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HomeMy WebLinkAboutMiscellaneous - 71 PINE RIDGE ROAD 4/30/2018S Date ... Z... /6..... v TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........t J.! ..'?.1.:............ . ............................................ M has permission to perform .... .... ..... ................ wiring in the building of ..... .,!.�..� 6.k ............ ............................... ....................................... at . ...... 7/ ................ I ........... Fee ..... ........ V . . ......... Lic. N4 a:3.�z ELECTRICAL � Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe for Wires: By this application the undersigned gives not' of his or her int ntion to perform the electrical work described below. Location (Street & Number) 71 1 '� h f %C 1 ��� Owner or Tenant Owner's Address J0 Is this permit in conjunction with a bui ding pe mit? Yes V Purpose of Building 2 Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity LocaY n and Nature of Proposed ??Electrical Work: �✓( �`P.� No. of Meters No. of Meters Com letion of the following table may be waived by the Inspector of Wires. V v / Attach addlMonal detail y aeslrea, or as regi irgL oy me ffrmpeuw vi r, Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: r Inspections to be requested in accordance with MEC Rule 10, and upon completion. .r INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless 1 the licensee provides proof of liability ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c?vepdge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0Z BOND ❑ OTHER ❑ (Specify:) I certify, under the as � nd enalti s ofper�ury, thatt the ' rmatron on this application is true and complete. FIRM NAME: �.J 1� �=c� LIC. NO.:� Licensee:- fit/1 �% S'gnature LIC. NO.: (If applicable, e r `exemp " in the license number lin . Bus. Tel. No.: Address: t C� Alt. Tel. No.: *Per M.G.L c. 141, s. 57-61, security work ij6quires Departnknt of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature __ Telephone No. of Total No, of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Trsformers KVA Tran s No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires A Swimming Pool rnd. ❑ rnd. ❑ No. of Emergency Ig tmg Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained Disposers No. of Waste Dis P Totals: ............. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Other Local ❑ ElConnection No. of Dryers Heating Appliances KW Security Systems.' No. of Devices or E uivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No, of Devices or Equivalent Telecommunications Wirin No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uiv ent OTHER: 0( 41 &1 C / t % V v / Attach addlMonal detail y aeslrea, or as regi irgL oy me ffrmpeuw vi r, Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: r Inspections to be requested in accordance with MEC Rule 10, and upon completion. .r INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless 1 the licensee provides proof of liability ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c?vepdge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0Z BOND ❑ OTHER ❑ (Specify:) I certify, under the as � nd enalti s ofper�ury, thatt the ' rmatron on this application is true and complete. FIRM NAME: �.J 1� �=c� LIC. NO.:� Licensee:- fit/1 �% S'gnature LIC. NO.: (If applicable, e r `exemp " in the license number lin . Bus. Tel. No.: Address: t C� Alt. Tel. No.: *Per M.G.L c. 141, s. 57-61, security work ij6quires Departnknt of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature __ Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: — ZJ DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com tr I ✓ e,r,i '1 9id1® The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 •` www mass.gov/dia •" Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: ( s,' c�/h` Cii City/State/Zip: rlreyo an employer? Check t� ppiopriate box: 1. I am a employer with _employees (full and/or part-time).* Phone #: T? 6 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors Bade employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 1 ..1. Type of project (required): 7. ❑ Ne onstruction 8.emodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. F1 Plumbing repairs or additions 13. E] Roof repairs 14.0 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 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-coritractors have employees, tliey must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy andjob site information. Insurance Company Name: 4 Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy dec aration 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 ffdliainl and penalties ofperjury that the information provided aove ' ItVue and correct. J 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-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-in'sur6d 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 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 ......+.2..".%.6......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...............T ....... b ....... A ................ E ...... I ....e ..... 6 .... fYI ... I ..... & ............ C ....... 6 .......................... has permission to perform ........... ..... ...... ................................... .... ...................... wiring in the building of.. ...... ......... 01 at ...... 7 ........................... ........ ....... b Andover, Mass. ...... Lic. NOA5-q 3.......Fee..Fee.. .. . ........... ................ . ....... ......... .. ELECTRICAL INSPECTOR Check # 13148-/ Commonwealth of Massachusetts Official Use Only ,Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MC) 527 CMR 12.00 (PLEASE PRTNT ININK OR TYPE ALL INFORMATIOA9 Date: 2 If - City or Town of. NORTH ANDOVER To the Inspelct& of Wires: By this application the undersigned gives notice of his her integtgn tolperform the electrical work described below. Location (Street & Number) r01 1.1 & Owner or Tenant ( )A Telephone No. Owner's Address / `a�< Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building �. '� Utility4uNorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters .4 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o 'Emergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW .................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritNo. o Systems:* or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of 07res. (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 operatio " coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof Ais e o th ennit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I' certify, under the pains and enalties erju that the information onppli a zon is true and complet FIRM NAME: -1,[/ O ,��� G2 [ (' �� LIC. NO. j Licensee: — ,,t .J � Sig ature / ' LIC. NO.: (If applicab4entee em " i the li nse, number n .) Bus. Tel. No.. Address: t U� Alt. Tel. No.*Per M.G.s. 57-61, iecuri,WoiklAnes Departm&ifofPublic Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that. the Licensee does not have the liability insurance coverag normally required by law. By my signature below, I hereby waive this requirement. Tam the (check one) ❑ owner ❑ owner's agent. Owner/Agent PENMIT FEE: $ Signature _, Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass n Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: •16 DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 021142017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PEP -NUTTING AUTHORITY. Name (Business/Organization/ladividual): ��✓ Address: City/State/Zip: Phone Are you a employer? Check ttie a 'ropriate box: Type of pro' ct (required): 1. am a employer with employees (full and/or part-time).* 7. ❑ N Construction 2. ❑ I am'a sole proprietor or partnership and have no employees working for me in 8, �Kodelihg 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 E] 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. 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. insu ance.1 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 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. $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 -contractors have employees, they must provide their workers' comp.. policy number. ' I ain an employer that is providiizg wo ers' compensation insurance for my employees.' Below is the policy and job site information. L /i 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 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 cert y cG d�/j tfll�pnsdpenallties ofperjury that the information provided aboeis ueandcorrect\� 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 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 lias 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 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-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia /" • O • P o NORTH ANDOVER BUILDING DEPARTMENT 27 CHARLES STREET 93SACNUgE� Tel: 978-688-9545 Fax: 978-688-9542 DATE: 1011-5-12-0o ME G��r / Uc� NA�ccy� ADDRESS ZONING DISTRICT: ?- TYPE OF BUSINESS: 7 YPc 6? ""f %•. +�� BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: 4z� ZONING BY LAW USAGE: YES NO %4-G01S BUILDING INSPECTOR SIGNATURE 'm p[J e �5Vo P" -1-a( ( �)�10�P&A ("� A57 -K �e © (3�c <e � L 1-r Location 7/ i ::, No. 46 _ Date 6247 TOWN OF NORTH ANDOVER ._,-Certificate of Occupancy $11 ,.Building/Frame Permit Fee $ Foundation Permit Fpe $ --�"— OtherPermit ee $ Y�?..� •U ee lqq' Connection Fee $ "—'---!'-" Watef Connection Fee $ TOTAL $ d Building Inspector Div. Public Works ation I No. d 6 l� Date 6 TORN OF NORTH ANDOVER Certidi ate of Occupancy $ Building/Frame Permit Fee $ ZJA °pdption Permit Fee $ t!Zbtlter Permit Fee $ Sewer Connection Fee $� Nater Connection Fee SUN' 170' $ /,//-r --6 Building Inspector` 6354 Div. Public Works 7 Location AVO. Date - i� a TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/FrarMP,mit Fee $ Foundation P`pw a.��°'" % U Other Permit Fee Sewer Connection Fee $ ~ Water Cone%EeG TOTAL L) Building Inspector Div. Public Works v �1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/FrarMP,mit Fee $ Foundation P`pw a.��°'" % U Other Permit Fee Sewer Connection Fee $ ~ Water Cone%EeG TOTAL L) Building Inspector Div. Public Works Location No. 0169 Date 3'd6 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ "f%yver Connection Fee $ `�CCAA�cf"�nection Fee $ r -G' r / Buildi ig Inspector Div. 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, " regulations or requirements. *****************Applicant fills out this section***************** ` APPLICANT: //i7 � _< Phone ���/-5 LOCATION: Assessor's Map Number S� Parcel f �% Subdivision /�irl� ,� Lot(s) Street z St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: n Date Approved 2 W,1,3 Conservation Administrator Date Rejected Comments Date Approved 2 q3 Town Planner Date Rejected Comments Food Inspector -Health Septic Inspector -Health Public Works - sewer/water connections - driveway p Fire Department n 0,d'Y 22 {t� Date Approved Date Rejected Date Approved / Date Rejected Date ' 'r, rr; +r•�v.�'earr+.M•.sd.:....+d,.. -� . _ nn'.+�;.^+I.N.. .h}-_ ..J!c�i :. R1 g N at moo v b 0-& Z r i %A = T co m m �p m Cp aria ZOoo va�m ♦ O O ;` 1. ai x !« '.' 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CHIMNEY APDL ICA11014 ANO A )ATE -OCATION m; v;-;; if 111 WNER'SNAME: 'UILVER'S NAME: ... iASON'S NAME: be, (It jevL- ASON'S ADDRESS: 7- ASON'S TELEPHONE: `702 3 ATERIAL OF CHIMNEY: NFERIOR CHIMNEY: [XILRIOR CHIMNEY: UMBER AND SIZE OF FLUES: HICKNESS OF HEARTH: itt cfvullney 0/1. 6i/Lepcace Con(011111 to Vi.e. V(l the cude a)ld havc nuCe.3 mid egLL&tiow been aece�ved: ATE: IGNATURE OF MASON: ERMIT GRANTED: F' L E 0 0 )BERT NICETTA GILDING INSPECTOR VSPECTEO: EAiARKS: SOLID BLOCK RE 0 U I R E 1) THIS PERMIT MUSF GE VISPLAYLL) 014 JHE PIZLMISP' CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number 069 Date OCTOBER 7, 1993 THIS CERTIFIES THAT THE BUILDING LOCATED ON 71 PINERIDGE ROAD (Lot #22) MAY BE OCCUPIED AS SINGLE FAMILY DWELING W/2 CAR GARAGE IN ACCORDANCE & DECK WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Flintlock Inc. P.O. 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