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Home My WebLink AboutBuilding Permit - 223 FOREST STREET 10/17/2011 (2) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CVx r b<, CAA Address: City/State/Zip: N1 . N�rNdo e c- QN��hone #: Are you an employer?Check the appropriate box: Type of project(required): 1. ❑ I am a employer with 4. ❑ I 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. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its equired.] officers have exercised their 10.❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.❑ Other comp. insurance required.] *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 isproviding workers'compensation insurance for nny employees. Below is thepolicy 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 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 paints and penalties of perjury that the infornttation provided above is true and correct. Si nature: t_ k,Il Date: 10 i`d ( it Phone#: Official use only. Do not write in this area,to be completer)by city or town offncial. 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#: µDKr" TOWN OF t`e NORTHANDOVER ~=bi� k6°�� - OFFICE OF BUILDING DEPARTMENT AL iiR 1600 Osgood Street Building 20,-Suite 2-36 "vss^1_ North Andover,Massachusetts 01845 A�HUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER-LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: (j JOB LOCATION: (j, w> Number Street Address Map/Lot OMEO ' IST WNER Name Home Phone Work Phone PRESENT MAILING ADDRESS ,)A ry re5.1 City T-0-w Ctatn. Zip Code The current exemption for"-homeowners"was extended to include owner-occupied dwellings to f-vo units or-less anal to allow such homeoVTers to engage an it Avid�tal-for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who Qwns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements.. HOMEOWNERS SIGNATURE L APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTI, own of0r �'', 11% Andove r ., 6 V O♦ F4� 14'51. '�.�K'�1.:��., (fir /� 1 -� LAKE O ove dCSS.' •Al ■� •' A ... COC HI C HE WICK rED BOARD OF HEALTH PERM ,1T , T D Food/Kitchen Septic System ® BUILDING INSPECTOR THIS CERTIFIES THAT................... .. ..1!!. r..s........... .. tt............................... Foundation has permission to erect. ..................................... buildings on ..a ... ............ k�� ........ .................... ............... Rough to be occupied as....4on� f.......................'................ ..jr�!r...................1 AW�. ...................................... Chimney provided that the pe accepting this permit sha in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMrr ENPIRES IN 6 THS ELECTRICAL INSPECTOR LESS CONS C S Rough .................... ........................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required t® Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.