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Miscellaneous - 796 CHICKERING ROAD 4/30/2018
N O � tOp N n n I _ m � � o z o � 0 0 � o Date937b �� � tlz - .. . HORT1� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ♦ i 4 SSACNUS� r E This certifies that has permission to perform .. j,. !.. ....`r° ... .......... . plumbing in the buildings of S.�!��-P YiLRc , . .. , , . "4C--. , o h Andove►, Mass. [) Fee . Ltc. No., .. PLUMBING INSPECTOR Check # , Q Yb of TYPE •bR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT' TO PERIFORM PLUMBING WORT{ CITY I jAlgI ,7741AIVO 1A, I MA DATE I gII6// 2- I PERMIT # JOBSITEADDRESS ! -7% CA i Ck Prr +. rc o I OWNER'S NAME) S77X- e.7 & rrl'j+ ' OWNEWDRESS I IFAXI I OCCUPANCY TYPE COMMERCIAL l ! EDUCATIONAL I RESIDENTIAL 154 NEW: i• i RENOVATi0k K REPLACEMENT: f I PLANS SUBMITTED: YES 1 I NOj i FIXTURES l FLOOR- $SM 1 2 3 4 5 B 7 a 9 10' 11 12 13 14 BATHTUB _I,.... .. i ...... _ . --- m6SS66NNECTIONDEVICE �. - .. _... . ............_.;.:.... .....,;...:_:. .. I .._... i .....1,,—.. DEDICATED SPk(JIALWASTE-SY$TEhi DEDICATED GASIOIUSAND SYSTEM - - - --.. •...i ., _ ..I ... _. . DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ;. J DEDICATED WATER RECYCLE SYSTEM ; ; DISHWASHER DRINKING FOUNTAIN - FOOD DISPOSER' •i ' FLOORIAREADRAIN I . f ! ► I ...1 , . I i INTERCEPTOR (INTERIOR) .. KITCHEN SINK 1 .. ... — - -- - ... — -• LAVATORY _.. _. ROOF DRAIN SHOWER STALL ,SERVICE/MOP SINKl . ; ..... - - ... .. TOILET I I , I I URINAL ... I WASHING MACHINE CONNECTION !NATER HEATER ALL TYPES WATER PIPING ..OTHER j INSURANCE COVERAGE: have a ctirrent.liability insilraljce policy.br its sufistantial equiValent vfi»ch meets the requirements of MGLCh.142. YES J NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE,BY CHECKING THE APPPOPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY i AOND (• j OWNER'S INSURANCE: WAIVER: f am aware that the licensee.does nt have the insurance coverage requited by Cfiapte042 of the Massachusetts General Laws, and that my signature on tiiis permit epplicatioil vaaives this rectttk011ent. CHECK-ONEONLY: OWNER AGENT. j SIGNATURE OF OWNER -OR AGENT I hereby certify that 211 of [lie details and Jhformallon I have eubnmilted of enlered regarding;lhts application are true and accurate to the best of my lcnolvlddge and that all plumbing work and installations performed under the permit issued for this application will be' complian a w lfm all P ' ro srbn of,ft Nlassachuselts Slate Plumbing Code and Chaplet 142 of the General Lags. PLUMBER'S NAME J.Pte, Wo(est46ok- ILICENSEt'I j/Ost? ; SIGNATURE —�-� MP 1,4 if' CORPORATION] .11II 1PARTNERSHIPl' 111I LLC I' ]III COMPANY NAME +Pi91.eS ® "�`� '� tj-'5 # ADDRESS ( 'Yb4 (,V6VCZ t&0 S T/. CITYI 4AVCf- ll' STATE I if" I ZIP 1. Of tM I !EL( 17�4n:-_ 1895 I FAKJ. I CELL .. l EMAIL (QFJtiL.Yo�� pU,�e�i �ll}Ol . cow { 40 r !C4 ® o Cd Cm, M The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations qu 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. 3d I am a sole proprietor or partner- listed on the attached sheet. x �• [J Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity, workers' comp. insurance. g• C] Building addition [[No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] ► employees. [No workers' .13.❑ Other comp. insurance required.] '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. 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 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 requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains andpenaldes ofperjury that the information provided above is true and correct. Z. Phone#: 97E1f77—/04I% Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation 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 j oint 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. lir an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 he. 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 (ifnecessary) 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 orpermit to burn leaves etc.) said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance, for your cooperation and should you haveany questions, please do not hesitate to give us a call. • The Department's address, telephone and fax number: The Commonwealth off-assachusetls Depaftent of ladustrial Accidents Office ofIuvestigatious 600 Wasbitigtau Street Boston, MA, 02111 Tel, # 617-727-4900 at 406 or 1-87TMASS.AFB Revised 5-26-05 Fax # 61T,727-7749 www mass,gov1dia DateAkl)7!......... ION TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . This certifies thaltf.�All &n 4 4eJj .................. has permission for gas ingallation .. . in the buildings of Zap ............... at h ndover Fee.'A.. Lic. No.Ab.e.. . GAS INSPECTOR Check # I �b b e 8121 Hoz MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:/t0t77J A Z. , MA. Date: 501 Ll -Z__ Permit# Building Location:_790P '�►t(l�P�-� 40 Owners Name: "cel Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: [K Replacement: ❑ Plans Submitted: Yes ❑ No ❑ ervr�mrn --- -- - - - -- coZy LU LU ~ - co fn W Q m= W IX o7 W 0 O 0 (0 F_�- = 0= I - CO CO z I— 0 z o > W Lu Z w w W 0 1-- 05 C0 v Z UJI a W W zLu fn = O F- W O= X LL Z W W Z O J F- 1— O z ..-i 0 LL. = W I.W. W w V LL C7 C7 = W m> O Z O W z z W a F- 01 SUB BSMT. BASEMENT 1 FLOOR Vu FLOOR FLOOR j-ff FLOOR FLOORFLOOR' -ff FLOOR 6 FLOOR4+1 1 1 Installing Name: 9/tLLS toX4,,/p1c, Q Check One Only Certificate # "`,Company Address:7t7 Cj"UC[/4LO a'►' City/Town: L A.I' ❑ Corporation -e State: i Business Tel: 578' Y75 -1695 Fax: 978-373- Z7Zg Li Partnership ❑ Firm/Company Name of Licensed Plumber/Gas Fitter:L viceS'N0G4L. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent El By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) reaardina this anniinnfinn ara trtto anti .0 t.ttt: urbL ur my nnowieage ana tnat an plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent arovision of the Massachusetts state Plitmhinn CnAn —1 Ch—f— 4AO —f a... r•_ _._t t _..._ B Type of License: y ['Plumber Tite � [ Gas Fitter ['Master Signature of Licensed Plumber/Gas Fitter City/town ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer The Commonweatth of Massachusetts Department of fndustrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �nlicani• Tnfnrm�f;.„ - Name (Business/Organization/Individual):�(�S - - Address:_ - .__ City/State/Zip: �r�„ 1 /%j Phone k g%F�— /899 r Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ��// employees (full and/or part-time).*' 2.1 1 am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t ship and have no employees These sub_contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ am a homeowner doing officers have exercised their .I all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' COMP. insurance required.] appiicaat that checks boy 41 must also fill out the section below shhovA, m T Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 111 -❑ Plumbing repairs or additions 12.❑ Roof repairs I3.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 employer that is providing workers' compensation ins information. urance for my employees Below is the policy and job site Insurance Company Name: Policy # or Self4m. 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern under thepains and alai ofperjury that the information provided above is true and correct. ' A,lfi Phone #: vfnczal use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town CIerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector Phone M 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 6r 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 datelhe affidavit. The affidavit should b .j + t r. that Lt f L s S as- a is avirequested, i � 4� P P f i s et_Te psi the F?ty or t+�Cn a tsa=F tit applicationu�r the uc: it O_ 1 •fi _ b ng requested, not the D part—me_t o_ Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' - compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be -used as a reference -number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business, or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations woulflike to thank you in advance f6r your cooperation and should you have any questions, please do nothesitate to give us a call. The Dopar tent's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 0Mee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77 MAS.SAl{E Fax 4 6.17-727-7749 Revised 5 -26 -OS urwv1_rn aqc a mdrTi n . . Date ...... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,S3ACMUSEt CO f / b -qk !)- rU This certifies that ............................. ...........L,�. �- . C r � U................. has permission to perform.................... ..... ' C.... ...........................:..................... wiring in the building of ......... — A U ' ` � ! ..... 1 n.................................................... at ..... ..1.10....`-7.1-r�j?ryvt,� ....�`�%............ North AndoverZMS. Fee.: . ... Lic. No... L..Z�r!��...... ,G�.....'. . EL CTRICAL INSPECTOR Check # `0710 Commonwealth of Massachusetts De partment of Fire Servlces BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ / 6 �'7 IV 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 (MEC), 527 C 12.00 (PLEASEPRINTXNINKORTYPEALLINFORMATION) Date: City or Town of- NORTH ANDOVER To the Inspector of 'Yes: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 096 C N (C( K16 M (D g7ji Owner or Tenantj�/ ("3 V i�-lZ Telephone No.61-7- �- Owner's Address �"�4�,t � Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No, Existing Service J 00 Amps t,,a2/-fdVolts Overhead Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Elec ical Work: 2R rwoll OLID L,)0j1.1 No. of Recessed Luminaires t No. of Luminaire Outlets of Luminaires of Receptacle Outlets No, of Switches No, of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KR' Heaters l No. Hydromassage Bathtubs OTHER: No. of Ceil.-Susp. (Paddle) Fans No, of Hot Tubs Swimming Pool A o a ❑Inn No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat Pump Number Tons ' I Space/Area Heating KW Heating Appliances No. of No. of Signs Ballasts No. of Motors Total HP win table m be waived b A - r- No, of Total Transformers KVA Generators KVA o. o mergency ig rng ❑ Battery Units FIRE ALARMS No. of Zones No. of Detection and Initiatin Devices No. of Alerting Devices Local ❑ iviumci at Connection F1 Other Security Systeifink No. of Devices or Equivalent Data Wiring: No. of Devices orEauivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �t coo Attach required by municipal policy.) Work to Start: 2 20 12- Inspections to be requested in accordance with MEC Rule 10, and upon completion. JNSURANCE VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coy rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE U BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofpedi,ry, thn_t the information on this application is true and cor pleie. FIRM NAME: 3RD i LIC. NO.: 41J Z 6rr4 Licensee; 3C6 -T--,- �2 D -zzDnt-1 Signature 2 ' LIC. NO.: 1- Z h l4- (Ifapplicab le,enter"exempt"in the licensen:rmberline.) Bus. Tel.No.• �l 4021`( Address: rA� t (j( Alt. Tel. No.: -J • - ` S? D *Per M.G. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. >3y my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No.PERMIT FEE: $ > g� Zg- ._ �E�►��T.t�T�.A� �'�3�iC'Z' I�®.. 7�1"�1����4�]' �P®k��`. y -'ailed�[e-inspecizan zer�nxzeci ($�O.OD) ~ [ j 72�s71-1D* InsxeJnts: - (fnspectore mgnataxe •• 3RO xiiials) Slate Passed Inv ecton, c mm tints: Q (Gi.s�ectors' Signa a -,n t date V 3. UNJ-1J�+CJ0. GRODJ.\JL/WJC WPM TION Passed--[ 1 Wed--[ ] �e-inspecizor�xet�uiret�($50.00)�[ ] inspectors' comments: (luspectore Signature- no Hifais) mate Passers— [ )`ailed-- hspectbrs' cammep s: (Zusp ectors' Wgaature - io r '. INSP.EcTXON - oMR:, I �e-xnspectiortx equixed {$50.00) •• [) ' Date X'ailecl--[ )_ to nspeetzonxe�ufzeii($50.OD)- [ zspectoxs' coznm.ents: i �lnsp eciors' signature xto yniais} • ,Trate 0DOR T`.A.GN TO BE EIGT,1D OPT AND LEFT ON BITE IF THE APXA TO BE INSPECTED ISNOT ACCESSIBLY, AND A'RF 1N.gP'VVTrO n*v ggn_nn xgrn np vffAp(,Y-1-i'.n_ ki, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 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/OrganizatiorAndividual): Address: `�2p�21t��Z7 57 City/State/Zip: 0 Oij Phone #:_��� Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I a employer with tmployees 4. El am a general contractor and I 6. ❑New construction (full and/or part-time).* have hired the sub -contractors 7• F1 Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. o workers' comp. Y LI`r p c. 152, 1 (4), and we have no § () 12.E]. Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name; Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date) Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern under the pains and penalties ofperjury that the information provided above is true and correct. 2-12- 2W -L- -of( Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massad vsetts Department of ladustrial Accidents Qface of Investigations 6.00 Washington Street Boston, ),YI,A. 021 It Tel, # 61.7-727-4900 ext 406 or 1.-87TMASS.A.FF Revised 5-26-05 Fax # 617-727-7749 wwwjnass,govfdia Location %Sl -? �; +u Ak%�ia,C, No. I p Date'""�''`'�"T7� NORTN TOWN OF NORTH ANDOVER - Certificate of Occupancy $ S0 Building/Frame Permit Fee $ �7' o K�i�� 4 � i � �• 'Jl 1 �� Fo p� i ,ermit Fee $ — low Oer ermit Fee $ ' � Connection Fee $ ate' � 5%`// Water Connection Fee $ it No. AndoveitdiJector $ b g�- i Building Inspector' Div. Public Works r Locationle�o- Y�'n�r -. No. C' Date . -F TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Building/Frame Permit Fee $ Area I Foundation Permit Fee $ SSA�MUSE Other Permit Fee $ ).? Sewer Connection Fee $ Water Connection Fee $ �- ` TOTAL' _ $ AUG 9199 Building Inspector Div. Public Works PER-Uff lgd.2,%n ' APPLkATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KVO. LOT NO. 6' 2 RECORD OF OWNERSHIP IIDATE BOOK 'PAGE 'PONE U DIV. LOT NO. LOCATION - �)��wt% PURPOSE OF BUILDING 0 fL ��L/.✓� OWNER'S NA E vV /fO -fir T'�fl� NO. OF STORIES -2 % j_ SIZE ��X'y/ C � 7?e �/ OWNER'S ADDRESS [mow /J BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST Fr10 2ND 2.r�G 3RD BUILDER'S NAME 0 �y �- /../ /(7 `�% "'v SPAN 1Z DISTANCE TO NEAREST BUILDING / DIMENSIONS OF SILLS DISTANCE FROM STREET 7o ✓- POSTS DISTANCE FROM LOT LINES SIDES / REAR 3o f GIRDERS AREA OF LOT 1317 / fig Z FRONTAGE /�JJJ /l HEIGHT OF FOUNDATION a / THICKNESS `o IS BUILDING NEW I /� �J� SIZE OF FOOTING O A, X ? Z // IS BUILDING ADDITION ✓� MATERIAL OF CHIMNEY /C IS BUILDING ALTERATION^va IS BUILDING LID FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE �3 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY N IS BUILDING CONNECTED TO TOWN SEWER t��s IS BUILDING CONNECTED TO NATURAL GAS LIIIN''E LL3 INSTRUCTIONS 3 PROPERTY INFORMATION SEE BOTH SIDES LAND COST ODPERMIT FOR FOUNDATION ONLY Q c B.C.EST. BLDG. COST / � / 1jFf -&-aa PAGE 1 FILL OUT SECTIONS 1 - 3 REGULATED BY PARA: 114. H -S. CEST. BLDG. COST PER SQ. ✓FT. S' -O PAGE 2 FILL OUT SECTIONS 1 - 12 . �(f EST. BLDG. COST PER ROOM �O voQ DATE. _,_.......FEE PAID,. SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APP- )VED &Y AT7.ACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED i SIGNATURE OF OWNER O!R- THORIZED AGENT ird OWNER TEL. # P- -- FEE 5°= PERMIT GRANTkD 4 Jul.. 3 19 l I PENIT FOR FRAME/BUILDING DATE: J!�.LgL FEE PAID:65.0�- CONTR. TEL. k CONTR. LIC. # DUB fir ,< W,.�.■ ' s�.-s_ -- I BOARD OF HEALTH PLANNING BOARD •BOARD OF SELECTMEN BUILDING INSPECTOR .;; -NV1d 10'�c I 0 �0e`dN�`i 3 ` w ' 013 'S3!DVU -V9 'S3HC)MOd H11M 'S9NIO11n9 3o SN S 3 1O l�t/X3 4NV S3N11 101 WOMB 3ONV1SIa 9NV 101 �1Q6Is�� �.e�3 �V1;0_F�'i�,l15`111 iV01103S SIHl �JNIIV3H ON A. J181J313. 110 SWOOM dO 'ON L SVo SM31V31-1 11Nn 01.H 1NVI4VM 'JNINOI'114NOJ MIV 09 Sd314Vd QOOM .;; -NV1d 10'�c I 0 �0e`dN�`i 3 ` w ' 013 'S3!DVU -V9 'S3HC)MOd H11M 'S9NIO11n9 3o SN S 3 1O l�t/X3 4NV S3N11 101 WOMB 3ONV1SIa 9NV 101 �1Q6Is�� �.e�3 �V1;0_F�'i�,l15`111 iV01103S SIHl Z l ADN 1/d n 000 I Gb0D38 OWaiins �JNIIV3H ON P'E I 49 PUZ 1.4V.8 J181J313. 110 SWOOM dO 'ON L SVo SM31V31-1 11Nn 01.H 1NVI4VM 'JNINOI'114NOJ MIV 09 Sd314Vd QOOM MOdVA 210 8.1.M 10H 'S10J B 'SW8 1331S WV31S N21nd NIV lOH (13:)dOd _ 'S10J S 'SW9 M38w11 3JVNMnd SS313d1d ONIIV3H ll 1SIof OOOM I 'JNIWVMd 9 OOVO 3111 MOOT, 3111 53MniXId NM OW ONIdOOM 11021 d3MOHS 11V1S JN18Wnld ON 13AVMO 9 MVI 31VIS XNIS N3HJ11X S30NIHS BOOM kdOlVAV1 S310NIHS 11VHdSV 13SO1J d31VM ('Xld ZI ms 131101 a3HS OMVSNVW I OX 1V1d 13a9WVJ •Xld CI H1V9 dIH 319V`J • 'JNIBWni4 OL 3 MOOd 1MOIM3dns BOOM 5 WHIM 3WVMd NO 3NO1S A2INOSVW NO 3NO1S X19 630NIJ MO 'JNOJ _I 8001A S 'SdIS DWV 3WVMd NO XJIH AMNOSVW NO XJIM9 —� —� _ £ Z _ l 9 9111 'HdSV NOWWOJ QPn4MVH 3WVMd NO 0JJn1S AMNOSVW NO OJJn1S JNIOIS -ln3 `JNIQIS SO1S39SV ONI41S 11VHdSV S310NIHS BOOM `)NIGIS dOMt7 HAV3 313dDNOJ SOMVO9dV15 SMOOId 6 S11CM b N3HJ11X N8340W - S3JVld 3MId -P WOOM GV3H 1.W 8 ON - V3MV J111V NI4 % 1/1 '/i V3MV .i.W.9 -NIA llnd V3MV 1N3W3SV8 £ _ E L 9 NIJNn 11VIA AMO M31SVld SM31d d.MdMVH 3NO1S NO XJIM9 3NId X.19 313MJNOJ 313MJNOJ HSINId VOIV31NI 9 NOI1VONnoi Z N0u:)nUlSN0:) S1N3WIdVdV S3JIdd0 �rAIIWVd '111nw S3140!S AIIWVd 316NIS Z l ADN 1/d n 000 I Gb0D38 OWaiins PERMIT NC. 305v APPLI ATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. ' PAGE 1 MAP 4qO. LOT NO. 12 RECORD OF OWNERSHIP iDATE BOOK 'PAGE 104E U DIV. LOT NO. LOCATION '7� —i% c, PURPOSE OF BUILDING OWNER'S NAE NO. OF STORIES % SIZE v V OWNER'S ADDRESS11 / � BASEMENT OR SLAB ARCHITECT'S NAME ��A, SIZE OF FLOOR TIMBERS IST Z��v 2ND 2 �% 3RD BUILDER'S NAME 7—A., /�7 ifi �. L SPAN `Z DISTANCE TO NEAREST BUILDING / DIMENSIONS OF SILLS --- DISTANCE FROM STREET ✓.o "' POSTS DISTANCE FROM LOT LINES — SIDES % REAR So / "" GIRDERS // I/la // /� AREA OF LOT 13/77/ r Z FRONTAGE /Z� ' HEIGHT OF FOUNDATION G / THICKNESS /0 e d IS BUILDING NEW ; z -s Y SIZE OF FOOTING ON X z z // IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING LID FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE c3 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY N IS BUILDING CONNECTED TO TOWN SEWER • t�l1 S IS BUILDING CONNECTED TO NATURAL GAS 6N''E LL3 INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST OO SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY -/ Q c r EST. BLDG. COST' PAGE 1 FILL OUT SECTIONS 1 - 3 REGULATED By PARA:114. 8-S• B.C• EBT. BLDG. COST PER SQ. FT. S O PAGE 2 FILL OUT SECTIONS 1 - 12 , •QI • EST. BLDG. COST PER ROOM /O voQ DATE. /._/ FEE PAID. j+Ji/ SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR a DATE FILED SIGNATURE OF OWNER rl F E E &rise PERMIT GRANTlD IZED AGENT r J Lt k- 31 19 ! I PENWIT FOR FRAMUBUILDING DATE:� FEE PAID:. OWNER TEL. CONTR. TEL, CONTR. LIC. 60 --ST 77 ?9 a t% V* S C9 DUE FRAME I 1R 5'$S v BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR 0 04 NV"id lO�y� 1 'a S�OdV.�!1 O'ght ;313 'S39VU -V9 'S3H380d H11M 'S9N1411 IS -40 SN S 3W1a 1�VX3 aNY S3N1"1 101 WO>1d 30NV1S1a aNV 10'1 df SJ�I�OS1�3II�lb`1�TJ011z3S SIHl °JNIPd3H ON P'E I +sL P"L 1.W.9 J180313. 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"0 SWOON 10 'ON L SVJ S831V3H 11Nn `o.1.H 1NVIOV8 JNINOIIIONOJ aIV Sa313V8 DOOM SOdVA 80 N.1.M lOH S10J 18 'swa 1331S " WV31S Nand NIV lOH O3JNOd 3JVNan3 SS313dId _ _ 'S10J '8 'SW9 839w11 1sior OOOM 0NIIV3H L L I ONIWVNd 9 OOVO 3111 boold 3111 S38n1XId N83OOW 0NI3008 1108 b3MOHS 11V1S 13AV8O V "I ON19Wnld ON 31V1S ANIS N3HJ11A S30NIHS DOOM A8O1VAV1 S310NIHS 11VHdSV 13SolJ 831VM 03HS lVld ('X13 LI W8 131101 OaVSNVW 13HMO ')(13 V H1V9 dIH 319vo Mownld OL 31NON 131VnC)3OV 800d 80183dnS JOOa 5 ONINIM 3WV83 NO 3NO1S ASNOSVW NO 3NO1S )119 83ONIJ NO 'JNOJ _I ao013 g 'sals July 3WV83 NO )IJIa9 ANNOSVW NO )IJIa9 —� — E L L _ 9 3111 'HdSV NOINWOJ 3WV8d NO OMms ABNOSVW NO O:):)mJJn1S ONIOIS '183A ONIOIS SOIS39SV JNI41S 1lVHdSV O.h\GdVH H18V3 S319NIHS BOOM 3138JNOJ `JNIOIS dOaO SO8V09dVlJ SN001d 6 II S11VM v N3HJ1D1 N83OOW W008 OV3H S3JVld 3813 1. W.9 ON V38V JIIIV 'NH % 1/1 '/i V36V .1.W.9 'N13 lln3 V3mv 1N3W3SV9 E — _ — N13Nn ,ti 11VM naa a31SV1d S83Id O.MOaVH 3NO1S NO AJ189 3NId '119 3138JNOJ 3138JNOJ NOILVONnoi Z HSINId NOIN31NI 8 N0u:)nLI1SN0:) \ L S1N3W1aVdV s3Jlddo �1Iwy3 '111nw 53180 5l �kIIWVA 310NIS zL ADNvdn000 L (31033b DWaiins PERMIT'340' ''3 ,* aJg APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, 'MASS. PAGE 1 MAP 440. LOT NO. S 2 RECORD OF OWNERSHIP DATE BOOK PAGE ZONE SUB DIV. LOT NO. ST. DG. COST Q.� � 3 rI C R PARA:114• •� 8A LOCATION 9� ,� ��' 01 14 1 L3 D PURPOSE OF BUILDING OWNER'S NAME &-,/ �G'{�j�p�G� 1 Ae LJ"_D NO. OF STORIES ';1 1 Z SIZE _'f 4S�r Vop y Via /� 7 OWNER'S ADDRESS l]� /��CvG!`�/J �(�LC BASEMENT RSLABO- ARCHITECT'S NAME %-gyp/) I z� '-7-�6,, SIZE OF FLOOR TIMBERS IST 2ND 2 ell) 3RD Z�%!! BUILDER'S NAME hr 1 1-,,9 r` SPAN' DISTANCE TO NEARES/T BUU/ILDIN/GG _/l d/ if DIMENSIONS OF SILLS DISTANCE FROM STREET ".jO •- POSTS DISTANCE FROM LOT LINES SIDES REAR3Q / " GIRDERS / VV/ AREA OF LOT `� J.'7� Fr 2 FRONTAGE i d /1 •`J HEIGHT OF FOUNDATION THICKNESS �Q IS BUILDING NEW /!, �. SIZE OF FOOTING X z Z IS BUILDING ADDITIONd"' �1 O ,Vjl MATERIAL OF CHIMN l - IS BUILDING ALTERATION /'`/U IS BUILDING O OLID.XDA FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTSOF CODE IS BUILDING CONNECTE TO TOWN WATER f_3 [' BOARD OF APPEALS ACTION. IF ANYI E A/1151 UILDING CONNECTS A TO TOWN SEWER Ml�fPbM _ ' IS B DING CONNECTED kO NATURAL GAS LINE L� r T{ INSTRUCTIONS 3 PROP RTY INFORMATION P RMIT F FOUNDATI ONLY LAND COS ot� ST. DG. COST Q.� � 3 SEE BOTH SIDES STRUCTI1 RL ULATED C R PARA:114• •� 8A E BLDG. COST PER SQ. FT. PAGE I FILL OUT SECTIONS I - . �0 r PAGE 2 FILL OUT SECTIONS 1 - 12 C �' 1 ' 'tri% -- EE PAID: EST. BLDG. COST PER ROOM ��o/VSO SEPTIC PERMIT NO. N ELECTRIC METEPS MUST BE ON OUTSI E OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO TATE FIRE REG LATIONS PLANS MUST BE FILED AND APPROVED BY UILDING INSP CTOR - 12-,f/ DATE FILED BOARD OF HEALTH SIGNATURE P OWNER OR AUTHORIZED AG rF a "ES S NER TEL 0. _ = = CONTR. TEL.� Q� PLANNING BOARD PERMIT,GR,!NJED CONTR,LIC.� o 0302 lam" 1 19 ;--= 3I V FOR AAME/BUILDING BOARD OF SELECTMEN PAID• ML'" --FEE C o I LO FDA FES..,.. pp - BUILDING INSPECTOR ._. SIF cRpM:r FFR 0 c 585• �r�S -°D NV1d 1O1d S3OV1d3U SIHl 'a3S0dW12l3d(1S '013 'S3E)vu -VE) 'S3HOE10d H11M 'SON1011f18 d0 SN0ISN3WIa 10VX3 aNV S3NI1 101 WO21d 3DNV1SIa aNV 101 d0 SNOISNfasl/�Sf1W NO1103'S SIHl Z l IL 1 SHOOId 6 N3H711'A N8300VI- S3JVld 38H V3dV•DId1V "''NIA- -• V38V ,1.W.9 'N13 77 NIANn 11VM A80 X, I ZwIA S08V09dV1:) S71VM v wood 0V3H 1. W 9 ON llnd V38V 1N3W3SV9 £ 3198:)N07 HSINIA 80193INI8 N011V0N00d Z NOi.Lon I1SN0D SIN3WI8VdV wvd Innw ADN V d f10OO 1 q VNIIV3H ON Pic DI80313 _I PSL 1.VY. 9 w 6V0 SWOON dO S831V3H" IMI °J.1:H 1NVI0Vd 1 :� 0NIN,O1110N05 8IV S831dV8 OOOM dOdVA 80 8.1..M.l0H S10D 8 'SW9 1331S "MRS _ 'S10J 8 'SW9 839WI1 MM 81V IOH 03J8od _ 3DVN8n3 SS313d1d 1Sl0f OOOM '�NI1V3H , l l I ONIWVVJ 9 OOVO 3111 .. • +, - - `•BO0ld 3]11'• S38n XI1 N$300w 0NId008 1108 83MO S 11V1S 13AV80 F 8V1 0NI9Wnld ON 31V1S > ANIS N3H:11A S30NIHS DOOM QOiVAV1 S310NIHS 11VHdSV 13S01J 831VM 03HS 1V1d I Xid LI 'W8 131101 08VSNVW 1389WVJ ' 'Xld E) H1V9 dIH 319V0 f)N19Wf11d Ol 1008 5 r 3N0N131Vno30V 8001 80183dns + k 3WV8d NO 3N0IS b• +j „ DNIMIM kSN0SVW NO 3N01S 'A19 830NID 80 ':)NO:) v 3WV83 No ADI89 • (•1•[I —I 80013 8 S81S 5I11V ABN0SVW NO ADI89 • �1• • +" : {4 3WV84 NO o:)Dn1S _ ABN0SVW NO 0DDn1S r ( 3111 'HdSV0N101S '183A NOVIWOD F ONI01S S0IS39SV (TPo\08VH ONIOIS 11VHdSV NV1d 1O1d S3OV1d3U SIHl 'a3S0dW12l3d(1S '013 'S3E)vu -VE) 'S3HOE10d H11M 'SON1011f18 d0 SN0ISN3WIa 10VX3 aNV S3NI1 101 WO21d 3DNV1SIa aNV 101 d0 SNOISNfasl/�Sf1W NO1103'S SIHl Z l IL 1 SHOOId 6 N3H711'A N8300VI- S3JVld 38H V3dV•DId1V "''NIA- -• V38V ,1.W.9 'N13 77 NIANn 11VM A80 X, I ZwIA S08V09dV1:) S71VM v wood 0V3H 1. W 9 ON llnd V38V 1N3W3SV9 £ 3198:)N07 HSINIA 80193INI8 N011V0N00d Z NOi.Lon I1SN0D SIN3WI8VdV wvd Innw ADN V d f10OO 1 cn m ,n o 7 i lz 0 �. 0 0 p" d li to Z Z Z t.: 0 �. LU U. CID RE Lu 6o ¢ U iL iii CCC co U- cc U. m' ai m ,n o rl 2 cc w W LU w y w 0 e C:) ) .X .Q J Ci 0 O O a E CL i 4 a. -p c W � L � w O WW > o ar a W E c a O O c 04 V Z = •c - .� ,i Z Z Z m Lai au �' O c m 4A W u u a z c p z z v C a cc Q o O o CID Z N < L6 O -' T u o CID m L C L J L U G. .0 L m Y E Ql W 0) 0 C O O L C O S O m O S N ¢ U ii Cc ii ¢ t4 u ¢ U. mp 2 cc w W LU w y w 0 e C:) ) .X .Q J Ci .m a E CL i 4 a. -p c O � L � w O 4 v > o ar a E c a O O c 04 V Z = •c - .� c � o m V 0 �' c m a 04 .= c s C a O o Z FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAPCJL2 * % I�A'el SUBDIVISION LOT(S) 1-G PERMANENT ADDRESS (ASSIGNED BY D.P.W.) -# 7Y6 -- '? 0214i STREET <' / i C APPLICANT a,�C�i %�S 1 svC. PHONE 6c:Y/- f/ fT j 6Y�-33-7J DATE OF APPLICATION TOWN USE BELOW THIS LINE CONS&RVATION COMMISSION 1 \ - 10L'u AJC CONSERVATION BOARD OF HEALTH HEALTii` SANITARIAN —70 DEPARTMENT OF PUB IC RKS o j< r 6a4T� DRIVEWAY PERMIT �"/ )M,4 l ,( SEWER/WATER CONNECTIONS E APPROVED E REJECTED DATE APPROVED DATE REJECTED DATE APPROVED�OZ20L DATE REJECTED FIRE DEPT. LN &I ✓t e� � o ce 6e� ec7D(' Q J. v2, 4. 066, 6 c 1 Fi e "l0 l T Tfr1(e, bJ k ISt-1se eckeli 0 Q F"N 12�d jqj RECEIVED BY BUILDING INSPECTION E DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission 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 NO. 5-2_ 055-5 Page 1 �^ DEPARTMENT OF PUBLIC WORKS PERMIT- NORTH ANDOVER Subject to all of the te=, conditions and restrictions printed or written below, and on the reverse bide hereof, permission is hereby granted to Mr. Regis Pelletier, 42 Golden Oaks Drive, Salem, NH 03079, to enter upon the State Highway Layout in the Town of North Andover, locally known as Chickering Road or Route 125 for the purpose of constructing drives to property on the west side of the highway as shown on a plan titled Regis Pelletier dated May 28, 1991 prepared by Scott L. Giles. No equipment, trucks, etc. shall occupy any part of the travelled way except between the hours of 8:00 A.M. and 4:30 P.M. from Monday through Friday. Weekend work is not permitted under the terms of this permit. Also, no work shall be allowed on the day before or the day after a long weekend which involves a holiday without the permission of the District Highway Engineer. It shall be the responsibility of the Grantee to contact the District Highway Engineer regarding the field location of any underground traffic control' devices on this project. Said drives shall be surfaced with Bituminous Concrete Type I and shall be laid in two courses to a depth of three,inches, after rolling, with a foundation of at least six inches.of compacted gravel. The finished surface shall butt into and not overlap the existing highway grade at the road edge. The drives shall be so graded that no water shall enter the layout nor pond or collect thereon, including the roadway surface. All disturbed areas, such as sidewalks, curbing, shoulder, grass plots., shall be restored to their original conditions. The curb corners or radii may be painted at the time of installation. Said curb shall be painted yellow only. The curb shall be placed in conjunction with or immediately following the completion of the driveway surfacing. The part of the drives located within the limits of the state highway shall be maintained by the Grantee, at his own expense and to the satisfaction of the Engineer. These drives shall not be connected at any time to form a circular drive. All work shall be done at the direction of and to the satisfaction of the District Engineer and at the Grantee's expense. No trees shall be cut or removed under this permit. THE GRANTEE SHALL ALSO ADHERE TO ALL STIPULATIONS AS STATED ON THE INSERT TO ACCOMPANY PERMIT ir'.5-20555. Continued...... i �~� tL ij Y v1 iTiIU11.0 i1 W t'u l i!j U t Y� ASBA1IjU.$ F 1; I9 Page 2 , DEPARTMENT OF PUBLIC WORKS P - NORTH'ANDOVER Subject to all of the tenni, condidons and restrictions printed or written below, and gn the reverse si& hereof, pertnisslon L hereby granted to All Utility Companies whose services are located. within or adjacent to the proposed installation areas shall be notified in writing of the proposed installation at least 48 hours prior to the start of any excavation in said areas. This is independent of required dig safe notification. No tracked vehicles shall be allowed on the highway Surface without a protective mat. If it becomes necessary to blast then the Grantee shall apply for an additional permit to cover this project along with written approval from the designated Police and Fire Chiefs. It shall be the responsibility of the Grantee to..supply this office with an as -built plan showing the location of the drives with any other appurtenances. Said plan shall be signed and stamped by a Registered Professional Engineer The Department shall not accept this job as being complete until this plan is received. Said plan shall also not any change in' elevations which might have been undertaken during the construction of these -drive's. The Grantee shall install all pavement markings as,shown on the plan and in conformance with the Manual on Uniform Traffic Control Devices and the Massachusetts Department of Public Works Specifications. Any.:eradiction of existing pavement markings shall also conform to the abov standards. - This permit does not allow for the installation of any utilities. DIG SAFE #: 91224035 (SEE OTHER SIDE FOR ADDITIONAL CONDITIONS) No work shall be done under this Permit until the Grantee shall have communi- euted with and meived instructions from the. District Rgbway Enginmr of the Depart• event of Public Worm, at P.O. Box 38/Hathorne, MA 01937 This permit shall be void unless the work herein contemplated shall have been Comp l e ted Wo" June 4, 1992. Dettd at Hathorne this Fifth day of June, 1991. HUD -602 Dcpzrtment of Public Works, By David J. Wilson District Highway Engineer i INSERT TO ACCOMPAN`j PERMIT # 5�_55 for the hiring of PO as during the as deemed one within The Grantee shall be responsible the State Highway Layout or entire time that work is being d the District Highway Engineer. necessary by and save harm less the Commonwealth and its Department fy ry name and The Grantee shall indemagainst ll suits, claims of liability acts OftheGrantee andre in of Public Works against consequences of the 1 with arising at any time out of or in conby this permit and/or failure employment of permit whether by itself or its the performance °ditionsoof thisrpd by rocurement of the necessary Town . the terms and conditions permit is subject to the p subcontractors. Grant. ector on this project Department shall place an Insp the Dep the Grantee. If it becinspectorsnecessary be paid for under a reimbursable by and said this project. way traffic shall be maintained at all times during necessary for the Two Y it becomes the District At any time during the operation of this project Y to notify t _two (72) hours in advance of this detour. Grantee to detour traffic it shall be his responsibility t Gra seven y Highway Engineer in writing plan showing the l the District Highway Engineer with a ro riate signing and the number The Grantee shall supply with the aPP P to this detour. The Grantee shall also state intended route of this detour along of Police Officers to be assigned detour will be in existence and he shall have concurrence the length of time said Chief this detour. from the area Police Chief regarding. t o review and concurrence by the District Traffic All said detours are subject Engineer.. both this office onsibility of the Grantee to notify his location of starting work on this project. It shall be the re�P4_3190, ext• 15, and the Area Maintenance Foreman telephone number-• forth -eight (48). hours in advance is listed below), completed this project. both parties when he has man for this area is: Mr. . John Ord .The Grantee shall also notify The Maintenance Fore - workers and the Telephone Number: for the protection of the Grantee shall place signs and cones roved Safety Manual on Uniform Traffic USDOT - Themot Gra in accordance with the App motoring public, Work Zone Traffic Control Standards and Guidelines Control Devices, and the FHWA, April, 1980 Edition. I. this work, the Grantee ice condition exists not less than 200 feet during the progress of beyond the When a snow or well sanded to a point shall keep the highway limits of the barriers and signs' removed or disturbed. If it becomes necessary to Grantee shall hire a registered The bound marked MHB shall not be rem be the responsibility highway bounds then thWork. It shall and a plan remove and reset anyperform this to office a statement in writing performed. professional land svey°submit to this that said work has been of this land surveyorand signature showing • containing his stamp W.. o4echitectmee Plej 9)1c. ARCHITECTS • PLANNERS 531 South Street Tewksbury, Mass. 01876 1 September 9, 1991 Building Inspector Town of No. Andover Town Hall No. Andover, Mass. 01841 RE: Duplex 196-798 Chickering Road Dear Bob, On August 29, 1991, I inspected the footings. On September 2, 1991, I inspected the foundation. The footings and foundation meet the Mass. State Building Code. Sincere y Yours, r� Charles A. Tanzi, Jr. SEP 1 I im -- /23.39' L o—r— 8 i3,t71 sr- � o° o Exi s riciG � Q Q � � r 4 D,A i �p lJ SEP _ 4 1991' BUiLMIG' DEP ARTF-A'E 9T lip, 1 .6i6.PEB>' CeXT/FY TO T*E TiTGE /.t/SU•eO.C,4,�/ // RL o T RL /Y AI TD T//E s?AN,t' T.S/gT T,VE O�+►'ELG/•tK' /s COC'ATEO O.c/ T/i�E GOT,lS S.fdi!►'N AND TiGGIT /T ORES CO.{/FAPA/ AIV iY/T/I T.S/E l�y�✓ OFn/O+A�v.Do✓d,� 20N/,vG .lE6vLAT,1�.vS ' / ,�6vI.e0/.1Ks SET�.4C.t'S F�o�1 STPEETS f GOT G/�✓6S. " /V o. Av",)o S Fli,�T.yE.r GE.eT/FY T//•IT Inv/ -f OArEGL/.V6 rs NOT . LOG4TEo /,{/ Tif! 4G a0lo lwz- eo ., Soo9B OOOSB Tya.�q 5 L,9i0A.v/ }� � ,�; +� � ✓�.�� /S 1983 T/1/.S Boy vvowsiivfo.P.fs- ,�rro-v T.oe�E.y F,roy� Exrsrivc ,«co,�os. 6G �'4.P� .ST.rEET ANOOYE.� /f1ASS.4C,fU/SETTS O/8/O oY )oe-? 64;7 TO BE SUBMITTED UPON COMPLETION OF CONSTRUCTION TO TOWN OF North Andover BUILDING bEPARTMENT THE COMMONWEALTH OF WkSSACHUSETTS r. f_ SS On this 2 day of. I /n eC-erAb�eK A.D.'= before me, a Notary Public, duly appearedCi( vt21 J( who, being duly sworn. de- poses and says that he had supervised the preparation of all the de- sign plans Of .Duplex at 796 & 798 Chickering Rd., North Andover,MA. 01845 Mass. as submitted to and on file in the No.Andover Build- ing Department. The structure was built under his supervision in accordance with the approved plans and progress reports were periodi- cally submitted to the No.Andover Building Department during construc- tion. The structure was built in accordance with the Mass. State Build- ing Code, and all the materials used in the construction were selected and approved by him in accordance with the Controlled Materials Pro- cedure therein defined. SUBSCRIBED AND SWORN TO BEFORE ME THIS -DAY OF A. D. (Notary Public) My Commission Expires ze Iq Le v r T rn m u a C a 0 •w S A 0 _ O �1 "A A 77 C H CLI y A � 3 m y; T m n b co Q' H oar A yy n � y CL gyp; w n► C a o _ ON t Mg th CD S, I> or► to 3 1 > > m o 1 o. o' �o o x m m w < m rn A ? r3 °' C W ^rn 1 nom, Z y el O \ O. OX r'1 = fA v 1 0 c c� Fc- is m a r 5e R ro n 0 ti (D n rt N• (D H n s to to n � e A �s g 1 VJ y w Lo 0 V O z � � x d v E � 00 HO0 C C7 f' (D 2 7C `C ri r H H Quo H '7, H z c� O all pq c E all pq c E z C g � =50 LIM C,j cn C r - O m m v ®u I m m z T� V m 10 3 3 �kA T W m o -1 o _a °c :p 1 • = Q °—' m � ? c_. !1 \co w '��-� �c W C 0 y o > y > rm n o Fin 0 c c� L..cC.AT�.O 1 U 120.00 -- t KI C— �— t 3, rrI S.F. i t�m• 1 ¢g -gr I h N Fva. '00 N p fo , 4, 3 C � z c ,e , `r ptzE s�vc-r s -r. G�2TIs=/ -r%4A- o F'(='S�'T'� vHow►J Ai�.� lc'oi�. THS, Of THE o�P'S�-t'S mac.! tT �-i `T' Et E. Za1.lt ��c't'� E.2. t`�'1 i w:t �T t c� 1J o �" L6 � t try G• � ® � , E5y L-"\oI . 132 .a" N Ir(e. �c141�i1 r�U t L --T- ` • � 5� Z31.4f . rn z CY) M t �, � N° 822 `> APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. 19 9,1 Application by the undersigned is hereby made to connect with the town sewer main in � p Street, subject to the rules and regulations of the Division of Public Worrks.�,, The premises are known as No. 7 9 _:z Street or subdivi n lot no. l 4 'C. OwnerZI � � Address Contractor Address i App icant's ignature PERMIT TO CONNECT WITH SEWER MAIN, The Division of Public Works hereby grants permission to to make a connection with the sewer main at Street subject to the rules and regulations of the Division of Public Works. Inspected by Date sion of lic Works By See back for rules and regulations I., RULES AND REGULATIONS FOR GOVERNING THE INSTALLATION OF SEWER SERVICES 1. No unauthorized person shall uncover, make any connections with or opening into, use, alter, or disturb any public sewer or appurtenance_thereof without first obtaining,a written permit from the Division of Public Works. 2. All costs and expense incident to the installation and connections of the building sewer shall be borne by the owner. The owner shall indemnify the (town) from any loss or damage that may directly or indirectly be occasioned by.the installation of the building sewer. 3. A separate and independent building sewer shall be provided for every building; except where one building stands at the rear of another on an interior lot and no private sewer is available or can be constructed to the rear building through an adjoining alley, court, yard, or driveway, the building sewer from the front building may be extended to the rear building and the whole considered as one building sewer. 4. Old building sewers may be used in connection with new buildings only when they are found, on examination and test by the (Superintendent), to meet all.requirements of this ordinance. 5. The size, slope, alignment, materials of construction of a building sewer, and the methods to be used in excavating, placing of the pipe, jointing, testing, and backfilling the trench, shall all conform to the following requirements. The sewer shall be 6" diameter SDR 35, PVC pipe. Minimum'slope shall be 1/8" per foot. The minimum depth of sewer shall be four feet below finish grade. Sewer pipe shall be installed on a stable trench bottom of hard durable crushed stone to a minimum (6) inch depth below the pipe. After the pipe has been installed, crushed stone shall be brought up to the crown of the pipe. Care shall be taken to carefully grade and compact the stone, and prevent pipe displacement. The remainder of the trench shall then be backfilled in one foot lifts with mechanical tamping after each lift. 6. Whenever possible, the building sewer shall be brought to the building at an elevation below the basement floor. In all buildings in which any building drain is too low to permit gravity flow to the public sewer, sanitary sewage carried by such building drain shall be lifted by an approved means and discharged to the building sewer. 7. No person shall make connection of roof downspouts, exterior foundation drains, or other sources of surface runoff or ground water to a building drain which in turn is connected directly or indirectly to a public sanitary sewer. 8. The applicant for the building sewer permit shall notify the (Superintendent) when the building sewer is ready for inspection and connection to the public -sewer. The connection shall be made under the supervision of the (Superinten- dent) or his representative. 9. All excavations for building sewer installation shall be adequately guarded with barricades and lights so as to protect the public from hazard. Streets, sidewalks, parkways, and other public property disturbed in the course of the work shall be restored in a manner satisfactory to the (town). r . , , I 1 ) o No 209 � APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. 4 199 / Application by the undersigned is hereby made to connect with the town water main in;, subject to the rules and regulations of the Division of Public o�ks. i '/)0) The premises are known as No. / / or subdivis' n lot no. Own e ti 4L Contractor PERMIT TO The Board of Public Works hereby grants per. to make a connection with the water main at subject to the rules and regulations of the Dig Inspected by Date � OW 166A o (J Address I Address AppIic 's Signature See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION Of WATER SERVICES 1. No person shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 41/2 foot rod and brass plug type cover. Location < C C. No. Date a Check # � V71-1 29144 TOWN OF NORTH ANDOVER 4r' Certificate of Occupancy $ Building/Frame Permit Fee $: Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Building Inspector = v z G) n O Z m cn O VI 0 i m X -v /55 Z < 00-0 =rO --I ��� 23 _i -DI O, CD O cn n O = rt - a � 70 Z 0 =rN � O• O t/� „- -- O TI O O •-• C m = W h =R� 9) rt � CD N CD"0 • CDCL 2 .� SCD 0 to Q. o to `n, O O rt W "'r lD CD Q- 0 < 0' O < c0CD ' v, oCD o, a .=r CD y Q U) 0 S O C C LI Q. fl1 (O _ U) Q < y O N CD O O CD CA W CD CD �Ch 0 i i'9. GAN, cl D� O G O CD I O CD C CD N D CD C � rt n O rt_ O O O O CL N p(D (p rD N - Z O W 3 T N �pT C 3 w N ;7 C S T N A C CQ =r T p=j n S 7 7p C S T C Q O VI -6 0 T O \ n �o m 'n m -Zi G1 H H O r m n r m C W m O W C 2 Z n 3 3 N 3 O O D rA rA v 7 REMCMULIMG SPEC=IALISTS 978-6►9'1-520'1 �, KeenConstructionCo.com Rollins, Jeffery & Stacey 796 Chickering Rd. N. Andover, MA 01845 Contract #5540; Appendix A. July 28, 2015 Remodel existing deck: • Remove and dispose of existing deck surface, railings and roof structure from existing 10' x 10' deck • Supply & install three 4" x 4" posts, standard pressure treated 2" x 2" baluster rail system and TimberTech Reliaboard Grey 5/4" x 6" decking • install customer supplied SunSetter awning Total Price: $3,810 (three thousand eight hundred ten dollars If an electric awning model is chosen, electrical work will be an additional cost. Prices do not include cost of permits, or repairs to any unsafe, unusual or non -code compliant existing conditions not addressed in this quote. Payment Schedule: $1000.00 due upon signing contract (paid) $1000.00 due the first day of work (plus permit fee) $1000.00 due when deck is done $810.00 due at completion of contracted work Customer /z/ Date 1175 Turnpike St. N. Andover, IIIA 01845 GSL #076691 Robert A. Keen yg r� Date Page 1 of 1 Sales@KeenGonstructio<o.com P: 978-691-5201 F: 978-682-3231 File #106383 55 t KEEN CONSTRUCTION CO. PROPOSAL a 1175 TURNPIKE STREET NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978) 691-5201 engaged in home improvement contracting, unless Fax: (978) 682-3231 specifically exempt from registration by Provisions of (^ �� ' Chapter 142A of the general laws, must be registered Submitted e }j c, C -e �� 0 ( '5 with the Commonwealth of Massachusetts. Inquiries To: / about registration and status should be made to the �G- Director, Home Improvement Contract Registration, 10 Park Plaza, Room 5170, Boston, MA 02116 617-973- + 8787 Owners who secure their own construction �p/� V e , V , Q 15 related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE DATE REGISTRATION NO. EIN NO. �7 �2 t, lGj MA. H.I.C. 108383 46 —3783401 > C/S = Customer Supplied S + I = Supply + Install 1k See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: X > Construction related permits: --.—_._._._.. — —_,..._...._.........__..................._...... _........__...,._.............,................ .... ........................................ ........................._...................:................... .................................... _......... . WORK SCHEDULE _..- ...................... ...... _.......... Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractors control, the work will be completed by (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We rOpOSe here bty,to furnish material and labor - complete in\ accordance with above specifications, for the sum of dollars($ Payment to be made as follows: ,tI I - _ % ($ ) upon S' in ontract ROBERT A. KEEN Name of Contractor / Designated Registrant ($ upon completion of 1175 TURNPIKE ST. Street Address � - ) upon completion of. N. ANDOVER, MA 01845 ~ City / State % ($ ) shall be made forthwith upon (978) 691-5201 (978) 682-3231 completion of work under this contract. Phon Fax I Notice: No agreement for home improvement contracting work shall require a U 6-aI � > down payment (advance deposit) of more than one-third of the total contract price Name of Salesm or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and Aulhod ed Signature equipment, whichever amount is greater. Note: This proposal may be withdrawn by us it not accepted within days. Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this tran action. Cancellation must be done in writing. DO NOT IGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. -i t Signature v� Date �'/ l Signature Dale IMPORTANT INFORMATION ON BACK OF NO R TF/ qN m 2j r WIC LSSA C H U s�� CONSERVATION DEPARTMENT Community Development Division July 28, 2015 Ms. Stacey Burritt 796 Chickering Road North Andover, MA 01845 RE: VIOLATION of the Massachusetts Wetland Protection Act (M.G.L. C.131 § 40) and the North Andover Wetland Protection Bylaw (C. 178 of the Code of North Andover) at 796 Chickering Road Dear Ms. Burritt, During a site inspection to review the wetland resource area related to the building permit submitted for deck reconstruction at the above referenced property, I observed unauthorized dumping of brush, yard waste and debris within the 100' Buffer Zone to jurisdictional wetland resource area. Yard waste observed included grass clippings, tree debris, a mailbox, bricks and other items (see photos attached). According to C. 178.2 of the Bylaw, "No person shall engage in the following activities: removal, filling, dredging, discharging into, building upon, or otherwise altering or degrading the wetland resource areas..." including any 100 -foot buffer zone. As such, The North Andover Conservation Department is hereby issuing this Violation Notice requiring that you cease the aforementioned activities within the jurisdictional resource area, remove all stockpiled materials by August 15, 2015 and relocate them to an area outside the 100 -foot buffer zone or properly dispose of them off site in an appropriate location (transfer station, Cyr Recycling Center, etc). All yard waste and debris should be temoved by hand (no machinery). Please inform this department when clean up is complete. The deck work is located within 100 feet of the wetland resource area but the revised building permit application received 7/30/15 shows the proposed work is limited to replacement of the decking, railings and posts and will utilize the existing footings with no ground disturbance proposed so that a permit should not be required. The NACC has the authority to undertake additional enforcement action including the levying of fines. The NACC does not feel such action is necessary at this time and looks forward to your immediate cooperation in this matter. Please do not hesitate to contact me should you have any further questions or concerns in this regard. Sincerely, ORTH AND VER CONSERVATION DEPARTMENT e ifer Hugh servation dministrator 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web www.townofnorthandover.com The Commonwealth of Massachusetts - - Department of IndustdglAccrdents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensationlnsurance Affidavit: Builders/Contractors/ElectriciansIPlumbers Applicant Information Please Print LeA. Name (Business/Organization/Individual): -0- V) t LAA 5+ ru c, Address: (� % L) City/State/Zip: t ,),XF Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. [ (1 am a employer with �_ 4• El am a general contractor and 1 6. EJ Now 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. 7. U Remodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. S. ❑ Demolition g. ❑ Building addition [No workers' comp. insurance 5. ]] We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3. ❑ l am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] �. ] � employees. [No workers' 13.E] other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t'Homeowners who submit this affidavit indicating they k're doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that cheek 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 formy employees: Below is thepolicy and job site information. Insurance Company Policy # or Self -ins. Lie. #: (o U \.l T � / ),,, SZ-2-14xpb'ation Date: Job Site Address: 6irkeriog Pity/State/Zip:,40J&I�C,4/,37q5 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 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 rine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido liereby Gertz_ u the airs dpenalties ofperjury that the information provided above is tr e and correct. Simaiure: Date:/30. 5 Phnne #: J 2 D 1-&! Official use only. Do not write in this area, to he 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 RightFax C3-1 3/24/2015 9:51:03 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE IMPORTANT: If the certHicate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX GILBERT INS AGCY INC 137 MAIN STREET (A/C, No, Ext): (A/C, No) - E -MAIL READING, MA 01867 ADDRESS: 246WY INSURER(S) AFFORDING COVERAGE MAIC # INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA INSURER B: KEEN CONSTRUCTION CO INSURER C: INSURER D- 1175 TURNPIKE STREET INSURER E: NORTH ANDOVER, MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 6 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMtDD\YYYY) (MLTDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE F-1 OCCUR. DAMAGE TO RENTED REMISES (Ea occurrence) $ ED EXP (Any one person) $ ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY El PROJECT LOC RODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY (Per accident) $ HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE $ 171 (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YM UB -9991M582-14 10/08/2014 10/08/2015 X we STATUTORY i OTHER LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE a OFFICER/MEMBER EXCLUDED? WA E. L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION t TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT VE ' NORTH ANDOVER, MA 01845 + ; X44. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1986-2010 ACORD CORPORATION. Ail rights reserved. Massachusetts - Department of Public Safety Board of Building Regulations and Standards LI/IIILI 111 L11111 au!'Fel VIi111 License: CS -076691 ``` `r. r i S ROBERT A KEEN-`' 12 E WATER ST North Andover M -A 0 •I, `1 954-� ��`"'Expiration Commissioner 08/1612017 ��e �poan�no�ruaea,�/� o�C>�aa�uaelta Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR d\ ,egistration: (1,08383 Type: xpiration K-A2�8/�8/0t6�, DBA F'A'.:'. KEEN CONSTRUCTIOJ0,. Kenneth Keen X 1175 TURNPIKE ST NO. ANDOVER, MA 01845`- Undersecretary Massachusetts - Department of Pubtic Safety Board of Building Regulations and Standards Construction Super%isor License: CS -076691 ROBERT A KEEN ` 12 E WATER ST North Andover NFA 011e t J,•G+� �. " "' Expiration Commissioner 08/16/2015` y� (9/4 Cpo7r�eai o��aao�Cuae Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistration:p8383 Type: xpiration:=1fi8%20-1.1 DBA � 9 KEEN CONSTRUCTI.Okt G©Y` Kennel 1175T NO. Ar Undersecretary