Loading...
HomeMy WebLinkAboutMiscellaneous - 36 Walnut StreetThis certifies that. V!?. . � l.,e jo.-4.4.,c has permission to perform . 4:(;5 ...................... wiring in the building of . .2). . ...................... at .. .............. N h Andover, Mas 'V 'n a. Fee EL ACTRICAL INSPE TOR Check # 2000- 10914 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Oficial Use Only 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 IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wiles: By this application the undersigned gives notice of hiWr 4Er intention to perform the electrical work described below. Location (Street & Owner or Tenant Telephone No. Owner's AddressJ Is this permit in conjunction with a building permit? o Yes 2' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / 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- Elo. rnd. rnd. o mergency Lighting Battery Units No. of'Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number ......................................................... Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: �. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ams and penalties of perjury, that the information on this plication is true and complete. FIRM NAME:.%� LIC. NO.: JY 7 Licensee: (195:2Signatu LIC. NO� 6 Z 7 (If applicable, ent "exe t" in the license nu ne) fyBus. Tel. No.• "0;?r Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Depdrtment of Pub is 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 my signature belywk hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Age Signature Telephone No PERMIT FEE. $ r f y. r „, �U.IJJPltil.rd.0i-t.�►.+'{���-�*r�Y•���Z{.0.�1Y%JiJ.��.ey1•�.1■�®np��r� . �j �i+7'[ SI.�Fy�.C't�.11.J.�.4'4 JL�rr-'/�®J-`�l•: � r . ��sset�•-^ _ �'ailefl-�� � �e-zz�pectiox� xet�uixed'($aO.QD) � � � us�Oec#oxs' �rawits: ' l7'vienPrfnreti�TOTfril. Bail - _Tff3rS'i .- ,nate _ n 1r 0 h f /Al /.GI '7 ZLrl-2— - - 1 1- 2. XNAL XNS PACtO1N, �.'assec�•-- �`aise�--I } � �e�ns,�eciion.xe�u3u'ed� ($x0.00}-• [ � . Tns,�ectoz-�' c mmi.ents: . ps�actors'signature-)ioW ials) Pate Passed- I � +ailed --I) �te�3nspectionae�ufred(��0.00)�[ � . his.pectors' comments; (lnspectoxs�,�ignaiuxe�aoisu`fiaTs) Date assec�--[) �'arled--I � �e-xnspectionxequired (50.00) � I � ' is,Qectbrs' eo�mm.eufs; ' (ttspectozs',�igntature�7aojniiza�s) Date ,sea ilea [ �- ate �nspecttott xer�uizeui ($50.00} - [ } pectoxs' coritzn.ents: _ . • 9 - 30P, TA(9,9.:AM MLE3D gVTA M 3 RFT Off' KITE M TMAPXA TO 3E INSPECTU D Xg NOT The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations UV 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/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I �ployees (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. ❑ New construction 7. [Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 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 ace 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 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 N 1. 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 requireclunder 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. Ido hereby cgttfj under the pains and,penalties,,ofperjury that the information provided above is true 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): 1. 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 employeiis 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of 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 Investigatiions 600 Washington Street Boston, MA. 02111 Tel, # 61.7-727-4900 ext 406 or 1-877rMASSAk'B Revised 5-26-05 Fax # 617-727-7749 wwv.mass.govfdia Date. . 9503 '0'< :otic TOWN OF NORTH ANDOVER .....'. 0 PERMIT FOR PLUMBING This certifies that ...!jl�Cf%�/1j/�'s' has permission to perform ... ✓?�1.'.!�T'!'� .......... plumbing in the buildi gs of ... Q!^ .................... at ...�� ../�' !r� ...... , North Andover, Mass. Fee. Lic. No..45 Z l PLUMBING INSPECTOR Check " %/Z Date��`? TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform ... plumbing in the buildings of �% �R.!� w ................... . at ......� ......................... :.. . 6rt Andover, Mass. Fee �'.00. Lic. No... a3 ....... PLUMBING SPECTOR Check ." _ 164012— � a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY V MA DATEL9PERMIT # JOBSITE ADDRESS J I f OWNER'S NAME POWNER ADDRESS _ TEL �FAXI TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Er PRINT CLEARLY NEW: RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES © NO[] FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - =- *====== CROSS CONNECTION DEVICE E]=-- DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER --- -- - - ---- _ - - - --- DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK --- - - - - TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING -- ---- - --- OTHER INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[D NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ BOND O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tre and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co pli &e with II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Nicholas Sawas LICENSE # 15234 I A URE MPO JP❑ CORPORATION❑#PARTNERSHIP❑#O LLC❑#E::= COMPANY NAME I NICHOLAS SAVVAS PLG AND HTG ADDRESS 115 SILVESTRI CIRCLE #24 CITY DERRY STATE NH ZIP 03038TEL 19788043303 FAX CELLI EMAILSAVAASPLG@GMAIL.COM H z z 0 H U w a Iz z w O Z El N El O H W � w O w : aLU z O a w � a LU W O w V) o d a a w oa � a �, J IL IL �s a ui x W F O z z � F' U W a N 0-4 a a ` � rq� 0 � 'J" o.5-- - m 0 DExMEvroFpvAMFET s '9(' BUARDOFF9REPREVEN7MM527aMj2,W 1►ermit No. o M:Mcy 8L Fen Checked —�••m A.PPLIC47TONFOR PERMIT TO PERFORMELECTRIC,AL Wm3xc (PLEAS C ALL WORK To BE PERFORMED IN ACCORDANCE WrM THE MASSACHUSSTS ELECTRICAL CODE, 527 CMB 12:00 E PRINT IN INK OR TYPE ALL MRMA1I0N) Da S Town of North Andova To the Inspector of Wires: The undersigned applies fora permit to perform the electrical work described below. EN Location (Street d Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes[2"No Purpose of Building Existing Service �� Amps./Volts New Service Amps../.Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work (Check Appropriate Box) Utility Authorization No. Overhead [J Underground Overhead a Underground C No. of Meters No. of Meters Na of Lighting Outlets No. of Hot Tube No. of Transom rs Total KVAKVA No. of Lighting R IUM Swirnadng Pool Above r7l Below rl Oeoeretate 001111dinti No. of Receptacle Outlets No. d Oil Burners No. of Emergency Lighting Battery Unite No. of Switch Outlets . No. does Bum= FIRE ALARMS Na of Zones No. of Ranges No. of Air Cond. Taal Tour No. of Detection and No. of Disposals No. of Hat TOW TOW Po Tons KW Initialing Davit= No. of Sounding Devices No. of Dishwuhas Space Ara Heating KW No. of Self Cantsiflift! TQC �, Wt+ Detectiow3oanding Device Local 06W No. of Dryers Heating Devices KW ❑Mwidpd Connections No. of Water Heaters KW No. of No. of Signs aihrfe No. Hydro Mawsge Tobe NO. of Mom Tot HP la=anaeOMIMP P==1Dlrwac}>: nsftdM=KbmaQmdLmw a IhmeaaaertLie*laa=Fb yixilftClc*rlpk� or�mbdwWegtivaht I �p Ih�nestfrnitedvafdpioafafsrno iD6cQ�'M 1 IrruhnediadQdYflS,pEaid�lemetYR� DELRANX Btu OM �1raeSpm�+) L 5�c7�S Book lltle VAzdHecl W Wear S WO&IDSM IlgaW Ro* lel 5gzdu�Pasftdpajlgy. HRMNAM , LialsNa Cal i. " Busn STUNa II aftwSIrIanaweedmotdrUn dwid teiaammoeaotwVoribambsTUN W" Atn arddilmystnaafta ak�picmtionwaiKafite1i� e t���bYMasaedsimselbGemtrallaws (Please check one) Owner � Agent Telephone No, pggyM FEE � Location ":?r � I)) C) No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 'mss_^�„sty Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 49 � Check # .5 ) C/ G 18434 Building Inspector 7,95� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioifer/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: —� 1.2 Assessors Map and Parcel Number: C;e3 • a d Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ElMunicipal 1.8 Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record 1 (0 Lk" I J� 4 G Name Print) Address for Service: Q2 -9-Ta� 7 Signature Telephone 2.2 Owner of Record: I Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Li ns onstruction Superviso Not Applicable ❑ tk 0 c' -I" (3 tj � Licensed Constluction Supervisor: �o 62 Q ((( � l� rY `I �/� l License Number ((( �i f� J Q A dr s �os �� o 6 r Expiration Date Signa rAPTelephone 3.2 Re Aster me Improve en Contractor P—rl4j Not Applicable El J LV / S � 0 Com y ame ,� ^ e ( Registration Number ryio Adres �/�2 0 ExpirationDate �O03 ✓� ( Signature Tele hone V�q M X e z O 0 0 M go 0 mn r r r _ ^2 Y/ SECTION 4 - WORKERS COMPENSATION (RG.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 7ition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 1&ke, J CaV / ('. I5fi f''t/q SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be0M Completed by permit applicant] CIAL USENL11 1. Building Q �Q(�. 00 / (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 • aO I Check Number SECTION 7a OWNER AUTHORIZATI N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, A r& u as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWN R/AUTHORIZ D AGENT DECLARATION 1,_ A UA fs-O !U ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of caner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TP BERS 1 2 3RD SPAN DRAENSIONS OF SILLS DINIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM i -a9-os INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT /-ft—� Ll V IL WQ, JCY& PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET_� �1=1 l9 I /ut Ave, ST. NUMBER 36 USE TOWN A BENTS: RVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Z W O � O FND OWNER INFORMATION: JAMES & NANCY BARRY 36 WALNUT AVENUE NORTH ANDOVER, MA 01845 WALNUT A VENUE ASSESSOR INFORMATION: MAP 33 PARCEL 35 DEED REFERENCE: BOOK: 1270 PAGE: 556 I CERTIFY THAT THE STRUCTURES SHOWN WERE LOCATED BY AN INSTRUMENT SURVEY AND EXIST ON THE GROUND AS SHOWN. I.P. SND ZONING INFORMATION: ZONING DISTRICT : R4 MIN. BLDG. SETBACKS: FRONT : 30 FEET SIDE : 15 FEET REAR : 30 FEET PLOT PLAN OF LAND #36 WALNUT A VENUE NORTH ANDOVER, MA 01845 PREPARED BY: ROBERT W. SMITH, PLS HEADQUARTERS: ROOM 111 18 PEABODY SQUARE PEABODY, MA 01960 SCALE: 1 "=20' DATE: 7/21/03 Department of IndustrW Accidents Office of Investigations klip 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Afl3davit: Builders/Contractors/Electridans/Plumbers Aoolicant Information Please Print Leeibly Name (Businessiorpnizationnndividual): Address: City/State/Zip: Phone M A,re,u an employer? Check the appropriate box: 1. FLJ I am a employer with 4. ❑ I am a general contractor and I employee's (full and/or part-time).' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 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 arc 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. [3 New construction 7. [remodeling S. [] Demolition 9. ❑ Building addition l0.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Odier -Ivey awivo nmai cac mec" wee w i neem' also IMI oat me 9=00 Derow snowing their worbu' eompenaation policy mfomraboa t Hoowneu wbo submit this affidavit indicaft they, are doing all work sod then bite outside eontraotors must submit a new affidavit indic� suck LContrwim that ebeck Ibis box now dumbed see additional abaet ahowiaa 61e non of ffie sub contuctors and their vvo*aa' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below Is dw pofig and, fob site Information. 11 Insurance Company Name: t4oe -e- 6r Aess / ti S Policy # or Self -ins. Lic_ M Expiration Date: Job Site Address:__ 1 Cn I I ).a I\ fU A tj An" AA, City/Srar�;n Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as require !f 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-yearimprisonment, 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 Posen H7 Pe peVury that the information provided &bow is true and correct Official use only. Do not write In this area, to be completed by city or town q,09cia2 City or Town: Permit/License g Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cky/fown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone 0: lniormalion aiiu 1115tl U%,Livi,* Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee!. 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 building, in the commonwealth for any applicant who bas 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 -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 outer 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 Depmtment at the number listed below. self-insured companies should enter their self-insurance license member 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 ,mist 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 sbould write "all locations in (city or town)." A copy of the affidavit been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a is on file for future permits or licenses. A new affidavit mast 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 oflnvestigations 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 Deparanent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 wwwmm.gov/dia NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit Signature of Permit Applicant Date E ri O W fA t" w 0 I- - ro 0 z O U a I Ccm C O■_ Q CA mm �3 O G OL Cc o a M: c"a co c CJ .3cv .0 G3 ■c Z CL V h � C c . C cc CLh a Az a O O r. a C N C.) C Ccd W A m c � r o . AL •o aJ LO' E a V m o l : iiC :y0r �.. v u � � chi a A w° I u W. 19 O C a �m o I- - ro 0 z O U a I Ccm C O■_ Q CA mm �3 O G OL Cc o a M: c"a co c CJ .3cv .0 G3 ■c Z CL V h � C c . C cc CLh Az O O r. C N C.) C Ccd W A m c � r o . AL •o aJ LO' E a V m o l : iiC :y0r �.. cw Of 19 O C �m O � vi � Z om ac, c cp �;=ma ac C2 O mO ♦: : e�s�Z ` �O o O •� CL CD F�0 = 40 m : m 3 QC nl D 0_ W O .0 '" 1=0 = w. H CC aft CML 00 h Z O LU CD r CL is CO2 = w in c =4"a�m210 I- - ro 0 z O U a I Ccm C O■_ Q CA mm �3 O G OL Cc o a M: c"a co c CJ .3cv .0 G3 ■c Z CL V h � C c . C cc CLh .Ah. W rl OD co CA 7'-4 7/16" 7'-4 7/16" 11 3/ " -2" 3'-71-41/411 3248 Z U W N N OD /�+ N m= W w FQ N w N v CA) w N_ OD OD = N W w IQ N w W Zen I --m 0 h C .N 6D v 00 Ul CA) .p 11 v 59:8 Date..tT^/6'_,o-T— . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ... 4 c�..............Q�..�. rvn. has permission to performDL 6 / I,U! /� ! 4u wiring in the building of ....... ............. 1 A,I........K ...................................... 6Lrd �...... � , North Andover, Mass. Fee ..: -C.00.... Lic. No. - ....... �& .l.Ct c l!4C ELECTRICAL INSPECTOR Check # 3� f' �0 v Iy i i APPUCATIONFOR PERNIlTTO PERFORM ALL WORK TO BE PERFORMED IN ACCORDANCE WrrH THE MASSACHUSSrS ELEC n (PLEASE PRINT IN INK OR TYPE ALL PMRMATION) Town of Noah Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street d Owner or Tenant Owner's Address & Fees Checked WCAL WO 527 cMR 12:00 Ela 31/ 0S_ To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes[SllNo (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps..�.V olts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tube No. of Trandom ms Total KVA No. of Lighting Fixtum 3 Swimming Pool' Above o Below o Oenmrtatr KVA grow—W yotonal No. Receptacle Outlets of No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets . No. of On Borneo FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Ton No. of Detection and No. of Disposals No. of Heat Total Total Pony@ Tons KW Inidaft Devices No. of Sounding Devices No. of Dishwasher Space Area Heating KW S No. of Self ContabW W Detectionr3ounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connection No. of Water Heaters KW No. of No. of Siam silssis No. Hydro Musge Tube No. of Motors Total HP istraneQMW Aaarettbdieragtaiar�atM�dastf<GmemlLBWa YE Q 1hanCaasi�tI Ttyii9lmr»UCi�icyraidr>gllornpl� or�sui��alec}iVeimt NO Ihmes bi&dvaidWdcfzmlDtte0llbr YID lfymihwdtadmdYBS Pkwn c*d typeafaotes by P&M NCE BCM E3 �� �IeaseSpeatj� Lr. 5,v/cz- E �i 1WdVv"dHm"Wc& $ WadcbSast IrtspocmtDaRmiewd Ra* Anti Vied urtda Fenl mdpm*.. RRMNAME Litt mNa van Liot�eNo S — 3 &&=TdNa SURANCEWAN iizwdmmtlingiheiec wworksub h"degiivakntis=iodbvhb=taaewQriaall.m ardtMtmys�textemiFispmritappicafianvwi�e8tlisreq�strat (Please check one) Owner Agent Telephone No. P$RMtI' FEE S Signature