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TOWN OF NORTH ANDOVER
Certificate of Occupancy
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Building/Frame Permit Fee
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Foundation Permit Fee
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SIGN PERMIT APPLICATION
1600 Osgood Street — Building 20, Suite 2035
TOWN OF NORTH ANDOVER
DATE SUBMITTEDi
Site Owner �(% 1-,C\
Site Address
How attached:Qhof
ainst the waUAUS4 �&
Ground
d) er i! t� u\ AlowsC �l1 GCI `zS
Proposed Colors: Background
Lettering( 0 UV
Borderjr(_L
Required Attachments:
Photographs of buil ingv
Material
Color sample ✓✓✓✓
Site or Plot Plan (Required for all free-standing signs)
Drawings of proposed sign/
Other, specify
Will sign overhang any public road or walkway Yes () No
If Yes, Name of Agency who will provide liability insurance:
AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED
DATE FILED:
lane - �� ��/Zo ►�
Applicant L' t,l An�. i�( Tel Q oO12,
Size of Proposed Sign Y, Z
WrEBNALL'Y ILL17M HATED SIGN PROHMMD
Illumination:(a) Not illuminated
aminated
Materials:
Note: No permanenthemporary sign shall be erected, or enlarged until an
application on the appropriate form furnished by the Sign Office has been
filed with the Sign Officer containing such information including
photographs, plans and scale drawings, as he may require, and a permit
for such erection, alteration, or enlargement has been issued by him.
Such permit shall be issued only of the Sign Officer determines that the
sign complies or will comply with all applicable provisions of the By -
Law.
OF
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation I nsuranceAffidavit: BuilderslContractor s/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
v
Phone #: `
Are y an employer? Check the appropriate
box:
1. I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and! have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required:]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
empl oyem [ No workers'
comp. insurance required.]
-00l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other
"Any appl i cant that checks box #1 must also fi I I out the section below showi ng thei r workers' compensati on policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have empl oyees, they must provi de thei r workers comp. pol i cy number.
I am an employer that is providing workers' compensation insurance for my employees. Below isthe policy and job site
information. M -
Insurance Company Name:
Policy # or Self -ins. Lic. #: X OE :13C) --4 Expiration Date:(0/aa &61 a
Job Site Address: Cit /State/Zi
Y pi-1� ,
Attach a copy of theworkers' co ensation policy declaration page (showing the policy number and expiration date).
Failure to secure 'coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500;00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerlifrgnder the pajusand penalties of perjury that the information provided above is true and correct.
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 #: