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HomeMy WebLinkAboutMiscellaneous - 94 FOXHILL ROAD 4/30/2018ORTfJ 0 Town of North Andover o D.B.A. —.Zoning Compliance Form ',trap 0 978-688-9545 This form must be reviewed with the Inspector of Buildhigs. Office Hours are Monday -Friday 8-10 am. and 1-2 pin Monday -Thursday,. 5-5 Ck UO Name of Business., : �-( � - i I 'C Zoning District Map_ k..J 3 Lot Cx-) Phone,11 I q—slq-'� V Nature of Business: wv\,rde-sAk- k 1'.r1e SS Do you own this provea�,? Yes, No If no, written permission is required from your landlord, Will you have clients coming to this property`? Yes- No X 'Will. you have. any employees? Yes No Will you. have any major deliveries? Yes- No Description of l3winess Activity (Must. be Completed) lkal-laavcu CA Signature of Applicazlt J, ;dcc For Signage R66- to North Andover Zoning Bylaw Section 6 The propos se 1, o us t, is zoning district. issued By ate V 2- tO . .. . . ......................... 2.40 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 and artist or _ instructor but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, orthe conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi -family district for a home occupation, the following conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the owner of the home occupation and residing in said dwelling. b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; d. Not more than twenty five (25) percent of the existing gross floor area of the dwelling unit so used, not to exceed one thousand (1000) square feet, is devoted to such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, omission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design not customarily in buildings for residential Muse. ' (Ja tqo Signature Date NORry �assac�us���� North Andover Health Department Community and Economic Development Division NORTH ANDOVER BOARD OF HEALTH. ORDER LETTER TO CEASE AND DESIST Issued under the provisions set forth in 105 Code of Massachusetts Regulations (CMR) 590.000. Date: January 30, 2017 To Owner of Record: Melissa S. Diminico 94 Foxhill Road North Andover, MA. 01845 Property Location: SAME Re: CEASE AND DESIST OPERATION OF A FOOD ESTABLISMENT Dear Candy Dish Owners and Operators: It has come to the North Andover Health Departments attention that The Candy Dish is doing business in the Town of North Andover. The Health Inspector has discovered your retail products in multiple stores throughout North Andover without proper permits. These products are being produced without a wholesaling license from the state, out of your home. We have also discovered through your advertising, that in addition to wholesaling, you are also Catering, out of an unlicensed and uninspected kitchen. To date, you have not registered, nor have you applied for any permitting through any department in North Andover. The North Andover Public Health Department has discussed these requirements with you on multiple occasions over the past four years to assist you in the proper permitting through the Town and State. In accordance with the provisions of 105 CMR 590.000 I am hereby ordering you 'to CEASE AND DESIST any and all FOOD SERVICE OPERATIONS IMMEDIATELY. You may not operate this food establishment business without valid permits, and must submit the proper applications to the Zoning Department, Building Department, the Town Clerk, the North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Page 1 of 2 Fax: 978.688.8476 Health Department and the State to renew for your Wholesaling License. The Health Department is here to assist you in any way possible. You have the right to request a hearing before the Board of Health if you feel this Order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from receipt of this Order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this Order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. You may be represented by an attorney. You have a right to inspect and obtain copies of all relevant records concerning the matter to be heard. If you have any questions, comments or concerns, please feel free to call me. Shicerely, C Y 11\ ichele Grant, ---�� Health Inspector CC: Brian J. LaGrasse, Director of Public Health BOH File Via: CERTIFIED MAIL # 7014 2140 0000 8322 4040 ; and Hand Delivery - Cease and Desist Issuance to on-site staff Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 ��,� . �. � �° �� `'�--�-t,�-J-� 1� �� � � cJv''` - 1�- g . �` � �� � � 5"�"`/ q5 ,�-� �a� ��" TOWN OF NORTH ANDOVER ORTy Office of the Building Department p 0 -futo ,61.y Community Development and Services O 120 Main Street % North Andover, MA 01845 a * 978-688-9545 Donald Belanger, Inspector of Buildings January 31, 2017 To: Catherine Canto Fr: Donald Belanger Re: 74 Fox Hill Road, North Andover MA 01845 Map 37C, Lot 44, Zoning District R2 Dear Ms. Canto, I conducted a site visit at your property located on 74 Fox Hill Road on January 9, 2017. At that visit I met with you and your father to follow up on a complaint that a hair salon was operating at the above property location. The following was revealed but not limited to; Catherine Canto is a hair stylist by profession and has a hair styling station set up in her basement that is used for practice on her relative's hair. Ms. Canto was informed that operation of a hair styling station in a R2 Zoning District is not an allowed use. This written complaint will stay on file and will be revisited if there is a status change and or further complaints are received. If in the future it is determined that a hair styling station is operating from the above address whether for profit or not, the hair styling station may have to be removed in kind. If you feel you have been aggrieved by any action/s that I have taken or failed to take, you have the right to appeal to the Town of North Andover Zoning Board of Appeals or the Massachusetts State Building Board of Appeals accordingly. Sincerely, Donald Belanger Inspector of Buildings Zoning Enforcement Officer 2����� rnOar-V14 vier lAsys 0 Dear Mr. Belanger, 1/09/2017 On January 9th 2017 at approximately 2:OOPM, you came to my home at 74 Fox Hill Road to conduct an inspection following up on a complaint that was received about my residence. Per your visit and observations, there were no findings that proved my residence had been being used as a small business. I will continue to adhere to all zoning regulations and not run a bi sina,qc in my residence. 1 acted in rf)mnlete cooperaboi-t and open ed my dors rIth no reluctance. Thank you for your professionalism and kindliness throughout your investigation. Cather^,�. Canto 74 Fox Hill Road North Andover, MR 01 845 Town of North Andover Building Department Community & Economic Development Division 120 Main Street North Andover, Massachusetts 0184 P (978) 688-9545 F (978) 688-9542 December 22, 2016 Catherine M. Canto 74 Foxhill Road North Andover, MA 01845 RE: 74 Foxhill Road, North Andover MA 01845 MAP 37C LOT 44 ZONE R2 Dear Catherine Canto: Our office received a complaint regarding your property at 74 Foxhill Road, there is allegedly a Hair Salon operating from your residence. Hair Salon is not an aloud R2 Zone, The complaint alleges that there is a Hair Salon operating at the aforementioned address. A Hair Salon is not an allowed use in a R2 Zoning district. Operation of such constitutes a violation of the Zoning Bylaw of The Town of North Andover as well as a violation of 8TH Edition of the Massachusetts State Building 780 CMR You are hereby ordered to Cease and Desist the aforementioned alleged violation and report to the Building Department within ten days upon receiving this letter to resolve any and all violations. If you feel you have been aggrieved by any action/s I have taken or failed to take, you have the right to appeal to the Town of North Andover Zoning Board of Appeals or the State Building Board of Appeals accordingly. Thank You Donald Belanger Inspector of Buildings/ Zoning Enforcement Officer ,, t%ORTH Of i�ao 6 Ah I-- IL w M 'F �ofp ♦r ��SSACHUS�t� 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE: October 20, 2016 FROM: GuntherHoffman ADDRESS: 64 Fox Hill Road ELECTRICAL: PLUMBING: GAS: Tel #: 978-828-7747 Complaint Against: BUILDING CONTRACTOR: PROPERTY OWNER: 74 Fox Hill Road OTHER: Question: My neighbor next door has opened a salon in their basement. The foot traffic and cars in front of oU ra home are a nuisance, and I'd like to understand if the salon is legal, and what niir nntinnc ara in farmc of limiting the impact nn us Si ned:_ see attache *yA',� 3 Ce*4 1,4.-1 L9 visa"IF-;WAe." Twrf— r'P ,North Andover MIMAP 037 C=.0049 �, 20�FOXHILL�R®i Q 137:0-0035f �037f C=„0048: 63FUXHTLLCRD N r Z37:C=003'W October 20, 2016 54 PLLASANT f-Tf 561;,PLEASAN, T §1 037CT0029 03760038+ 037:0=0047 03T:C 004,4, 037„C OOQS? 48FOXHILLjRD /J < 164�FOXHILL,�RD;< r16, i �74�F0?CHIL�L�$D` 37#C 0037 C9 FOXF IL_ 150' 125" 124' ..oz'Nill Road 161` 037 C=0038;: 125' 15 FOXHILLRD,I �03,7C 0039 t037C 0040a 037°C 0041; C,:0021P07 FOXHILL�R7g: ;037,; 75(FOXI ILL RU;< MVPC Bo Zoning Overlay Zoning [] Municipal Boundary 13 Adult Entertainment Distric ii Busine s 1 District Rail Line Machine Shop Village Ove ❑ Watershed Protection Dist 13 Busine Businei s 2 District s 3 District Horizontal Datum: MA Slateplane Coordinate System, Datum NAD83, Interstates 0 Historic Mill Area O Busine s 4 District yORT11 Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of . I — SR 13 Medical Marijuanad Q Downtown Overlay District GeneraBusiness O Planned District Commercial Dev O f q t e • O + North Andover. Additional data provided by the Executive Office of Environmental AffairslMassGIS. The information depicted Roads Historic DisMct Ct Corrido Development Dist et e O �' L on this map is for planning purposes only. may not for legal t i Easements [� Osgood Smart Growth (40 it Hydrographic Features A Corrido O Corrido Development Dist Development Dist Q _ � I. 1A >D H adequate boundary definition or regulatory r eg ry Interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, ❑ Parcels Streams :n us SS Industri I 1 District 12 District * EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT Wetlands 0 6 Industri O Industri 13 District I S District 9 . ..w �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF tf Exempt lands - _ Reside Reside ce 1 District ce 2 District �1O� •rs° dt,�°J SSA THIS INFORMATION f! 0 Reside ce 3 District CNUSE de ce 4 District - - 1” = 72 ft w�rde ce5 District de %1-22 ce 6 District esidential District - 11478 Date... ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that .... . ............................... j . .............................................. has permission to perforin ..... . .......... ........ ... 0.1t -le . .......................... . ......... ..... .. .................. plumbing in41-1 the buildings off........... . ................. .................... ' at .............. I .. ... ;.E '/. ..... g ......d ..................... North Andover, Mass. Fee.'.5q-- ... ............ Lic. No. �5�3/0 .. ..................................................... PLUMBING INSPECTOR Check #IM N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y CITY � `� oVG < _ (MA DATE PERMIT # JOBSITE ADDRESS KJ4, I I R OWNER'S NAME OWNER ADDRESS �j TEL JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL~' PRINT CLEARLY NEW: RENOVATION: 011", REPLACEMENT: Q PLANS SUBMITTED: YES ® NO 0I FIXTURES 7 FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ) .,-.._.. . __.! . _ II ,_.._l ___. --J1= _! DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _Ri ( --__-_. _.__...._(- -...__f __...._-f .-____! ---i ._-..._..!-_..._- ____...J __.._j .....__ FOOD DISPOSER FLOOR/AREA DRAIN _1 ..__._..-! __-- ► ._..__� f 1 _._..._.(' --_.- I i . INTERCEPTOR (INTERIOR) _._.._._I __J _-_. r ._._..___! .-_.__-1 ..__,�_1' _ _I ._ _i ._.____► KITCHEN SINK LAVATORY ROOF DRAIN __+� _!I SHOWER STALL t1 _.-___..._.__�._ SERVICE / MOP SINK I== TOILET _ ___ URINAL _ _ t _...__[ ! i ... _ ! I F-73 ..-__! .._-.__J .......__t WASHING MACHINE CONNECTION WATER HEATER ALL TYPES -4 _I t WATER PIPING OTHER M INSURANCE COVERAGE: haiAlp ZNO current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 01' IF YOU CHECKED YES, PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - 1 OTHER TYPE OF INDEMNITY 0 BOND 0 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: OWNERF-11 AGENT 0 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wilh all PertlaW provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. «! PLUMBER']LICENSE # I SIGNATURE VIP JP CORPORATION0! #PARTNERSHIP D#= LLCC�% COMPANY NAME 0t -0`,; "fADDRESS CITY 7C w ,t 5✓ _ (STATE � ZIPp / Yui 7� TEL FAX –� CELL 2.70— EMAIL N ❑ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIIT TI1�TG AUTHORITY. Name (Businesslorgabhation/Indivi.dual).— 00 P�""� Address: �/ �9 /�>`^ �✓��/2 �4� City/State/Zip: e ,,v K -- Are yo employer? Check the appropriate box: J.V I am a employer with __-_-_.employees (frill and/or part-time)'..' 2.01 am a sole proprietor or partnership and have no employees W01king for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] fi 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no'employees. 5. ❑I am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its, officers,have exercised their right of exemption per MGL c. 152 §1(4), and we have rio employdes [No workers' comp. insurance required.] Phone #: Type of project (xequired) 7. [1 N6 'colistr& ion 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ El ical repairs or additio,s 12. `,w Plumbing repairs or additions 11 n Roo£repair§ 14.Other *Any applicant that check's bbx #1_ must also fill out the section below showing their workers' compensation policy information. Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check" box must attache additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. orkers' compensation insurance for my employees. -below is the policy and job site jam an employer that is providingw information. l - Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: City/State/Zip: Job Site Address: policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation c. 152, §25A is a criminal violation punishable by a Pirie up to $1,500.00 Failure to secure coverage as requited under MGL 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 ay be forwarded to the Office of Investigations of the DIA. for insurance day against the violator. A copy of this statement m coverage verification. X do hereby certify under thepains and penalties of perjury that the information provided above is tr .e andcorrect. Phone # Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their e6ployees. Pursuant to this statute, an employee is defined as "...every 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 including the legal representatives of a deceased employer, or the receiver'or trustee pf 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 Iicensing 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(1) 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 Pleasb 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatioii 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 "fob Site Address" the applicant should write •"a11 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 Department's address,.telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia 01876- i ` i� i f l� r • , i r' i� t r" i Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thi . s, . certifies that k1l C. cln 7 .............................................................................................. ........................... has 'Permission to perform ......... . ...... . ... ......... . .............................. 4�,� wiring in thebuilding of ............ 0 / .............4............................................................ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 12a t Lt — I Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 CW 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: ;QZ City or Town of: NORTH ANDOVER To the Inspector Of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant 10102,141 C'/' Telephone No. Owner's Address %5 q)10: Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building AWW2E AdSeA94 i Utility Authorization No. Existing Service QD Amps /C20 / o9!/,sj Volts Overhead ❑ Undgrd ❑ No. of Meters T New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature ofProvosed Electrical Work: �i�C�r1Dv,�ir —2?~, lea -)1 ffdw Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires /� No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets !� No. of Hot Tubs Generators KVA No. of Luminairesf` 5° swimmin Pool Above ❑ In- ❑ g rnd. grnd. o. o mergency lig ting 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. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW """"..... ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances Key Security. Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent FoTHER- ,4ttach 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: /a 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 :1 the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA=NCE X� BOND ❑ OTHER ❑ (Specify) Y certify, under the pains and penalties of perjury, that the inforination on this FIRM NAME: <2A . AIA -Ae Licensee:ro�jQr�� C4— Z/ d Signature (If applicable, enter "exempt" in the license number line) Address: is true and complete. LIC. NO.: 41.2.2 ZA _ LTC. NO.: Bus. Tel. No.: W/—off%� —IVI Alt. Tel. No. • ' — 7aZ *Per M.G.L c. 147, s. 57-61, security work requires Department of Public 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 p PERMIT FEE. $ Signature Telephone No. ^ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the r r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an �+ electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the i notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass F?1 Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL, ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP C -TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 1",r— Date: , FINAL. INSPECTION: Pass 0 Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Zo Inspectors Signature:. Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com °�M 5yru Werke& Compensation Insurance Affidavit: Builders/Contractors/Electricians/1'l4mbers. TO BE FILED WITH THE PERMCTTING AUTHORTi Y. ..Pleas Print Legibly Applicant Information �' ` Name(Busin6ss/Oigapization/Individual): w, A/� , 1" . Address: City/State/Zip:LII J)7, 7UM Are you an employer? Checic the appropriate box: Phone #: ' 7o-? ` Z// `f ,l 1.Q I am a employer with employees (fiill and/or part time).* 2.X1 am a sole proprietor or partnership and have no employees 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 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employee` S. 5. ❑ I am a general contraor cfand T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have iio employees: [No workers' comp. insurance required.] Type of project (required): 7. ❑ N&W'donstruct[on 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12,, ;.; 'Plumbing repairs or additions 13•.0 Roof repairs 14. [] Other *Any applicant that checks bbk 4l _must also fill out the section below showing their workers' compensation 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 boas 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 employees, They must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Pe low is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $I,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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Sheet, Suite 100 ^ Boston, MA. 02114-2017 www mass.gov/dia °�M 5yru Werke& Compensation Insurance Affidavit: Builders/Contractors/Electricians/1'l4mbers. TO BE FILED WITH THE PERMCTTING AUTHORTi Y. ..Pleas Print Legibly Applicant Information �' ` Name(Busin6ss/Oigapization/Individual): w, A/� , 1" . Address: City/State/Zip:LII J)7, 7UM Are you an employer? Checic the appropriate box: Phone #: ' 7o-? ` Z// `f ,l 1.Q I am a employer with employees (fiill and/or part time).* 2.X1 am a sole proprietor or partnership and have no employees 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 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employee` S. 5. ❑ I am a general contraor cfand T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have iio employees: [No workers' comp. insurance required.] Type of project (required): 7. ❑ N&W'donstruct[on 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12,, ;.; 'Plumbing repairs or additions 13•.0 Roof repairs 14. [] Other *Any applicant that checks bbk 4l _must also fill out the section below showing their workers' compensation 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 boas 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 employees, They must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Pe low is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $I,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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 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 enferprise, 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 occupani ofthe 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 license or permit to operate a business or to construct buildings in the commonwealth for any applicaftt-whO:has not produced -acceptable evidence of compliance with the insurance coverage requhred." Additionally, MGL chapter 152, §25C('1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 certificates) 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 "fob 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Location 5f llf b k 14R -L h L7 / NO. %' Date w ,< NO TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Alva �cNus S Foundation Permit Fee $ s CF/�j�nnther Permit Fee $ -� 11 r. . Connection Fee $ �p y!Water'F ction Fee $ Q *L QjY Building Inspector Q0 Div. Public Works PERMIT NO i APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �/GE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. F LOCATIONPURPOSE /_• _.. _ _ OWNER'S NAME - -`' NO. OF STORIES SIZE _ OWNER'S ADDRESS G%l1 ' I`')j` f 7 /( BASEMENT OR SLAB — ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME\v SPAN ---- ' DISTANCE TO NEAREST BUILDING W[ DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS -15'1-STANCE FROM LOT LINES - SIDES �` 1 REAR q caW 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 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER OARD OF APPEALS ACTION. IF ANY 1 v io ! IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS s PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED fiI(rjs % 77 02 L/ SIGNATURE,OF OWNER OR AUT"6klZp:D AGENT FEE �'�� Ck:::) PERMIT G L Ig T �— UU i JUN 81992 i BUILDING DERAR16., NT OWNER TEL CONTR.TEL CON11L LIC. 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD OF I OCCUPANCY SINGLE-FAMILY STORIES MULTI. FAMILYOFFICES APARTMENTS . -i CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ _ _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T' AREA 114 1/1 l/. FIN. ATTIC AREA N_O BM'T FIRE PLACES HEAD ROOM MODERN KITCHEN BUILDING RECORD THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OFA BUILDINGS. WITH %PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACE9_PLOT PLAN. ASPHALT SHINGLES LAVATORY 4 WALLS II 9 FLOORS CLAPBOARDS WOOD SHINGES B 1 2 _ DROP SIDING WOOD SHINGLES NO PLUMBING CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARD\,✓'D COMMON ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ MODERN FIXTURES _ ' BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR CONC; OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I�POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBREL WOOD JOIST HIP PIPELESS FURNACE BATH Q FIX.) MANSARD TOILET RM. 12 FIX.) FLAT TIMBER BMS. & COLS. SHED STEAM WATER CLOSET BUILDING RECORD THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OFA BUILDINGS. WITH %PORCHES. GA- RAGES. ETC. SUPERIMPOSED. 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