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Miscellaneous - 72 PHEASANT BROOK ROAD 4/30/2018 (3)
H v .. m Wl a 0 C m t _ H v .. m Wl a 0 C m = —" o M CL �:.=C2 of^, `I VJ-- m Z__�.oy� N H o`` M H T m�o o o � ,o.F �• o f m o: m n _ O o: CD (> o ZS q r M ' m : CD = v C_ a y z y S = Mm . CPD o 'p o n ..: —• co o = � : 06 � C� � C/)„ m m y c , fl.n CL m CO) tTj CD v, CD m O H CK a C) n z '.� "o 7d CnCD ft CL C ►Q H to Ca CDC/)CA CL ra, i m: cr �+ � of vo+ oCD %�t v -a C O OpC-) CD O CD ao c CUD CD y 0 Z CD CL CO) mz� CO ,. A �F bd m r • n CCZCD D 7 n � �; • jiff___}r o c y 10 co CD r _ ° CL CD "� 3r oca w CR N C o �= o . G v' : ^. CD c o M 0 G 5 0 w G 5 0 G � � o o p� G G ( b o O _ rte” n �_ rrl a-` w 0 C� a n r tS C) :Z7- Z -O na� `O' x y Location -- �� eG'? 'No. Date NORTM -TOWN OF NORTH ANDOVER �x ; dCertificate of Occupancy $� #° Building/Frame Permit Fee $ .. Foundation Permit Fee $ � sAMU_ Cst Permit Fee $ Sewer Connection Fee $ Water Connection Fee TOTAL $ Idi Inspeclor 025 l Div. Pli orks vocation Date '-''"`�">? No.LE NORT„ O�tt.ao TOWN OF NORTH ANDOVEi C> ,a'�.yoo '* p Certificate of Occupancy $ Building/Frame Permit Fee $ s^�MUSE<�' Foundation Permit Fee $ u= Other Permit Fee $ ' Sewer Connection Fee $ v Water Connection Fee $ t 3 =• TOTAL $ Inspector , `---,__._Building Div. Public4orks r T m it z z z O z z z z z z 'C o -C z Z N r n z z z z z z o z Z z r m z m z m o v z f'� N N z tr 1 m z o z� m m m CM n m v � N D m yzy 7 tmii m �I�+ z © Ln z T mm Z Eli z " n m 'V r � 2 l l i O O CyNt Pr" O O !2 2 T O ^ n x ^� n n Z Z Q 6 �,rA L n L N Q r. z? r'i z V C x rt � 7 Q p .� z o Z O ry =_ ww N Z WWI s O 0 4 - OM A� c y C � d C/)CDC" n Z CO) cD o a r. c. c CO) O v CD a� rr CD CD O w ca CD C O N' CD a O CA CC O CD � v t/! O 'O Z co a a O CD O C CD 0 b C) 0 Oq a go p cn \ / 0 V J 9 0 1•� VqJ 0 z cn C. z r O c N ny o y m 0 m n N m a O Z =r,o y _I tz� m o. T o o x �a-•a m O CD O N O -i o i ?m m a > >� c C to O C y: X09 00 c m C H a ,..... to C2 mc O N CD CD ,om CLte. CD COO O p� N V \VI N d :\ C O Vni _ m 4 N N mC � m w N O 0 0 CD N N0 . m o �� T N CD o CD d d a C) o� � c CD o_ Co C. 6- 0 G z r a 0 0 z G � 0 x G C R tz� D C O x o o x 6- 0 G 9 The ( bottom of bed; ( ) septic system located at 267- c3/� �V��G�FEIJ cc `s - , has been inspected and approved on ( /(3/ l48 by Board of Health personnel, and the Health Department has no objection to a construction permit being issued for this lot. -.,�4f,� �3 /3 A9 Inspector Date i ,R.. it'»�'vl !t� '! �4 I•X,x�`t{'s •'�'M a";t 1 x-ytr ^w..,.r ti',• ;�'; i� r M k "lx#i ,� ° ero 5 Y�yt � {Y i. 'x•'•3! 7• *C rr -.� t :..i a+ x.. "„� :. 4"�k x ua?:a�¢?�c �'4S' '� �� ,•, x � ,. �„ ', ��; !' •,, s : s e� .�i 'i i b, s.y" �� ''d`n k 1 ' r C u � t> J s• + FORM U = LOT RELEASE FORM. G i a 'y •:I. r �� ,��i w, � ,r tiro s -. � t va ,t r +rr� d g� : fi t , .: yP ,f `� �"r INSTRUTION$i R.� ,�..r, ,.,rThis form is used to verify that alitinecessary^approvals/permits frire om_; Boards find Departments having jurisdiction have been obtained: ',This does not trelieve the appllbant and/or landowner from compliance with an' y`opplicable or, requirements 4 a « aq .. .. � '!_ • t.. `.t" .,i's" r .fit„ { F.�t'iy ��)r % 3•-w7$f } � r�i I• 7TSVF*;j' #., rHINAPPLICANT FILLS OUT THIS SECTION$�!-0.3 s'.�t�`a, r. Cxhc Ap I.,iCANT PHONE �'"✓y7�b,�j !' wrs4 5 N ,j+, -,'t,,, rjr�+ tsS .. ' S•>, ..i, /�R J^'�/I F"r 777)17" (..L NI TI lel .� M� Number'. IVr✓.. W./, a /'„ #'^'i� ='�°3�"C: -r { r��Fr� `�'�' y� na €fit r�;,txabf Y +. 3 .rc f p (; , PARCEL �aJ4m. u�...'`S, ,3'i'! xf[h iii 9 raft tl n t{d x t i r hZ y.1 iii Oji '�{ t,� (//�/''Q�P�// b �•. •�+f �r 'S 'j £�;i}4M .,/ x :✓ rpy,'e',"q! giroFN�fp.dpY't' M.r4r� iV �+�rfl1�j4 .. •.!5` t4$^�,i`7 �X.I�:'i#ill^`;ii�GYyy�%.. ts^Y+•'� p'IS�5rr.�".y+t:1s.9x•� 3,ri "�1vVid N,l— ,/+TV.�I�/i1�yF"tus G�z...:�. r- t}'a��Ia>. / ,�� y1 rk Y 1 r( ,x� tq Fb' '�n.t.!� ; rro 'tS'4s :.'.,, �a '_ Tro4fi LOTS rySk `�4 Kr°:,6�L� �G4 rS t 111' y d�iy. K iy%f 4 &.�7ia NUMBER fa dy.*Y'atiAi2f , YT's( ., ._J/ ,iS... F �'+'t,` Sam ' t �5+!'t„t-;2' o-��R•„T'fjl�s:ro{ + 1 x ( 1a+kjx R' kc .t COMMENT 1� {ts�ti ! , • � � r �; i a ' TOWN PLANNER DATE �PPROVED ` DATE-0EJECTED COMMENTS • 1 ` t � t4 I is • FOOD INSPECTOR -HEALTH DATE APPROVED +r + ; •' DATE REJECTED A fI } y SEPTIC I SPECTOR-HEALTH -•-= , - T ,` " r+ DATE APPROVED' rr F DATE REJEC?D {t ^. S`• "��r`�r �, Sxa >tit` ±�.Cq �y{w ro�r�;z�q'j°��. �`a7f +�' w' �'t,` #,fit+ a:;4.i�,�' � � ,� � I ,� 3��'*div _s_�".{{`5 a�'� it�w'..Y�+ik, }i'�.�R ,:, r�i,��..• `i+�.i�.: ��'?� `n 1.'yx,.r rA�''e,3 �IrIMGf�J S t .;tf; w.� r•Yk F D;%''k+t .iz;n.� fax sa ,;'t' �f ,t.,,.%s �k�'Sx 1 �i.; ,ta xd `r r,�i'i. ..>,� r° {LA •Ev,�}Y ,�S�.Y,iw 3, .i,3 tntr.,fw tn• a 6�i y-+.�:- , .['.�a b., �{ `d�t.'i'x rtXA k x rYBLIW CORKS gEWE ,; Y 7 . �} J .�•# f f !r..erf f S -"F p t«�' w":' �c' RNVATER CONNECTIONS i j'� �i �. i�`�; ` ra.G��fi,_�;.y F �•�q,^a<,k iy.J�� 1 itt� t.:.`.$ i� �,, r,it 4 rw:: � C`�' p n 1 t,� tv+ t : y y�±`� °t{ �yk r $ ,j t� t)RIVEWAY �'ERMIT . �� t. ,AFfJ 7 FIRE DEPARTMENT r ;Y} 'Sk SC��rlfc-d dfl 1��CV �' RECEIVED BY 9UILI�ING INSPEITOR _ tiro,, DATE" RACKING # PCs TOTAL PER HOOK: ANTITY: OPERATOR: ..... ....... ......... . . ......... ................. - ................. ........ . .. . ....... *''***'*:**' .......... ..... .. ...... ....... ......... ... ...... ... ... ....... ....... ......... tor. . ............... ........ ............ ........... ....... .... ........ ..................... - ... ........ ................................. ... -- ................ .................................. ....... ............................... ............ ........................... ............ ..................... ............. ... .......... ...... ............... .. MASKING PLATE PER PLATE PER PLATE PER POST PLATE BAKE Yes [] No E] TME: TEMP: OPERATOR: UNRACK & PACK SHIPPING FINAL INSPECTION PER: OPERATOR: DATE: — 100%:7 MnSTD-105: 7 AQL: LVL: SAMPLE SIZE: ACCEPT: F-1 REJECT CERTIFICATION REQUIRED: YES: El NO: 11 X-RAY READINGS REQUIRED: YES 7 NO: ❑ Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. 1 Name of Applicant on Building Permit (below) Address of Property for Permit (below) � et�s�� AA -79 PkAsW Map and Parcel : INA-��urpose of Application (check below) " Ptne ��' oL(ofepplicant: _X Single Family —Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit iq issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in exlsten s of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior' shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION, Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inacc"infotior the checking off of an above item which does not comply, whether done to my knowlunds for re sal by a Building Department to issue a Building Permit. Skgna(WP, dt Owner or horized Agent who sign a Attached Building Permit D to This fonrVibust be attached to the Building Permit upon application for such permit to / � l j rn D 7" off/ rn D 7" off/ r �� :� ����, i - _----'����-----__-^=--_----' � �_--' -' ������ . . . |F7� . . . . . . 49� . . . . . . . . . . . . . . . . . . . . . . . | . . . | . . . . . . . . . . . . | . . � . | . . . . . . . . . . . . . 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SCN,i:PAZ:�Er: • �� ��� �"�1" ISA 511'�F1" 1.01' 3n -I 1 / 8" - I 1-0i1 13UIL12F-12 OF FINF- I-OMF!5 L, FTANIS WMI.MVON5 AwN�Y: d f0 12 HOOpF-p 1 1'KO.iGf 1ftI.E. SCN,i:PAZ:�Er: • �� ��� �"�1" ISA 511'�F1" 1.01' 3n -I 1 / 8" - I 1-0i1 13UIL12F-12 OF FINF- I-OMF!5 L, FTANIS WMI.MVON5 AwN�Y: d f0 12 HOOpF-p !�m r 1 I I I I II I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I II I I II I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I I 1 I I i y I I I I I I I I I I I I I I I I I I I I I t ----------- I— —a I I L ---------- LJ MaoMlm: MA 5TMrf�: nnr=: 1.01' 3n -I 3/ 16"S011,011 '7/ 31 / 97 %arnu: MAf? UVA110N nr vmPY: 1'Obn HOOFFIR ftr: a W S� ftr: a W s rn b rn d w rn YI N a -f -- —— —— —----� r-------- --- —T I I I I I p I I I = I i I I I I I i I I I I I I I I I I I 1 I I I I I I I I I I I I I Q) 2I I ><0111 N I O n I I I I I I I I I I I I I I I I loll I I I I i I I y I I I I I I I I I I I I I I 7'-0" 9 --all - - - — - - - I I ---------- I I I I I a I I � I I I I � I N I I I i I L _ I I � I I \ I I I I � I I 1 � 1 I I I 1 I I I -73 I � I - I I I I I I I i m I I CS t i I � I I I I I I I I I I I 1 I � I I 1 � 1 I I I 1 I I � � � I I I I I I I I I I I I I I I I I I rn I � I = I I I I - - I a I cn I � I I I I I � — — — — — — I — — — — — — — — — J --------------- O O 1 ,Ou 1 Q9 N FPO.ECf Ime: 5CU: W L - L- � /\� � �� �"�' IfA 5TVfff LOr 3n -1M6110-111-01 DAfE: 1/ 31 / 91 5Eef: E3IM 1F- 12 OF r- I NF: HOMF- 5 "af w` FIV5f FOR PLAN VRAVYNBY; A -rorr HOOr�r I �f Q9 N FPO.ECf Ime: 5CU: W L - L- � /\� � �� �"�' IfA 5TVfff LOr 3n -1M6110-111-01 DAfE: 1/ 31 / 91 5Eef: E3IM 1F- 12 OF r- I NF: HOMF- 5 "af w` FIV5f FOR PLAN VRAVYNBY; A -rorr HOOr�r I 26'-O" s 5 9''1" 73 W � � O i Ppo,Ecrrm.e: 5CA4 W �- L D �� Q3 P� ` l- MA 5T RT�Ff Eofn-I 3/ 16"= I' -0• vnr�; sl ur; j 13UILPA�P2 OF FINF, HOMF-5 ffffTw: �IP?51"F1.001?I'I.AN mmOY� 1'OI2I� I-IOOpr- P? i i W k V N � W b b W. Q� w d b = d� a w .s 26'-O" s 5 9''1" 73 W � � O i Ppo,Ecrrm.e: 5CA4 W �- L D �� Q3 P� ` l- MA 5T RT�Ff Eofn-I 3/ 16"= I' -0• vnr�; sl ur; j 13UILPA�P2 OF FINF, HOMF-5 ffffTw: �IP?51"F1.001?I'I.AN mmOY� 1'OI2I� I-IOOpr- P? i i 26'-O" s 5 9''1" 73 W � � O i Ppo,Ecrrm.e: 5CA4 W �- L D �� Q3 P� ` l- MA 5T RT�Ff Eofn-I 3/ 16"= I' -0• vnr�; sl ur; j 13UILPA�P2 OF FINF, HOMF-5 ffffTw: �IP?51"F1.001?I'I.AN mmOY� 1'OI2I� I-IOOpr- P? i L -----------------------------------------------j t't 0 Cf 11iLi; 5C&ti WH L- � /\m nAn: OI% FINF— HOAAF—S SECONP FLO01? pI.AN 1-022 HOOpF-I? w w � N yW V = r I I I I Q I rn I L -----------------------------------------------j t't 0 Cf 11iLi; 5C&ti WH L- � /\m nAn: OI% FINF— HOAAF—S SECONP FLO01? pI.AN 1-022 HOOpF-I? ►0 no NO i W L - L- 0 AM 03AP��� �'�" rrno �crrm �; MA 51 MFf I.Oi 3n -I 1/8''-1'-0 i i dnr�: -715119-1 I3m-rr-r, Or PINE- HOMF-5 r'" ` FLAMING PLM5 v�eY' 1' 01�6� NOOpF-p i i W L - L- 0 AM 03AP��� �'�" rrno �crrm �; MA 51 MFf I.Oi 3n -I 1/8''-1'-0 i i dnr�: -715119-1 I3m-rr-r, Or PINE- HOMF-5 r'" ` FLAMING PLM5 v�eY' 1' 01�6� NOOpF-p r, 4 i.. I -------------- I 0 I I I I _ I 016" Of- L2',xlr 2., x irwa - j � I y Z I r' x 10'. roti MR . I I 10' N @ < Q cR cR m N W W N \ ON O� v �� cs �_ x %z N 2� O , Ct tJ NXX -< ... x Xp-A IDN S_ ��illl W L- L- 0 �/���� �"�" too �crml : MA 5TMF I Or 3n-1 A5 NOgn "A": -7151/ 97 I3U LPF-p OF FI NF- HOMF-5 "} r„" : V00F PLAN & PULPING 5FCf. nrvwNBY: -rorr HOOpF-l2 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'v%,LED �676NO� 6 . e Permit NO: Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other -- -��_ ❑ Septic i�p ater/Sewer p •"� 3 DESCRIPTION OF WORK TO BE PREFORMED: c. . _ _ . L _ Identification Please Type or Print Clearly) OWNER: Name: Phone: A ri ri rim Q C' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ (e 2 Q 0 ' OC FEE: $ v� Check No.: Receipt No.: gso) NOTE: Persons celntracting with unregistered contractors do not have access to the guarantyfund 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 a Building Permit Application a Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses o. Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass'check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to"Iissuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o -'Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract E, Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products M OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 be submitted with the building application Doc: INSPECTIONAL SERVICES MARTMENTMFORM07 Revised 2.2008 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ COMME CONSERVATION Reviewed on Siqnature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comm Waiter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector lies No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 3 Location No. Date /�-- Check #�'���,� 25237 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $_� Foundation Permit Fee $ t' Other Permit Fee $ TOTAL $ f Building Inspector m m m m VI m v m _v, co -o C � d CA Cl) 10 0 CD n Z y CD O 'v C r ) CO c CL � y O CD o p � O CL c �C d CD CDo CD ww 23 c CD y CL C3 y •O CO CD � v y O � Z CD O CD O CD cn V I n O cn / l 0 a?�c m C7 y .v »cw 8 m N m dC°�� MCD 1 • - ='p 'C -. CO a o CD O m N O m ? = CD.V, CD o. C �. SCD o O O N� gi 0 �ti .y ate..«. o =r N ; ,. C-)= CL � : m z COD Cl) O m m CO) --1 44 S N .•�} d N crrl C a -b C7 y .v IE m N MCD 1 o pGp C37 ro 7d W o c W O o G R' 0 n C �. SCD o O 0 W � : m; r« : CD: a3: CO) m m CD m m cam• :. n� o: v cC 7�G" eb d 9tz ..� P z RR ~ bCl zi FI �. o pGp C37 ro 7d W o r W G o G R' 0 n 'b n o O y 09 0 c Gerald A. Brown Inspector of Buildings Please print TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT •1600 Osgood Street Building 20, -Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Fax (978) 688-9542 HOMEOWNER -LICENSE EXEMPTION GUIDING PER HT APPLICATION DATE: Z/// 4 _ JOB LOCATION: IiOMEOWNER Number Street Address .PoC qi 7'9 -Lar yl . ff� -,9 Name Home Phone PRESENT MAILING ADDRESS Map/Lot _9M- 9 Work Phone Cit;; Town � 0lE�l Zip Code The current exemption for "•homeowners" was extended to include owner -occupied dwellings to two units or less and allow such homeolT ers to engage a- ir for hire who does not possess a license, provided that the owne acts as supervisor). State Building (Code Section 108.3.5.1) r DEFINITION OF HOMEOWNER Person(s) who awns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, considered a homeowner. one or two family structures cons. A person who constructs more that one home in a two-year period shall not be The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-Iaws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said —A requirements_ HOMEOWNERSSIGNATURI= APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption ' •BOARD OF APPEALS 688-9541• - `_ "� CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9531 M The Commonwealth ofMassachusetts Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationftdividual): C Address: City/State/Zip: Phone L-2 7� 4 �/ Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. x ship and'have no employees working forme in any capacity. [No workers' comp. insurance required.] 3V I am a homeowner doing all work myself. [No workers' comp. insurance required.] Ti These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and wehave no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy anrZ job site information. Insurance Company N Policy # or Self -ins. Lic. Job Site Expiration City/State/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.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 maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Ido hereby certt o %under the iu and penalties of perjury that the information provide/d/a/b-ov/e its true and correct. - Si' mature. / 1'� T7ata Y lam ! l 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 an -Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-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. De 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. 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 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 ofmassachj) tt, Department of industdat Accidents Office ofIiivestigation 600 wasldvola Street Boston, MA 02111 TO, # 61.7-727-4900 oxt 406 or 1-877:,MASSAk`B Revised 5-26-05 Fay, # 617727-7749 wwW-mass,govfdia