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Miscellaneous - 876 FOREST STREET 4/30/2018
TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings To: David and Kimberly Timpe Fr: Gerald Brown Re: Forest Street, Map 105 Parcel 0076 DT Landscaping August 5, 2015 A written complaint letter was received by the Building office on August 2, 2015 regarding concerns about a commercial landscaping/plowing business being operated out of Map 105 Parcel 0076 on Forest Street. Gerald Brown, Building Inspector, made a site visit on August 4, 2015 and observed a landscaping business being operated on the property. Forest Street is in the R1 Residential Zoning District and according to the Zoning By Law Section 4.121, Paragraph F, "The building or premises occupied shall not be rendered or objectionable or detrimental to the residential character of the neighborhood due to the emission of odor, gas, smoke, dust, noise, disturbance, or in ay other way become objectionable or detrimental to the residential use within the neighborhood". According to the letter received several trucks enter and exit the lot seven days a week as well as landscaping debris being dumped on said lot which creates noise and emissions. Observed on August 4, 2015 were two large red trucks, one with no plates and the other with plate number MA K42 172. Based on Table 1 Summary of Use Regulations, Businesses and Other Offices and Lumber, Fuel Storage or Contractor's Yard are not allowed in the R1 Residential Zoning District. Under Administration Section 10.13 of the North Andover Zoning Bylaw Penalty for Violation, "Whoever continues to violate the provisions of this Bylaw after written notice from the Building Inspector demanding an abatement of zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Please call our office with any questions. Sincerely, Gerald Brown Inspector of Buildings Cc: Andrew Maylor Eric Khoury TOWN OF NORTH ANDOVER Office of the Building Department r10RT11 1 O tt�., ,6 ,y Community Development and Services 1600.Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings August 5, 2015 To: David and Kimberly Timpe Fr: Gerald Brown Re: Forest Street, Map 105 Parcel 0076 DT Landscaping A written complaint letter was received by the Building office on August 2, 2015 regarding concerns about a commercial landscaping/plowing business being operated out of Map 105 Parcel 0076 on Forest Street. Gerald Brown, Building Inspector, made a site visit on August 4, 2015 and observed a landscaping business being operated on the property. Forest Street is in the R1 Residential Zoning District and according to the Zoning By Law Section 4.121, Paragraph F, "The building or premises occupied shall not be rendered or objectionable or detrimental to the residential character of the neighborhood due to the emission of odor, gas, smoke, dust, noise, disturbance, or in ay other way become objectionable or detrimental to the residential use within the neighborhood". According to the letter received several trucks enter and exit the lot seven days a week as well as landscaping debris being dumped on said lot which creates noise and emissions. Observed on August 4, 2015 were two large red trucks, one with no plates and the other with plate number MA K42 172. Based on Table 1 Summary of Use Regulations, Businesses and Other Offices and Lumber, Fuel Storage or Contractor's Yard are not allowed in the R1 Residential Zoning District. Under Administration Section 10.13 of the North Andover Zoning Bylaw Penalty for Violation, "Whoever continues to violate the provisions of this Bylaw after written notice from the Building Inspector demanding an abatement of zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Please call our office with any questions. Sincerely, Gerald Brown Inspector of Buildings Cc: Andrew Maylor Eric Khoury TOWN OF NORTH ANDOVER {�10RTly Office of the Building Department O� � �s��o 06 q. Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 7D North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings May 12, 2014 To: Jane S. Watson Fr: Gerald Brown Re: Forest Street, Map 105 Parcel 0076 DT Landscaping A written letter was received by the Town Manager's office April 28, 2014 regarding concerns about a commercial landscaping/plowing business being operated out of Map 105 Parcel 0076 on Forest Street. Gerald Brown, Building Inspector, made a site visit on May 12, 2014 and observed a landscaping business being operated on the property. Forest Street is in the R1 Residential Zoning District and according to the Zoning By Law Section 4.121, Paragraph F, "The building or premises occupied shall not be rendered or objectionable or detrimental to the residential character of the neighborhood due to the emission of odor, gas, smoke, dust, noise, disturbance, or in ay other way become objectionable or detrimental to the residential use within the neighborhood". According to the letter received several trucks enter and exit the lot seven days a week as well as landscaping debris is dumped on said lot which creates noise and emissions. Based on Table 1 Summary of Use Regulations, Businesses and Other Offices and Lumber, Fuel Storage or Contractor's Yard are not allowed in the R1 Residential Zoning District. Under Administration Section 10.13 of the North Andover Zoning Bylaw Penalty for Violation, "Whoever continues to violate the provisions of this Bylaw after written notice from the Building Inspector demanding an abatement of a zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Please call our office with any questions. Sincerely, Gerald Brown Inspector of Buildings t North Andover Board of Assessors Public Access ILI Parcel ID: 210/105.D-0036-0000.0 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO N o Pictu1&ak re Available Location: 876 FOREST STREET Owner Name: ECHO GLEN FARM TRUST JANE S WATSON, TR Owner Address: 876 FOREST STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 6 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 3500 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 488,100 457,000 Building Value: 254,600 239,200 Land Value. 233,500 217,800 Market Land Value: 233,500 Zhapter Land Value: LATEST SALE Sale Price: 1 Sale Date: 08/17/1995 Arms Length Sale Code: F-NO-CONVNIENT Grantor: WYSOCKI/WATSON Cert Doc: Book: 04318 Page: 0338 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=808432 Page 1 of 1 2/6/2006 Dumpster DelleChiaie, Pamela From: Grant, Michele Sent: Tuesday, January 31, 2006 3:25 PM / To: Melnikas, Andrew; Sawyer, Susan; Dolan, William; DelleChiaie, Pamela Subject: RE: Dumpster Page 1 of 4 Lisa Sheehy called. She is the niece of Jane Watson, which is the owner of the property. She will have the dumpster removed within a week. I will await Dana Dubois's phone call. It sounds like a very small dumpster!!!!! I informed Lisa of the regulations and told her were she can download the regs. from, so as she can be better prepared for this sort of situation in the future. Thanks Andy Michele -----Original Message ----- From: Melnikas, Andrew Sent: Tuesday, January 31, 2006 1:04 PM To: Dana Dubois Cc: Dolan, William; Martineau, William; Grant, Michele Subject: RE: Dumpster I spoke with Northside Cartage and told them to remove the dumpster. He stated that they would remove it and they would also let the property owner know that this was going to occur. -----Original Message ----- From: Dana Dubois [mailto:danad123@comcast.net] Sent: Tuesday, January 31, 2006 8:59 AM To: Melnikas, Andrew Cc: Leonard_Dubois@trilliumsoftware.com Subject: Re: Dumpster Thanks so much ! I'll wait to hear back. Dana ----- Original Message ----- From: Melnikas, Andrew_ To: Dana Dubois Sent: Tuesday, January 31, 2006 6:57 AM Subject: RE: Dumpster I will check with Sue Sawyer -----Original Message ----- From: Dana Dubois [mailto:danad123@comcast.net] Sent: Monday, January 30, 2006 8:48 PM To: Melnikas, Andrew Cc: Sawyer, Susan; Dolan, William; Leonard Dubois@trilliumsoftware.com Subject: Re: Dumpster Hi Lt. Melnikas, 1/31/2006 Dumpster Thanks for your reply. Who will notify the property owner (and when) that they are in violation and that the dumpster needs to be removed? We just want to be prepared in case there is any retaliation again. Dana Dubois ----- Original Message ----- From: Melnikas,..Andrew To: Dana Dubois Sent: Monday, January 30, 2006 2:57 PM Subject: RE: Dumpster I spoke with Sue Sawyer and she stated that the only way someone could have a dumpster constantly is if it were a business. In this case you are only allowed a dumpster on a temporary basis . Since the building inspector has given the owner a cease operations order, then I would think the dumpster is not allowed Lt. Andy Melnikas -----Original Message ----- From: Dana Dubois [mailto:danad123@comcast.net] Sent: Saturday, January 28, 2006 4:51 PM To: Dolan, William Cc: Melnikas, Andrew; Sawyer, Susan Subject: Re: Dumpster Hello Chief Dolan, Lt. Melnikas and Ms. Sawyer, My husband has returned from his business trip. Can you tell me what the next steps will be re: investigating the dumpster and the truck tires on Ms. Watson's property? Thank you. Dana Dubois ----- Original Message ----- From: Dolan,. William To: Dana Dubois Cc: Melnikas,-Andrew; Sawyer,_Susan Sent: Friday, January 20, 2006 9:14 AM Subject: RE: Dumpster Will do. I am also copying this to Sue Sawyer the Director of the Board of Health. 1/31/2006 Page 2 of 4 Dumpster ` -----Original Message ----- From: Dana Dubois [mailto:danad 123@comcast. net] Sent: Thursday, January 19, 2006 8:10 AM To: Melnikas, Andrew Cc: Dolan, William; Martineau, William; Grant, Michele; Leonard _Dubois @trilliumsoftware.com Subject: Re: Dumpster Hi Lt Melnikas and Chief Dolan, Thanks for your email. We are concerned that they will move the dumpster right over to our property line to harass us. The most important aspect to us is the health issue of trash and tires being dumped on this property (not to mention that it's an un -permitted dumpster in a residential zone). Please hold off contacting Jane Watson (the owner) until Feb 1 when my husband will be back in down. As mentioned previously, we are concerned about retaliation based on the incident in November. Thank you. Dana Dubois ---- Original Message ----- From: Melnikas, ndrew o: anad123@comcast.net Vc: Dolan, illiam ; 1/31/2006 Page 3 of 4 Dumpster Martineau, William; Grant, Michele Sent: Wednesday, January 18, 2006 1:44 PM Subject: Dumpster I spoke with Northside Cartage concerning the dumpster. . I stated that it need to be farther away from the building . I also asked as to who owns the unit. He stated that Northside actually owns the dumpster and that the property owner rents it from them . Lt. Andrew Melnikas Page 4 of 4 Add Emotion Icons to your EmailsClick Here 1/31/2006 ■ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: A. 13 Agent .Z Addressee by f Printed Name) C. Date of Delivery D. Is delivery address different from item 1? ❑ Yes If YES, enter delivery address below: ❑ No 3. Se ice Type 10 Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2.- Article Number 7002 0570 0000 0894 3025 (transferrfromrom service lawn UNITED STATES POSTAL SERVICE • Sender: Please print y6u nau*,% First -Class Mail Postage & Fees Paid USPS Permit No. G-10 ansi.Zl.P+4-in�t+�is_box'--��.�•__. ,� NORTH ANDOVER BLDG DEPT 400 OSGOOD STREET NORTH ANDOVER MA 01845 �s�ii�ttil�iltlsils{�istttliisi!! a �iilsiitltifsll�s�ctls Ln ti O M Q' Postage $ co O Certified Fee Postmark O Return Receipt Fee Here O (Endorsement Required) O O Restricted Delivery Fee (Endorsement Required) O r-1 Total Postage & Fees Z N O Sent To Pl.! Street, Apt o.;----•--------- ------•-----•----•----------------------------------- O O or PO Box 1 C- City, State, ZIP+4 Certified Mail Provides: 0 A mailing receipt 0 A unique identifier for your mailpiece 0 A signature upon delivery 0 A record of delivery kept by the Postal Service for two years Important Reminders: 0 Certified Mail may ONLY be combined with First -Class Mail or Priority Mail. 0 Certified Mail is not available for any class of international mail. 0 NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. 0 For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece 'Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. 0 For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restricted Delivery". 0 If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT. Save this receipt and present it when making an inquiry. PS Form 3800, January 2001 (Reverse) 102595-02-M-0452 Gerald A. Brown inspector of Buildings Echo Glen Farm Trust Ms. Jane Watson 876 Forest Street North Andover MA 01845 Dear Ms. Watson; TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, :Massachusetts 01845 Telephone (973) 688-9545 Fax (974) 688-9542 October 19, 2005 Please be advised that upon an inspection of vacant property on Map 105.1), Parcel 0076 identified as your ownership, it appears that the operation of a trucking/contractors yard is occurring from this location. Please be aware that this type of activity is not allowed in a residential area and that the penalties for violations of this type after notification are three hundred ($300) dollars per violation and that every day that a violation continues is a separate violation. The following excerpts are from the Zoning By Law. Home Occupation (1989/32) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use of the building for living purposes. Home occupations shall include, but not limited to the following uses: personal services such as furnished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood. Penalty for Violation Whoever continues to violate the provisions of this By Law after written notice from the Building Inspector demanding an abatement of a zoning violation within a reasonable time, shall be subject to a fine of three hundred dollars ($300). Each day that such violation continues shall be considered a separate offense. (1986/15) Please contact me so that we may begin the process to remedy this issue in a timely manner. I may be reached at 978-688-9545 between the hours of 8:30 to 10:00 AM, Monday through Friday. Respectfully, Gerald A. Brown, Inspector of Buildings CC: Mark Rees, Town Manager Receipt/Received — 7002 0510 0000 0894 3025 CC: File ;30:ARID OF APPh:.1LS Pa88-9541 I CONSERVATION 688 ')530 HE U CEI688-9540 PLANNING (,88-9535 4. TOWN OF NORTH ANDOVER Building Department 400 Osgood Street North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION Dam: 10 �i?)laS NORT#f'* C t%.ID 16 0- ,/_O COCNIC IWICN rep CH TEL #: �> ;- - �- IF2 - Y?l r;L FROM: Y)AAAa . �- L'P-- V� t - ADDRESS: °I q S �COCq S`r Wil' f AoQ c 1 � ISA- eq COMPLAINT AGAINST: PV,© Electrical: Plumbing: Gas: Building Contractor: Property Owner Address Other: �1,t tPW4AAi V)0a VI W Ce -rA-,u SIC g , Signed: Revised 11.5.04 RECEIVED OCT 18 2005 BUILDING DEPS`. � �t�., . .��� � � �L ...� � �,n �x , = ,, �� � � �. ��;,"'` ��'. 71 FOR DATE TIMC�B ✓ P. M. M PHONE AREA CODE NUMB E p EXTENSION �— WILL 1. nr SIGNED u in►verSGI 48003 J Bellavance,,Curt From: Rees, Mark Sent: Monday, October 03, 2005 10:28 AM To: McGuire, Mike Cc: Bellavance, Curt Subject: Resident Concern Mike, �� � Please contact Mr. Leonard A. Dubois or his wife at 978-0-8912. He told me he is having problems with his neighbors who are allegedly doing loud work in a Red Barn between 875-975 Forrest Street. In addition to the excessive noise, he states that tractor trailers are parked on site, engine parts are stored and some light mechanical work is being done. He further stated that he talked with the owner of the property several times -but nothing had been done to alleviate the situation. Please investigate and let me know what you find out. Thanks, Mark ..-- ---------•� P /e -IF 6s" SPECIFY NUMBER OF PRINTS OR ENLARGEMENTS DESIRED OPPOSITE NEGATIVE NUMBER. IMPORTANT- PLEASE DO NOT CUT NEGATIVES FOR REGULAR PRINTS 0 DA 8 8A 16 16A:: 24 24A:: 32 32A:: 1 1 A 9 9A 17 17A: 25 25A: 33 33A::- 2 2A 10 10A: 18 18A 26 26A:: 34 34A:: 3 3A 11 11A:: 19 19A:: 27 27A:: 35 35A:: 4 4A 12 12A:: 20 20A:: 28 i 28A:: 36 36A: 5 5A E 13 13A:: 21 21 A:: 29 29A: 37 37A:: 6 6A 14 14A:: 22 22A:: 30 30A:: 38 38A: 7 7A 15 15A:: 23 23A:: 31 31 A: 39 39A:: SPECIAL INSTRUCTIONS NNOVISION TEW NWM2471 MADE IN USA FOR ENLARGEMENTS NEG. NO. I QUANT SIZE rrr 44 'v. lrTF I :.�•.y�'r.�a. .: • r .r At tV � � (NAPA) "'Wivtv- :a > � rte►;' ..., .r- . Al.LANDSCAPMOi V, ' ' 1 , V, ' R 1. 661� i r Y 4 Ago %. 4po'.`- - C7 il; 10' -I T � V1 r 'T.- ,ti=�`�'I tgp 1., � R J +, 4 � � sJ . � , � �; �- � �� R � { �� I�r, � l _. _ . _ _. a_ __ :-::� f ... ... ... ... ... ... ,�� it �,1r A Y � y,� •fit �' 0.. t = d7 1�N ,2 it •ate �� ` A.A . Alm .'fes t '• f .f.=.'. Vit'; �,,.�,�� ���- •+�, .A r This certifies that .................... has permission for gas installation. (? N ,0.0 ,..._._............... in the buildings of ... l ),� ............................ at ........ 5c, `� l�.. -n-) r :P X . -% ......... North Andover . Mass. Fee . U��.. Lic. No. O� ... , '� GASINSPECTOR Check # X311 tAg1 t pa'-,o,w a��t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s CITY I NORTH ANDOVER MA DATE OCT. 9,2012____PERMIT # JOBSITE ADDRESS 876 FOREST ST. _ OWNER'S NAME I BOB WATSON 7771 GOWNER ADDRESS BOB WATSON TE 978-688-4546 AFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES® NO® APPLIANCES Z FLOORS- BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE - — INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - - - - - -_- POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST -- — -- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I CONNECT TO A PLUMBERS INSPECTED GAS LINE -- - — 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE 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: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the be fm owledge and that all plumbing work and installations performed under the permit issued for this application will be i o nce withal erti en rov n the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JjOHN MARSHALL LICENSE # 778 SIGNATURE MP MGF ® JP El JGF LPGI CORPORATION �# _ PARTNERSHIP D# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS131 WATER ST. CITY I DANVERS STATE MA ZIP 01923 'STEL800-322-6628 FAX CELL EMAIL 1 a��4 Commonwealth Of Mass achLLS emr DCparrmenr of Iriduszrial Accidents OfTace of 1 nvesiio aiions Ic ? Cancarfss Szreg_> Suite 100 yi wwr . mass_ C ovidia rF 4r icians[,plumbers %.o p �om�alar�.in�urance _ _frida��z�ul�ler / _onrs _ lamc Busm,2ss/C)rLr=:zanc)m individualj: �/� � =RPS! PROPANE 8 OIL -ddrtss City/Stag 3 i VV A71 EP STPEE DANV_RS, I'", , 01923 Phone #: 978-75D-6500 Are yon an employer`' Chea: the appropriate bob: 1. �✓ I : am a employ�r with 4`' q. D 1 -am a general cmiraczo- and I employees (full and/or ,par-nrnej." have aired the sut-conaaciors Listed on the a ached sheet. 2.7 I am a sole proprietor o= TD -.T - T ship and have no employees hese sub -contractors have worlcino for me in an capaci employees and have wori ers' Y T [leo workers' comp. insurance comp. insuranct.' T equired.] 5. ❑ We are a corporation pd its 3. 1 am a homeowner dome all worl omcers have exercised their myself. rNo workers' comp. ri'bi of exemption per MGL insurance required.] t c. 15?, g l (4), and wt have no emplovees. INo workers' comp. jM=ance required-] Type of project (req_uired) 6. eu- corsrrucUon 7. ❑ R°znodeiing o. LJ Demoiitior, 9 _El Builaing addition 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.jl Roof repairs 13.� Oise GAS F1 FING /may applicant that ch=ecks box rl mns also a o=tne section below showing tr,� workers 1=MPensanan policy mfor =. th Homeovm=s uiho suoma is amdavii inaicaling t xy are nomas all work. and theme but c) d` cDIlIra PrS mnc submit 2I2 ' 2fna3V1? I=t affiQ sures. Coram mor. that chacl, this box. mus---anached an s.ddniona] shoe_ showing the name of th:. sut-cone." tots and s= whetn.:_ o- not (nose �titi s nave =ploy= -s- L the sub-c=m-a=r. have employm< taey must Provide theme workerscomp. policy numb. am an 9"TLOyCr LILQLL iS providiA rvork.erS' Cornpe=aLion insurance for Tnry employees. Below is the policy and job siie nformaaon. assurance Company Name: LIBERTY MUTUAL INSURAN=L CDJIP.ANY >olic+ or Self-insWC7-54 1-435806-052 03/15/2013 v ,- . Lic. Expiration Date: Db Site Adaress: 9-7 �c�JC'Jf S* City/Stab/Zip:x tn�t.�u•'� ✓1'��' d." ittach a copy of the wor kltrs' cotnpen_sa.tion policy declaration pace (showin- the policy' number and expiration date). =ailure to secure coverage as required under Section 25A of NGL c. 152 can lead to the imposition of erimmal penalties of a lase up to 51,500.00 and/or ons -yea. impriso_.nment_as well as civil penalties in the form of a STOP WOPY ORDER and a fine )f up to 5'250.00 a day against the violator _ Be advised that a copy of this statement may be for to rile Office of nvestigations of the DIA for insurance cover ale veriucation. do hereby CeTZ'ft under The pains and p--nalries Qf Periurl: thaz the info rmatior_ provided above is true and com=L o / 13 / 20=3 978- 750-6500 GJJZCial U_Se only. Do Yca: writ Zn zhLS QTeIi; t0 by cOmple[ed by CZI}- DT =Owl ofj`LciaZ City or To-F�,n: Permii-'License '�'. � T _._ ..<..t-Cli��'T-o�-CIe L -z. F,TecL_1021 �IVAector 5. P1LmD�n.� irLspe'' 1. Board oa � F 7tth 2. ': lld zt✓ 1}eper��n �z 6. Other "�nntart Pc+ -:nn• Phone-: i ainivuGiS (n LLI LU. CU LLI fn �z U)[L cn u7 m L,3,:::c Lu 2 LL C -j O. LLI >-j 0 LLI "1 Z Z LU < cn cn (01 W LU ct< m Ul W< MC M: co z LLI < V) CD LU > Z —j c7d r- < —1 i N° 9589 Date.l.adif.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING v n ,Q% This certifies that ..!� .. C..![�.,tr• �,��.. �! Q°...... x has permission to perform ... {/ .................... plumbing in the buildings of . !?-7r°e ....................... . at ......... h Andov r SS. Fee�.S-.... Lic. No: � qle.. .. . PL MBING INSPECTOR Check # �L�_ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ly MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ _�L�� _ _. MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME _ /?NR POWNER ADDRESS _( TEL ___JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: it/ RENOVATION: © REPLACEMENT: PLANS SUBMITTED: YES NOQ FIXTURES 1 FLOOR- BSM 1 2 3 4 5 610_12 13 14 9_ BATHTUB (( _..__...1.._..1_. CROSS CONNECTION DEVICE ..,._.,7 ........8._1{ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _I _._...... i _......__I .____. f ___._..._I _i f .._I FOOD DISPOSER FLOOR/AREA DRAIN _....__._1 A ___.__E ___J (_.._..._...[ _.___1 I Jll_..... INTERCEPTOR (INTERIOR) _ i ! i _-_---._i .._._I(_._._.__{ KITCHEN SINK__._..__� _ LAVATORY J J ...---._..� I { I _...._.__! I I __._._.1 ._..._. { ROOF DRAIN SHOWER STALL i __._.._1 _._-.._( .____I __.__. (____� .._.___► _.__..__1 _.._I .._____J _ ___i _._---)----_....J —.{ _ i SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES 1 WATER PIPING OTHER ... _ JR. .-- JI - INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ff"NO E] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY II OTHER TYPE OF INDEMNITY © BOND Q 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: OWNER -i AGENT]1 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nce wit P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i .� „f�y�— i LICENSE # _ i SIGNATURE MP ._ I JP CORPORATION # PARTNERSHIP O# _ _ LLC S,4 i �Di COMPANY NAME L�7 —__'_ it ADDRESS (,(J ` i CITYA STATE ® ZIP i TEL ' Lr FAX CELL EMAIL L, ly o z Fl TO W a ui w U - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual� e ..a A P& J0 Address: City/State/Zip:A'� Uhone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors el 2. [� I am a sole proprietor or partner- listed on the attached sheet. I 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.] officers have exercised their 3 . ❑ I 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.] 1 employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I LC[J P umbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. [assurance Company Name: ?olicy # or Self -ins. Lic. #: Expiration Date: iob Site Address: � / � / "G��� Y City/State/Zip:JJ,4/n f littach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ?'ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Me 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 )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify u r 1111 pains V,penalties of perjury that the information provided above is tree 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 #• 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia 4 COMMONWEALTH OF MASSACHUSETTSmuo I LA:J��s m PLUMBERS AND GASFITTERS D ASA LICENSEJOURNEYMAN PLUMBER `ISSUES THE ABOVE LICENSE TO: CRAIG B ADAM co 6 WHITE AVE 14ETHUEN MA 01844-6234 26318 05/01/14 183473 ROHN