Tj �'�Y/ I � r � 41 � Ls .. 11! 1111 pct OmIl ni, T 7. T`T 1 1 11 aairi�iV : l flJ11111 var* , MEN Mom fir � r ^ fl • t I r deo «+✓'.ate'* '�. ' "� !'���w�l�� Ili z I � � eSt, I V' II II, 4 .,r G R"- Y e '� d MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE 76.165 tf:13753 DATE OF INSTRUMENT DOCUMENT DATE AND TIME NUMBER KIND RUNNING IN FAVOR OF TERMS OF REGISTRATION DISCHARGE SIGNATURE 81.831 MTG MORTGAGE ELECTRONIC REG LOT 20C PLAN 8813-R 03-26-2003• 89,962 1 1 SYSTEMS INC ACCORDING TO NOTE 04-01-2003 1:26 $245,000.00 (� 81,$ 2 DH JDARRYL 1 MA NAIR SE DOCUMENT NO 81832 03-26- 003 � 04-01-2003 1:26 84,026 MTG M RTGAGE ELECTRONIC REG LOT 20C PLAN 8813- 08-1 -2003 86,519 1 1 SYSTEMS INC ACCORDING TO NOTE 08-25-2003 1:48 $69,000.00 4,557 IS DAR YL MACNAIR ET AL OF MTG DOC 7 24$ 07-15-2003 1 10-03-2003 8:44 85,830 MTG MORTGAGE ELECTRONIC REG L T 20C PLAN 8813-R 02-25-2004 90.346 1 1 SYSTEMS INC ACCORDING TO NOTE 03-01-2004 1:07 $327.200.00 ----s-6-.-5T-9-DIS DARRYL MACNAIR ET AL OF MTG DOC 84026 03-22-2004 1 05-07-2004 2:20 89,487 ASGT MORTGAGE ELECTRONIC REG OF MTG DOC 76167 01- 8-2005 1 SYSTEMS INC 06-08-2005 2;44 89.488 DIS DARRYL MACNAIR ET AL OF MTG DOC 76167 02-02-2004 1 06-08-2005 2:44 89,489 .MTG MORTGAGE ELECTRONIC REG LOT 20C PLA 8813-R 06-03-2005 1 SYSTEMS INC ACCORDING TO NOTE 06-08-2005 2:44 $350,000.00 ( ` MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE Ctf:l 753 76.165 DOCUMENT DATE OF INSTRUMENT NUMBER KINp RUNNING IN FAVOR OF TERMS DATE AND TIME OF REGISTRATION DISCHARGE SIGNATURE 89,962 DIS JDARRYL MACNAIR ET ALOF MTG DOC 81831 06-16-2005 1 07-29-2005 1 :34 90.346 DIS DARRYL MACNAFR ET AL OF MTG DOC 85830 08-31-2005 1 09-21-2005 1:05 91 .325 MTG DIRECT FEDERAL CREDIT LOT 20C PLAN 8813-R 12-29-2005 1 JUNION ACCORDING TO NOTE 02-21-2006 2:58 $75,000.00 105,825 MTG MURRAY HILL PARTNERS LLC LOT 20C PLAN 8813-R r12- 16-2011 ACCORDING TO NOTE -18-2012 12:07 $50,000,00 105,990 ASGT CITIMORTGAGE INC OF MTG DOC 89489 06-2 -2012 1 07-11-2012 10;44 107,893 ASGT PENNYMAC MTG INVSTMNT TR OF MTG DO 89489 03-19-2013 1 HOLDINGS I LLC 03-25-2013 3:31 109,294 PATY CITIBANK N A SEE DOC 109294 1 11-01-2013 3:48 00, 109.295 ASGT CITIBANK N A TR OF MTG DOC 89489 10-15-2013 1 11-01-2013 3:48 i MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE f:l 7 3 DOCUMENT DATE OF INSTRUMENT 76 .165 NUMBER KIND RUNNING IN FAVOR OF TERMS DATE AND TIME OF REGISTRATION DISCHARGE SIGNATURE 76, 166 MTG MORTGAGE ELECTRONIC REG LOT 20C PLAN 8813-R 09-27-2001 79,499 1 1 SYSTEMS INC ACCORDING TO NOTE 09-27-2001 10:04 $206,400.00 76,167 MTG PRISM MORTGAGE COMPANY LOT 20C PLAN 8813-R 09-27-2001 89.488 1 1 ACCORDING TO NOTE 09-27-2001 10:04 $38,700.00 77,179 ASGT AAMES CAPITAL CORPORATION OF MTG DOC 69031 12-01-1998 1 BOOK: 108 PAGE:' 121 01-23-2002 20:31 77.180 ASGT NATIONS CREDIT TINA CIAL OF MTG DOC 69031 12-01-1998 1 SERVICES CORP 01-23-2002 10:31 77,181 DIS COLLEEN M HAMEL ET AL OF MTG DOC 69031 01-14-2002 2 01-23-2002 10 :31 79,247 MLC DARRYL MACNAIR ET AL 13EE DOCUMENT NO 7.9247 08-15-2002 1 08-28-2002 3:25 MOR79,248 MTG SYSTEMSGAGINCCTRONIC REG LOT 20C PLAN 8813-R 08-23-2002 84,557 1 1 SYSTEMS INC ACCORDING TO NOTE 08-28-2002 3:25 $245,000.00 79,499 DIS DARRYL MACNAIR ET AL OF MTG DOC 76166 09-12-2002 1 BOOK: 108 PAGE: 157 09-19-2002 8:52 81,830 MLC DARRYL MACNAIR ET AL 7SEE DOCUMENT NO 81830 03-20-2003 2 04-0-1-2003 - 1:26 - - TRANSFER CERTIFICATE OF TITLE Book 108 Page 157 Cert.No.13753 Doc.No.76165 From TRANSFER Certificate No. originally Registered December 17,1985 in Registration Book 69 Page 329 for the Northern Registry District of Essex County. THIS IS TO CERTIFY that DARRYL MACNAIR and TARA MACNAIR of 66 HERRICK ROAD,NORTH ANDOVER,MA is/are the owner(s)in fee simple AS TENANTS BY THE ENTIRETY Of that land situated in NORTH ANDOVER. In the County of Essex and Commonwealth of Massachusetts,bounded and described as follows: SOUTHERLY BY HERRICK ROAD SIXTY EIGHT(68)FEET; WESTERLY BY LOT TWENTY D(20D)AS SHOWN ON PLAN HEREINAFTER MENTIONED NINETY SIX AND 35/100(96.35)FEET; NORTHERLY BY LOT TWENTY B(20B)ON SAID PLAN SEVENTY NINE AND 801100 (79.80)FEET,AND EASTERLY BY LOT TEN(10)ON SAID PLAN SEVENTY ONE AND 511100 (71.51)FEET. ALL OF SAID BOUNDARIES ARE DETERMINED BY THE COURT TO BE LOCATED AS SHOWN ON PLAN NO.8813R,FILED WITH CERTIFICATE OF TITLE NO.2067,BOOK 14,PAGE 269,THE SAME BEING A COPY OF A PORTION OF THE PLAN DRAWN BY RALPH B.BRASSEUR,CIVIL ENGINEER, DATED AUGUST 1934,ALL AS MODIFIED AND APPROVED BY THE COURT,TOGETHER WITH THE FEE IN THE STREET OR WAY UPON WHICH SAID LOT ABUTS TO THE MIDDLE LINE THEREOF, AND BEING DESIGNATED AS LOT TWENTY C(20C)THEREON. SO MUCH OF THE LAND AS IS INCLUDED WITHIN THE STREET OR WAY IS SUBJECT TO ITS USE BY ALL PARTIES ENTITLED AND TO ANY RIGHTS AND EASEMENTS,SO FAR AS APPLICABLE,AS SET FORTH IN CERTIFICATE OF TITLE NO.1251,BOOK 9,PAGE 1. THE ABOVE DESCRIBED LAND IS SUBJECT TO AND HAS THE BENEFITS OF THE RIGHTS, EASEMENTS AND RESTRICTIONS REFERRED TO OR IMPLIED IN A DEED FROM PACIFIC MILLS, DATED DECEMBER 17,1927,FILED AND REGISTERED AS DOCUMENT NO.4379i SO FAR AS THE SAME ARE APPLICABLE,AND TO THE RESTRICTIONS CONTAINED IN DEEDS FROM LEONARD FIRTH TO FLORENCE E.SAWYER AND TO JOHN E.MCCRILLIS,BOTH DATED MAY 13.1937.FILED AND REGISTERED AS DOCUMENT NOS.6252 AND 6253. And it is further certified that said land is under the operation and provisions of Chapter 185 of the General Laws,and that the title of said DARRYL MACNAIR and TARA MACNAIR. I to said land is registered under said chapter,subject,however,to any of the encumbrances mentioned in section forty-six of said chapter,which may be subsisting and subject as aforesaid,and to the memoranda of encumbrances for this certificate. WITNESS,PETER W.KILBORN,Chief Justice of the Land Court,at Lawrence,in said County of Essex The twenty-seventh day of September in the year two thousand and one at 10 o'clock and 4 minutes in the forenoon. Attest,with the seal of said court, THOMAS J.BURKE,Assistant Recorder Case#8813 Purported Address-of Property: 66 HERRICK ROAD NORTH ANDOVER,MA I i TOWN OF NORTH ANDOVER Nosry Office of the Building Department 3?°4 LIED '6 Community Development and Services y 1600 Osgood Street North Andover Massachusetts 01845 CKustc� Jerry Brown Telephone(978)688-9545 Inspector of Buildings FAX(978)688-9542 July 16, 2014 Daryland Tara Macnair 509 Commons Walk Circle Cary,NC 27519 RE: 66 Herrick Road,N. Andover MA 01845 Dear Mr. and Mrs. Macnair, Please be advised that upon a visual inspection of the dwelling unit at 66 Herrick Road on July 15, 2014 it has been deemed that the structure is in unsafe condition and abandoned with the electrical service damaged due to storm activity. This may result in injury to abutters or abutting property,local children or anyone utilizing the structure. Please accept this letter as official notice under the Mass State Building Code (780 CMR) section Unsafe Structure 116.1 Conditions: Whoever violates any provision of 780 CMR, except any specialized code referenced herein, shall be punishable by a fine of not more than.$1000.00. Each day that a violation exists shall constitute a separate offense. You have thirty(30) days to contact this office so that we may begin the process to remedy this in a timely fashion. If you do not contact me within the thirty(30) day time frame we will need to initiate court proceedings. I may be reached between the hours of 8:00— 10:00 AM at 978-688- 9545. Respectfully, Gerald Brown I Inspector of Buildings i i j 1 '"+gin i� I 4 , �! ' .t fr' k �•.ti • T� • si , r E ;1 w. Y t a F - r ... � r. 7� x4C•. ,rr . , p t r r r fir' , e � a I • 4 �A SSS , , a a r.: !. I. s" w S' rt 4 .v."....i..... .r 8 t _ 1�iMM11TAl 1 , t � i - f Iip t t TRANSFER CERTIFICATE OF TITLE Book 108 Page 157 Cert.No.13753 Doc.No.76165 From TRANSFER Certificate No.9881 Originally Registered December 17,1985 in Registration Book 69 Page 329 for the Northern Registry District of Essex County. THIS IS TO CERTIFY that DARRYL MACNAIR and TARA MACNAIR of 66 HERRICK ROAD,NORTH ANDOVER,MA is/are the owner(s)in fee simple AS TENANTS BY THE ENTIRETY Of that land situated in NORTH ANDOVER. In the County of Essex and Commonwealth of Massachusetts,bounded and described as follows: SOUTHERLY BY HERRICK ROAD SIXTY EIGHT(68)FEET; WESTERLY BY LOT TWENTY D(20D)AS SHOWN ON PLAN HEREINAFTER MENTIONED NINETY SIX AND 35/100(96.35)FEET; NORTHERLY BY LOT TWENTY B(20B)ON SAID PLAN SEVENTY NINE AND 80/100 (79.80)FEET,AND EASTERLY BY LOT TEN(10)ON SAID PLAN SEVENTY ONE AND 51/100 (71.51)FEET. ALL OF SAID BOUNDARIES ARE DETERMINED BY THE COURT TO BE LOCATED AS SHOWN ON PLAN NO.8813K FILED WITH CERTIFICATE OF TITLE NO.2067,BOOK 14,PAGE 269,THE SAME BEING A COPY OF A PORTION OF THE PLAN DRAWN BY RALPH B.BRASSEUR,CIVIL ENGINEER, DATED AUGUST 1934,ALL AS MODIFIED AND APPROVED BY THE COURT,TOGETHER WITH THE FEE IN THE STREET OR WAY UPON WHICH SAID LOT ABUTS TO THE MIDDLE LINE THEREOF, AND BEING DESIGNATED AS LOT TWENTY C(20C)THEREON. SO MUCH OF THE LAND AS IS INCLUDED WITHIN THE STREET OR WAY IS SUBJECT TO ITS USE BY ALL PARTIES ENTITLED AND TO ANY RIGHTS AND EASEMENTS,SO FAR AS APPLICABLE,AS SET FORTH IN CERTIFICATE OF TITLE NO.1251,BOOK 9,PAGE 1. THE ABOVE DESCRIBED LAND IS SUBJECT TO AND HAS THE BENEFITS OF THE RIGHTS, EASEMENTS AND RESTRICTIONS REFERRED TO OR IMPLIED IN A DEED FROM PACIFIC MILLS, DATED DECEMBER 17,1927,FILED AND REGISTERED AS DOCUMENT NO.4379,SO FAR AS THE SAME ARE APPLICABLE,AND TO THE RESTRICTIONS CONTAINED IN DEEDS FROM LEONARD FIRTH TO FLORENCE E.SAWYER AND TO JOHN E.MCCRILLIS,BOTH DATED MAY 13.1937.FILED AND REGISTERED AS DOCUMENT NOS.6252 AND 6253. And it is further certified that said land is under the operation and provisions of Chapter 185 of the General Laws,and that the title of said DARRYL MACNAIR and TARA MACNAIR. I ' to said land is registered under said chapter,subject,however,to any of the encumbrances mentioned in section forty-six of said chapter,which may be subsisting and subject as aforesaid;and to the memoranda of encumbrances for this certificate. WITNESS,PETER W.KILBORN,Chief Justice of the Land Court,.at Lawrence,in said County of Essex The twenty-seventh day of September in the year two thousand and one at 10 o'clock and 4 minutes in the forenoon. Attest,with the seal of said court, THOMAS J.BURKE,Assistant Recorder Case#8813 Purported Address of Property. 66 HERRICK ROAD NORTH ANDOVER,MA i i I I I ' MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE C,tf:13753 76.16 GATE OF INSTRUMENT DOCUMENT DATE AND TIME NUMBER- KIND RUNNING IN FAVOR OF TERMS OF REGISTRATION DISCHARGE SIGNATURE 76,166 MTG MORTGAGE ELECTRONIC REG LOT 20C PLAN 8813-R 09-27-2001 79,499 1 1 SYSTEMS INC ACCORDING TO NOTE 09-27-2001 10:04 $206,400.00 76,167 MTG PRISM MORTGAGE COMPANY LO 20C PLAN 8813-R 09-27-2001 89,488 1 1 ACCORDING TO NOTE 09-27-2001 10:04 $38,700.00 77, 9 ASGT AA ES CAPITAL COR ORAT OF MTG DOC 69031 - 1 BOOK: 108 PAGE: 121 01-23-2002 10:31 180 ASGT NATIO CRED FINANCI L OF MTG DOC 69031 -1-2-71--1 98 1 SERVICES CORP 01-23-2002 10:31 77,181 DIS JCOLLEEN M HAME ET AL OF MTG DOC 69031 01-14-2002 1 01-23-2002 10 :31 [: 79,247 MLC DARRY MAC AIR E AL SEE DOC.0 ENT NO 7:92 7 OS-15-2002 1 08-28-2002 3:25 79.248 MTG MORTGAGE ELE TRONIC REG LOT 20C PLAN 8813-R 08-23-2002 84,557 1 1 SYSTEMS INC ACCORDING TO NOTE 08-28-2002 3:25 $245,000.00 7 ,499 DIS DARRYL MACNAIR ET AL OF MTG DOC 76166 0 -12-200 1 BOOK: 108 PAGE: 157 09-19-2002 8:52 _81,83.0- MLC - ARRYL MACNA R ET AL SEE DOCUMENT NO 81830 03-20-2003 1 04-01-2003 1:26 MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE 7 DATE OF INSTRUMENT DOCUMENT DATE AND TIME NUMBER KIND RUNNING IN FAVOR OF TERMS OF REGISTRATION DISCHARGE SIGNATURE 81.831 MTG MORTGAGE ELECTRONIC REG LOT 20C PLAN 8813-R 03-26-2003 89,962 1 1 SYSTEMS INC ACCORDING TO NOTE 04-01-2003 1:26 $245,000.00 81,8 2 DH RYL MA NAIR S£ 0 UMEN 818 -03-26-200Y-- 04-01-2003 1:26 1 .026 MTGIMORT—GAGE ELECTRONIC EG LOT 20C PLAN 813- -0-8-18-2003 86,5191 1 SYSTEMS INC ACCORDING TO NOTE 08-25-2003 1:48 $69.000.00 ( ' 4. 57IS DAR YL MAC AIR ET AL OF MTG DOC 79248 07-15-200 1 10-03-2003 8:44 ¢' 85.830 MTG MORLEPL TG GE CTR NIC REG- L T 20C AN 8813-R 0 -25-2004 90.3 1 1 SYSTEMS INC ACCORDING TO NOTE 03-01-2004 1:07 $327.200.00 6.5 9 DIS JDARRYLMACNAIR ET AL OF MTG DOC 84026 03-22-2004 05-07-2004 2:20 1 89,487SGT MORTGAGE EL CTRONIC REG OF MTG—DOC-76167 O1- 8-2005 1 SYSTEMS INC 06-08-2005 2:44 89.488 DIS DARRYL MACNAIR ET AL OF MTG DOC 76167 02-02-2004 06-08-2005 2:44 1 89.489 MTG M R GAGE ELECTRONIC REG OT 20C PLA 8813-R 0 -03--2005 - --- 1 SYSTEMS INC ACCORDING TO NOTE 06-08-2005 2:44 $350.000.00 ( ' b MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE tf: 13753 DOCUMENT DATE OF INSTRUMENT 76.165 NUMBER KIND RUNNING IN FAVOR OF TERMSDATE AND TIME OF REGISTRATION DISCHARGE SIGNATURE 89.962 DIS DARRYL MACNAIR ET AL OF MTG DOC 81831 06-16-2005 1 07-29-2005 1 :34 90,346 DIS DARRYL ACNAI AL OF MTG DOC 85830 08-31-20 5 1 09-21-2005 1 :05 91.325 MTG DIRECT FEDERAL CREDIT LOT 20C PLAN 8813-R 12-29-20 1 UNION ACCORDING TO NOTE 02-21-2006 2:58 $75,000.00 105.825 MTG MURRAY HILL PARTNERS LLC ILOT 20C PLAN 8813-R 12-16-2011 1 ACCORDING TO NOTE 06-18-2012 12:07 $50,000,00 105,990 ASUT CITIMORTGAGE INC OF MTG 'DO C 89489 06-27-2012 1 07-11-2012 10:44 107.,89 ASGT PENN-YR AC MTG OF MTG 06C 89489 ; 03-19-2013 1 HOLDINGS I LLC 03-25-2013 3:31 109.294 PATY CITIBANK N A SEE DOC 109294 1 11-01-2013 3:48 109.295 ASGT CITIBANK N A TR OF MTG DOC 89 89 10-154-013 1 11-01-2013 3:48 (�lfe hlommoufnettlfC� of jfflassar4useffs OFFICE OF THE ATTORNEY GENERAL GOVERNMENT BUREAU NATHAN GARDNER PARALEGAL,ABANDONED HOUSING INITIATIVE TRIAL DIVISION ONE ASHBURTON PLACE. I8TH FLR BOSTON, MA 02108 PHONE:(617)963-2150 Nathan.Gardner@state.ma.us FAX:(617)727-3076 www.mass.gov/ago TTY:(61 7)727-4765 w i x Date.....�.............. .... HORT" ` TOWN OF NORTH ANDOVER Aimm PERMIT FOR WIRING ,SSACMus� C This certifies that AL�rxl� ............................................................................................. has permission to perform , r2 Vie .... ......................... ................ . ..... wiring in the building of !✓�5 �� ........... .......... ............. ........................................... at.........t.".( .......................:..............7,North Andover,Mass. Fee.. ... Lic.No. 1 z3/�/?.............. /..................... ELEcrxicAL NsrEcrolc Check # 770 Fly 7976 Commonwealth of Massachusetts y - Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULAT IONS Occupancy and Fee Checked Rev.-1/07j I� (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( EC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVERTo the By this application the undersigned gives notice of his or her intention to perform the electrical workles nbed below. Location(Street&Number) 10( Owner or Tenant N 6 C:N Telephone No. Owner's Address 4p 14e-rq"` c Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building R,4SG Me-&-7 4- FZiNrA; �� v�.� Utility Authorization No. Existing Service ZiM, Amps L?.o / yy Volts Overhead erhead 0 Undgrd❑ No.of Meters I New Service Amps /� Volts Overhead❑ Unil rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: s t rn,e>v Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires E3 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.o mergency ig g rnd. rnd. ❑ Batte 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 Initiatin Devices No.of.Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: .. .... Detection/Alertin Devices No.of Dishwashers S ace/Area Heating unici al P tm KW �}"� ❑ P ❑ Other 1 g Local Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Water No.of No.of Devices or Equivalent No. Heaters KW o. Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring: OTHER: No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required b municipal q Y p poIicy.) Work to Start: i 2 y^ v �, Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete- FIRM NAME:21 LIC.NO.: l Z 3 4A lz Licensee: � Y'r y i�C Signature LIC.NO.: r Z 3 W YZ (If applicable, ter" mpt"in the hcene1number li'}e Bus.Tel.No.: S' ZIo- �'� Address: PD �ox t?(, IT414Y PtcD N FAIk, MIA 03g5� *Per M.G.L c. 147,s.57-61,security work requires Department of Public SafetyAlt.Tel.No.: 4 S`T? OWNER' S License: Lic.No. j OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ I �t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ,. Boston, MA 02111 c 3 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Atinlicant Information Please Print Leaibiy Name(Business/Organization/Individual), 1&e t CAV,%C_ Address- 1:0C 12 City/State/Zip:_+414 r»�aN P,41 I 5 pal [-} ""Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.131 am a employer with 4, F11 am a general contractor and I 6. ❑New construction 2,9employees(full and/or part-time).* have hired the sub-contractors 1 am asole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. .Q Demolition 'working for mein 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 11.Q Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),'and we have no 12.[] Roof repairs insurance required.]t employees. [No workers' 13 [1Other comp.insurance required.] *Any applicant that checks bo0l must also fill out the section below showing their workers'dompensation policy infomtation. ?Homeownen,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 sheat 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 isthe policy and job site information.. Insurance Company Name: Policy#'or Self-ins.Lie.#: 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 fine up to$4500.00 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 DTA for insurance coverage verification. I do hereby ce nder the pains an en of perjury that the information provided above is true and correct Si ature: `� Date: Z S D Phone#: 4Pb 3 - 9 Z <n - 3 a� / 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 l 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 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 insumnce'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 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia