HomeMy WebLinkAboutMiscellaneous - Exception (75)Phone: 978-632-2660
JAMES A. TRUDEAU
Fax. 978-632-2662
Adjustment Service Inc.
P. O.Box 7
Gardner, MA 01440
claims(&trudeauadi.com
Notice of Casualty Loss of Building
Under Massachusetts General Laws, Chapter 139, Section 313
January 12, 2015.
Building Inspector
120 Main Street
North Andover, MA 01845
Board of Health
120 Main Street
North Andover, MA 01845
Fire Department
Dept. of Records
124. Main Street
North Andover, MA 01845
Insured:
Jeffrey Piantidosi
Loss Location:
311 Dale Street, North Andover, MA 01845
Insurance Company:
The. Concord. Group, Ins. Companies .
Policy No.:
1031212
Date of Loss:
January 9, 2015
File Number:
15-12551
Claim Number:
0001149343
Type of Loss:
Freeze -Up
Claim has been made involving loss, damage, or destruction of the above captioned property, which may either
exceed $1,000.00 or cause ".Mass. Gen. Laws, Chapter 143, Section 6" to be applicable. If any notice under "Mass.
Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the writer and include a reference to the
captioned insured, location, policy number, date of loss, and file or claim number.
Claim has been made involving loss, damage or destruction of the above -captioned property, which may
exceed $5000. If any notice under Massachusetts General Laws, Chapter 175, Section 97A is appropriate,
please direct it to the attention of this writer and include a reference to the above -captioned insured,
location, policy number, date of loss and claim number.
On this date, I cause copies of this notice,to be sent to.the.person(s) named above at the address indicated by first
class, mail... .
Sincerely,
Joshua M. Trudeau
Claims Adjuster
Phone: 978-632-2660
JAMES A. TRUDEAU
Adjustment Service Inc.
P. O. Box 7
Fax: 978-632-2662
Gardner, MA 01440
claims(&trudeauadi.com
Notice of Casualty Loss of Building
Under Massachusetts General Laws, Chapter 139, Section 313
January 1.2, 2015
Building Inspector
120 Main Street
North Andover, MA 01845
Board of Health
120 Main Street
North Andover, MA 01845
Fire Department
Dept. of Records
124 Main Street
North Andover, MA 01845
Insured:
Jeffrey Piantidosi
Loss Location:
311 Dale Street, North Andover, MA 01845
Insurance Company:
The Concord Group Ins. Companies
Policy No.:
1031212
Date of Loss:
January 9, 2015
File Number:
15-12551
Claim Number:
0001149343
Type of Loss:
Freeze -Up
Claim has been made involving loss, damage, or destruction of the above captioned property, which may either
exceed $1,000.00 or cause "Mass. Gen. Laws, Chapter 143, Section 6" to be applicable. If any notice under "Mass.
Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the
captioned insured, location, policy number, date of loss, and file or claim number.
Claim has been made involving loss, damage or destruction of the above -captioned property, which may
exceed $5000. If any notice under Massachusetts General Laws, Chanter 175, Section 97A is appropriate,
please direct it to the attention of this writer and include a reference to the above -captioned insured,
location, policy number, date of loss and claim number.
On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first
class mail.
Sincerely,
Joshua M. Trudeau
Claims Adjuster
Location
No. Date — •fCJ/
tpRTN TOWN OF NORTH ANDOVER
16.•
• i ; . Certificate of Occupancy $
CNUs <� Building/Frame Permit Fee $ A)
Foundation Permit Fee $
Other Permit Fee $
TOTAL $S
Check # V12
14 6 7' 9
ji' p Building Inspectol /
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DyEMrOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: O DATE ISSUED: r / _ d 00/
6e
SIGNATURE: INN -,—
Building Commissioner,"InspecKor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 J /Property Address: c
1.2 Assessors Map and Parcel Number:
! 1
ap
Map Number Parcel Number
��yV
1.3 Zoning Information:
1.4 Property Dimensions:
z/,?, & sv /sU
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUIIAING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
R aired Provided
30
4t
1.7 Water Supply M.GL.C.40. S4) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
r) Ah '
Name (Print) Address for Service:
L697Z, f32 -6 & q a
Signature Telepho6e
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
•rhe✓/ L����► i �
Licensed Construction Supervisor:
oi z
( 7
O S 4
License NumberI
Ad r ss
to ' 06
Expirati D to
n
nature I,, Telephone
3.2 Registered Ho a Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
8 �/�D Z
476 -7" %V 4o
J/
Expiration Date
Si ature Telephone
V
1V
0
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 $ 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 ....... 0
SECTION 5 Description of Proposed Work check all a licable
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other/ Specify.
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Com leted by permit applicant
; QF +ICY,
VISE QNLy
1. Building
Z 0-0 b
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
C9 51
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
D D
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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 OWNER/AUTHORIZED AGENT DECLARATION
1, 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 belief9
Print Nam
L. -,"U 4� 6 /p, C
Si ature wne en Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIvMERS 1 2 ND3 PD
SPAN
DEMENSIONS OF SILLS'
DM4ENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CH1Iv INEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
T "niyl U LV 1
j INSTRUCTIONS. This form is used to.verify that all -necessary approval /permits from
~ Boards and Departments having jurisdiction have been obtained. This. does not relieve the
applicant and or landowner from compliance with any applicable requirements.
.■s..■s■■..s.■R■r■0s..■sr.■.s■.a.■.■s`ss..■■..■s.sOswego
.■..ss.■s■.s■.■0■s..
APPLICANT PHONE
I
ASSESSORS MAP NUMBER � LOT NUMBER
SUBDIVISION LOT NUMBER
STREET STREET NUMBER 311
,■■.ssss..■sss...sss.s.■s■.smama s■SON .■■a■■s.■ssOsman smassage .....■s.gaseous
OFFICIAL USE ONLY
■■■■.■■s■■.■s■■..■■■..■■.s.■■'■ss■.s■■sssssss■■ssss■.s-s.ssss■■■..■s■s■s■■■■■
RECONgvfENDATIONS OF TOWN AGENTS
lc� DATE APPROVED �lot � i i a 0 0 0 0 0 a a 0.0 .
C NSERNATIONADMDFISTRATOR
DATE REJECTED
CO&M-NIS
RECEIVED BY BUILDING INSPECTOR:
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMIvv1R'N I S
DATE APPROVED
FOOD INSPECTOR -HEALTH)
SEPTIC INSPECTOR - HEALTH
DATE REJECTED
IRATE APPROVED, ` A� `
DATE REJECT -ED
CONRvfENTS (2Ae�%-996_4P �%�fl�d� �J�
C�`�JJ 7-o
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FME DEPARTMENT
DATE REJECTED
CO&M-NIS
RECEIVED BY BUILDING INSPECTOR:
ri
COT
Pro PaS e j -Deck—
a
11
Job No.861769..:...
C
27,0
O.
1
This plan was not prepared from an instrument
survey. Offsets and distances shown should not
be used to establish property lines.
This plan is intended for mortgage purposes
only.
I certify that the structure shown on this
Plan - WA S in conformance with the zoning
setbacks in effect at the time of construction.
I certify that the parcel shown' is N O T
located within a'flood hazard area as depicted
on FEMA Flood Insurance Rate Maps for
Community No: 2 S 0 0 9 R
yj3 9
R,6
MORTGAGE LOAN INSPECTION
LOCATION: 311 DALE STT,
NO ANDOVER MA
SCALE: 1'/ = 60 DATE:
REGISTRY: NO ESSEX
TITLE REFERENCE:_BK 1726 PG 121
PLAN REFERENCE: __PL -'P 9067
COREY &D ONAHUE. INC.
Engineers & Surveyors
198 Cnmbridge Road, Woburn, h1A 01801
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RD OE
Lice seA BUILDING REGULATIONS
Number C5
CONSTRUCT101V SUPERVISOR t
001724 +
14i►thdVe: 03/05/1958 i
E�Alres: 03/05/2002 Tr. no: 28194
Ros�cted To 00'
LEVIN J SMITH
0 HIGH STREET' c+
14 ANDOVER MA 01845
Administrator
✓fie i1a»z�no�zu�eall� o�,,/i%2ucr,./j �
Board of BuiWin6 Rrniatiens a rd Sfau.;� .•��
HOME it'APROVEMENT
CONTRACTOR
'I
r/ Ro3istraCon: 108511
v cxpiratio;t:,03/19/2002
Type: INDIVIDUAL r, �
Sib4TH CONSTRUCTION CO.
Kevin Srrfth
110 High St y
N PAA Andover, 1
_ o Bay
4sim;r.��rruro-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
City jJ, A.JV U&--- _ IKA- Phone 7- 7
F-1 I am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
E-1 I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
Cily: Phone
Insurance Co.. Policv#
Company name:
Address
City: Phone #:
Failure to secure coverage -required under section 25A or MGL 152 can It -ad to, the Iniposition ofcriminalpenalties ofdfirie up to $1,500
as,
.,ii..penafties.inlhelam.,of-a-ST WORK _($ _94a -againstm I
and/or one years' imprisonment _ as -well -as -civ, OP. .-ORE)JEFLand.o-firte-Of 1-00.0% Y e,
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/ do hereby certify unqarythe par and Penjifies opflegury that the information provided above is true and correct.
Print name
A
Official use only do not write in this area to be completed by city or town 7,clar
City or Town PArmit1IJr_en-:--
0 Building Dept
E]Check if immediate response is required .0 Licensing Board
E] Selectman's Office
Contact person: phone # F-1 Health Department
0 Other
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ :.............. ....................................
has permission to perform
............. 41 ........................
wiring in the building of ............
.........................................................................
ae..........................
Fee/ ................
y'
Check #
...................................................... . North Andover, Mass.
Lic. No .............. ..............................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
101 N THE MMMUM AL1H13; Uttice Use only
DEPARTAZQVTOFPUBLICSAFM Permit No. c,� %
BOARDOFFMPREVEMONREGMTIONS527O R12:W v�
Occupancy & Fees Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date /,:;L - / a - Oma_
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
5A(n
E
OS i
1.
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes � No (Check Appropriate Box)
Purpose of Building R Q Q e AJ C 0 Utility Authorization No.
Existing Service Amps / Volts 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 Tubs
No. ofTransforners
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
1:1ound
Below
Generators
KVA
ground
No. of Receptacle Outlets
No. of Oil Bumers
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local F-1 Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER • y i N 44 s i's:/,) ci
hrstrdroeCo Rrt&miDthelequi<aia-ltsdN4a%adtase1isGalaalLaws
IhoNeaamiLdxltyhmra=Pchcyudu&gCotrVI&Opw`cmCaaag critsabsbnialacltdv& t YES ® NO
Iha�eWmidodvMptoofofsametDthe0ffim YES U NO r-1 Ifjcuha%edwdWYESpleaseitdial6ethetypeofWgrd ebyd=kwtgthe
)TIS[JRAT � [J WM [] OTHR FJ WkwespecifiY) I A 1 /t c7 s Y ' t to �, a L
EMm&d Valuecf3ectiral Wotk $
Waktosin - /G _Q 0 hnspec6mDaleR4xsted Rauh Final
signed t j-xkrTie R3taltes cfpajtay.
FIRMNAME
Licat9ee I C PC) �.ev. R . Slg
LioaiseN i 3 & / O e15,
— L cffwNo
BtsirmTeLNa ( ) - Y "S c9
0 Lirv�e� S S A 7o Alt TA X"
OWNER'S INSURANCE WAIVER, IamawmthattheLisedomnot thean�aaneco►eagear�ss lr>Vate astecg>IIedby�Certaaliaws
atrithatmysernthis patt�app6�onwai� this teigtaanart.
(Please check one) Owner r7 Agent Q
Telephone No. .PERMIT FEE J
SECTION 4 -WORKERS COMPENSATION (M.G.L. C 152 § 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 buildin rmit.
Si ned affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work cher au applicable)
New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
Nvee~ /911 ��0 -sem d I �Z� 1l')f l /B:'�`W �J► I ii sT Y !
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed b ermit a licant
pICCIA �USENI:Y
1. Building
Q
(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
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 OWNER/AUTHORIZED AGENT DECLARATION
I, ,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
y
Signature of Owner/A ent Date
MEEMMI 1111 mill
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T VIBERS I ST 2 3
SPAN
DRVIENSIONS OF SILLS
DIMENSIONS OF POSTS
DI vIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION . THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
T777777
BUILDING PERMIT NUMBER: j �� DATE ISSUED:
SIGNATURE: Ul
Building Commissioder/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number
Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area 00
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Re red Provided
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
i f, %r dfl�, 9 Q� � s /UQ �pidnoe- .
Name (Print)
Address for Service
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
��Ir r� rit
,
Licensed Construction Supervisor:''✓
03O9���
License Number
AddressRj—
+�4y #/ ��
(� 6 % /
Expiration Date
Signature 1
Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
11
Company Name a.
I
�Q
Registration Number
f
f -
f)inoo (� U �y
Address
�A �l
4 r/ 0 d J
Expiration
f Jt%�f
Date
Signature
Telephone
w
SECTION 4 - WORKERS COMPENSATION (M.G.I. 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 Pro osed Work cher au applicable)
New Construction ❑
Existing Building V
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
u1,� 11 1�y r ,�j bre i9 Y� Ury � � ? 1 is �� L.��',v 1'() Y, W)q
T Prr�
6�P-Lo 140801-1 101-1 oil,l i� e- leo LJ
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be��Q'FICIA)
Completed b permit a licant
USE c?NLy
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee tat X (b)
/
1/0
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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 OWNER/AUTHORIZED AGENT DECLARATION
I, ,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
Signature of Owner/A ent Date
I
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS IST 2 ND3RD
SPAN
DlIv1ENSIONS OF SILLS
DUAENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
.fie i�a�rr�zza�z�ae2�ll• a�✓l�z;:sc�eludelta
Board of Building Regulations and Standards
HOME IMPROVEtMENT CONTRACTOR
k" F�V' Re9 ist.-aticn: 103577
5;,pira:ion: 071091a002
INDIVIDUAL
PA'JL A. FSEROG
Paul Pierog
10050 Turnoike St
No Andover, MA 01845 Adminintrator
License or registration valid for individul use onr
before the expiration date. If found r -,turn to:
Board of 3reilding Regulation-, and Standards
One Ashburf m blare Rm 13nl
Boston, M. a. 0210S
hint valid withoert Sig RNIJe
✓�e -�an�moouceczl!/i o�'✓l' ��ao�ruteQs
BOARD OF BUILDING REGULATIONS I
License: CONSTRUCTION SUPERVISOR
= Number: CS 039928
Birthdate: 03/16/1944
E Expires: 03/16/2002 Tr. no: 18190
Restricted To: 00
PAULA PIEROG
1 1000 TURNPIKE ST . r, -e4lr4-i
N ANDOVER, MA 01845 Administrator
IIIC lilJl/IIIIUI/VVGOII/1 U/ /V/dJJal.//UJC(tJ
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 62111
Workers' Compensation Insurance Affidavit
Please Print
Name,
Location l �f�C11 ��1 ►� L
%/e) U C' ► f �1 6 ` _ Phone
am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
QI am an employer providing workers' compensation for my employees working on this job -
Company name:
Address
City- Phone #:__
Insurance Co. Policy.#
Company name:
Address
City: Phone* -
Insurance Co Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone #
Official use only do not write in this area to be completed by city or town official' F Building Dept
OCheck if immediate response is required Building Dept p Licensing Board
F1 Selectman's Office
Contact person:_ Phone #: Health Department
Other
FORM WORKMAN'S COMPENSATION
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978)688-9545 Fax(978)688-9542
DEBRIS DISPOSAL FORM
f p►ORTH '9A-
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In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
Facility location
Signature of Applicant-)
/�,-�- baa
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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