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Building Permit # 6/4/2015
BUILDING PERMIT %AORTil 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION it4000 - 4 4 Permit No#: Date Received ��A�RATeuWAP" 4y �SSacHus�� Date Issued: IMPORTANT:Applicant must complete all items on this page N 'S Of il"R, Nl- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building [YCOne family Jff.Addition El Two or more family El Industrial tAlteration No. of units: El Commercial El Repair, replacement El Assessory Bldg 11 Others: 0 Demolition El Other ill'I/V5JR/111" U, ❑ tershiM District' 5 DESCRIPTION OF WORK TO BE PERFORMED: I L 'S e�c +i y�,J to re-c, Y- e,-1 C— r e no 14 Identification- Please Type or Print Clearly OWNER: Name: Phone: ' ,tet e) kol� l Address: 3 x/1",E'77, 30F ,",Ar AN; & i V11111" ARCHITECT/ENGINEER Phone: Address: 'I v3 Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ VO FEE: $ .i % q \n, Check No.: 12 7 Receipt No.:— NOTE: Persons contracting ith nregi wred contractors do not have ac ess to the-Aluaranty fu Si nature of Agent/Own nature of contracto tu Plans Submitted.'�$ Plans Waived El Certified Plot Plan6 Stamped Plans ❑ TYPE'OF SEWERAGE DISPOSAL Public Sewer El Tanning/Massage/Body Art ❑ Swinuning Pools El Well El Tobacco Sales ❑ Food Packaging/Sales El Private(septic tank,etc. ❑ Permanent Durapster on Site ❑ Li THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM it it -9 Reviewed On Signature PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS. 'Jo HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Oood Street 'FIR ',ART ,Temp„ ut'-p'pster",on site'.�, no DEPARTMENT Located at 1�4-,Main Street-, .......... - a �'4 , : , �'" Fkd,Ddhn1 '0aen1t smghatu're/da e COMMENTS`` -� t%ORTy Town of _ s E ndover jo o h ver, Mass, coc"Ic"twic« �.es RA rE c) I.P�A U BOARD OF HEALTH Food/Kitchen PER MIT T LD Septic System THIS CERTIFIES THAT ..... ...���.F.,�:,�"!.n-r.�:..�.....................................................................:..... BUILDING INSPECTOR has permission to erect .......................... buildings on ...:......�.... ...................................................... Foundation Rough to be occupied as ....................... r..� ,,� !�.�. .......... �....�....r.�� .....�/'�r�y�.. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough �j7 Service ...................... .'�. .v........ ....--..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. • 98 Forest Street Kevl . h . Mi,trphy ® North Andover,MA 01845 • PH:978-688-5335 Building Contractor • FAX:978-688-7207 Proposal To: Sam&Laurie Messina 129 Winter Street All Home improvement Contractors and Subcontractors engaged in home improvement contracting,unless North Andover, Ma. 01845 specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and Status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place, From: Kevin Murphy Room 1301,Boston,MA 02108.(617)-727 8598 CC: Date: 4/30/2015 Job: Garage addition/Kitchen renovation Date of plans: 3/11 Architect: Alfred Warren Location: Same Section 1—Work Schedule Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 5/1/15. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 8/30/15.The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11-Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair correct, replace,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section 111-Scope of Work Page 1 of 5 Keviii Murphy Page 2 of 5 Building4:rai-ttractoi 9 98 Forest Street North Andover,MA 01845 PH:978-688-5335 FAX 9781887207 General Proposal is to add 16'x26'section to rear of existing garage, and renovate existing kitchen/family room/dining room. Building permit will be provided by contractor. Any conservation / board of health approvals to be obtained by owner. Buillding plans/plot plan to be provided by owner. Demolition Existing kitchen and family room areas will be completely gutted. Wall between dining room and living room will be removed. Rear wall and foundation of existing garage will be removed. No allowance has been made to cut any existing interior brickwork. Excavating Excavation required to install frost wall foundation for new garage will be provided. Backfilling and rough grading will be provided. Loam will be stripped, set aside, and spread after foundation is complete. No allowance has been made for removal of ledge, relocation of any underground utilities/sprinklers, installation of erosion control, landscaping or lawn repairs.Any additional fill will be removed from site. Foundation Poured concrete foundation will be provided as shown on plans/to meet code. Footings will be 10"x20", walls will be 10"thick, grade to match existing. Five inch thick concrete floor will be poured over crushed stone base. Concrete cutting will be performed to remove rear wall of garage. Front corner of garage will have portion of wood frame removed, and concrete block wall installed. Concrete pad will be poured outside rear garage door. Building All frame, roof, and siding materials will be supplied / installed as shown on plans / to match existing / meet code. Sills will be pressure treated 2x6, walls of garage will be 2x4, ceiling joists/ rafters will be 2x10. All wall and roof sheathing will be fir plywood ( 1/2 on walls, 5/8 on roof) . Roof shingles to match existing. Exterior garage walls will be wrapped with Tyvek or equivalent. Siding will be vinyl shingles. Cornerboards will be Azek. Frame material required to create tray ceiling in family room will be provided. Miscellaneous trim/siding on front dormers, and gable end vents will be replaced/repaired as required. Garage door openings will be re-trimmed with Azek. Landing/step off rear of garage will be built to match existing.Anderson triple casement window will be supplied and installed in rear wall of kitchen. New fiberglass entry door will be supplied and installed in rear of garage. 1 Plumbing Plumbing required to renovate kitchen will be provided. Sink to stay in same location. Gas piping for appliances, and heater in garage will be provided. No allowance has been included to supply/install heater in garage. An allowance of$1500 has been included for new sink and faucet. Electrical Electrical work required to wire garage/kitchen to code will be provided. Twelve five inch recessed lights have been included. Phone / cable / computer lines to be roughed in by electrician, to be connected by service provider at owner's expense. Surface mounted fixtures to be supplied by owner, installed by contractor. General layout to be approved by owner, prior to rough. No allowance has been made to upgrade existing electrical service. Kevin Murphy Page 3 of 5 Building Contrwtor 98 Forest Street North Andover,MA 01845 PH:97&688-5335 FAX 978E88-7207 Heating/Air Conditioning Forced hot water heating will be relocated as required. Air conditioning supplies / returns will be relocated as required. Insulation Kitchen/family room areas will have fiberglass insulation installed to meet code. Plaster Renovated areas will be blueboarded and skimcoat plastered. Walls will be smooth, ceilings to match existing. Garage will be to firecode. Interior Trim/Doors Interior trim will be supplied and installed to match existing. New fire rated six panel door will be provided at garage entry. Beadboard will be supplied and installed in entry area. No allowance has been made to replace mantle around existing fireplace. Kitchen cabinets to be supplied by owner, installed by contractor. Kitchen counters to be supplied/installed by others. Painting All interior painting will be provided. One coat of primer and two coats of finish will be applied to all painted surfaces. Flooring Hardwood floors will be supplied / installed /finished in kitchen /family room. Existing hardwood floors will be refinished. Three coats of oil based urethane will be applied. Floor in dining room/living room will be patched as required. Other Allowances Tile back splash will be installed in kitchen. An allowance of $7 per square foot has been included for tile materials. Central vacuum outlet will be relocated as required. If kitchen window is not built out, a credit of$1500 will be given. Waste Removal All demolition/construction debris will be disposed of by contractor. Kevin Murphy Building Contractor Page 5 of 5 98 Forest Street North Andover,MA 01845 PH:97&6885335 FAX:978588-7207 Section IV-Price Schedule We hereby propose to furnish material and labor-complete in Accordance with above specifications for the sum of... ... ... ... ... ... ... ... ... .. $ 118,000 Payment to be made as follows: Percenta a/Item Descrinition Amount 1 Permit obtained / deposit $10,000 2 Foundation complete $15,000- 3 Roof framing complete $20,000 4 Siding complete $15,000 5 Rough plumbing / electric complete $18,000 6 --Plastering complete $12,000 7 Cabinets installed /trim com tete , $10,000 8 Painting /flooring complete $10,000 9 Job 100% complete $8000 Total 9 $118,000.00 "Notice:No agreement for Home improvement contracting work shall require a doom payment(advance deposit)of more that one-third of the total contract price of the total amount of all deposits or payments which the contractor must make,in advance,to order and/or otherwise obtain delivery of special order materials and equipment,whichever is greater Contractor: Kevin Murphy 98 Forest Street No.Andover, MA 01845 Registration No: 101874 Section V—Acceptance Acceptance of Proposal—I have read this document and accept the prices, specifications,and conditions stated. I understand that upon signing, this proposal becomes a binding contract, You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing O NOT SIGN THIS ONTRACT IF THERE ARE ANY BLANK SPACES Signature t Date Signature �``�'" C` . '''7 c,s ,,�� Date a �lzoG'- Gr1� (�' ,Ll D O l T►o s-4 A W r-1 � T UrP'o ? teW t-t. `/z 570 - U d, co @ 0 w IE m ® D o��c is RFS r MAY NORTH ANDOVER PLANNING DEPARTMENT DRIP EDGE DETAIL (n.t.s.) Print Form NORTH _nftt4�a s�'b0 OL O � * 5 ATIP 04, t: X ��SSACHUSE{fig PLANNING DEPARTMENT Community Development Division Special Permit —Watershed Permit Application Please type or print clearly. Y� t✓ N A 1. Petitioner: SAt.N To RC A- NazTEi �,vpovE� . r✓d9- Petitioner's Address: 129 t-'PI tr"e2 ST Telephone number: 2.owners of the Land: SA �yA ►o G - `�s 'N� Address: 124 W-/AJTclz Number of years of ownership: Z9 3.Year lot was created: 1" 8 5 4. Is the lot currently on septic or sewer? g6WE5�e— lf on sewer,please provide date the sewer connection was completed: M, g + 5.Description of Proposed Project: t 6o �� A L' 1�-- o f A 1 !n! T/ /V !3 B1& G16 K-1 S- t/Cr 6T�BLC r--,M dy 625 h r=v(L A-1?D�) - 6.Description of Premises: s/N(r' 7.Address of Property Being Affected: /2 4 ►�/ �2 `�7 Zoning District: R I Assessors Map:–lAe 5 B1-IC i t S Lot#: Registry of Deeds: Book#: 41 S y0 Page#: D Z 8. Existing Lot: Lot Area(Sq. Ft): Building Height: Street Frontage: /8 9. '5 Side Setbacks: Front Setback: 75; ' * Rear Setback: Floor Area Ratio: D, 025 Lot Coverage: 9. Proposed Lot(if applicable): Lot Area(Sq. Ft): Building Height: Street Frontage: Side Setbacks: Page 1 of 2 1600 Osgood Street,North Andover,Bldg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.688.9535 Fax 978.688.9542 Web www.townofnorthandover.com Edited 8/6/07 Front Setback: Rear Setback: Floor Area Ratio: Lot Coverage: 10,Required Lot(as required by Zoning Bylaw): Lot Area(Sq. Ft): Building Height: Street Frontage: Side Setbacks: Front Setback: Rear Setback: ------ LotCoverage: Floor area Ratio: 11.Existing Building(if applicable): Ground Floor(Sq. Ft.): 17 67 #of Floors: 2 Total Sq. Ft.: Z 87`i Height: Use: 'e J6 LE Type of Construction: woop fR'tM E 12.Proposed Building: Ground Floor(Sq. Ft.): �l 1 #of Floors: ) Height: ►M h-r erl Hei CK i ST. 2 Total Sq. Ft, 4 I �_. 9 Use:_�'t, "/;-' rXTF,a- Type of Construction: woo D 13.Has there been a previous application for a Special Permit from the Planning Board on these premises? P o If so,when and for what type of construction? -_cb T r1 e P,,7 GSA v. V__NOuJ 4-65D 14.Section of Zoning Bylaw that Special Permit Is Being Requested `f•/310 15.Petitioner and Landowner signature(s): Every application for a Special Permit shall be made on this form, which is the official form of the Planning Board. Every application shall be filed with the Town Clerk's office. It shall be the responsibility of the petitioner to furnish all supporting documentation with this application. The dated copy of this application received by the Town Clerk or Planning Office does not absolve the applicant from this responsibility. The petitioner shall be responsible for all expenses for filing and legal notification. Failure to comply with application requirements, as cited herein and in the Planning Board Rules and Regulations may result in a dismissal by the Planning Board of this application as incomplete. Petitioner's Signature: Print or type name here: ✓►�tA/ Owner's Signature: S Print or type name here: 16.Please list title of plans and documents you will be attaching to this application. Page 2 of 2 1600 Osgood Street,North Andover,Bldg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.688.9535 Fox 978.688.9542 Web www.townofnorthandover.com Edited 8/6/07 Abutter to Abutter ) Building Dept. ( ) Conservation ( ) Zoning ( ) MGL 40A,Section 11 stales in part"Parties in Interest as used in this chapter shall mean the petitioner, RE�UI�EMEIJT: abutters,owners of land directly oppositeon any pudic or private way,and abutters to abutters within three hundred(300)feet of the property line of the petitioner as they appear on the most-cent applicable tax list,not withstanding that the land of any such owner is located in another city or town, planning board of the city or town,and the planning board of every abutting city or town Subtest Property: Name Address MAP PARCEL 103 118 Salvatore A.Messina 129 Winter Street North Andover,MA 0184 Abutters Proaerties Map Parcel Name Address 145 South Bradford Street North Andover,MA 01845 103 30 Rodney Hollenbeck 135 South Bradford Street North Andover,MA 01845 103 31 Carolyn McDermott 140 Winter Street North Andover,MA 01845 103 99 David Williams 855 Great Pond Road North Andover,MA 01845 103 117 Oleksandr Stupnyskyi 115 Winter Street North Andover,MA 01845 103 119 Mary Messina 95 Winter Street North Andover,MA 01845 103 120 David Bourassa 159 Writer o.Bradford Street North Andover,MA 01845 1103 10 Verne Westgate 201 So.Bradford Street North Andover,MA 01845 104.0 11 C.Perkins 70 Bridle Path North Andover,MA 01845 104.0 13 Kenneth Tilley 96 Bridle Path North Andover,MA 01845 104.0 17 Richard Balmas 187 So.Bradford Street North Andover,MA 01845 104.0 44 Alan Yost 175 So.Bradford Street North Andover,MA 01845 104.0 71 Richard Hadjian 100 Bridle Bradford ath North Andover,MA 01845 104.0 72 Brendan Salach 124 Bridle Path North Andover,MA 01845 104.0 73 William Orlansky 136 Bridle Path North Andover,MA 01845 104.0 74 Stephen Lopilato 148 Bridle Path North Andover,MA 01845 104.0 75 Linda Weeks 145 Bridle Path North Andover,MA 01845 104.0 87 Joseph Blackburn 127 Bridle Path North Andover,MA 01845 104.0 88 Kimberlee Chatson 117 Bridle Path North Andover,MA 01845 104.0 89 Loren Carlson 57 Old Village Lane North Andover,MA 01845 104.0 166 Cameron Deery Date 5/15/2014 1 This certifies that the names appearing on the Page 1 of records of the Assessors Office as of Certified by' Date /J FOR REGISTI (VARIABLE WIDTH) STREET --- Fr- (PRIVATE) D H(set) _ a'a,c�<-°.A A-_ WR D.H(set) N 59°36'34"W ' N 3 Z+K D H(set) D H(set) DH(sett O H(set) -- -'� 7 17845' s N ` 91 25• W 48!038 2, 0.61,6) � //�Ira.3'a'�� E // DH(se0 ��a5"W ... 159B'': 4?' . .. 5129° _ 53'32'17"W ------- / .. 134.02 5!BJ 9a 31'S7rW N SP125TW N g 8.36' 7602 _ -16165' N ._ _ N N 63 -44.43 13' DH.(tnd.) �✓ (57.21 105.` 150.00'TOTAL 15000, '2800' N�� 3 ?qqq fly N la 19`N N 60 96 5x..65': IOTA 227.63 TOTAL L e•""'"- TOTAL L 18965' TOTAL W y cl. . 94 55 150.00 / DH.lzetl .• : 3455 DH(set) yl O 55.00 � 9� 10TPL RP.(set) 152 t6'TO".AL N/F 'r�>/ Cormello B Anpelike pp' 0 1113 /L rn 2 Gelmbella D H.lsefl y a 330 LOT 3 LOT_2 SOT I - NOTE' ZONING DIST 3 LOT 5 LO�.T 4 114,668 S.F. 103,925 S.F. n 148,847 S.F. 137,025 S.E 122,988 S.F 8 DH(fnd) y D H(md) 110,271 S F __ NORTH_ANDQY.0 ,PLP�NNL // i393•S }- T 7 ,, „70'� THIS PLAN DOES NOT REGI APPROAL Q, 108,062 S.F PLANNING OFTHENORTH AN n ?. e WF F- Ernest aAntari uc OH(Ina) Romaw.) 3 N h 1m D.H.(rKl) THE ABOVE ENDORSEMEMENT N� N DETERMINATION AS TO CONFO is S.8 Margaret L. 9 ;a ': WITH ZONING REGULATION, Walker H w N O.H.(fnd) 1 a in N �'or� N N D.H-Ifnd) O�• �W N £ SOUTH / Andover Swings Bank \�v SITE'1 C S 2 �, BRIDLE pp,M F /O° N/F \yams, William W.Hurley R' � h 5 D.H.(frd) a'd `p.H.(set) N/F .cg... MiUgel A a Maureen A.M. S , I HEREBY CERTIFY THAT �� �2 PLAN CONFORMS TO THE RULES �.y REGULATIONS OF THE REGISTER' yS. DEEDS OF MASSACHUSETTS, F ' W REGI ALL) I-AND SrIJ-a S/O Cg -ry NOIE-SEE PGQEF.ENT O TCI IOIL 26.1985SILE INTHEOFFICEOFIHEPIDNNINGEDAIDFWTHETONN F OF NORTH ANDPIET,Nps HUSFTTS- O.Hf;etl O?9g 9r m PLAN of LAND yob _ m in D.n.(fnd] NORTH ANDOVER . MAS N/F �3°/"33 Scolex I"=501 Dafe- March 2E Andover Sau(nps Bank �3g E - - _ PREPARF�FOR' SANTO 8 ANNA MESSINA AN OH.(}rd] /g9 lag vj N/F SALVATORE A.B LAURIE ME 4q. 4q• n William W.Hurley PREPARED BY S ?e° and over AZ \ig F 47• / consultants , 30.00-. 8 inc. OH.(tnd) S 42"341' 114.72' rR ,'4q"E 174.7?• N/F D.H.((ndRobert S��4,1?, D.H-(tOd) 213 BroaO 50 Methuen,Maw. Richard S.8 Carol Ann Balmas �' 0 50 100 150 N/F Robert R.8 Poula M.Dozoi; Residential Property Record Card PARCEL_ID:210/103.0-0118-0000.0 MAP:103.0 BLOCK:0118 LOT:0000.0 PARCEL ADDRESS:129 WINTER STREET FY:2014 PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 04850 Road Type: T Inspect Date: 04/27/2010 Tax Class: T Sale Date: 09/23/97 Page: 0025 Rd Condition: P Meas Date: 04/27/2010 Owner: Tot Fin Area: 2874 Sale Type: P Cert/Doc: Traffic: M Entrance: C WINTER STREET REALTY TRUST Tot Land Area: 2.39 Sale Valid Inspe F Water: tld: RRC C/O SALVATORE A.MESSINA Grantor: SALVATORE MESSINA Sewer nspect,Reas: C Address: 129 WINTER STREET Exempt-B/L% / Resid-B/L% 1001100 Comm-1311-P/6Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CP Tot Rooms: 7 -Main Fn Area: 1767 Attic: NBHD CODE: C NBHD CLASS: 6 c ZONE: Inf1u-Y/N Value Class Story Height: 1.75 Bedrooms: 4 Up Fn Area: 1107 Bsmt Area: 1746 9 yP i 198,412 Se T e Code Method S Ft Acres In Roof: G Full Baths: 1 Add Fn Area: Fn Bsmt Area: 250 1 P 101 S 43560 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 1.390 10,564 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2874 DETACHED STRUCTURE INFORMATION Foundation: CN Bath Qual: T RCNLD: 320500 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%GQod P/F/E/R 'Cost Class Kitch Q4al: T Eff Yr Built: 1985 Mkt Adj: - SE S 160 0.00 2002 A A ///94, 2,400 Heat Type: HW Ext Kitch: Year Built: 1984 Sound Value: Fuel Type: G Grade: AG Cost Bldg: 320,500 VALUATION INFORMATION Fireplace: 1 Bsmt Gar Cap: Condition: AG Att Str Val 1: Current Total: 531,900 Bldg: 322,900 Land:', 209,000 MktLnd: 209,000 Central AC: Y Bsmt Gar SF: Pct Complete: Att Str Va12: g 219,200 MktLnd: 219,200 Prior Total: 542,100 Bldg: 322,900 Land: Aft Gar SF: 728%Good P/F/E/R: /1001100185 Porch ym Porch Area Porch Grade Factor P 60 S 196 T 210 W 368 Parcel ID:210/103.0-0118-0000.0 as of 4/29/14 Page 1 of 2 BK 4850 RG 25 2s DEED We, SALVATORE A. MESSINA and LAURIE A. MESSINA a/k/a LAURIE MESSINA, of North Andover, Massachusetts, for consideration paid, and in fall consideration of less than $100.00, hereby grant to LAURIE A. IvIESSINA;-Trustee of the-_Winter-_Street- Realty__Trust u/d/t da ted zv 1997, and recorded with the Essex North District Registry of Deeds imm rarely prior hereto, of 129 Winter Street, North Andover, Massachusetts, d WITH QUITCLAIM COVENANTS,the following: ro Massachusetts,bounded and described as follows: The land in North Andover,Essex County, a m 1ph NORTHWESTERLY:By the southerly line of Winter Street 161.65 feet; again by the >a southerly line of Winter Street 28.00 feet; �. SOUTHWESTERLY:By land now or formerly of said Santo Messina and Anne Messina and Salvatore A. Messina and Laurie Messina in two courses, 175.00 feet and 816.96 feet; SEP 24197 AM10:30 NORTHEASTERLY:In five courses, 365.11 feet by land now or formerly of William Hurley; 153.06 feet by land now or formerly of William W. Hurley; w 200.30 feet by land now or formerly of William W. Hurley; 155.14 feet N by land now or formerly of Ernest and Antionette Romano; 150.77 feet o by land now or formerly of Carmello and Angelike Genzabella to the R a point of beginning. 1 ribed shown as Lot I o AndoveLand in North r`, Massach�usetts, recorded with the C4 The mises ceEssex North District Registryoof Deeds as Plan c #12017. Being the same premises conveyed to the Grantors herein by Deed dated April 29, 1992 and a° recorded with the Essex North District Registry of Deeds in Book 3452, Page 278. H d a 0 H a BK 4850 PG 26 Signed as a sealed instrument this dy of + 1997. + alvatore A. Messina Laurie A. Messina a/k/a Laurie Messina COMMONWEALTH OF MASSACHUSETTS ESSEX, ss A, 1997 Then personally appeared the above-named Salvatore A. Messina and acknowledged the foregoing instrument to be his free act and deed, before me, o Richard G. Asoian My commission expires: MYCOAM?IBf EMFEB FEBAM 28,t498 COMMONWEALTH OF MASSACHUSETTS ESSEX,ss -/� � 1 997 Then personally appeared the above-named Laurie A. Messina a/k/a Laurie Messina and acknowledged the foregoing instrument to be her free act and deed, before me, lIC0tf9_YjbIbJJ0 Richard G. Asoian My commission expires: MY CCIAMIs M E)FM FEBRUARY 28,1299 Q:kommonVed-ea\deea.Une,dna.aed f Residential Property Record Card MAP:103.0 BLOCK:0118 LOT:0000.0 PARCELPOTO E ADDRESS:129 WINTER STRET FY:2014 PARCEL ID:210I103.0-0118-0000.0 SKETCH bur S w 186 Sq M 196 S j4 182 FU-0.75 FM/B _. . a 1476 Sq.Ft 18270 Sq 728 Sq.Ft 28 28 FM 36 1497 Sq.Ft 4 gg T 1476 Sq.1pt4 210S I 129 WINTER STREET K, Page 2 of 2 Parcel ID:210/103.0-0118-0000.0 as of 4/29/14 d�tie3fi /s° /02 40 tiiF aoao /��/ LAND 1- PL-AN of LAND NORTH /�NztoVE.R, SCALE � I"� 50' Qars. �6p�RUA0.Y s7,1942 //f�/D� PRC PARED Fo Ts' N SANTO ANA lklM A _ It � SALV AT�C.)RE ! LAURIEa MMssINA PREPARED B Y ENVppIRONEERS, INc.- P O. L7ok S1lo M [� D NORTH ANDOVER, i•\A Q18�I5 _ roR R-G,STTky se ONLY LOCUS HCRQEY CERTIFY -THAL THE..•pRopwKTY 04 A r LINKS SI•bWN AR= TMC LINE- DIVIDING EMIsriNG. 51T6 r• Ow jeK SHI'Ps, ANO To,- LINIGS of sTRGCCS _ n N H AND MAYS ARn Those QP T>U%LIC Ota PRIVATG _ Ir N SrREHTS OR WAYS. ALREADY sSTARLIaHGD-c- -� //\ VIIIn C AND No NEW 61NGS FaR DIVISION of li/II TIN 1t. .pl j •l OWNGRS}11T-s. oR NEW WAYS Aue S1AoWN1 _ ANO THAT TR— PLAN CONFORras TO THG 'RULES_ k ANO A60 UL4TION 3�GOF7 TTME�RGGIST!•fa, OF DEEDS, 3/ 1 LOT I ONLY TO 8E DAEw�2DE0 TU N SALVATOR'E � LAUhI> i'\E 331 N.1 h '.. 3 M N 2 0 7 n, LOT a � n 103,925 t S.F. h p 0 2.3q rAc. m H CIRA Ex-mwbs `IS"/ NOTE LOTS 2--7 ARE CVMBWEn OF �LON6D AARA _ BY THIS pL.AN To FtZ2 aM/LOT A- SeQ -FY- " 'gY ANDOVER CONSuLTANTS lNC. •LIAfrEL. MA-FI--H 28, 19 d•S.'ScE AL-s0 RoM�ND � 3 AGRGEME'NT DTD ApplL 26.IgHS FIL.iO IN oPFlrp 0 ' OF rL ANNING --N of NoRTH ANDOVER,M4, n /� D n T NORTH nNDOVER I LANNING �OARp ry h n h a 7� TNI, PLAN/ DoMS NOT Rao ZeG 1 Ne �• A'PPROV/ l o, 'HE NoRTHANDOVER PL.ANNI G 8t '0A -� N/v Gt~74O�C THE Qi3oVG E7NDORSCM¢NT IS NOT A�1 N 1• Sq,i 0� j DETEAININATION As To Cot.)FORM c- 0 t ,' NN 7G 4f ( tl WITH �ONING R(�GU-AT IG NS J , N i N 2 ZONING DIST'ia1CT �- i r TAL i 1 I61.G5' ' N33 23=17"W_ -- ' 20.0 C I' ao zoo Fr, O` WINTER- (WIDTH E5S (WITH VARI ) TREET -- so IYo TQ•' t4ORTH 0.4 ,,.[LED 16Ati Town of North Andover 32 a�;r •_ a L - - 10 0 Office of the Planning Department Community Development and Services Division 1600 Osgood Street �gSACHUSEt " North Andover,Massachusetts 01845 NOTICE OF DECISION Any appeal shall be filed within (20) days after the date of filing this notice in the office of the Town Clerk. Date: July 15,2014 Date of Hearings: July 1,2014 and July 15,2014 Date of Decision: July 15,2014 Petition of: Salvatore A.Messina,129 Winter Street,North Andover,Ma 01845 Premises Affected: 129 Winter Street,North Andover,Massachusetts,01845. Assessor's Map 103, Parcel 118 and located in the Residential 1 Zoning District. The above petition for a Watershed Special Permit is in accordance to the requirements of the North Andover Zoning Bylaw,Sections 4.136 and 10.3. This petition is to allow the construction of a 416 sq. ft. addition to the rear of the garage and the installation of 2' x 2' stone drip trench on two sides of the addition within the Non-Discharge Zone of the Watershed Protection District. After a Public Hearing given on the above date,and upon a motion by Lynn Rudnicki and 2nd by D.Kellogg to APPROVE the Special Permit for the Watershed Protection District, as amended and based upon the following conditions.Vote was 5-0,unanimous in favor of the application. Planning Board John Simons,Chairman Lora McSherry Dave Kellogg Michael Colantoni Lynne Rudnicki 129 Winter Street,Map 103,Parcel 118 Watershed Special Permit—Addition July 15,2014 The Public Hearing on the above referenced application was opened on July 1, 2014, no evidence was heard, and was continued until July 15, 2015. The public hearing was closed by the North Andover Planning Board on July 15,2014. On July 15, 2014, upon a motion made by L. Rudnicki and seconded by D. Kellogg to GRANT a Watershed Special Permit to allow the construction of 416 sq. ft. addition to the rear of the garage and the installation of 2' x 2' stone drip trench on two sides of the addition within the Non-Discharge Zone of the Watershed Protection District. This Special Permit was requested by Salvatore A. Messina, 129 Winter Street, North Andover, MA 01845 on May 21, 2014. The applicant submitted a complete application, which was noticed and reviewed in accordance with Section 10.52 of the Town of North Andover Zoning Bylaw and MGL Chapter 40A, Section 9. The motion to approve was subject to the FINDINGS OF FACTS and SPECIAL CONDITIONS set forth in this decision. The Planning Board vote was unanimous. A special permit issued by the special permit granting authority requires a vote of at least four members of a five-member board. The applicant is hereby notified that should the applicant disagree with this decision, the applicant has the right, under MGL Chapter 40A, Section 17, to appeal this decision within twenty days after the date this decision has been filed with the Town Clerk. In accordance with 4.136 the Planning Board makes the finding that the intent of the Bylaw, as well as its specific criteria is met. This decision specifically stated by the Planning Board makes the following FINDINGS OF FACT: 1) That as a result of the proposed construction with other uses nearby,the Board has determined there will not be any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. The final design reflects adequate safeguards to mitigate pollutants from entering Lake Cochichewick. The 416 sq. ft. addition is approximately 150' from a tributary wetland to the Lake. The proposed construction complies with Best Management Practices for erosion, siltation, and stormwater control. The Planning Board bases this finding on the following facts: a) The construction has been reviewed by Town Staff, and with the application of erosion control measures the proposed project will not result in any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. b) The new project will create approximately 416 sq. ft. of new impervious area. Stormwater runoff associated with the new impervious surface will be routed to a stone drip trench to promote groundwater recharge. c) Fertilizers will be limited to those which are either organic or slow-release nitrogen and phosphorous-free. The use of coal tar-based pavement sealants is prohibited. These restrictions will be noted in the deed. d) The existing structure is connected to the Town sewer and water systems. 2) The existing lot complies with the current Zoning Bylaw with regard to frontage and acreage. The lot was created before 1994 and is not subject to the Conservation Zone, as described in section 4.136.2 Table 1. 2 129 Winter Street,Map 103,Parcel 118 Watershed Special Permit—Addition July 15,2014 3) There is no reasonable alternative location outside the General, Non-Disturbance, and the Discharge Zones for any discharge,structure or activity. In accordance with Section 10.31 of the North Andover Zoning Bylaw, the Planning Board makes the following FINDINGS OF FACT: 1) The location is appropriate for the proposed use as the wetlands delineation reviewed and approved by the Town of North Andover Conservation staff. 2) The proposed addition will not adversely affect the neighborhood as the lot is located in a Residential 1 Zoning District; 3) There will be no nuisance or serious hazard to vehicles or pedestrians; 4) Adequate and appropriate facilities are provided for the proper operation of the proposed use; 5) The Planning Board also makes a specific finding that the use is in harmony with the general purpose and intent of the North Andover Zoning Bylaw. Upon reaching the above findings,the Planning Board approves this Special Permit based upon the following SPECIAL CONDITIONS: 1)Permit Definitions: a) The"Locus"refers to the 2.39 acre parcel of land with frontage on Winter Street as shown on Assessors Map 103,Parcel 118, and also known as 129 Winter Street,North Andover, Massachusetts. b) The"Plans"refer to the plans prepared by Joseph J. Serwatka,P.E.,dated May 16, 2014,entitled "Permit Site Plan 129 Winter Street North Andover,MA". c) The"Project"or"129 Winter Street"refers to the construction of 416 sq.ft.addition to the rear of the garage and the installation of 2'x 2' stone drip trench on two sides of the addition,within the Non-Discharge Zone of the Watershed Protection District. d) The"Applicant"refers to Salvatore A.Messina,the applicant for the Watershed Special Permit. e) The"Project Owner"refers to the person or entity holding the fee interest to the title to the Locus from time to time,which can include but is not limited to the applicant, developer,and owner. 2) The Town Planner shall approve any changes made to these plans. Any changes deemed substantial by the Town Planner would require a Public Hearing and Modification by the Planning Board. 3) Fertilizers are limited to those which are either organic or slow-release nitrogen and phosphorous-free. The use of coal tar-based pavement sealants is prohibited.This restriction will be noted on the deed. 4) Prior to any work performed on the site,the applicant must conform with the following: a) A bond in the amount of four thousand dollars ($4,000.00) shall be posted for the purpose of insuring that the site is constructed in accordance with the approved plan and that a final as-built 3 129 Winter Street,Map 103,Parcel 118 Watershed Special Permit—Addition July 15,2014 plan is provided, showing the location of the addition. This bond shall be in the form of a check made out to the Town of North Andover. This check will then be deposited into an interest bearing bond account. b) Fertilizers are limited to those which are either organic or slow-release nitrogen and phosphorous- free. The use of coal tar-based pavement sealants is prohibited. The applicant shall incorporate this condition as a deed restriction and a copy of the recorded deed shall be submitted to the Town Planner and included in the file. c) All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Conservation Department. d) A pre-construction meeting must be held with the developer, their construction employees, and Planning Department (and other applicable departments)to discuss scheduling of inspections to be conducted on the project and the construction schedule. 5) Prior to release of the Performance Bond: a) The applicant shall submit an as-built plan stamped by a Registered Professional Engineer in Massachusetts that shows all construction and other pertinent site features. This as-built plan shall be submitted to the Town Planner for approval and must be provided in paper form as well as in SDF (Standard Digital File) format. The applicant must also submit a letter from the architect and engineer of the project stating that the addition and site layout substantially comply with the plans referenced at the end of this decision as endorsed by the Planning Board. b) The Planning Board must by a majority vote make a finding that the site is in conformance with the approved plan. 6) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. 7) The Contractor shall contact Dig Safe at least 72 hours prior to commencing excavation. 8) The provisions of this conditional approval shall apply to and be binding upon the applicant, it's employees and all successors and assigns in interest or control. 9) This Special Permit approval shall be deemed to have lapsed July 15, 2016 (two years from the date of issuance) exclusive of the time required to pursue or await determination of any appeals, unless substantial use or construction has commenced within said two-year period. Substantial use or construction will be determined by a majority vote of the Planning Board. 10) This decision must be recorded with the North Essex Registry of Deeds.The following information is included as part of this decision: Plan titled: "Permit Site Plan 129 Winter Street North Andover,MA" Prepared for: Salvatore A.Messina 129 Winter Street North Andover,MA 01845 Prepared by: Joseph J. Servatka,P.E. 4 129 Winter Street,Map 103,Parcel 118 Watershed Special Permit—Addition July 15,2014 65 Bailey's Court Haverhill,Ma 01832 Date: May 16,2014 Sheets: 1 Scale: Sheet 1: 1"=40' cc: Town Engineer Building Inspector Conservation Administrator Applicant Assessor's Office File 5 Pdotfor wCHU PLANNING DEPARTMENT Community Development Division For - PERFORMANCE BOND DEPOSIT OF MONEY 20_ North Andover, Massachusetts AGREEMENT is made this date between the Town of North Andover and hereinafter with his or its executors,devisees, administrators,heirs,successors and assigns, referred to as the"Applicant"of: with business address of and/or,for individual residence address of to secure construction of as shown on a plan entitled prepared By dated, owned by ,with business address of and/or,for individual, residence address of for land located at; KNOW ALL MEN by these presents that the Applicant hereby binds and obligates himself,to the Town of North Andover, a Massachusetts municipal corporation, acting through its Planning Board,in the sum of dollars, and has secured this obligation by depositing with the Treasurer of the Town of North Andover a deposit of money in the above sum to be deposited in an interest-bearing account as designated by the Town Treasurer in the name of the Town.The deposit of money is to be used to insure the performance by the Applicant of all covenants,conditions,agreements, terms and provisions contained in the following: 1.Application for Approval of Definitive Plan(Form C),dated 2.The Subdivision Control Law and the Planning Board's Rules and Regulations governing the subdivision of land- dated 3.Conditions included in the Certificate of Approval issued by the Planning Board and dated 4.The Definitive Plan as qualified by the Certificate of Approval. 5.Other document(s)specifying construction or installation to be completed, namely Page 1 of 4 1600 Osgood Street,North Andover,Bldg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.688.9535 Fox 978.688.9542 Web www.townofoorthandover.com Revised 10/01/2010 COMMONWEALTH OF MASSACHUSETTS S.S. Date: 20_ Then personally appeared as the Applicant or his/its authorized agent and acknowledged the foregoing instrument to be his or her free act and deed and the free act and deed of the Applicant, before me. Notary Public My Commission Expires: COMMONWEALTH OF MASSACHUSETTS S.S. Date: 20_ Then personally appeared as the Planning Board Chair or his/its authorized agent and acknowledged the foregoing instrument to be his or her free act and deed and the free act and deed of the Applicant, before me. Notary Public My Commission Expires: Page 3 of 4 1600 Osgood Street,North Andover,Bldg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.688.9535 Fox 978.688.9542 Web www.townofnorthandover.com Revised 10/01/2010 Print F�orrri: a- w v 40 PLANNING DEPARTMENT Community Development Division For G ® PERFORMANCE BOND DEPOSIT OF MONEY 20_ North Andover, Massachusetts AGREEMENT is made this date between the Town of North Andover and hereinafter with his or its executors,devisees, administrators, heirs,successors and assigns, referred to as the"Applicant"of: with business address of and/or,for individual residence address of to secure construction of as shown on a plan entitled prepared By dated, owned by ,with business address of and/or,for individual, residence address of for land located at: KNOW ALL MEN by these presents that the Applicant hereby binds and obligates himself,to the Town of North Andover, a Massachusetts municipal corporation,acting through its Planning Board,in the sum of dollars,and has secured this obligation by depositing with the Treasurer of the Town of North Andover a deposit of money in the above sum to be deposited in an interest-bearing account as designated by the Town Treasurer in the name of the Town.The deposit of money is to be used to insure the performance by the Applicant of all covenants,conditions,agreements, terms and provisions contained in the following: 1.Application for Approval of Definitive Plan(Form C),dated 2.The Subdivision Control Law and the Planning Board's Rules and Regulations governing the subdivision of land- dated 3, Conditions included in the Certificate of Approval issued by the Planning Board and dated 4.The Definitive Plan as qualified by the Certificate of Approval. 5. Other document(s)specifying construction or installation to be completed, namely Page 1 of 4 1600 Osgood Street,North Andover,81dg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.688.9535 Fox 978.688.9542 Web www.townofnorthandover.com Revised 10/01/2010 COMMONWEALTH F MASSACHUSETTS S.S. Date: 20_ Then personally appeared as the Applicant or his/its authorized agent and acknowledged the foregoing instrument to be his or her free act and deed and the free act and deed of the Applicant, before me. Notary Public My Commission Expires: COMMONWEALTH OF MASSACHUSETTS S.S. Date: 20_ Then personally appeared as the Planning Board Chair or his/its authorized agent and acknowledged the foregoing instrument to be his or her free act and deed and the free act and deed of the Applicant, before me. Notary Public My Commission Expires: Page 3 of 4 1600 Osgood Street,North Andover,Bidg.20,Suite 2-36 Planning Dept.,Massachusetts 01845 Phone 978.6889535 Fox 978.688.9542 Web www.townofnorthandover.com Revised 10/01/2010 .a► t:� CERTIFICATE OF LIABILITY INSURANCE 6/25/0 4 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT SNAME: alld.Z Munroe M P ROBERTS INS AGCY INC PHONE /978) 683-8073 FAX Ne (978) 683-3147 1060 Osgood Street AEb-,,'L,,,,:sand!Ldmprobertsinsurance.com North Andover, MA 01845 INSURERS AFFORDING COVERAGE MAIC# INSURERA: MERCHANTS INSURANCE INSURED KEVIN MURPHY BUILDING & REMODELING INSURERB: GUARD INSURANCE 169 BOXFORD STREET INSURER c: NORTH ANDOVER, MA 01845 INSURER D: INSURER E: INSU ER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT TIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ',... INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD WYD POLICY NUMBER Me,.1/od NM Q' LIMITS }� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 ,000 ,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 500 ,000 BOPI068945 11/22/13 1/22/14 MED (Anyone arson $ 15,000 A HPERSONAL&ADVINJURY $ INCLUDED GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY❑JECTT ®LOC PRODUCTS-COMP/OP AGG $ 2 000,000 OTHER- $ AUTOMOBILE LIABILITY CFO ac den tl SINGLE LIMIT $ nn'noo ANYAUTO MCA7013608 01/23/14 1J23/15 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AAUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA UABOCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB HCLAIMS.MADE AGGREGATE $ 1, ,0 CUP9145304 11/22/1311/22/14 006 DED RETENTION WORKERS COMPENSATION 7 STATUTE ER AND EMPLOYERS LIABILITY Y ANY PROPRIEFOR/PARTNER/DCECUTIVE E.L.EACH ACCIDENT $ 500,000 B (Mandatory EXCLUDED? N/A KEWC527844 07/01/1437/01/15 U , 0 (Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $ Ifyes,descrbeunder 5500 000 DESCRIPTION OF OPERATIONS 4elmv E. .DISEASE-POI T / DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addifiwa1 Rematks Schedule,maybe attached if more space's requred) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF TFE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD STREET TI-E EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents 0 1 Congress Street,Suite 100 Boston,MA 0211412017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERK TTING AUTHORITY. Applicant Information Please Print Legib1Y w w Nalne(Business/Organization/Individual): p Address: c.« City/State/Zip: t Phone#: � Are you an employer?Check the appropriate box: Type of project(required): 1. , am a employer with employees(full and/or part-time).* 7. F1 New construction 2.n I am a sole proprietor or partnership and have no employees working for me in $. tRRemodeling any capacity.[No workers'comp.insurance required.] In I am a homeowner doing all work myself[No workers'comp.insurance required.]t 1 [1 Demolition 10 wilding addition 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 11.0 Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairsThese sub-contractors have employees and have workers'comp.insurance. 6.n We are a corporation and its officers have exercised theirright of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. tContractors that check this box 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'camp.policy number. I an:an employer that is providing workers'compensation insurance for my employees. Below is the policy mid job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie,#: " 9 ! Job Site Address: w City/State/Zip; ` t . I 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD 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 DIA.for insurance coverage verification. fy p in J p of pe►jrary that the information provided above is h a and cor•ect. I do here cern under thepains andpenalties M Date: C Si nature. Phone#: . 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: