HomeMy WebLinkAboutMiscellaneous - 998 SALEM STREET 4/30/2018lw
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....... ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... ...... ..... .. � . ..................................
has permission to perform .... k�y .... qp('tr .........................................
wiring in the building of ......... ................................
at ........ . . .............. North Andover, Mass.
Lic. No.I.N..44-M .......... ......
Fee..8:q ............. FA4'4411e6
it 4EiCIMC�ALINSPECTOR
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Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Permit No.
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT I1V INK OR TYPE ALL INFORMATION) Date: :2 -- l ,�-- t 0
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) $1<}1° -,cA 57
Owner or Tenant M%4 'r) s{', \,A yV\ik, Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building ZAVS'2 Utility Authorization No.—70? 0? f-1fr6 �r
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service D,!�0 Amps Ikv / )4,o Volts Overhead ❑ Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the 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 Luminaires
Swimming Pool Above ❑In- 11
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets SU
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
a
No. of Gas Burners
1
No. of Detection and
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Number
I Tons
KWNo.
..........
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El Other
Connection
No. of Dryers
Heating Appliances KW
Security
of Systems:*
or E uivalent
No. of Water
Heaters KW
No. of ..No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications
No. of Devices or Equivalent
OTHER:
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start: -7-0-1 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
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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: 20G LIC. NO.: l l q 6 3M
Licensee: � (� Cc9KK-s,%� Signature LIC. NO.:
(If applicable, enter ""exempt" in the license number line) Bus. Tel. No.: e1/'1?
Address: ch h4l Cry /l/ PI'llti"t AMy3,)7f- Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security ork 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
Owner/Agent PERMIT FEE. $
Signature Telephone No.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
swww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nDlicant Information Please Print Legibl'
Name (Business/Organization/Individual):
Address: 9,1A L t\,)
City/State/Zip:�t1\� iVVI (130.7 � Phone #: 603 63 (i%,-xt�
Are you an employer? Check the appropriate box:
LEI ❑ I am a employer with 1
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. [T New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
'Any applicant that checks box #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 attached an additional sheet showing the name of the sub -contractors 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.
Insurance Company Name: h" v4 --r l!� I rVV11\TCW_1Q
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: A_ 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c5p y ur#,erfe pains and pens of perjury that the information provided above is true and correct.
Phone #: ' �% r 8-1 S— 1,,�?- P
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/Licerise #
—/J—/ U
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 #:
s"3los�o
Location 95� I /4l
No. Date
MORTil TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $ s
r� s• �'° U Eta'
MUS Building/Frame Permit Fee $
�G
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check # (~
22985
Building Inspector
Dae ..711a...... .7
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
'This certifies that .. U, C. 41�. ��.... �. ° .�'`
has permission for, gas installation ....% f L: ../ • G `?:. "
in the buildings of ..................
at .. .c? ` . 144—, :. ...... North Andover, Mass,
T O v AS INSPECTOR
Check #
7301
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date Z
NORTH ANDOVER, MASSACHUSETTS
Building Locations.
`Q w% 5
Owner's Name
New Renovation ❑ Replacement ❑
Permit # v I
Amount $ _40 b
Plans Submitted ❑
(Print or type) Check one: Certificate Installing Company
Name V L C 16-w— (� Ljr26 c ^�
❑ Corp.
❑ Partner.
® Firm7Co.
Name of Licensed Plumber or Gas Fitter , 6i� _3
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
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 Owner's Agent Owner ❑ Agent
• L.._..L.. _Ya: L. .L _. _11 _r.t_
---�.7 -.--, "--A WL "AV WALL u,iviii,auvu i iiavc suvuuueu kor enterea) in above application are true and 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 State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of;
pPlumber
❑
Gas Fitter
❑Master
journeyman
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SUB-BASEM ENT
F
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BASEMENT
1ST. FLOOR
2N'D. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
,8-T H. FLOOR
(Print or type) Check one: Certificate Installing Company
Name V L C 16-w— (� Ljr26 c ^�
❑ Corp.
❑ Partner.
® Firm7Co.
Name of Licensed Plumber or Gas Fitter , 6i� _3
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
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 Owner's Agent Owner ❑ Agent
• L.._..L.. _Ya: L. .L _. _11 _r.t_
---�.7 -.--, "--A WL "AV WALL u,iviii,auvu i iiavc suvuuueu kor enterea) in above application are true and 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 State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
2(,835—
Signature of;
pPlumber
❑
Gas Fitter
❑Master
journeyman
2(,835—
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/lndividual):
Address: 10tJ cr-- ti. � � l
City/State/Zip:I N )� ,6>3' �6
Phone #: to (5 3 ,- 23 3 ^ g t 7
ox:L❑Are you an employer? Check the appropriate box.-
LEII am a employer with
4. ❑ I am a general contractor and I
(full and/orpart-time).*
el
have hired the sub -contractors
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.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp,
c. 152, § 1(4), and we have no
insurance required.] t
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
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-- — ----•— �« �,� uut <uc a rubra Qe:ov, snov'mb +.s. ar ,.,o y compeusation policy tnfo^u� ion.
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 attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for
information. my employees Below is the policy and job site
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature:
Date.:
Phone #:
Official use only. Do not write in this. area, to be completed by city or town official,
City or Town:
Issuing Authority (circle one):
Permit/License #
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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 orother 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 cox npliance 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 inm=ce
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 perp it or license is being requested, not the DeparCmenT. of
industrial Accidents. Should you have any questions regardirig 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 -than k 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.
500 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
v rwv,.mass._ c ov/dia
Date........... .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... ...........
has permission to perform .... ...........
plumbing in the buildings of ..f. 1.. .��,7./.14 All c. 41',' ......... .
at , North Andover, Mass.
Fee.. ! 5' . Lic. No.. i �. �? . ....... V.,.....y /.I .......
4 rPLUMBING INSPECTOR
Check
8367
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
c� c�,1 Date
BuildingLocation / Sip'µ^ 5 Owners Name M,4 � G Pr rn � 1 Permit # "
Amount Z2 V
Type of Occupancy
New Renovation Replacement Plans Submitted Yes ® No
(Print or type)
Installing Company Name'
Address t S �U G
d3V7
Check one: Certificate
Cc': -
j> n Corp.
?% ` N ° Partner.
rl Firm/Co.
Name of Licensed Plumber: 'V, C-Ime_ 1t- SP -0a ��^
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature 7.1 Owner Agent E
I hereby certify that all of the details and informatiW I have submitted (or entered) in above application are. true and accurate to the
best of my knowledge and that all plumbing wor m ta11 tions erforined under Permit Issued for this application will be in
compliance with all pertinent provisions of the IVjas clietts StP }ibing Code�t�hapter 142 of the General Laws.
Title
City/Town
APPROVED (OFFICE USE ONLY
Type o Plumbing License
2 - X-5 �
icense um er Master Journeyman 0
/ /1 -NMI
owl
(Print or type)
Installing Company Name'
Address t S �U G
d3V7
Check one: Certificate
Cc': -
j> n Corp.
?% ` N ° Partner.
rl Firm/Co.
Name of Licensed Plumber: 'V, C-Ime_ 1t- SP -0a ��^
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature 7.1 Owner Agent E
I hereby certify that all of the details and informatiW I have submitted (or entered) in above application are. true and accurate to the
best of my knowledge and that all plumbing wor m ta11 tions erforined under Permit Issued for this application will be in
compliance with all pertinent provisions of the IVjas clietts StP }ibing Code�t�hapter 142 of the General Laws.
Title
City/Town
APPROVED (OFFICE USE ONLY
Type o Plumbing License
2 - X-5 �
icense um er Master Journeyman 0
The Commonwe¢lth of Alassachusetts
Department o f £radustrial Accidents
Office of£iivestigations
600 Washinboton Street
Boston, M4 02111
WWW_mass-govidia
Workers' Compensation Insurance -Affidavit: Builders/Contractors/Electricians/Plumbers
�p icant Information
Name (Business/organization/individual): `f
Address:fJF�,�
City/state/zip:
f
., Dib
----_ Phone#: (QC33- 2,33 -
Are -
You an employer., Check the appropriate box:
I. ❑ I am a employer with 4. ❑ I am a aeiaeral contractor and I
oyees (full and/or part-time).* have hired the sub -contractors
2 I am a sole proprietor or partner- listed on theattached sheet I
ship and have no employees These sub -contractors have
worlang for me m any capacity.
[No workers' comp. insurance
s
' required]
3. [].1 am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
workers' comp, insurance.
5. ❑ We are a corporation and its
officers hake exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. in required.]
= ?ica^ t5st chic .. bo : #' w_st also a, ou: a ecrioa ew
...::g =--ti
Type of project (required):
6. ❑ Nein construction
7. Remodeling
8. [] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
y(� . wners wno submit tins affidavit indicating thea a,, d " w ck and
omr ^ „r -a
l ontractors f} of eII Ca LS^ }sur m�.nr C .—
all Q ihed hrIe D f ... • uC`L
s _ox at -ch-- an additional sheet showinP the nrside con' -Met= 4t st s-uhntit a new amdavit indicating such.
acme of the sub -contractors and their workers' comp. Policy information.
f am an employer ghat is providing workers' compensation insurance for hr
information. my employees Belowis the policy and job site
Insurance Company
Policy # or Self --ins. Lic.
ity to Zip.
y of the workers' compensation policy declaration page (showing the policy number.and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in criminal penalties of a
the form of a STOP WORK ORDER and a fine
of up to $250:00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office a
Investigations of the DIA for insurance coverage verification
I fy do hereby certiunder the pains and penalties of perjury thcat the � formation provided above is true and correct
Expiration Date:
Job Site Address:
• C' /Sia / • .
Attach a cop
_ __._ Lane:.__ . _. ..- -- - •--
hone #:
Official use only. Do not write' in this area, to be completed by ciip or town ofliciaL
City or Town: 1 ermitUcense #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector
6. Other
Contact Person:
Phone#:
16
Information an- ci 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 "...everypt✓rson in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership,•associattion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the Iegal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association oo<- other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartmL tints and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mtemaance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be4--a se 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 C--onsiruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimp)iance 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 ua-tfl 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 bores that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone mumber(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' comp emsation 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 c,�7onfirmation of in ranee coverage. .Also be stare to sign and date the affidavit The affidavit should
be. returned to the city or tovim that the auu%rcaurin'r the uermaIt'QI 1:^.e::ge is being reqestd,-not the Depart---ot
oI
Industrial Accidents. Should yon have any questions regard' =b `?:e law or if you aye m ;'red to obtain a workers,
compensation policy, please call the Department at the numbe=r 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 '& 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 bum leaves etc.) said person is NOT required to complete this affidavit
The Office oflnvestigations worald lilm to than you in advance for your cooperation and should you have any questions,
please do not hesitate to eve us a call.
The Department's address, telephone and.fiznumbcr.__..
The Co=onwealtl- of Massachusetts
Department ofEadustrial Accidents
Dice of Inwesfiaations
600 Washing—tan Street
Bacton, M A 02111
Tel. # 617-72.7-4900 ext 406 or 1-9%-KkS-.S-A.FE
Revised ;-2F-05
Fa.: # 6.17-727-7749
vrvm, mass.-c,ov/dia
From :CHRISTIANSEN&SERGI
Fax No. :978 372 3958 May ef--� --010 11:G(Hll r L
#998 sALEM STREET
EXISTING
FOUNDATION
NOTE: STAIRS ARE
PROPOSED
a
in
Li
FOUNDATION
L OCA TION PLAN
CLIENT: J.MANGIAMELI &
BRISTOL COUNTY SAVINGS
THIS CERTIFICATION IS MAOE AND LIMITED TO THE ABOWF. CLIENT
LOCATION: NORTHANDOVER,MA.
DATE. .4/10 SCALE.•1"S60'
A1< *
i •1p+
ICERTIF'Y'(HAT TWE PRIMARY STRUCTURE SHOWN CONFORMS TO
THE HORD;ONTAL SETBACK REOUIREMENTS OF Tl4r LOCAL
APPLICAKE ZONING BYLAWS IN EFFFCT WHEN CONSTRUCTED.
Ma CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCH AS COVENANTS,WETtANDSAASEMENTS,
ORDERS Or CONDITftg.FTC.) THIS DRAWING SHALL NOT BE USED
DY THE CLIENT FOR ANY PURPOSE OTHER THAN YHAT OUTLINED
ABOVE,EXCEPT WON M WRITTEN PERMISSION OF CHMSTIANSF,N
Q SEROL INC. FUR7TILRMORE THIS GRAY" IS THE MPYRIMM-D
PROPERTY OF CHRISTIANSEN 5 SERGI INC. AND ANY
UNAUTHORIZED USE IS PHOINBITED.CHRtSTTANSEN A SERGI TAKES
ND RESPOMM&ITY FOR THE UNAIMIORIZED USE OF'IHIS
DRAWING OR ANY INFOR-MATION CONTAINED HEREON.
DASED ON SCALED DATA ONLY TIIC PRIMARY STRUCTURE 9HOWN
IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA
FLOOD INSURANCE RATE MAP. COMMUNITY N0.2 0118 000 C
DATE: JUNE 2.1q-93
PROFESSIONAL ENGINEERS & LAND SURVEYORS
CHRIS TIANSEN & SERGI, INC.
160 SUMMER STREET. HAVERHILL, MASSACHUSETTS 01830
W1NW.CSI-ENGR.COM TEL. 978-373-0310 FAX, 978-372-3960
D WO. NO- : 08011.001.00$