HomeMy WebLinkAboutMiscellaneous - 91 MILK STREET 4/30/2018Date./ g .......
TOWN OF NORTHfANDOVER
9
' PERMIT FOR -GAS INSTALLATION
This certifies that . .� .i ..�..... . �.%� ?!�............ .
has permissionfor gas installation .CP4u.Q... 4 14.!¢. � ... .
in the buildings of f` � (q , -j ................... .... .
at ...C7l. fir./. ... T-1.1 .......... , o�rth Andover, Mass.
Fee .3. 1: v . Lic. No.. //). U ..
f GAS INSPECTOR
Check #
T
6787
MASSACHUSEIM LNNff0RM APPLICA,7MN FOR PERMIT TO DO GAS Ff Tf NG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date%p'l
Building Logations _ /'VI, I k 1+
Owner's Name
New U Renovation Replacement 11
Permit # 7
Amount $ v
Plans Submitted
o
cc
Z d W E., zzQ E� w W v r� W EO w � �-
W > Z Z 4 �' Z 0 z W .7 F W
c x Z z 3 c a o o w S o v, x
SUB -BASEM ENT > a a O
BASEMENT
1ST. FLOOR
-----------
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
5TH. FLOOR
TH. FLOOR
I .
T . FLOOR.
(Print or type)
Name__ Check one: Certificate Installing Company
Corp.
Address 22� �..^.z i (, I,, QQ
aQ, rod MA pig 0 Partner.
csusmess "I eiep one _ 6th �t3fl 6L9ti n Firm/Co.
Name ofLicensed Plumber'or Gas Fitter er, ,.- . _ : _ n_
1NS J NCE COVERAGE
1 have a current liability insurance, policy or it's substantial equivalent. Check one:
If you have checked -yes, please indicate the type coverage Yes . No�
Liability insurance oticby checking the appropriate box.
p y 0 Other type of indemnity D
Bond 13
Owner's Insurance Waiver. 1 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.
Signature of Owner or Owner's Agent Check one:
i hereby certify that all of the details and infoer 13 Agent
rmation I have submitted or ente
red) ed) in above applications
d accurate to the
best of my knowledge and that all plumbing work and. installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S, O-G��odeerd)Lhapter .142 of the General Laws.
l�
By:
Signature
ignatur of Licen mber Or Gas Fitter
Title ® Plumber
City/TownI Gas Fitter 11 t� 0
License um er
Master
APPROVED (OFFICE USE ONLY) ® Journeyman
1 ne (ommonwealth of Massachusetts
Department of Ind111tri-1 Accidents
Office of rnver i;atiom
600 Wasizinaton ,Street
Boston, M4 02111
WN�YV, nZQSS.e Oi��dia
Workers' Compensation Iasurance.Afdavlt. guilders/Coniraciors/Elecir�cians
Acant 1nfornaa>Lion /Plumbers
T) -
Name (Business/Organization/Individual):
Address:
City/State/Zip: �n.)�,r,� ►M�
Are You an employer? Check the appropriate box:
❑ I am a employer with []
Phare #: � i1
4. i am a aAn I
employees (Hill and/or part-time).*
2. 1 an a sole proprietor or partner.
ship and have no empioyees
working for me in any capacity.
[No workers' comp. insurance
required.]
3.❑ I am a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
=.- esa contractor and I
have hired the sub -contractors
Iisted oni the attached sheet I
These stab -contractors have
workers' comp. insurance.
❑ Weare .a corporation and its
officers have exercised.their
right of exemption per MGL
C. 152, § 1(4); and we have no
employees. [No workers'
TYPe of project (required):
6• ❑ New construction
7• ❑ Remodeling
g• ❑ Demolition
9. ❑ Building addition
10:❑.Electrical repairs or additions
11.❑ Plumbing repairs or additions
12:0 Roof repairs
comp. insurance required) 13•❑ Other
*Any appii attt.that checks box # 1 .must aiso fill our the section below showing their workers' compensation ofr
t Homcowuers who submil.this affidavit indicating G - ,
..tcct then hire outside cnntraciors umst su'omi�an� amuavii indi�n -
Contractors Thal eheci: this box.must attached an additional sheet showing the nkne.of the sub-ccrnactots and their.,=_ --
r €� n
. . =1iWz %ycr Mai a provuitrng workers' co ensafion ' ---- -• -V. F!ve1r 31 mrormatzon,
information.° uzsurance for ny' employees. Below, is theofi
P c) and job site
Insurance Company Name:
Policy # or Self -.ins. Lite. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation tic tleeEa City/State/Zip:
P° ration page (showing the policy number and expiration date).
-----------
Failure to secure coverage as required under Section 25A of
MGL c. 152 fine up to $1,500.00 and/or one-year imprisonment, as well as civil P_ allies in the to
imposition Of criminal penalties of a
of up to .S250.00 a day against the violator. Be advised that a copy of thin ormof a STOP statement may RK ORDER and a fine
Investigations of the DIA for insurance coverage verification. ) be forwarded to the Office of
•I Ifs %on ;i _-,:4
J� " "`C peons ane penalties of perjurf' "hx the information provided above is true and correct
offCcwl use onlp. DO not write in this area, to be corrrpleted h3' city or town official
Cite or Town:
Issuing Authority (circle one):
Permit/License 4
I. Board of Health 2. Building Department 3. CitylTown
fi. Other Cierk 4. Electrical Inspector S. Plumbing Inspector
Ins ector
Contact Person:
Phone 4-
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 ".. giver -y person in the service of another under any contract ofhire,
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 inclucii ng the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .three ap artments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maint-nance, 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 o r local licensing agency shall withhold the issuance or
renewal of a license or permit.to operate a basiness or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence (it, f 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 ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit compi•etely, 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or. partners, are not required tocarr}'. compensation ompensation 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. Theaffidavit should e
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 regia" rding the-iam, or if you are required to obtain a workers'
..compensation policy;please call the Department at the nmrnberiis+.ed below. Self-insured companies shodld enter their
self-insurance license number on the appropriate lire.
City or Town Officials
Please be sure that the affidavit :is complete and printed legibly. The Dr
parhtient 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.pemlit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitnicense applications in arty 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 Iicenses. A new affidavit must be filled out each
year. 'Arhere 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 burnleaves 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 fay, number:
The Commonwealth of Massachusetts
Department Of 1xidustr-ial Accidents.
Office of 11tvest:ivatioaa
600 Washington Street
Boston; MA (12111
Tel. # 617-727-4900 =--t 406 or 1-877-MAS&AE
Revised 5-2645 Fax 4 617-727-7749
'.mass.Dovldia
•
LOT #40-2A
MILK(-v�au►B� vnarn) S
o f"
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NO TES
1. PROPERTY LINES FROM EXISTING PLANS' ANDaREl
SEE TOWN OF NORTH ANDOVER ASSESSOR P
AND DEED BOOK #559 PAGE,#32LD.R.D."
2. ZONE DISTRICT IS R3�
� mgr
aL
STEPHEN E;:
CF
12/7/07
R.L.S. DATE
PLAN OF LAND
IN
NORTH ANDOVER, MASSACHUSETTS
DRAWN FOR
HIGHVIEW, LLC
1501 MAIN STREET—UNIT 47
TEWKSBURY, MASSACHUSETTS 01876
SCALE: 1"=40' DATE: DECEMBER 7, 2007
0 20 40 80 120
MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
<J�
o�
LOT #40 3
h AREA=38,595 S.F.
=0.8860 AC.
CBA=19,058 S.F.
=76.23%
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NO TD'S
1. PROPERTY LINES FROM EXISTING PLANS AND RECORDS.
SEE TOWN OF NORTH ANDOVER ASSESSORS MAP #59 LOT #40
AND DEED BOOK #559 PAGE #32 E.N.D.R.D.
2. ZONE DISTRICT IS R3
PLAN OF LAND
IN
NORTH ANDOVER, MASSACHUSETTS
DRAWN FOR
HIGHVIEW, LLC
1501 MAIN STREET—UNIT 47
TEWKSBURY, MASSACHUSETTS 01876
SCALE: 1"=40' DATE: SEPTEMBER 19, 2007
REVISED: DECEMBER 4, 2007
0 20 40 80 120
7"A� � IMERRIMACK ENGINEERING SERVICES
l; 9/1 07 66 PARK STREET
STEPHEN -Y`' STARINSKI, R.L.S. DATE I ANDOVER, MASSACHUSETTS 01810
r
t •
Date. ./— /7 . j ... .
I
TOWN OF NO, FIT e NOOVER
PERMIT FOR GAS INSTALLATION
This certifies that,. ... ....... r.....
t
has permission for gas installation !I.. ............
. ,' 'ti -t
in the buildings of ..., ...� ... ........................
atNorth Andover, Mass.
Fee .`ta...... Lic. No..�:.�'... .t. ��rt .......
-6AS INSPECT ORS
Check # /0/,-' - /09 % ( �i
6297
M 1. ASSAC1iUSE- TS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
(Maass. Dale Alp2r- Permit # I All -V
Building Location i `h Owner's Name �J
Type of Occupancy
New (J Renovation U Replacement U Plans Submitted: YesU No ❑
Installing Company Name
hires
Business Telephon(cpa-" $�(�
Name of Licensed Plumber or Gas Fitter
Check one:
Corporatlon
❑ Partnership
0- Flrm/Co.
Certificate #
93c
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 �, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy ❑ Other type of Indemnity O 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 waNes this requirement.
Check one:
5+gnalure of Owner or Owner's Agent , 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 Installations performed under the permit Issued for this application will be In compliance with Sri
pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Genera ws.
BY TrPlumber
cense:
rgnaIure o cense I m er or Gas rl er
Title er Ucense NumberCily/Town neyman
1V'I'f1C7,TffT5 TTC _
sell
NIMEERM
no
M
NONE
No
M
MENEM
MENSIMINEM
0
no
'NOOSE
INEOREENERMEN
MOMMENNEEMMINIM
MEN
0
son
ME
ME
0
no
MEN
01
SK
Installing Company Name
hires
Business Telephon(cpa-" $�(�
Name of Licensed Plumber or Gas Fitter
Check one:
Corporatlon
❑ Partnership
0- Flrm/Co.
Certificate #
93c
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 �, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy ❑ Other type of Indemnity O 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 waNes this requirement.
Check one:
5+gnalure of Owner or Owner's Agent , 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 Installations performed under the permit Issued for this application will be In compliance with Sri
pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Genera ws.
BY TrPlumber
cense:
rgnaIure o cense I m er or Gas rl er
Title er Ucense NumberCily/Town neyman
1V'I'f1C7,TffT5 TTC _
i -.
7-11'
............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING.
,SSACHUS�t
This certifies that ...........
has permission to perform.........................
-X�
plumbing in the buildings of ............. ,
.....................
at ................ & .. ........ North'Andover, Mass.
....... ....
Fee ...... Lic. No.. `3. .-.,.. . --........
INSPECTOR
Check N
7630
MASSACHUSETTS UNIFORM aAPPLICATION FOR PERMIT TO DO PLUMBING
,-\ (Print or Type)
Mass. Date I 1 Q �U� Permit # 610
Building Location (9�`�k—owners Name �WA A
v�
Type of Occupancy _
0
New
Renovation ❑. ,
Replacement- ❑
- Plans Submitted: " Yes D No ❑
B.P.,
_...._ SEWER#
FIXTURES
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SUB—BSMT.
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BASEMENT
IST FLOOR
l
2ND FLOOR
3RD FLOOR
•
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4TH FLOOR
r''Y
STH FLOOR
i
67H FLOOR
_
...
_.._ .._
7TH FLOOR
8TH'FLOOR
_EE
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Installing Company
Address
i Business Telephone
A
Name of Licensed Plumber
Check one:
10Corporatiog
❑ Partnership
❑ Firm/Co.
Certificate #
.0gIG
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑ 1
If you have checked yes. 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:
-Signature of Owner or Owners Aaent Owner ❑ Agent ❑
r nereoy 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
knowltidge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Cod and Chapter 142 of theGeneral Laws.
Title 'gig -nature of Licensed lumb -
Type of Ucense: Master
.rJourneyman ❑ �r�
APPROVED 0 IC US ONLY) Ucense Number
MASSACHUSETTS UNIFORM APPLICATON FORPERMPT TO DO GAS FITTING
(Type or print) Date��
NORTH ANDOVER, MASSACHUSETTS
G "
Building Locations ! I (� I ` Permit #
LL ` Amount S� p
Owner's NamLe ���� Ll�
New Renovation Replacement 11 Plans Submitted 11
Date...,... .
MORTM
1.O
TOWN OF NORTH ANDOVER
D
PERMIT FOR GA's INSTALLATION
o .'
This certifies that .. _.-?-�,4 . :� .......... .
has permission for gas installation .
.. . ._...
in the buildings of .. �-�. ..... ...... .
at ...f .............. ....... North Andover, Mass.
Fee ..... Lic. No..6f ,
�S v INSPEC'Ty'�f
Check
6405
(OFFICE USE ONLY) I rl Joumeyman
I
ie: Certificate Installing Company
xp.
irtner.
;rm/Co.
No�
,ond 13
required by Chapter 142 of the
)lication are true and accurate to the
ed for th' application will be in
of`the7eral Laws.
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SUB -BASEMENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH.TFL00R
Date...,... .
MORTM
1.O
TOWN OF NORTH ANDOVER
D
PERMIT FOR GA's INSTALLATION
o .'
This certifies that .. _.-?-�,4 . :� .......... .
has permission for gas installation .
.. . ._...
in the buildings of .. �-�. ..... ...... .
at ...f .............. ....... North Andover, Mass.
Fee ..... Lic. No..6f ,
�S v INSPEC'Ty'�f
Check
6405
(OFFICE USE ONLY) I rl Joumeyman
I
ie: Certificate Installing Company
xp.
irtner.
;rm/Co.
No�
,ond 13
required by Chapter 142 of the
)lication are true and accurate to the
ed for th' application will be in
of`the7eral Laws.
Fitter
PI
/ � -0�.
Date..................................
+ TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
3S US
This certifies that ....
..... ......... ...................................................
has permission to perform-............ ... ..................................
wiringqi the building of... &e'� ...................................................................
at ....
.................... ......................... . ........ . North Andover,, Mass.
Fee..�/ ...... Lic. No.4/ .........
ELECTRICAL INSPE 04
Check #
7950
Commonwealth of Massachusetts Official Use Only /
Department of Fire Services Permit No. 5`S -d
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( EC) 527 CMR 12.00 ,(
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:-�2
City or Town of: NORTH ANDOVER To the f4peclor of Wires:
By this application the undersigned gives no 'ce of his or her intention to perform the electrical work described below.
Location (Street & Number) q1M 1.�.
Owner or Tenant 11 1-1— , Telephone No.
Owner's Address / 4_xi S' A/"401, , I` A,,, Oe�3f
Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box)
Purpose of Building ALet.4.2 Utility Authorization No. 3900 %77
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service ao Amps /
,�2 p / c;)40.Volts Overhead � Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Comnletinn nfthe fnl)nu)ino tnhly mnv ho
No, of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
1
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑N
rnd. grnd.
o. of Emergency ig g
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. f Tons Tot
No. of Alerting Devices .
No. of Waste Disposers.
l
Heat Pump
Totals:
Number
_....... .........*****----I"""""""
Tons
KW
"""'
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal 11 Other
Connection
No. of DryersHeating
roh J
No. of Water KW
Heaters �j 4S
Appliances KW
No. of No. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: 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 covers is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ETBOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the informa 6n mg, this application is true and complete
FIItM NAME:
Licensee:
LIC. NO.:,y"�%
LIC. NO.:
(If applicable, enter "exem t" in the licens nu r line. Bus. Tel. No.:�y%E
Address: Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of P lic Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ o"i
0
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13
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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 Leaibly
Name (Business/OrganizatiWindividual);
Address:
City/State/Zip:
Ti
Are yan employer? Check the appropriate box: Type of project (required):
l . ' i am a employer with 4. F1 am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. x Remodeling
ship and have no employees These sub -contractors have 8. ❑ Demolition
working for mein any capacity, workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.] officers have exercised their
3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No-worke'rs' comp. c. 152, § 1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required_] 1317 Other
*Any applicant that checks botf # I 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.
,Contractors that check this box must artached an additional sheet showing the name of the subcontractors 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, i , /
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration
Job Site Address: - B�/- 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 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 5250.00 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.
1 do hereby certify fidothe pasand penalties of perjury that the information provided above is true and correct
Of}'icial'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 deemedto be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of 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 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
heirself-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 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
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_ NORTH
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDO`TER
1�
Building Permit Number 413 (12/4/2008) Date: December 9. 2008
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 91 Milk Street
MAY BE OCCUPIED AS Single Family Dwelling IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Highvi6w LLC
1501 Main Street
Tewksbury MA 01876
Building Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
43
Buildin4 Permit # 1 11
ADDRESSILOCATION OF PROPERTY
9 Parcel q 6
SUBDIVISION
9 i OIL
k,s�
Lot Number
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY:
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES. ff66
Perm Issued to: 1� 1 6 � 6 L0 �.
Addressr f ,,� ISO/ MAIN S—( Volt
vzg/ r•
\ROUTING
CONSERVATION d
a PLANNING .2
V
DPW - WATER METER
SEWER/WATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
�j
DPWL�
Signature
File: Application for OC form revised Jan 2007
- IE�0
(pU8L1C�VAoADLE I,.
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DD
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NOTES
1. PROPERTY LINES FROM EXISTING PLANS AND RECORDS.
SEE TOWN OF NORTH ANDOVER ASSESSORS MAP #59 LOT #40
AND DEED BOOK #559 PAGE #32 E.N.D.R.D.
2. ZONE DISTRICT IS R3
0
�br
STEPHEN E.
8/05/08
R.L.S. DATE
PLAN OF LAND
IN
NORTH ANDOVER, MASSACHUSETTS
DRAWN FOR
HIGHVIEW, LLC
1501 MAIN STREET -UNIT 47
TEWKSBURY, MASSACHUSETTS 01876
SCALE: 1 "=40' DATE: AUGUST 05, 2008
0 20 40 80 120
MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
e
Location��r/
No. Date X� �r
NORTH TOWN OF NORTH ANDOVER
Of.o y�ti�
3? OL
Fmaagiliftp
" Certificate of Occupancy $ %�y
s i #
sACNUs t�' Building/Frame Permit Fee $.
Foundation Permit Fee $ /00
`
Other Permit Fee $
TOTAL $
Check #/1-1
20857 /X/
Building/inspector