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HomeMy WebLinkAboutMiscellaneous - 84 FOXHILL ROAD 4/30/2018 (2)Date... NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......................... has permission for gas installation in the buildings of ... . .......................... S) %, `V —JQ"C at .......I .............. North Andover, Mass. Fee,. Lit. No../O. .......................... GASINSPECTOR Check #t 7018 C a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:,,....•my %� ( Date:Permit# Building Locatlo_,, ..� ✓.l,%%(� m.,..� Owners Name: Z��Y(� Type of Occupancy: Commercial, Educational �, Industrial Institutlonali Residential, H ~ U z New ,w a Alteration << Renovation Replacement ; Plans Submitted:. Yes No FIXTURFR z t- O Z rn W �1ccurate to the Pest of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in omPliance with all Pertinent Provision of the Massachusetts State Piumhina Cnda and Chantar 1d9 of rhe (Zan—i i — By! Title< Cityrrown Type of License: Plumber Gas Fitter Signature 6f Lice Master Journeyman License Number: LP Installer lumber/Gas Fitter i W co W W to Y rn W QO w Q O J H ~ U z CO to W c9 W z t- O Z rn W z W w a4 O tw- m o W OO a a W H Q W O d H _J x > U w Lu Z V' J u� z Lu w o In 2 W W a W W > W Z W �- U o o 1w- a: m Q W W F- O Z J (DLL Q m w O z W > O g 0~~ O w Z w H Q W H H Q Q O a tY h- >> S O SUB BSMT. BASEMENT C 1 FLOOR N! FLOOR ' FLOOR 4 FLOOR STH FLOOR 6TR FLOOR 7 FLOOR 8 FLOOR Installing Company Name ? ( jK Check One Only Certificate # �Address ')- 1 City/Town:/ ' / > J State MA Corporation - i Partnership Business Tel:,, Q Fax � � -. I Firm/Company; _ __.. Name of Licensed Plumber/Gas Fitter:' _ —___j n$ �1ccurate to the Pest of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in omPliance with all Pertinent Provision of the Massachusetts State Piumhina Cnda and Chantar 1d9 of rhe (Zan—i i — By! Title< Cityrrown Type of License: Plumber Gas Fitter Signature 6f Lice Master Journeyman License Number: LP Installer lumber/Gas Fitter i 0 y m r 0 a 0 z O Irl ou C r 0 z 0 It = � \ � ` �� ' --—'' '' '' '' '' '' ' OF NORTH ANDOVER PERMIT FOR PLUMBING � _ This certifies that at. North Andover, Mass. Check # 21 C MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: / `1 7/f �G'� MA. Date: Permit# Y4 IL j �toBuilding Location: ?y ,%�li�� �Y/!/`e Owners Name: Zzlwotilwo Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES . SURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesK 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: 1 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 Siqnature of Owner or Owner's Aoent Owner El Agent ❑ I hereby certify that all of the details and information I have submitted for entered) regarding this application are true and accurate to the best of my Knowieage and tnat all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I II y Type of License: �9TitlePI ber Signatur of Licen Plumber CitylTown aster J 09 / 1" APPROVED (OFFICE USE ONLY( ❑Journeyman License Number:V/ � 30 Z z rn Y N J O U = UP W U) d z H Y Q ga ~ to W z Q Q Z OJ x QZQ rn Z.( Q 0 W 0 a w U) m Q w OE 0 0 N Y N W z W J Z o- U CL Q Y= fw 0 O0 H 2 Z Q a Y Q= w w W IX a a X IL i a o� °O °x ° a a a a O SUB BSMT. BASEMENT IST FLOOR 2 FLOOR 3 FLOOR 4 FLOOR FLOOR >o FLOOR 7 FLOOR 8 TH FLOOR 1ne-r-r1111&rzL Check One Only Certificate # Installing _Comp ny Name: A � Corporation Address: �f_ U # City/Towrr eState: pQ `� (� �7 p �7I� Business Tel: ! 7� 6V i�,Q7 Fax: I / O l��c �/0 ❑Partnership ❑ Firm/Company name of Licensed Plumber: r (� . SURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesK 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: 1 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 Siqnature of Owner or Owner's Aoent Owner El Agent ❑ I hereby certify that all of the details and information I have submitted for entered) regarding this application are true and accurate to the best of my Knowieage and tnat all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I II y Type of License: �9TitlePI ber Signatur of Licen Plumber CitylTown aster J 09 / 1" APPROVED (OFFICE USE ONLY( ❑Journeyman License Number:V/ � 30 In to h Lbcation t _ No. _ _Date �3 _i t Nom,.N=flfNO'RTH ANDOVER ; NA /Certificate_of_.OccuDanev----$ But ind/Frame Permit Fee $ cMuEck' Foundation�PermitFee $ s�s Othee rml"t�ee $ J Sewer Connection Fee $ Water Connection Fee $ TOTAL •.0 /���� � � Building Inspector _ 21/94 3:08 32.50 PAID _. `-' 6595 Div. Public Works i r v � PERJtIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. 1V PAGE 1 MAP 4-40. LOT NO. I 2 RECORD OF OWNERSHIP IDATE BOOK iPAGE ZONE SUB DIV. LOT NO.—I LOCATION !. J ®- G.` C` PURPOSE OF BUILDING t -z- OWNER'S OWNER'S NAME Y1� __ NO. OF STORIES SIZE OWNER'S ADDRESS :2r'I+ ri_ i nn BASEMENT OR SLAB r ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1STnAy.//© NCD3RD v BUILDER'S NAME �,�� SPAN 12 DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES —SIDES 75 65 REAR ; pV i V GIRDERS ' AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION Yrs wl&VW4 ® IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 Z PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OL ATTACHED GARAGES MUST F PLANS MUST BE FIL NO A RC DATE FILED INSTRUCTIONS JOE OF BUILDING TO E FIRE REGULATIONS BUIy� ING INSPECTOR �t 7 SIGDI'11TURE OF OWNER OR AUTHORIZED AGENT FEE .��ts OWNER TEL. # _� PERMIT GRANTED'' CONTR. TEL. #�/[ 22- LfNJ3 19 �- CONTR. LIC. #-23J s PROPERTY INFORMATION LAND COST EST. BLDG. COST EJ EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY ]BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN a1 &— o / �� BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY_ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. Rli CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE PINE d 1 2 13 CONCRETE BL'K. BRICK OR STONE HARDW D PIERS PLAST ER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/. % 1/1 _ FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 22 J 3 DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING CONCRETE EARTH HARD!✓'D COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ _ BRICK ON MASONRY BRICK ON FRAME ATTIC STIRS. 8 FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE I HIP BATH (3 FIX.) GAMBREL] MANSARD TOILET RM. 12 FIX.( FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING 11 MODERN FIXTURES _ 11 TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ rd ELECTRIC NO HEATING Rli KAREN H.P. NELSON, DIRECTOR In accordance with the provisions of MGL c 40, S 54, a. condition of Building Permit Number !LV 2 is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: (Location of .Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. TOw©.. 120 Main Street , OFFICES OF:r� APPEALS ;t '`N; NORTH ANDOVER North Andover. Massachusetts ot8a BUILDING(617)6854775 DIVISION OF'. CONSERVATION HEALTH PLANNING & COMMUNITY` DEVELOPMENT PLANNING KAREN H.P. NELSON, DIRECTOR In accordance with the provisions of MGL c 40, S 54, a. condition of Building Permit Number !LV 2 is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: (Location of .Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. T Cr c s Cl* 'P4 ep-j 2b Or N�.TN KAREN H.P. NELSON r ° Town Of D ' NORTH ANDOVER BUILDING CONSERVATION @@�C.0 DIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT January 19, 1994 Mr. Lawrence Ward 84 Fox Hill Road North Andover, MA Dear Mr. Ward: 120 Main Street, 01845 (508)682-6483 We are in possession of a Building Permit Application dated 09/27/93 filed by one Tom Sullivan for 84 Fox Hill Road. Please pick up the permit in question immediately or the Town will be compelled to take the proper legal action regarding this matter. /gb c: K. Nelson, Dir. PCD 0 Yours truly, Walter Cahill, Ass't Building Inspector �. �� C �Ci O ` � � ..�-»... 'r -� m s t'� 1 _ �� r -- O G i i i t f ci 0 i_ c 4 u w K �, Q � T F z l h N N � A �J\ ce a � v+ ti" _ �' � � 3 '+� H N O Cf) -0 m O S. CO) O Q' to C Z C. O C 0 CO) m Cl. C') z ® O y CD a c = �. _w..c O Vp .dr CDS N T ...r =r CD a w O y pCD CD CA N =r CD p = > >'O C CD O -% =wo ^► O CO) y p o C'7 . CD =r='R C', D Z 0 acmCL CD �a o DdCfj CD cD �, o CD y (� d CD • o N d d �_ O � C� -� C7 C�a CD CL Nj S. O H � CD OC � O , , CD �. /_ /n y � O CL �-j � �.II to =r CD ccD Im 2 1 =-=. CD DO o CCD o CD 0 0 p CCI �t < z n D o m a M y� CIj O N m D a. y -CD o CD r, m O I c CDCD CD CD :fbr v a� Cl) O ; (� CO) CD •-« .. m CD —1 CSD c z o. O TI o O �: y c: D CD te, omi 0 0 c tf Deo 7 a Q) w C r O y cm r y0 phi G G C d r y0 O O CL r tz z o y� x omi 0 0 c 4 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING "�Hu"c" This certifies that ............ . ............... has permission to perform ...tel .. .................. plumbing in the buildings of a ..................... at A ... ...... North Andover, Mass. Fee;�P. Lic. No. -1.�2 .. ... . .......... NG ��PLUMBI Vr CTOR Check # 5204 MASSACHUSETTS UNIFORM APPLICATION (Print or Type) Mass. Date 19 FOR PERMIT TO DO PLUMBING 1--mr-law WYA01 "NEA N IKA K 02.0 FIFA 71A WA 0 New ❑ Renovation ❑ Replacement E FIXTURES 2 Permit # ti cv - Submitted: Yes ❑ No ❑ Installing. Company Name i lOtY k£e,"i (r^47Ajef Check one: Certificate Address 7) (") pj' ❑ Corporation lr ET Ni' 7A)� Al a 01S,(/L/ ❑] �Partnership Business Telephone ��?7 Z -2177 1 2-6irm/co. Name of Licensed Plumber ' , (� F,P T ftp .5'I ,MVV)A r'0C", INSURANCE COVERAGE: I have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ ' If you have checked ve, please/indicate the type coverage by checking the appropriate box 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: _ Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installationspagormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum de and apter of the oral Laws. By 't/(s7i Title SoAre of Licensed Plum i Type of License: Master jam/ Joumeymah ❑ OFFICE USE ONL License Number Y3.3 5 • Y • • • ■�����������������t����MEN Installing. Company Name i lOtY k£e,"i (r^47Ajef Check one: Certificate Address 7) (") pj' ❑ Corporation lr ET Ni' 7A)� Al a 01S,(/L/ ❑] �Partnership Business Telephone ��?7 Z -2177 1 2-6irm/co. Name of Licensed Plumber ' , (� F,P T ftp .5'I ,MVV)A r'0C", INSURANCE COVERAGE: I have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ ' If you have checked ve, please/indicate the type coverage by checking the appropriate box 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: _ Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installationspagormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum de and apter of the oral Laws. By 't/(s7i Title SoAre of Licensed Plum i Type of License: Master jam/ Joumeymah ❑ OFFICE USE ONL License Number Y3.3 5 E N m 0 m 1 N im -1 O Z IN x Z r O m V m C A 10 m m z w C 'On O Z D c Z Zm v Z O p Z o O O V r c 3 Location 9 c9f, No.��- Date '1(6 TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 18483 Building. Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED:If 8 /r /0 qr SIGNATURE: 0—,4 Building Commissioner/I for of Buddings Date SECTION 1- SITE INFORMATION 1.1 Pr erty Address: j% n �%`��.e `m n fd F/ P�K 1.2 Assessors Map and Parcel Number: 5 mber Map NuParcel Number 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'redProvided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1. Owner of Record E Name (Print) Address for Service : ~� Signature Telephone �`'j �C ( (� 2.2 Owner o eco Name Print Address for Service: t Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ CompAy Name O �O/ k 2 9 x' �� p V • Registration Number 4 �� ` �® Address 126 Expiration D to r Telephone 'r - SECTION SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all applicabte New Construction 0 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant��,, 3 OMC Ya. 1. Building / D D [D (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) O 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ISECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this bu; lding'pennit' application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, As Owner/Authorized Agent of subject € property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/Agent Date r NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED -LAND, IS BUILDING CONNECTED TO NATURAL GAS LINE f Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrid2=MlUnibers Name (Business/orpnizatibNMviduai):. Address: -IJ ,,Y (-- Gty/State/Zip:Q)dV-rsfC-1z ME n ( D4 Are you aq employer? Check the appropriate bob .-- 1. ElI am a employer with 4.'al am a general contractor and I employee§ (full and/or part-time)." have hired the sub-contracbors 2. ❑ I am a sole proprietor or partner- listed 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. ❑ Weare a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing 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' cww. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.11 Electrical repairs or additions 11.❑ Phimbing repairs or additions 13 ru.y oy,r�w.r.. — cubo cow n a urns yw aur uta = Mccuou below mowing ftk work&", OOQ�dp policy �n t Homeowners► who subn>;t Sig at6devit they an: doing all work and Ilion Imo outside eoahacton nnut submit a =w,affdevit indi� such tCont w1 oe that check this box =W attached m additional :beet sbownlg me name of the ab• 011hacton and their wotkM, policy infestation. I an an emPlaYer that Is providing nwrkers' compensaden Iasarsenec or Information. f MY e� Blow is the poJlq► uWijob she Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: City/State/Zin: Job Site Address: 'I 140, Attach a copy'of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to segue coverage as requiref under Section 25A of MGL c. 152 can lead to the imposition of crhnloal 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 de Office of Investigations of the DIA for insurance coverage vcrification. I do hereby eert(fy pond t and penakin of pedury thmr dire In formNdoa proylkd abyve lspnue and corrrccax: 09kial use only, Do not write In thb area, to be completed by city or town offlcw City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Ckyfrowa Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: 1111Vi inaimpim amuta ZAAosA s,ars,avaaei 1 Laws chapter 152 requires all employers b provide workers' compensation for their enaploxexa. Massachusetts Genera is defined as -...every person in the service of another under auy wntract of hire, Pursuant to this statute, an employee express or implied, oral or written" An empWer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engagod in a joint enterprise, and including the legal representatives of a deceased employer, or tale receiver or trustee of an individual, parmenbip, association or other legal entity, employing employed. Howevesr the owner of a dwelling bouse having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons 10 do maintenance, construction or repair work on such dwelling bouw shall not because of such employment be deemed to be an employer." or on the grounds or building appurtenant thereto MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withholithe lasnance or wal of a license or per renemit to operate a business or to constrict buildings Im the commonwealth for any appUcant who hu not produced acceptable evidence of compliance with the insurance coverage required. " Additionally, MGL chapter 152,125C(7) states "Ncitha the commonwealth nor any of its political subdivisions shall cuter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone m mbe:r(s) along with their certificate(s) of insurance. Limited hubs* 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 employ, 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 aflidaty% The affidavit should of be returned to the city or town that the application for the permit or license is being requested, not the DeparUn ent Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a worke n' imp anon policy, please call the De�m�ent at the nunim fisted 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 me Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pamitticense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, aced 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 � been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a is on file for future permits or licenses. A new affidavit mast be filed out each year. Where a borne 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 bice to tbmk 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 member: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26.05 www.mLw.gov/dia Corporation Adifikitrgtor �Sxt' ..n��_�u �._......a..tiw__a..s'2.�. l.NuiL+•iFF1tY�.yi+'L .�..__ -,s- �"� SALUM PAINTERSINC } �'� V !W l%04YUrILO�IZC(%P�GGiL O� /VLLCOo�7.I.lOG'000 DEIVISON FONSECA F 19 EVERTON ST #B" Board of Building Regulations and Standards WORCESTER MA 0.1604 HOM E. I M P[tOV E M E NT, C O NTRACTO.R Registratjon 141425 Expra"tion t4%22/2006 Corporation Adifikitrgtor SALUM PAINTERSINC } DEIVISON FONSECA 19 EVERTON ST #B" WORCESTER MA 0.1604 Corporation Adifikitrgtor NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordant with the provision of MGL c 40 S 54, a condition of Building Permit at: d is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in.- (Location n: (Location of Facility ----Si of Permit Applicant Fire Department Sign off: Dumpster Permit Date ` t• CA m m m y m CO) B m 2 y d -• w d -Wv o CD MZ y d O Com-'!• C CL y a� o 0 m CD o, v CD o CL c� �dCD CD CD C r. CD y �. CD o, v y CD FA t w?10g mr - cGo acr G _ Mo am y cc O � 1 Cl) ZO O pC 3 n o a y �g > >•a O� O cc f.: R o mom. CTi a = a Sao t o . J= <CD ?�7 ._ c ' 0 a CL CCOD lam O �f O m y CL �C.CDm .. IE m y cn CA a D q m N co CD O ,_ z ��:Ll N ce A d s: o d d aIO c OR o i O C w O o o O bx o i O C