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HomeMy WebLinkAboutMiscellaneous - Exception (123)i NORTH OF ,°u '6,ti0 Town of North Andover +� �o : Machine Shop Village Neighborhood Conservation District Commission 1600 Osgood Street North Andov=er, MA 01845 S�CHUS Application For EXCLUSION From Certificate to Alter Certain alterations are excluded from review by the Machine Shop Village Neighborhood Conservation District Commission in accordance with the Bylaw. Applicants for exempt projects must fill out the form below and submit to the Commission Chairperson (contact info below). Date: 2— U Contact Name & Address: Wa,y t em , 'S =,Q�_f'oyt j ..��D Pro ect Address: Project Description (attach additional pages, il )20 (1 rr 12a t f S it Exclusion From Review Requested For. ❑ 1. Interior Alterations ❑ 2. Storm windows and doors, screen windows and doors. ❑ 3. Removal, replacement or installation of gutters and downspouts. ❑ 4. Removal, replacement or installation of window and door shutters. ❑ 5. Accessory buildings of less than 100 square feet of floor area. ❑ 6. Removal of substitute siding. ❑ 7. Alterations not visible from a public way. ... — 8. Ordinary maintenance and repair of architectural features that match the MSV NCDC Pagel Current Chair. Liz Fennessy, 77 NORTH OF,t��c s,ti� Town of North Andover Machine Shop Village Neighborhood Conservation District Commission 1600 Osgood Strcct North Andovcr, MA 01845 ,SSACHUSSt Application For EXCLUSION From Certificate to Alter For Items 9,10 or 11, provide the following documentation: Photos/drawings of existing doors, windows or siding, as applicable Description/Catalog Cuts of proposed materials to be iised for doors, windows or siding Plan and elevation of reconstruction for Item 11 Determination: This project is determined to be plEIxempt ❑ not exempt from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects that are not exempt must complete the Application for Certificate to Alter, available from the Building Department and be reviewed by the Commission. Determination made by: bL fC005SY Signature A Conservation / 2-, J t/,;,? '� o-' /�L Date MSV NCDC Page 2 Current Chair: Liz Fennessy, 77 Elm Street, lizettafennessy@vahoo.com, 978-688-2915 „oera Of T�.o •6,�C Town of North Andover +� �o Machine Shop village Neighborhood Conservation District Commission 1600 Osgood Street North AndoN cr, MA 01845 S�CNUS Application For EXCLUSION From Certificate to Alter . Certain alterations are excluded from review by the Machine Shop Village Neighborhood Conservation District Commission in accordance with the Bylaw. Applicants for exempt projects must fill out the form below and submit to the Commission Chairperson (contact info below). Date: 1.1 Contact Name & Address: 2.1 Project Address: Project Description (attach additional pages, if needed): Exclusion From Review Requested For. ❑ 1. Interior Alterations ❑ 2. Storm windows and doors, screen windows and doors. ❑ 3. Removal, replacement or installation of gutters and downspouts. ❑ 4. Removal, replacement or installation of window and door shutters. ❑ 5. Accessory buildings of less than 100 square feet of floor area. ❑ b. Removal of substitute siding ❑ 7. Alterations not visible from a public way - 8. Ordinary ay.8.Ordinaryd maintenance and repair of architectural features that match the existing conditions including materials, design and dimensions. ❑ 9. Replacement of existing substitute doors, substitute siding or substitute windows with new materials that are substantially similar to the existing condition. ❑ 10. Replacement of original fabric windows or doors with substitute windows or doors that maintain the architectural integrity with respect to form, ft and function of the original windows or doors. ❑ 11. Reconstruction, substantially similar in exterior design, of a building, damaged or destroyed by fire, storm or other disaster, provided such reconstruction is begun within one year thereafter. MSV NCDC Pagel Current Chair. Liz Fennessy, 77 Elm Street, lizettafennesUftahoo.com, 978-688-2915 NORTH Town of North Andover F 71 Machine Shop Village Neighborhood Conservation District Commission 4;f b*.nn 1600 Osgood Street North Andover, MA 01845 SSACHUSS Application For EXCLUSION From Certificate to .Alter For Items 9,10 or 11, provide the following documentation: Photosldrawings of existing doors, windows or siding, as applicable DescriptionlCatalog Cuts of proposed materials to be used for doors, windows or siding Plan and elevation of reconstruction for Item 11 Determination: This project is determined to be X—Ixempt ❑ not exempt from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects that are not exempt must complete the Application for Certificate to Alter, available from the Building Department and be reviewed by the Commission. Determination made by: bL f-CONSW Signature n _ Conservation Date MSV NCDC Page 2 Current Chair: Liz Fennessy, 77 Elm Street, lizettafennessy@yahoo.com, 978-688-2915 `0042 Date.. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................... 6 /2 L) ......... U30.6a. 0 1) ..................... 4 has permission to perform .....& ...5.I- ....... 5�4,. wiring in the building .......................................... at .......... ........T ............................. .. North Andover, Mass. Fee ... qd.S2... Lic. No... ......... .. . ........ Check# -3qz-8-- C� . 'i§ -16� �i�SPEC�OR: -Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. l QE q z, Occupancy and Fee Checked tev. 1/07] (1P.AVP h�anUl 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 IN INK OR TYPE ALL INFORMATION) Date: 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) Owner or Tenant %1 �1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Pur os f B 'ld' p e o ui mg Utility Ant ization No. Existing Service,/Amps �/� olts Overhead Undgrd ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity No. of Meters Undgrd ❑ No. of Meters Location /and Nature of Proposed Electrical Work: ��� � .A �'z/� a tea. %`_ i 25'. 70_ ._ c. .�.«�."ceauwrnat aerau v aesirea, or as required by the Inspector of Wires. Estimated ValAofc ' al Work: (When required by municipal policy.) Work to Start:// Inspections to be requested in accordance with MEC Rule 10, and upon completion. CE GE: Unless waived. by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins ance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover 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 o his application is true and complete. FIRMNA LIC. NO. Licensee: (If applicable, enter "exem t" in the license umber in . � Address: �� ©� Yult.: Tel. No.• *Per M.G.L c. 147, s. 57-61, security work requires Departm 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) ❑ own Owner/Agent er El owner's agent. Signature Telephone No. PERMIT FEE: $ ELECTRICAL PFpMT No. _ �tSpECTIOrT REPORT: ELECTRICAL INSPECTOR - DOUG SMALL f ROUGH1NSECTION:assed — Failed — [) Re -inspection required($50.00)spectors' comments: t • i uR.v ., (Inspectors' Signa re - n zfials) Date 2. FINAL INSPE ON; Passed — [ Failed — j ,] Re -inspection required ($50.00) Inspectors' comments: ki syc-urs• signature - no 3. UNDERGROUND INSPECTION. Passed — j I Failed — j ] Inspectors' comments: k..Lu�prcwrs- signature - no ii 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed — [ ] Failed Inspectors' comments: (Inspectors' Signature - no ini — �.XLV'JA - vlttLt4: ham ,I r i xaLLea — Inspectors' comments: 0 1 Re -inspection required ($50.00) Date NAME: inspection required ($50.00) Date -inspection required ($50.00) 7lafr> D OOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TBE AREA TO BE ACCESSIBLE AND A RE -INSPECTION O ��ECTED IS NOT F $50.00 IS TO . BE AGED. 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 Name (Business/Organization/Individual): Address: 60 M /� City/State/Zip: Zig 411e� Phone 4.Z!� /� Are you an employer? Check the appropriate box: 1. ❑ I am a oyer with 4. ❑ I am a general contractor and I e oyees (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sh%et. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We ate 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. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer 'r the pains apenfilties o� pery that the information provided abovyis tru$'and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy; please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia