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Miscellaneous - 711 DALE STREET 4/30/2018 (2)
Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Inspector Building 20, Suite 2035 1600 Osgood Street North Andover, MA 01845 RE: Insured: John & Mary Smolak Property Address: 711 Dale Street Company: Merrimack Mutual Fire Insurance Company Policy/Claim Number: HP3107476, HP3107476 Date/Cause of Loss: 2/14/2016, Water/Pipe Burst Our File Number: 33030-C Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Chris Town, Ext. 114 On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: North Andover Health Department Building 20, Suite 2035 1600 Osgood Street North Andover, MA 01845 North Andover Fire Department 795 Chickering Road North Andover, MA 01845 Date ....... 9:::. Z -.. -3. m..(' ) 7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING 9 This certifies that ................a.)6 ..... olz .. ..... 4. Z' C . ........ has permission to perform........... ..... :50willee: ...................... wiring in the building of ........................... P4.4.k .............................. at ....71/ ....... D4 4!!5 .........:ST ........................ . rth Andover, Mass. Fee..��Lic. No./Vks-/6 ...................... /I .... I ...... , ICAL INSPECMR ELEcr./ - - - - !1-1 -T Check # T 7595 a' Je Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 7,s-9,-5— Occupancy S9,-5—Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co�TZ,31-0-7 C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant SCh% S Telephone No. Owner's Address !S 4 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 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: 100 A PPD651v�, r No. of Recessed Luminaires .�< No. of Ceil: Susp. (Paddle) Fans "u1c frig m waivea ov the i! S ector of wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ -rnd. rnd. o. o Emergency Lighting- 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 InitiatingTotDevices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number. Tons KW.... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No. of Dryers No. of Water KW Heating Appliances KW No. No. of BNo.al of Signs Ballasts . Security.o D vie s or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Hrtacn aaditionai detail if desired, or as required by the Inspector of Wires. Estimated Valuef El ctrical Work: 2-1 nbp. (When required by municipal policy.) Work to Start: ��2 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera s in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th in and penalties of perjury, that the information on this application is true and complete. FIRM NAME: jh,l.-IA-r-- l!��� ,L _ �j� LIC. NO.:--,t-f6 Licensee:,/t4— VJ,.a,¢(� _ LA ,,4 L Signature 1. .� rL___�LIC. NO.: (If applicable ent "exempt " in the license number line.) Bus. Tel. No.: f7 Z -toy Address: l,i.(�S "l1'�-�> r (�� �c.{, 5?>� Alt. Tel. No.: Ya 6 *Per M.G.L c. 147, s. 57-61, sec rity work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Tp,,��t ot-r- 0 a /"� gr 23 a 7 3--//- 00 Al"ll P -3f M t s 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 e l www mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers Annlicant Information Please Print URN Name (Business/Organization/individual): Address: City/State/Zip-Phone #: . Are you an employer? Check the appropriate box: Type of project (required). 1-0 I am a employer with 4. ❑ I am a general contractor and I 6. Q New construction employees (full and/or part-time).* 2. ❑ I am a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet + �• ❑Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for mein any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, Q ,Building addition required.]officers have exercised their 10. ❑ Electrical repairs or additions 3. Q I am a homeowner doing all work right of exemption per MGT, 1 1.Q Plumbing repairs or additions myself. [Nonworkers' comp. c. 152, § 1(4), and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' 13 Q Other comp. insurance required-] • '•v ^rY••`•••••• •••�• .mwno uvn rr ���, msu nu out me section Cetow snowing meir woncers compensation policy information. t Homeowner; 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 mustattached an additional sheetshowing the name of the subcontractors 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. 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 $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 certify under the pains and penalties of perjury that the information provided above is true and correct, Signature: Dom. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• ±l� 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 numberlisted 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 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Location No. .S Date / 1401MI TOWN OF NORTH ANDOVER 0. p Certificate of Occupancy $ Building/Frame Permit Fee $ '�— '�S'"°'''t�' S�cMusE Foundation Permit Fee, $ _ Other P rmit Fee �� $ -Sewer-Connection Fee $ -W1 ter ConnectionFee $ TOTAL N Building Inspector 6593 Div. Public Works I { al 0 0 i 7 m �\ I� \{` 0- K LL W I W _Z o N_ Z � W r J 0 a N Q X a. U) F- -1) V a F J E W 0 ul p Z 0 W z 0 LL 0 0 N 0 z _m gW U Z U Z LL p W IC O 0 zin J yW W frA I D N m d d O z J < 2 m E O Z 0 t r 0 W a a W 1 d Z U i z be s t N OJ 0 O < 1 HZ Q tj O O K th 0 z N 0 r N N K W m f F C O 0 J LL LL O W N_ a a J J a 4 O Z 0 N Z W L i U) a r 0 L a C W 0 0 Z f 0 LL LL 0 W N a o 7 m CL I� K LL I W _Z o Z Z � W r J 0 Z O r F- m a a F J E W 0 J u 0 W 0 LL 0 LL 0 z N z i U Z U Z O _Z J _Z J J yW LL < < W m m m J < 2 E O Z m r 0 O a a W 1 a Z U i z x t N OJ 0 O < 1 u tj O i L m l7 �I tl G W a J J a 4 O Z 0 N Z W L i U) a r 0 L a C W 0 0 Z f 0 LL LL 0 W N a N Z 0 U N Z N N a a O O W W a a p 0 0 m J J_ x LL LL 0 - N m W W a L d o 7 m a 111 K LL I W _Z o Z O f i O W r J 0 Z O r O C 0 p a a F J E W O J u 0 W 0 LL 0 LL 0 z a< z i U Z U Z O _Z J _Z J J m LL < < W m m m J < 2 • m N Z 0 U N Z N N a a O O W W a a p 0 0 m J J_ x LL LL 0 - N m W W a L d o o 0 0 a z • H a z 0 2 • m W u 1g- U t 0 u tj O L m l7 O G tl G W u A m m F_U PlW W W le G IV I N Z 0 U N Z N N a a O O W W a a p 0 0 m J J_ x LL LL 0 - N m W W a L d N_I V Oma p Qr Aye �'D°�gv�3� DmG1 G1 VI In Nnco <D D�On OOZnnccnmvOpa A mZ DIp -D m W vmnn pnZZ N y;N aclz .. Qr T O /c Z1 p1 mO D a+m O mmn7c 0ry< 7Cnn �N D 0 ,�, DN OC yOm 001 DD D N 7cnn ID p _O m 0 pN Tp a, DN; m¢V1 O N DT Z OGl OA Ny ZN ZS G12 DA OOOp ZZAZZOOONNSOM ;;np3ZZZN DDZ>) yO OONOyNN Al G0o°c� VD Z20 ZD °;� p"� 3 c s N pmm ATm y O W T C Z �' ZD -- W Diin G1 NpN S p ;NO3p Dp„ Z�r y T Z x C << n.a Op Nm Dv mZA1^Zap O N T m z ° D 1n ° 0 0 II�1 VAiA A Dm < D /c Z1 I 0 C DA D O O 0ry< m DN OC yOm DD ODDO ID OA mZZ „ pN Tp p DT Z Z A DA yO om ZD m 0 0Z O OA OmO 3„ 20O 0 { pA Z yZDD AD D O A z I I II O oz Q Q Z I � I I 11J�� IIIII" III I I I IIIII- I I I Vv >01 C)�N N N r N z m qM,4 N- n O yz �v3 Q MXN 1 k D� 3n�► 040 ND:E p 3 m mx w `_ N 0 'Al.— 4 r� \ �z° �QZ0 m 07 N M 0 C r `°-m v Ivo -1 Z 6) r 6f N Tog N, �� a * > z�z m n n 0 0y v M> , 10 mm om D3 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and pepartments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state lav, regulations or requirements. ****************Applicant fillso this ✓PLICANT: ` Phone ✓LOCATION: Assessor's Map Number Parcel. ` Subdivision Lots) Street St. Number_ ************************Official Use Only************************ RECOMMMATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments V Sc'phite. Health Agenz Comments 0/f �Z7 X1116 Public Worcs - sewer/water connections - drivewav pe--=i-,- Fire ermit Data Approved Date Rejected oA... Date Approved Date Rejected Fire Department ' Received by Building Insrector Dare O' ` 0 1993 OCT -1 1993 D,4Z E S7- 7` m �\V m '� io ����I�I 000 N tit =0 �b e..., 2 pOp°� ati Pi OSI COMM Nh 6 -50 m(n `'�a C y °fig "o' m� ��zC� o�yo :y��� I m = <�101g�§ . ��I�y��j� C�i�pOA �'y�ly�l �kl'� � v S113Sa��'� 0 O Z m C C p v g a N U � io ����I�I 000 N tit =0 �b e..., 2 pOp°� ati Pi OSI COMM Nh 6 -50 m(n `'�a C y °fig "o' m� ��zC� o�yo :y��� I m = <�101g�§ . ��I�y��j� C�i�pOA �'y�ly�l �kl'� � v S113Sa��'� 0 O Z m C C LS cz H z o A O L cn v a u � z z a C p O v -a C a u z z p C a z U p n4 v V) C w o z CO a C w a w W 20 L U) D O V) c c m c o c i O i O N cc O V V G C O W ' O C = O T O � 6i N = CE CD .1. o. NkN C o as Co., � m CL E m m a c C'CD 3 r_ N QI O J N -v — °o ON 2 C O O: y C O EN m mo ` CLC.3 CD y CD z s o os : CM • livor w N o 0 cm C.3 CL c Q � �`oc o = m m p N d yo, N m o OD L C LL N m m W A O N �C.t C Z E C �N o U ® c m= c g CO a m O :5 _.a F- scc C2 P. U 0 O i __j Q z O E C L 0 0 V CO Z 0. O o CO) � cocao� z o o� c_ yO �� m m W z O L O O C i � O Q a �a y C o � � v J� .c O Z 0 _z V CO) R C d V! co — � z z z J CL Location No. �. Date �oRTM TOWN OF NORTH ANDOVER 3?0',•�'D I •,h�0 p Certificate of Occupancy $ 1 •P12 /c * _ Building/Frame Permit Fee $ �� G ,SSACMUSEt� Found tion Permit Fee �fher Permit Fee $ OCA 2 Quer Connection Fee $ Water Connection Fee $ TOTAL Building Inspector Div. Public Works / r Location Nod Date - TOWN OF NORTH ANDOVER )IQ r- U011eci, Building Inspector Div. Public Works Certificate of Occupancy $ _ • i Building/Frame Permit Fee $ 41n Foundation Permit Fee $ _ Rs�,,CH 6/vs Other Permit Fee $ _ �q Fee $ �QU i; TConnection _ 6 %9 9�TOTAL Water Connection Fee $ _ ��, nQ1�e $ )IQ r- U011eci, Building Inspector Div. Public Works a a d x W Z 0 3. 00 i N Z W o 0 sY J = O m m LL K �W00 0 W N I i LL 0 D N d Z I O a 0 . z 0 N f1 I� e! A O O N M M W N W W Z F z Z a F to 0 N N W C f W � z U z z N O O O< m 0 r< O N O z N O fJ N N m W m F F- 0 0 J LL LL 0 W N N Z I x o 0 0 r x Z \ w�1W W k N Z < W IN` N INMa �t N Z w 0 Jap _ N m < O m a L7 Z CL :,0 LL LL 0 0 m t - a f U) O x �-1 I w ME MM Z 0 O LL W 0 N_ N W 0QH Z M a J 0 0 z LL 0 L7 J Z VLL O Z 0 0 r W Z F li A[ O v. ru to U O Z Q J O (J ci W K W z W z U U 0 K J Jm m 6 V i` W W W m N L Z i 0 W L N 4 N F i p 0 f N J J FLL L 0 e m W L W a m a i Ix L U m LL W a Q h W Q tL O ct a a j Gj ci AJ r =/ i i v lk c ui �i CJI N V. !i1 Z 0 p O J m 0 W O I N z F N L Z i 0 W L N 4 N F i p 0 f N J J FLL L 0 e m W L W a m a i Ix L U m LL W a Q h W Q tL O ct a a j Gj ci AJ r =/ c �i CJI e 9 � o ) v t Sa P1 1 bO y J W � F k X�Ypj CD W F W cc IL d I -N 00 -I 1 1 1 1 1 1 1 � Ul I1 -III I m - o Z Q W Q 2 00�J N J n. Z=N Omu o o Z gO�, d2 m zOg I m w w �Oul azo QZF=xw- W213 IIx II w 000 NUS t d Ulww - a - - :- �Z0 Z < U) " Ut uz w l3 _LL (n ,# a e4 w. z F-JIr I -N -I 1 1 1 1 1 1 1 I1 -III I w o o Z gO�, d2 m LL w 1,'o.. azo IIx II I I O d _LL Z Q Q 3 6 N< V' Y Z j X" _¢ u 0 d NN 0 W ti Z ��a .� 1- U u f� a Y z w �O� K W x w G O} N m O>p W G O LL O Nx �zr-.N x< Z �a y u. V N z m a o v o i v Oa D - O 0 n°Cvpz�hZOa ` w x w ¢ d J p W w �w u 3 Q Q Z u a.x 0 2 a} D 220 �- y, �y O1 z Oaa0N V K w x d U¢ H ¢ d a N¢ ¢ O N ¢ i ¢- ...i U �paO�� Y Z N i W W _ 1� H ,. K ii O d 'f• O I x¢ ON ¢¢ d'n ..� O0 O w l 1�TT1-T I I I I I I� I z I I� 0 — o a. 0 O 2 J Z } m e 2 0 ? 6 0. J o YZ W a W Oz p O Q¢p�o0� Z ocz O d¢=w x:NoW i O u0 LL O vv Nc� J f ° O a i ; Np C��D�LLQ¢Z¢LL LL ea ZO -Z m Z f aLLw O "' ww0 n oe m J 10 LL= Z �p?NN_OOzz°CzZ Z N Z Z Z u� 000 = '^S Z Q ccO o m Q o Oma uuY� iop w mo ti¢N O dd>ppx SO -000 W 0 d wo,¢ J 1,10 m 7 NIS¢ "UUma O 0. "' `" O ¢�ZIx a�V�>¢¢1NM oc NNW jjYYuOO mm UUoN (�(�LL¢3N�K OaF� t0 O iF0 1-N� P i m� `. - ' .'i s 4 >+ .7 iy T YFi r .d. �„ � C yw�S t� L hi •ii 'f.�ji.j r A !I �' ••�7 S �.. } "` mfr;` ► 37C:,�7r, FL 44 .-�'Y{d i` ~iyZ-¢ i�.y �. ?ter ii .gyp r { �•- yl� ry�r4� �.• ; . "�� . =,,,YFF�. s a ;cam. < = r � ` � A ,�'t r �� i � fi� � fD � � a• lJ k A ,,� a . :r 41• ,� CL t'- � � a �}� -y. lT ? �~ 'Cr• }!fes ��Sfi 2 K , _ r • (". r it A a• �MIN r - 41) , �. -.. .i � .�'f. • ,t t ,'�"! �' r' „Ski, ralt N Q7 n tt fA 40 ?! .C7 10 Ile `' t ;\ H y V�• N I IMA ... __ _`_ -.- �..._. _ ..... _.-�. ..___. -� .-.4.. �...r... � v:.�-._.r .4 - � ... .:�"Si,.`•G :'_. •t+-a7r'•'.Cr.,l ]s. e�-.n-n - ♦ -� ..r- r _ _- __ .. .. .- ..... rn 00 swift Z 0 ;L .V) =M >: Ro =1 CL o o 01, 0 NMI Z 0 Falul U TOWN OF NORTH ANDOVER LOT RELEASE FOIUI SUBDIVISION Fop M A AssEssoRs MAP Idq ttd 31 SUBDIVISION LOT(S) L ()T 3jA .PERMANENT ADDRrESS`(ASSIGNED BY DP.W. STREET f r� 11 a 1n �-t I0 raa�- k (\ 4%,1A w APPLICANT �Solo, S"10 6K Momao Go ru' (L) PHONE DATE OF APPLICATION /3b��i2, TOWN USE BELOW THIS LINE PLANNING B AAAA DATE APPROVED '7.5 'q4 TOW PL NER DATE REJECTED CONSERVATION.COMMISSION DATE APPROVED 7�� CO SERVV:ATION ADMIN. DATE REJECTED BOARD OF HEALTH DATE APPROVED 002 HEALTH SANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERriIT oD/Lc,u-C' (&81z�A 02A=4i SEWER/WATER CONNECTIONS No " S FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE e ., 4 1"4 •' 14 1 11 W. .This form shall be signed by the agents of the Planning and Health hoards, the Conservation Conunission prior to the issuance of any building permits for 'the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. R lw M C C H A �D 7 eD Ma m 3 ��l in T1 31 T cp m T m T 0 37 3 c o m o o h o co m m T Ccc O X > N � z T �i Vrn T m T 0 m -o m Zi a D,44,E I� 0 � ?I a D,44,E I� 0 Location D I I Q A t F- 5,+- No. +'No. 39S- Date Check # d'') A TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ d l O ,--- Foundation Permit Fee $ Other Permit Fee TOTAL 1619 4�" �- -- ` C -1 - Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING rid BUILDING PERMIT NUMBER: DATE ISSUED -3 - o?o o,3 SIGNATURE: 114 (L��-- — Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: Date 5i 1.2 Assessors Map and Parcel Number: )rq C Map Number Parcel Numbef 1.3 Zoning information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide R red Provided RecMired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 11Municipal 1.8 Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2 Owner of Record jo�A 140 VA Da 1'e - N rint) Address for Service �1,14_ 7 gV Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Cons ruction rvisor: 1 C ,-A— ,7 - ensed ConstructiX Supervisor: Address / Signature Telephone Not Applicable ❑ License Number -SU/© 5 Expiration D 77 atee 3.2 ered Home Improvement Contractor 17 Not Applicable ❑ p / 49li9 75-6,-- 5-6Registration Company Name 4�'�� ~29 Ze,Expirat RegistrationNumber G a3 Gy on Da e Si nature Telephone 09 M ic Z O SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ I Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 11 Frim` krte wa l th 4rf1L re r s-farQ c . Frame Law�j7Jr I'oo c2p�rax . �0 K I . etn�sh fe►-►�u��►,�,� o„�eoL w��'b. e(�cl-r-t ��, dry,�� �( r 1��.�'. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bV permit applicant OFFICIAL,USE ONLY 1. Building (a) Building Permit Fee Multiplier r 2 Electrical (b) Estimated Total Cost of Construction O o Lq 3 Plumbing Building Permit fee (e) X (b) a Q 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CON TOR APPLIES FOR BUILDING PERMIT �-e-- as Owner Authorized Agent f subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I 2 ND3 RD SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE lia��L FORM U - LOT RELEASE FORM 03 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT Jd f► .5,n 1 PHONE 78' 6; S`' 3 % LOCATION: Assessor's Map Number. SUBDIVISION �O STREET Zfe PARCEL LOT (S) "T. NUMBER_fi ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMM TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH IC INSPECTOR -HEALTH COMME DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED A1/ OS �5- / =5 DATE REJECTED PUBLIC WORKS - SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm FEE: -13-03 0-=.:25 Fr9 JOHN i' rliiLilh:: „- f , - ���- r � •? "jay I I _. ._,�--- ! � j .-�___ � i ' � � r* � � ^ ” ' �.^ ��-.i _'•.I. � r,.-..I 1. 4 ; t _ `J � �� ,.,_.:..I �... - _ _ i �_ � , t { � pS".�Cks nth .'+-`t`•; 44: a"1 - 1.' �... t I c �'- ! - i ...�_i l . i _ i I .. 1 . ,- I : f'1"• l��S�'�'d „� i ( '� y ✓'Sh I 1. 1' i I' I ' I - j I f I } 5t� .f }t -,�.�+,. i __. o- i 1�.1 � ! - -- +I � t I , I � - _.- (� I I • , } y .kgs '"a ,&. 1 <;� ,.3 ti �� _ �,~ 1 I - I� I.; I -__i.. 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J r,���i'� t+A7 G� j North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) /Zj �/2z, Signature of Permit Applicant as fj� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02119 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. FTI am a sole proprietor and have no one working in any capacity I am an empl� providing workers' compensation for my employees working on this job. i Address City %/� �. �% !.�/ S� Yy Phone # ft+ 7 9-) 94 y2 - Insurance. Co. / rcr rs c% -S Policy # �9� x Y ig 3— 9d 2 Company name: Address City: Phone #: Insurance Co. Policy # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of crirrinal penalties of.a fine up to $1.500.00 and/or one years' imprisonment_as_weU_as_sxvi[4ienattiesin2he-h m.jd-a-STDP.MRKORDERand_a.fine_cf-($1DO-00)-ajdW -against_me 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penaltiesof pert ry that the information provided above is true and correct. Signatur { Date :20 a Print nameo-c'z�Pborle.# ?71r gjg�;,S— Official use only do not write in this area to be completed by city or town official' City or Town Permit/l.icensing Building Dept E]Check if immediate response is required .0 Licensing Board E] Selectman's Office Contact person: Phone #• 0 Health Department D Other -�e Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reqistration: 100756 Type: DBA Expiration: 6/23/2004 RUBERA CONSTRUCTION INC. Richard. Rubera _ 201 Wheeler Street Methuen, MA 01844 Update Address and return card. Mark reason for change. Address I ' Renewal ' .Employment lost Card C -Ow wna"aAl, o/!lt/.ab.11xlldl iT t Board of Building Regulations and Standards � HOME IMPROVEMENT CONTRACTOR Registration: 100756 Expiration: 6/23/2004 Type: DBA RUBERA CONSTRUCTION INC. Richard Rubera 201 Wheeler Street Methuen, MA 01844 Administrwor License or registration valid for individul use only before the expiration date. if found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 N.,+w-1i 1 wOhniet Ounati'ire _ �llC I,/J/Yi7L93KYfPfIlCaLCJI O�..i1Zt"60.k7f�UdC�4 BOARD OF BUILDING REGULATIONS trey License: CONSTRUCTION SUPERVISOR _ Number: CS 025158 Birthdate: 08/1911956 Expires: 08/1912003 Tr. no: 1132 Restricted: 00 RICHARD J RUBERA 7 ,J 201 WHEELER ST METHUEN, MA 01844 Administrator m m m m 0 A, CO) .0 c CD 0 z CU C:L. �• 0 CA O CCS �. -- CD CA 0 CA �w B i CCt y" Q � co �CT)COO) 0 i "o z CD CD0 C CA C C 2:-4O m S -. y O Q' CA co C1 O CD n to m n -4 m O CO) P C a Z Erm H --I o m o T m a=m = m H CD -4 O m CA O N O �m I S >_ >mCA _� to � o m Z `. C.) : �l O N CD :M C O ' to 0 (V(^I CD CD H VJ to C')= m Q ^ C CZE i �CD W�� CRLr.J " •� C CL cc H� :R o � y :ti = o G1 m CD : w �.CDy: OIN CD cm O A CD CD O O O moo: z "oo . cc - CO) o� � CD cn r CA I' • C/) Co s =: CD C n' c d �Z s cn: o n: o_• m o: d 0 0 d x w 0 °5° w f9 ry 0 x �' n 0 u 0 0 �' r CCA 0 0 x CL o W 0 rD r)a y rD o x 7 0 c a Date ..�x� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... /s/�-c //I. -( .......................................... .... . . .. ..... has permission to perform ............ X.I.I! ..0 ............................. .......... z wiring in the building of...... � ............................................................. ........ .. 2 ................. V!? . /� .................................... . Orth Andover Mass,./, Fvx..-� ... Lic. Nor ... .... 7. ';.�TRIQXL INSPE R Check # 43� 2 THE COMMONWE4LTHOFM4SS CHUSETTS Office Use only DEPAR7AffiVT0FPUXJ'CS4FE7Y Permit No. r%7� � BOARDOFF)REPIZEVE1V770NREGUTATIONSSZ7CNIRI2� Occupancy & Fees Checked ........ "PIJCA77ONFOR PERMIT TO PERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 3 -/3-03 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)��-- Owner or Tenant t`j �► N �t ��a k Owner's Address gel 0--e Is this permit in conjunction with a building permit: YesN ® (Check Appropriate Box) Purpose of Buildings_ ,��/�� Utility Authorization. No. Existing Service c2 a b Amps iAa/ d Y Volts Overhead Underground No. Meters of New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity —� d Location and Nature of Proposed Electrical Work ,,l, ty Q7�11c 6Mee No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures / Swimming Pool Above Below KVA Generators KVA ground round No. of Receptacle Outlets l No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal ^ Other Connections IL��11 No. of Wa er Heaters KW No. of No. of Signs Bailasis No. Hydroassage Tubs No. of Motors Total HP tTHER a rmce Covaage Pawiaxbtherecl m ma&cfMa%adnsetlsGa> dI aws iateaamMLiabl7ityhlsur =Pbhcymcl xk gQwple>e�a&"CmeWontsWeqn� vYES NOED avesubrnitmdva&dproofofsametatheOffca YES --j' FT ffycuhavedledodYES,p1mwk �ethetypeofeov�by �rgthe box L SURANCE J- -BpNp OrIHQt xktoStatt �� / % -`' 3 _ L>Sp�tionDRecAresied nedunderTri mitiesofpajtny Al %% :MNANM Vit? ✓rte /C�rcl A4rC Sigrottim > - -3 EVkdfim Date EsWr"DriVaWoffiecrrica Wc& $ Rough Final L+croseNo ? J 3/,t7 LxerwNo Att Tel No. 1NFR'S INSURANCE WAIVER; I am aware that the licem does nothave dr-trutrance coverage orits st tantialegwvalatt as required byMasswhugEztts GemalLaws that my sight ue on this permit applicabon waives this re#ernalt , v :ase check one) Owner ® Agent ® �� Telephone No. PERIAIT FEE $ lgnature o' wner or gen The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: City Phone # Insurance. Co. Policy # Company name: Address City: Phone#. Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the irnposition of criminal penalties of•a fine up to $1,50t1.0o and/or one years' imprisonment_as_weU_as_civil.penattiesjnlhelmn-da-STOPlNDRK-ORD,ER-anid_afme-of_($111t).OD)adayagainst.me. 1 understated that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby certify under (fie pains and penaAfies of perjury that the mWonnation provided above is bye and correct. Signature [late Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing D Building Dept rICheck if immediate response is required Licensing Board F1 Selectman's Office Contact person: Phone #- E] Health Department 0 Other Permit N0: Datc Issued:�'� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Recei IMPORTANT: Applicant must complete all items on this page LOCATION— Print PROPERTY OWNER TO aA Print MAP NO.:/'r�C PARCF.I.: -(�L ZONING DISTRICT: TVPF ANTI INF nr Rilri.nINC _. HISTORIC DISTRICT YES ❑ /NORTH 1 C �A TYPE OF IMPROVEMENTv v PROPOSED USE Residential Non- Residential New Building -. Addition E Alteration t?One family - Two or more family No. of units: =Industrial ie Repair, replacement Demolition Assessory Bldg Commercial Moving; (relocation) Other -i Others: -. Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: TOC-- Phone: Address: K 6C 0/4c - CONTRACTOR Name: c 1 6hh �,A'n-ZAT�tCl PLI- V►,o-CA oMI. /?At"- Phone: 9?9- kddress: 6 0 -"P I-.,- 0/t -.r—v6,3 -&. p►++ /a T Supervisor's Construction License: 66912-6 Exp. Date: I Ion-ic Impro- client License: 139 0sn Exp. Date: /-A./" ,\RCI-IITLC'T, EN1GINEER Namc: Phone: ,-�ddress: Rcg. No FEE SCHEDULE: BULDING PERMIT:.510.00 PER 51200.00 OF THE TOTAL ESTLNATED COST BASED On 5125.00 PER S. F. 'Total Project Cost :S i- 4tc,. 4" x12.00 -==FEE:$ Check No.: � �� Receipt No.: I ta&? Page 144 TYPE OF SEWERAGE DISPOSAL _ _ Tanning MassageiBody Art _ Swimming Pools Public Sewer Well _ Tobacco Sales — Food Packaging, Sales — Permanent Dumpster on Site Private (septic tank. etc. _ Electric deter location to project renuns cumrucung wun unreglsterea courriu-tors tto not have ac•eess to the gaarantt'.%and Signature of Agent/OwnerSignature of contractoFtampedPlans Plans Submitted ❑ Plans Waived ! Certified Plot Plan .❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMNIENTS -v 11 •, DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ CONINIENTS DATE REJECTED DATE APPROVED .� HEALTH COMMENTS Zoning Board of Appeals: Variance. Petition No: Zoninv Decision: receipt submitted )es Plannin- Board Decision: Comments Conservation Decision: Comments Water & Sewer connection, Signature & Date Driveway Permit Temp Dumpster on site yes_no4 Fire Department signature date __ Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NO' i s and DATA —1 For denartment use 0,,� c4pr � .11, c4pr � .11, Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.T.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ tilass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must he submitted with the building application Dor. INSPECTIONALSEAN RFS DEPAR'1'\IP..V'r:1 i,i:oi 1115 Location �& D4 /e, .0— No. Date -4'01e, TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�t: Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # _1 `f 19637 �--- Building Inspector �12 V1 G , CA( -Ti-- I ! ECIALI saw ' Prattpi;Ljubmitted `le Phone p 7 Date StteU Job Name City, State & Zip Codd / n Job Location /V �4- `f � fi Job Phone Chimneys Residential S Commerciale Roofing A11 Types Of Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work. Mass Toll Free *Roof Leaks Experts >f Licensed & Insured 1 -800 -WAIT -4 -US Locnlry 0,~d G 0, ._"d r 976 g IKOa C�of� J otJt1 BtC 911-11 �LQ, License #034200 we W.k Year Round saw ' Prattpi;Ljubmitted `le Phone p 7 Date StteU Job Name City, State & Zip Codd / n Job Location /V �4- `f � fi Job Phone We Propose hereby to furnish and labor in with specifications below, for the sum of, jaccordance -t AV 7- �. a7 +1sH /- !r'' d /J Dollars �S�t�6.3 . 0 6 }. JGr tFA1-1660-—9YTIZA , ©a v � ImUln—u l eed to be as specified. All work to be completed in a workmanlike Authorized ! }&4,L Malaccording to standard practices. Any alteration or deviation from specifications be- $i grtattue:y(i L low involving extra casts will be executed only upon written ordcrs, and will become an extra charge over end above the raimate. All agreemems contingent upon vrikcs, accidents NOTE. This pro I n^y be or de9ays beyond out control, Owner to a=trY fire, tornada and other ncces ary in sutanee. Our workers are fully covemd by Workrnen'n Compemuon insurance withdrawn by us if not accepted within'days. Noe hereby submit specifications and estimates for: .yt- t %?o nr= lnstali,�feet of special "Save Seal" ice and water barrier protection alongall bottom edges of roof and top to bottom in each valley. Q roof is stripped, we will apply conventional ice and water shield ( ) ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at ( c } per linear ft. or (._._ ) per sheet of plywood. L nstall heavy gauge aluminum drip edges along every edge surface of each roofline c tt{; TL- 1d'cover entire roof (s)withIKO -fiberglass, premium grade shingles (Color of choice). ld Replace all pipe boots where possible &,Seal all flashings with clear Geo -Cel sealant No black tar unless previously applied. k1 Remove all work-related debris. contractor warrants roof against all leaks due to defects In his workmanship for 12 years under circumstances. /normal id Local current references and proof of workman's compensation insurance gladly given. Remarks: t. ccL'rG.dAC��c= - ---- _ L� c-Ft.W �r a rn-.- Q. jb—Z0 130rt_ V%1ft vp-1 So 6C OUT Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Sirtaturt : _. will be made as outlined above % r / Tinto of Arrrntance: `Y l / 1 _ Sitgnatum ! I[Zf / ! / L L� d~ C. S 0� CA m X C X m m CO) CD 0z CD O 06 to a� .o .o 0 CD CL C �C Cst CD O O co CD CO) CD O d CD O CD CD H CD CO) O CCD O CD 9 C C cm h �. d 9 O' C K IF® O C H C-) d CC2 w ® o ,.•_ w O BY ®' co) o' O .. it -� CL �,sd °o P5 =r o m o O ..� O h G O =r m O > >-0G n mo p N Z H Co ` O � y _ CL 0 CL, to O _? O m H 3i : CD 1 C%- __ a m '� d m�. N 94; O d H CLCL Ci CO) m Ip � :Em :� N H .0 fA 7 m CD � 3 .dam► H om: m 0 es moo: m o' 53; N � O N .� : •C . r: CD d � c. IO : • how a e4 m m COD 31 3 o d 9 w w C ►� w °c t7i w G x C aoil b cn °o P5 O 7d O y 0 9 0 c The Commonwealth of massacnusens Depat-anent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrgarnzationfIDdividual):d0 cx_ Vr104"n oNJt 0 o Address: 3t. T-r__j?Lt_ 0R Pty ry1 r►+t/.4 J City/State/Zip: 0(3'+4 Phone#: Are you an employer? Check the appropriate box: am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8_ ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I an: an employer that is providing workers' compensation insurance for n:y employees. Below is the.policy and job site information. Insurance Company Name: A l -m 1-1vTvr+ i Policy # or Self -ins. Lic. #: f We 2 o o 74(.140t Za m Expiration Date: /I /q/0 /a 6 Job Site Address:. C CV*1 e sJ City/State/Zip: AJI--4 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 $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 coverg. verification. I do hereby certify undeiAhe pains andpenalties ofperjury that the information provided above is true and correct. Phone #: —?,7 2 %'%S*''/ Sa 1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfLicense # -/i/oc 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 legalentity, 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'persoris to do maintenance,•construction of 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 lousiness 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), addresses) 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 thatthis 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 pe - it/liceuse applications i any given year, need only submit one affidavit jridicating 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 (Le. a dog license or pemut 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, telepbone.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 Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia