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HomeMy WebLinkAboutBuilding Permit #511 - 190 CHICKERING ROAD 3/7/2008Permit NO: V BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received E ,1, ,�..M, O OL PROPOSED USE Residential ,p 1. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Iteration No. of units: % Assessory Bldg Commercial epair, rep acemen Others: Demo l ion Other Septic „ .Well Floodplain Wetlands Watershed'District, aterfsewer DESCRIPTION OF WO allot lw• , . TO BE PREFORMED: Identificati Plea a Type or Print Clearly) WN Name: Ali%- �,C�� e� u�-I IV Ph 7J-- Address: Uri�O f GONTRAOI'OR Name nsurcottit.v% I c as�ruc tori Phone: qsD ?Ja 1 rt Address. n. S cd cR C i d_ e- Exp. Date Exp. Date: ARCHITECT/ENGINEER IVZZ Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 21,100.00 FEE: $ a fo Check No.:, _,t(a Receipt No.:� 16 i) NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i Location� l U �'1 t�L VI V�1� �D � No. Date TOWN OF NORTH ANDOVER ►°. i v ' Certificate of Occupancy $ �'�a''•°'t<� Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ r Other Permit Fee $ l TOTAL $ Check # 2 1 001 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS 9 DATE .REJECTED DATE APPROVED CONSERVATION COMMENTS' DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes' no rn Located,at T24`Main Street Fire Departmentsgnature/date COMMENTS- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NU 1 t5 and UA 1 A — (For tlepartment Use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Li Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New .Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 D O b IL O o o o - a o H w z a m 0 c 0 , v U cov w a w a � w a R. w � w W n°' cn co w a O `� c� rx° w z w w a w z cn v Q i o cn W I � 5 0 Cc w c V C y O :oc c c kit ® c s mom >���y E a ..,o rr: oQQ G m a O� i c `NG L% � O O r a Q * m CD C H O ��■■� j mIA- C42 (� O m�as �m CA H O O to :� •rte � � •� 1 av m Wm iz:s CM cc cm" c acz m .mom ca o :coo cm o, c 1 = o :ago N COO. _ w z �' Z uj C3 'v CLC.3 m :yus .0 �N.� O 0 O H Z Gg comrbCL 3- m ZIP 41 U O 4 v v O � O v CL O y G C Ico cm C y p 'v y O O CD 0 a- mt) mo a CL CDQ o � C ev �v G. O CD C Z CD 0 CL V y O C C CL to CO3 E 0 w U) 19 W 19 W x Insurcomm Const mefion IIIc Client: Marie Loughlin Home: 190 Chickering Street Unit 101 D North Andover, MA 01845 Operator Info: Operator: ANDREW Estimator: Andrew Radar Reference: Company: Craig Gellespie Type of Estimate: Water Damage Dates: Date Entered: 09/12/2007 Price List: MAEM4B7D Restoration/Service/Remodel Estimate: 2007-09-12-1329 Business: (781) 245-9516 1. Insurcomm Construction Inc Room: Entry Missing Wall: 1- 4'11" X 8'6" Missing Wall: 1 - 0'5" X 8'6" Missing Wall: 1- 117" X 8'6" DESCRIPTION 2007-09-12-1329 Main Level Opens into Kitchen Opens into Dinning Room Opens into Dinning Room QNTV Ceiling Height: 8' 6" Goes to Floor/Ceiling Goes to Floor/Ceiling Goes to Floor/Ceiling UNIT COST TOTAL R&R 5/8" drywall - hung, taped, floated, ready for paint 33.62 SF @ 2.16 = 72.61 Seal/prime the ceiling - one coat 33.62 SF @ 0.41 = 13.78 Paint the walls and ceiling - two coats 175.51 SF @ 0.73 = 128.12 Pre -finished solid wood flooring 33.62 SF @ 8.43 = 283.42 Paint baseboard - two coats 16.69 LF @ 1.09 = 18.19 Room: Kitchen Missing Wall: Missing Wall: Missing Wall: DESCRIPTION 1-2'610X81610 1- 918" X 816" 1 - 4'11" X 8'611 R&R 5/8" drywall - hung, taped, floated, ready for paint Seal/prime the ceiling - one coat Paint the walls and ceiling - two coats Recessed light fixture - Detach & reset urian only Light fixture - Detach & reset R&R Cabinetry - lower (base) units - Deluxe grade R&R Cabinetry - upper (wall) units - Deluxe grade R&R Countertop - Flat laid plastic laminate Dishwasher - Detach & reset Garbage disposer - Detach & reset Range - electric - Remove & reset R&R 4" backsplash for fiat laid countertop Sink - single - Detach & reset Sink faucet - Detach & reset Paint casing - two coats Paint door slab only - 2 coats (per side) Interior door - Detach & reset - slab only R&R Tile floor covering - High grade 2007-09-12-1329 1117Z-7 f1`Z Opens into Dinning Room Opens into Dinning Room Opens into Entry QNTY U 3.82 SF @ 97.82 SF @ 289.78 SF @ 3.00 EA @ 1.00 EA @ 20.00 LF @ 16.00 LF @. 24.00 LF @ 1.00 EA @ 1.00 EA ,@ 1.00 EA @ 24.00 LF @ 1.00 EA @ 1.00 EA @ 40.00 LF @ 3.00 EA @ 2.00 EA @ 97.82 SF @ Ceiling Height: 8' 6" Goes to Floor/Ceiling Goes to Floor/Ceiling Goes to Floor/Ceiling UNIT COST TOTAL 2.16 = 0.41= 0.73 = 2.66 = 43.88 = 314.97 = 245.19 = 41.10= 206.75 = 121.54 = 36.95 = 8.14 = 113.43 = 90.97 = 1.09 = 22.33 = 13.81 13.34 = 245.85 40.11 211.54 7.98 43.88 S 206.75 121.54 36.95 195.3 113.43 90.97 43.60 66.99 27.62 1,304.91 11/05/2007 Page: 2 Insurcomm Construction Inc CONTINUED - Kitchen DESCRIPTION QNTY UNIT COST TOTAL Remove Additional labor to remove tile from concrete slab 97.82 SF @ 1.42 = 138.90 Room: Dinning Room 64.00 SF @ 2.16 = 138.24 Ceiling Height: 8' 6" Missing Wall: 1 - 97" X 8'6" Opens into Living Room Goes to Floor/Ceiling Missing Wall: 1- 015" X 8'6" Opens into Entry Goes to Floor/Ceiling Missing Wall: 1- 11" X 816" Opens into Entry Goes to Floor/Ceiling Missing Wall: 1 - 2'6" X 8'6" Opens into Kitchen Goes to Floor/Ceiling Missing Wall: 1- 918" X 8'6" Opens into Kitchen Goes to Floor/Ceiling DESCRIPTION QNTY UNIT COST TOTAL R&R 5/8" drywall - hung, taped, floated, ready for paint 64.00 SF @ 2.16 = 138.24 Seal/prime the surface area - one coat 64.00 SF :@ 0.41 = 26.24 Paint the walls and ceiling - two coats 540.08 SF @ 0.73 = 394.26 Casing - Detach & reset 60.00 LF @ 1.64 = 98.40 Paint casing - two coats 100.00 LF @ 1.09 = 109.00 Paint door slab only - 2 coats (per side) 3.00 EA @ 22.33 = 66.99 Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @ 35.61 = 35.61 Smoke detector - Detach & reset 1.00 EA @ 42.49 = 42.49 Cold air return cover - Detach & reset 1.00 EA @ 17.57 = 17.57 Baseboard - Detach and reset - oversized or multimember 42.88 IF @ 2.71 =116.20 Paint baseboard - two coats 42.88 LF @ 1.09 = 46.74 R&R Pre -finished solid wood flooring 175.58 SF @. 10.28 = , 04.9 Room: Living Room Missing Wan: DESCRIPTION 1 - 917" X 896" Opens into Dinning Room am Ceiling Height: 8' 6" Goes to Floor/Ceiling UNIT COST TOTAL Paint the walls - two coats 467.25 SF @ 0.73-- 341.09 Paint casing - two coats 40.00 LF @ 1.09 = 43.60 2007-09-12-1329 11/05/2007 Page: 3 Insurcomm Construction Inc CONTINUED - Living Room DESCRIPTION QNTY UNIT COST TOTAL Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @. 35.61= 35.61 Baseboard - Detach and reset - oversized or multimember 54.97 LF @ 2.71 = 148.97 Paint baseboard - two coats 54.97 LF @ 1.09 = 59.92 R&R Pre -finished solid wood flooring 244.56 SF @ 10.28 = 2,514.08 Room: Mstr Bedroom Ceiling Height: 8' 6" DESCRIPTION QNTY UNIT COST TOTAL Paint the walls - two coats 420.76 SF @ 0.73 = 307.15 Casing - Detach & reset 40.00 LF @ 1.64 = 65.60 Paint casing - two coats 40.00 LF @ 1.09 = 43.60 Paint door slab only - 2 coats (per side) 2.00 EA @ 22.33 = 44.66 Paint bifold door set - slab only - 2 coats (per side) 2.00 EA @ 35.61 = 71.22 Baseboard - Detach and reset - oversized or multimember 49.50 LF @ 2.71 = 134.15 Paint baseboard - two coats 49.50 LF @ 1.09 = 53.96 R&R Pre -finished solid wood flooring 131.60 SF @ 10.28 = 1,352.85 Room: Mstr Closetl Ceiling Height: 8' 6" DESCRIPTION QNTY UNIT COST TOTAL Paint the walls - two coats 89.26 SF @ 0.73 = 65.16 Casing - Detach & reset 20.00 LF @ 1.64 = 32.80 Paint casing - two coats 20.00 LF @ 1.09 = 21.80 Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @ 35.61 = 35.61 Baseboard - Detach and reset - oversized or multimember 10.50 LF @ 2.71 = 28.46 Paint baseboard - two coats 10.50 LF @ 1.09 = 11.45 R&R Pre -finished solid wood flooring 6.50 SF @. 10.28 = 66.83 Room: Mstr CloseU Ceiling Height: 8' 6" 2007-09-12-1329 11/05/2007 Page: 4 Insurcomm Construction Inc DESCRIPTION QNTY UNIT COST TOTAL Paint the walls - two coats 96.43 SF @ 0.73 = 70.39 Casing - Detach & reset 20.00 LF @ 1.64 = 32.80 Paint casing - two coats 20.00 LF @ 1.09 = 21.80 Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @. 35.61 = 35.61 Baseboard - Detach and reset. - oversized or multimember 11.35 LF @ 2.71 = 30.76 Paint baseboard - two coats 11.35 LF :@ 1.09 = 12.37 R&R Pre -finished solid wood flooring 7.33 SF @ 10.28 = 75.35 Room: Mstr Bath Ceiling Height: 8' 6" DESCRIPTION QNTY UNIT COST TOTAL R&R Tile floor covering - High grade 42.17 SF @ 13.34 = 562.54 Remove Additional Tabor to remove tile from concrete slab 42.17 SF @ 1.42 = 59.88 Baseboard - Detach and reset 26.33 LF @ 2.30 = 60.56 Paint baseboard - two coats 26.33 LF @ 1.09 = 28.70 Casing - Detach & reset 20.00 LF @ 1.64 = 32.80 Paint door slab only - 2 coats (per side) 1.00 EA @ 2233 = 22.33 Paint casing - two coats 20.00 LF @ 1.09 = 21.80 Toilet - Detach & reset 1.00 EA @ 183.64 = 183.64 Drywall Installer:/ Finisher - per hour 1.00 HR :@ 58.08 = 58.08 one hour repair Paint the walls - two coats 223.83 SF @ 0.73 = 163.40 Room: Closet Ceiling Height: 8' 6" DESCRIPTION QNTY UNIT COST TOTAL Paint the walls - two coats 127.50 SF @ 0.73 = 93.08 Paint casing - two coats 20.00 LF @ 1.09 = 21.80 Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @ 35.61 = 35.61 R&R Baseboard - 3 1/4" 15.00 LF @ 3.08 = 46.20 R&R Quarter round - 3/4" 15.00 LF @ 1.14 = 17.10 Paint baseboard - two coats 15.00 LF @ 1.09 = 16.35 R&R Pre -finished solid wood flooring 11.00 SF @ 10.28 = 113.08 Room: Bed2 Ceiling Height: 8' 6" 2007-09-12-1329 11/05/2007 Page: 5 Insurcomm Construction Inc DESCRIPTION QNTY UNIT COST TOTAL Paint the walls - two coats 369.75 SF @ 0.73 = 269.92 Casing - Detach & reset 40.00 LF @ 1.64 = 65.60 Paint casing - two coats 40.00 LF @ 1.09 = 43.60 Paint door slab only - 2 coats (per side) 1.00 EA @. 22.33 = 22.33 Paint bifold door set - slab only - 2 coats (per side) 1.00 EA @ 35.61 = 35.61 Baseboard - Detach and reset - oversized or multimember 43.50 LF @ 2.71= 117.89 Paint baseboard - two coats 43.50 LF :@ 1.09 = 47.42 R&R Pre -finished solid wood flooring 116.14 SF @ 10.28 = 1,193.92 Room: Exterior/General DESCRIPTION QNTY UNIT COST TOTAL Cleaning Technician - per hour 6.00 HR (cad 33.56 = 201.36 Grand Total Areas: 2,493.15 SF Walls 866.31 SF Floor 0.00 SF Long Wall 866.31 Floor Area 1,321.85 Exterior Wall Area 0.00 Surface Area 0.00 Total Ridge Length 2007-09-12-1329 866.31 SF Ceiling 96.26 SY Flooring 0.00 SF Short Wall 941.85 Total Area 155.51 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length �i7 o C) - 3,359.46 SF Walls and Ceiling 293.31 LF Floor Perimeter 293.31 LF Cell. Perimeter 2,493.18 Interior Wall Area 0.00 Total Perimeter Length 11/05/2007 Page: 6 Insurcomm Construction Inc Line Item Total Permit Material Sales Tax Subtotal Overhead Profit Replacement Cost Value Net Claim 2007-09-12-1329 Summary for Water Damage @ 5.000% x 14,617.52 @ 10.0% x 27,976.67 @ 10.0"/o x 30,774.34 Andrew Radar 26,810.29 435.50 730.88 27,976.67 2,797.67 3,077.43 33,851.77 33,851.77 3-0 S l /Zoo 11 /05/2007 Page: 7 ►t 00 N bD Cd 0. O O N v O N M N O O O N (5). WARRANTY: In addition to any additional warranties agreed to by both parties, the contractor warrants that the work will be free from faulty materials; constructed according to the standards of building code applicable for this location; constructed in a skillful manner and fit for habitation. Our workers are fully covered by Workmans's Compensation & Liabilty Insurance. The warranty rights and remedies set forth in the State Uniform Commercial Code apply to this contract. (6). RESOLUTION OF DISPUTES: If for any reason a dispute arises as to the terms of this contract or the performance of either party, then the parties agree to settle the dispute by jointly paying for the following. MEDIATION: With the parties agreeing to enter into good faith negotiations through a neutral mediator in order to resolve their differences. IN WITNESS WHEREOF: The parties hereto have executed this contract as of the date below written. (CONTRACTOR) (a DATE: ] 3-Og (OWNER) DATE: �� CONTRACT This CONTRACT, made This Day__,S--: Month 3 Yearz!POL: By: Marie Laughlin Of: 190 Chickering St: Unit 101D North Andover, MA 01845 . (.Hereinafter called the OWNER) And: INSURCOMM CONSTRUCTION INC Of: 8 BLAKELIN STREET LAWRENCE, MA (Hereinafter called the CONTRACTOR) WITNESSETH THAT THE PARTIES HERETO AGREE AS FOLLOWS: (A) The CONTRACTOR will furnish materials and perform the work for the consideration of: TWENTY THOUSAND NINE HUNDRED AND XX/100 ( $20,900.00) Dollars In accordance with the (GENERAL CONDITIONS) shown in this contract and attached detailed estimate number 0303 Dated 03-03-2008 (B) The CONTRACTOR will start work (weather permitting) by March 3, 2008 with estimated completion date of ASAP (C) The OWNER will make payment as follows $20,900.00 In full within ten days of completion to satisfaction. Each invoice is due according to the terms of payment stated herein. If not paid if full by due date, OWNER expressly agrees to pay a service charge of one and one-half percent per month, unless applicable laws requires a lessor charge, computed on the unpaid deliquent balance until the account is paid in full. For any credit which may be extended pursuant to the terms hereof, OWNER agrees to pay reasonable attorney fees and other costs incurred for collection. GENERAL CONDITIONS (1). CHANGES IN WORK: The OWNER who may at any time, with the approval of representative designated by the Financial Institution involved, make changes in the specifications, within the general scope thereof. If such changes may cause an increase or decrease in the amount due under this contract or in the time required for its performance, an equitable adjustment will be made, and this contract will be modified accordingly by the (Contract Change Order). (2). INSPECTION OF WORK: All materials and workmanship will be subject to inspection and test, by the OWNER or their Representative, who will have the right to reject defective material and workmanship or require its correction. (3). NOTICES AND APPROVAL IN WRITING: Any notice, consent, or other act to be given or done hereunder will be valid only if in writing. (4). CLEANING UP: The CONTRACTOR shall keep the premises free from excessive accumulation of waste material and rubbish, and at the completion of the work shall remove from the premises all implements, surplus materials and rubbish. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations y d 600 Washington Street .Boston, MA 02111 f: www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual :if3urtevkwk ► �� JIM 10tracA>m Mc Address: A M' . G _1.;. City/State/Zip: Areyou an employer? Check the appy 1.0 I am a employer with employees (full and/or part-time),* 2.[] I am a: sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself: [No workers' comp. insurance required.] t Phone.#: riate bog: 4. 0 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' -comp. insurance.# 5. [ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance reouired.l m Type of project (required)': 6. 0 New construction 7. RrRemodeling 8. 0 Demolition 9. Building. addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other Any applicant that checks box #/1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp; policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (<r . Policy # or Self -ins. Lic. #`' U c Z 41 Z Z SS 61 Expiration Date:_ )) LZ S1 op . Job Site A City/State/Zip: . y4l ue'r'�, 4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure. to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator.. Be advised that a copy of this statement may be forwarded to the Office of Tnveatiaatinnc of tl— 11T e I do hereby the pains and penalties of perjury that the information ,AIV _ provided above is true and correct ujitcuu..use only. Do not write in this area, City or Town: Issuing Authority (circle one): or town offtciaL Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6., Other Contact Person• Phone #: AcvRaa CERTIFICATE OF LIABILITY INSURANCE OP IDINS D- DATE 3/08 INSUR-2 03/0 03/03/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Santo Insurance - Salem HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 224 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem NH 03079 GENERAL LIABILITY Phone:603-890-6439 Fax:603-890-0315 INSURERS AFFORDING COVERAGE MAIC# INSURED INSURER A: American International Group INSURER B: Travelers Indemnity Co Znsurcomm Construction Inc Matt INSURER C: 8 Blakelin Street Lawrence MA 01830 INSURER D: INSURER E: PREMISES(Eaoccurence) $100,000 COVERAGES THE 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE (MM/MYY) DATE (Mv�(M I LIMITS ---- AUTHORM REPRESENTATIVE Af�AC•f1 AL I GENERAL LIABILITY EACH OCCURRENCE $1,000,000 B X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR I680229SC560IM06 11/15/06 11/15/07 PREMISES(Eaoccurence) $100,000 I MED EXP (Any one person) $5,000 I680229SC560IND07 11/15/07 11/15/08 PERSONAL&ADvINJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE UMRT APPLIES PER PRODUCTS - COMP.�OP AGG $2,000,000 POLICY E T LOC AUTOMOBILE LIABILITY ANY ALIT I COMBINED SINGLE LIMIT $ (Ea aWdenl) ALL D'J'1�IED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON-O,AT4ED ALTOS BODILY INJURY $ (Per acaden'[) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $1,000,000 B X OCCUR ❑ CLAIMSMADE I680229SC560IND06 11/15/07 11/15/08 AGGREGATE $ $ DEDUCTIBLE $ X RETENTION $nil $ A WORKERS COMPENSATION AND EMPLOYERS'LLABILITY ANY PROPRIETORtPAP.TNERIFXECUTI'YE WC8977059 11/25/06 11/25/07 X TORY LIMITS X ER E.L.EACHACCIDENT $500000 OFFICEPft,UABEREXCLUDED? If yes, desenbe under WC2922559 11/25/07 11/25/08 E.LDISEASE-EAEMPLOYEE $500000 E.L. DISEASE -POLICY LIMIT $ 500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS job name: Laughlin SCR I ortupki C nvLvtK CANCELLATInN TOT4NNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LLABFLIiY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 400 Osgood St REPRESENTATIVES. North Andover MA 01845 AUTHORM REPRESENTATIVE Af�AC•f1 AL I James A Santo " " - `" J —J O ACORD CORPORATION 1988 ►°3eaasiu►wPd l08£0 ti 31111S HN HlIIOWSla( Oa.,3-LLaAv qb'lOG; ON1 N': SN"Is 113 uoi;e�od�o NN1SN00 WWOOanS 0 aaenud S j 9002/ZZ2� uol�B�ld' Z6l9til 3 aOJ-3"j1VO31N uo(7ejaslBaa S#�lep°�S ug-suo► 3W3AO�dwf 3W0 J2uolssiwwoJ.. _ £90£O,.HN ',A8130NO-ON0I N34S321a' L =r }iVOVId S MMKIN`d A2�r�i21 6ti8;16 :ou !1 60QZ21/£0 sb�ldx3 $ g.K` ` wn 6AT60 SO fro N ipsiA-63dns NOIlOflb1SNOOP asuaa11 k $NOIldlflJ321�JN1a"I1f18'j0 42108 s q�gm�yp�o 2�armao�uvuooril Date,.,-.) /f - - TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ TY �:MA DATE �"-[�� PERMIT # � W� BSITE ADDRES G OWNER'S NAME ^� OWNER ADDRESS 110 TETYPE OR FAX PRINTOCCUPANCYTYPE COMMERCIAL[j EDUCATIONAL [ RESIDENTIAL CLEARLY NEW:El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E] NO® APPLIANCES -1 FLOORS BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER - FIREPLACE FRYOLATOR FURNACE GENERATOR — GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I have a current liabil ity insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES go NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY BOND 0 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. SIGNATURE OF OWNER OR CHECK ONE ONLY: OWNER 0 AGENT El ��r 1,110. Gil Ul LIM UVLdI13 dna inrormauon i nave submitted or entered regarding this application are t and accurate, tot be my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i om lance e ' en ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME' LICENSE # IGNATURE MP f4 MGF �d JP 0 JGF ® LPGI CORPORATION Il SSG. , PARTNERSHIP [J#= LLC []# COMPANY NAME: -11 vY1,V, r, Ptifi► ADDRESS LIX 54cpMA.rI CITY STATE � � tiS LL �� �. TEL ��w� 1,1,,1,1,•„��, FAX EMAIL >��10h�} QOI•Loyh - Y t O c c� a z b °z z 0 H C� m x m N rs► v r n � � a Z � r N m Oil m ca m N m n m ❑y O ❑o �z �r z b n H O z z 0 H The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ivww. moss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): L 1-��I p� li ,(�l (fit 1 11, , Address: k'J� City/State/Zip: (N..1r0.,_ '. , _ Uk$APhone #: Are ou an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. E]I am a general contractor and I 6. E] New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance required.] comp. insurance. # 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. o workers' com Y � P• right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance reauired.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: qao�A MbLt Expiration Date: .z 1� Job Site Address:_City/State/Zip: MA)&Q z' \% Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D,1A for insurance gage verification. I do hereby �j ,finder that the information provided above is true and correct. Official use only. Do not write in dliis 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 #: W A� CERTIFICATE OF LIABILITY INSURANCE 07 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: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 NOME: CT CLIC CONTACT CENTER AIC, No No.: 888-333-4949 Fac No): 507-446-4664 ADDRESS: CLIENTCONTACTCENTER FEDINS.COM OWATONNA, MN 55060 INSURERS AFFORDING COVERAGE NAIC # INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 247-960-8 INSURER 8: MILLTOWN PLUMBING & HEATING INC 131 STEDMAN ST UNIT 6 INSURER C: INSURER D: CHELMSFORD, MA 01824-1868 INSURER E: INSURER F: AMAGE TO RENTED, ncel $100,000 D=110 ES (E ccurrCLAIMS-MADE COVERAGES CERTIFICATE NUMBER: 119 REVISION NUMBER* n THIS IS TO CERTIFY THAT THE 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 BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED, ncel $100,000 D=110 ES (E ccurrCLAIMS-MADE FX OCCUR MED EXP (Any one person) A X BUSINESS OWNER'S LIABILITY N N 9064734 06/15/2015 06/15/2016 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO $2,000,000 X POLICY jE O- LOC A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N N 9064735 06/15/2015 06/15/2016 COMBINED SINGLE LIMIT $1,000,000 _ BODILY INJURY (Per person) BODILY INJURY (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY PROPERTY DAMAGE c d X UMBRELLA LIAB X IOCCUR EACH OCCURRENCE $1,000,000 A __FDEDT1 1 EXCESS LIAB CLAIMS -MADE N N 9064736 06/15/2015 06/15/2016 AOOREGATE $1,000,000 RETENTION A WORKERS COMPENSATIONX AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA N 9354812 06/15/2015 06/15/2016 WC STATU-OTH- TORY LIMITS ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 (Mandatory in NH) It yes, describe under E.L DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atlach ACORD 101, AddiSonal Remarks Schedufe, It more space is required) CERTIFICATE HOLDER CAM/YI I ATI^U 247-960-8 1190 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA 01845-2420 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 4 0 4 V.4". rri 'a�w ii in r n • ,,JLJLCs- G r T O i7+ 0, Oil . mrn mer •Zi' CD ;v Ln CIO MV —1 rnrn i -- y � 4 V.4". rri 'a�w ii in r n • ,,JLJLCs- G t V Tuesday, Jun 21, 2016 01:00 PM ,�----- > __,. r f —> C uh-ps:lbwta-dovefta.viewpointioLid.com/4Ae.cords;205%2/41416 ABPs ... Town of North Andover, MA 4 ex cr ,_1..,.. ..._....... ....... _.... 20672 - `Gas Permit - Replacement of Existing Fixtures/Appliances (Commercial of Residential) O Permit issued TIMELINE 0 Submission received - J- 21, 2016 at 6:51 em Permit Fee Gar Permit ReNew ® ® ... . - C—pleredw� 21,2016 n9:00em _ Thank You This fee is paid in full Permit Fee _. ... ... ......... .... .......... ._ .... ' Zd)un 21,2016 et 9:01— - Price for residential furnace or gas $30.00 ! boiler and conversion burner _. . - ®Permit Issuance Minimum price for single family $25.00 Issued Jun 21, 2016 .9:01.m dpplidnces/ibnure5 Total per appliance/fixture price $5.50 - _ Total Fee Amount: $35.50 - 1 / - - Payments Date Method Note Amount Processing - - --- - - - - - Jun.21.2016 Check 4094 $35.50 i .. ., ...._. .._........ _.......... _.... ... Say omeching abcut this... ......._._. -. ........... l W O * 40 .J.sb uu.6hlf}fli6 Tuesday, Jun 21, 2016 01:00 PM n Is .;_ ,�Iz �t tM1tpiJJnadhapdave[rtM vieYdpaintdoud.comJ+fyrecard,F106Ti-Q (+i. fAI'Gash—ita10672-Vew9...x Town of North Andover. MA �" a search ®- ^ 2672 . - *Gas Permit - Replacement of Existing Fixtures/Appliances (Commercial of Residential) i TIMELINE 0 submission received Your request Is In progress Jun 21, 2016 at 8:51am we'll letyou know of any updates via email. Feel free to check the status at any time by coming back to this page. - - 0Gas Permit Review In Progress Permit Fee !'1 &Pan FSyment � 5 �N`, Pemleum o Permitissuance ,:ice. Harrison'sRoast Beef V Milk & somoo r d. ' n • 't ..-_ .._,......�..__�_ Applfcant Location - - Jeffrey hutnick 190 CHICKERING ROAD n10o;, NORTH ANDOVER, MA AHERN, EDWINA L. Attachments f .. + plead Ftie . No Files... v � a Tuesday, Jun 21, 2016 09:00 AM The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letsibly Name (Business/Organization/Individual): 4�fd 11,0'1%a12 i Address: �?/ ge- /17?1/7 f City/State/Zip: M/ /�, IWP, G%W Phone #: Are you an employer? Check the appropriate box: LR am a employer with _& _employees (full and/or part-time)_* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3_❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.E] I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensue that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance. 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. . 152, §1(4). and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Belmp is the policy and job site information. n T� rJ Gi Insurance Company Name: Policy # or Self -ins. Lia #: , (/J G e UG % 3 Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 WORK 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 DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #' OP ID: PS AC"RIU ° CERTIFICATE OF LIABILITY INSURANCE DATE;(MMID61YYYY) '11116f2o� � . TH)S CERTIFICATE IS ISSUED AS A. MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE. HOLDER. THIS."-- HIS:CEP. CERTIFICATE iIFICATE 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(Sh AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER - IMPORTANT: If the certificate holder !San ADDITIONAL INSURED, the policy(les) 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 Foster Sullivan insurance 163 Main St. CONrAc' Pete.SUIIIVan PHONE ac. .. Et: 978-686-2266 IAXC, No): 978=686=6410 North Andover, MA 01845 Stephen Sullivan AQr�Ss: psuiiivan@_fostersuliivangroup:cam PROD CER CUSTOMER ID': CALLA -1 INSUREr2(S)AFFORDINGCOVERA_GE I NAICs EACH OCCURRENCE 5 1,000,00 INSURED Callahan A C and Heating Services, Inc. Kate Callahan INSURER A: LIBERTY MUTUAL INS CO. 128043 INSURERB:GUARD INSURANCE COMPANY INSURER C : 91 Belmont Street INSURERD: North Andover, MA 01845 INSURER E : INSURER F �.vv ere,.aa�r_a c -+ w 111-11 _a 11- wi oe�nern►e err r�s�ra. THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOP, THE POLICY PERIOD INDICATED_ NOT Aldi' 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 SEEN BY CLAIMS. POLICYL LITSR ! TYPE OF INSURANCE ,INSR I POLICY NUMBER `REDUCED i Er !!PAID I 4MINDSM 1 LIMITS A GE[+C-RALUABILITY X CofsMEi:CIALGENERAL LIASIL1TY CLf1t1S4A1,DE- OCCURiy' X �CBP4016154 10912512015 09125/2016 EACH OCCURRENCE 5 1,000,00 IQQ-pQ4 P, cMiSES IEA OLgSTM_". J , . MEDEiP/Anyon=per on) � c 5,00 CONTRACTUAL.LIAB ; PERSONPL&AWIN JRY $ 1,000,00 GENERALAGGREGATE s 2,000,00 —GcJ41AGGREGATEIi,,",P.TA°PLIESPi R; I I POLICY � IE 7 LOC I PRODum-s-coawifOPAGG ( 5 2,000;00 j I IS A AUTOMOBILE LIABILITY L— ANY AUTO X BA4544035 I 1 09125/2015 i 09/2512016 COMBINED SINGLE LI!YfA 00000 1 (Ee `:cadent) ` > BODILYn.IURY(Parperron) $ X ALLOY;i�lEDAUTOS SOD!LY �Jt PY Igor accident) $ SCHE6ULEDAUTOS X HIREDAUTOS j I PROPET ;r DM/LAGE !PEP?.CC1]EKT) X NON-OVNEDAUTOS 4i4 is X UMBRELLA LIAB X OCCrUREA.. I r OCCURRENCE -+ is 5,000,00 A EXCESS LIAB Cifilk9� LADE . v � CU88(19.,34 09/2512015 09125/2015 AGGREGATE S 5,006,00 DEDUCT IBL S 1 Rci�ri-IOiJ. . 1 B AND EMPLOYERS' LIABILITY YIN Ari• PRO.PRIETOR,?A.RTr!EPJE}CCUriVEc C1-riCr'�,f.9F,.h'l?tnCLUt}�`? (f,iandatoryinNn) If yes, dewj1e under. , - DESCRIPTION OF OPERATIONS belo:•i N/A j CAWC604073 1.0912512013 10,912512016 j } OR SL J IS i X E -L EACH ACCIDENT s 509,000 E .L DISEASE -EAc�rPLO cj 5 500,000 E! _ DISEASE -POLICY LIMIT $ -500,000 DESCRIP`nON OF OPERATIONS l LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remariis Schedule, if more space is recitilred) " EVIDENCE ** fax # 978.688-9542 ...ten nn1..,yt c.nva.vnn - I,.HIVI.CUGHIIVIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF„ NOTICE .trdlLL .BE DELIVERED .IN TOWN OFNORTH ANDOVER- ACCORDANCE WITHTHE POLJCYPROVISIONS. 1600 OSGOOD STREET AUTHOR1z=0 REPREse�1TATivE NORTH-ANDOVER,:MA 01845 f, 01988-2009ACORD CORPORATION. All rights reserved. ACORD25 (2009109) The ACORD;name and logo are registered marks ofACORD I 00 E 00 Z 00 Z" w U - z o 0 -z 0 Lu W LLLLU) z w W Ina X.. W uj ui. N W Luo' CW LL Lu fLL p. LU CO, UJ D 1 5 JL cNiJw-j ..x 0 4 0 0 LL. LL pr F C14 LU Ina ui. N W UJ LL Lu Qo�fn z LL C*' ..x 0 4 0 0 LL. LU < w Xt' DWn _j 5 LU IL V). Z-% ui liJ w LL Ill C LU co 6/10/2016 20559 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20559 p10RTH O 9�O 3= OL o �m A 5 �QSSACHusE�( TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Peter G Viens has permission for gas installation replacing gas furnace in the buildings of HELLER, KARIN at 190 CHICKERING ROAD 210.D, North Andover, Mass. Lic. No. 12116 Date: June 10, 2016 1/1 GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY,% YIelodZf MA DATE 6,Y-16 PERMIT# JOBSITE ADDRESS 1 i O G%i ekY. . n � & Uyh i2 /0 '*b OWNER'S NAME ;4 4 m4 ADDRESS ,S'�D.�►7� TEL FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES © NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X❑ OTHER TYPE INDEMNITY ❑ BOND ❑ 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 true and pettlate to the best ofmpkpowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant wit all Pertinent pro .si the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ® # 3631C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit # 3 CITY Methuen STATE MA ZIP 01844 TEL (978) 689-0224 FAX CELL EMAIL pviensj�mvalleycorpxom W F O z z 0 U W 0, z a d z °❑ Z z o >w ❑ W ~ w � F O W O z F' aLU `nU)w Z N a W O W Q W N W (� ZO 0. a a U F a IL Q � N NA 2 W F W W F" O z z 0 F U W a z Q c� m 0 `i ;J The Commonwealth of Massachusetts Department of Industrial Accidents - - Office of Investigations 1 Congress Street, Suite 100 Boston, NIA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): jO�Lrr-, m . le- dey L.0 C -rA L Address: City/State/Zip:/rte,,t t4 o &Y -f Phone #: .9 2.6 - to 6 9- z1. Are you an employer? Check the appropriate box: Type of project (required): 1.9ram a employer with 4. Fj I am a general contractor and I 6. F1 New construction employees (full and/or part-time). have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. r� Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. F1 Building addition (No workers' comp. insurance required.) 5. We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1(4), and we have no 11M Roof repairs employees. [No workers' 13. comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:`�,^� Policy # or Self -ins. Lic. #: 0 1 4 6 S',3 5-.5- c T I L s 6 Expiration Date: 6 - 13- / (a Job Site Address: 190 X e- 6A �1 O J City/State/Zip: �k�o��r, 1'✓[Qk '01A J— Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her64Lcertifv under the pains and that the information provided above is true and correct. //!s rYlrKdLK (/mss-!/t�/Gr.dH Tl�ro! Lei � 1 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 #: Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner dfi Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: Janet M. Msumba Property address: 190 Chickering Rd. Unit 205 North Andover, MA 01845 Policy #: 2382572 Loss of: 2016/01/28 File or Claim No. AD 1958 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,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by firs class mail. 1-29-16 Signature and date Date... 0��5 TOWN OF. NORTH ANDOVER PERMIT FOR GAS INSTALLATION %-` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `{ CITY i ;! V ef.r � ,�„ �,,a `, �� _WMA DATE // — f � �-/,i- jj PERMIT # JOBSITE ADDRESS �OWNER'SNAMEti�� GOWNER ADDRESS a7 tV LAe— 12 TEL��_ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL �- CLEARLY NEW: F-1 RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES NO [Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =1 L= I R . I _ .. =:j BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER Fi L INSURANCE COVERAGE havet current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1.. NO El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND 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 0 AGENT [�I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and in I have submitted or entered regarding this application are true 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 compliancQ with all P inent prov(isionY the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUM BER-GASFITTER NAME o_._ (�► ey1 y LICENSE # SIGNATURE MP [I MGF Ej JPE3 JGF LPGI © CORPORATION Ej#I PARTNERSHIP 0#= LLC E]#= COMPANY NAME: ^` }�(�ADDRESS CITY 4 ,.- 4STATE JV & ZIP FAX�— _ CELL _ EMAIL . .,v cc 7- 5r H O z 0 H U a �1 az° � O Nrl W ►� W U w �* W acn �+ w w c a o a a a U J ' E., a a Q � x w N LL LC w H 0 z 0 H U w P-1 Un °a Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/1<'lumbers. TO BE FILED WITH THE PERAflTTING AUTHORITY. Name (Business[Oigauization/Individual): Address: City/State/Zip: if*A-v ^OS7Y A- I Are yon an employer? Check the appropriate box: Phone #: 1.[] I am a employer with employees (full and/or part-time)'* 2. N`I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no 6niployees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insuranceJ 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, §1(4), and we have rio employees: [No workers' comp. insurance required.] 2C6 /;7J �Z-- Type of project (required); 7. ❑ New'constrtiction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12� Plumbing repairs or additions 13•. [] Roof repairs 14.[] Other xapplicant that checks box #1 must also sill out the section below showing their workers' compensation policy information: 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Mow is the policy and job site information. Insurance Company Name:, Expiration Date, Policy # or Self -ins. Lic. Job Site Address: l-� 210� t Ciiy/State/Zip•t� Attach a copy of the workers' compensation po cy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a iuie up to $I,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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify�unr thepiins andpenalties ofpeijury that the information provided above is true and correct..!;- Y Date: s 7 - /7-f-5— 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 The Commonwealth of Massachusetts F Department of IndustrialAecidents n ... _ `�~ 1 Congress Street, Suite 100 - Boston, MA. 02114-2017 9` www mass.gov/dia Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/1<'lumbers. TO BE FILED WITH THE PERAflTTING AUTHORITY. Name (Business[Oigauization/Individual): Address: City/State/Zip: if*A-v ^OS7Y A- I Are yon an employer? Check the appropriate box: Phone #: 1.[] I am a employer with employees (full and/or part-time)'* 2. N`I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no 6niployees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insuranceJ 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, §1(4), and we have rio employees: [No workers' comp. insurance required.] 2C6 /;7J �Z-- Type of project (required); 7. ❑ New'constrtiction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12� Plumbing repairs or additions 13•. [] Roof repairs 14.[] Other xapplicant that checks box #1 must also sill out the section below showing their workers' compensation policy information: 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Mow is the policy and job site information. Insurance Company Name:, Expiration Date, Policy # or Self -ins. Lic. Job Site Address: l-� 210� t Ciiy/State/Zip•t� Attach a copy of the workers' compensation po cy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a iuie up to $I,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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify�unr thepiins andpenalties ofpeijury that the information provided above is true and correct..!;- Y Date: s 7 - /7-f-5— 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 Gj I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empldAes. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of bite, express or implied, oral or written." An employer is d'e%nied 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:lias not produced -acceptable evidence of compliance with the insurance coverage ieequiied." Additionally, MGL chapter 152, §25C(1) 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 certificates) 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 to -sin)." 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia c a EAD NH 03841-21 L 1 )r it I1 L 4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /d 7 `7— Occupancy and Fee Checked [Rev. 1/071 (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 ININK OR TYPE ALL INFORMATION) Date: &– jZ – / f City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersignedives notice of his or her intention to perform the electrical work described below. Location (Street & Number) __/ ?U e k& i`fN Q Y� UA/ i—r I0 )O, Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building e) ,%J� C) ( Qom 'p le k - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: }�,eC_00ueeT t-[ 1�Ursua c_.P S irMQV4Cl nr Mo)A rernecliariu aAy _ Y.P('c-)NN,e cT- Comnletion ofthe following table may he waived by the Tn.vnectnr of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El ❑ rnd. rnd. o. o Emergency Lighting Batter 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 g No. of Waste Disposers Heat Pump Totals: 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 Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiriuivalenng: No. of Devices or E t OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: G Go (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 'OND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. . Lo e oA, A., ! e,q I r �! LIC. NO.: t-/ 7 l Licensee: M_ e /J Za CaSignatu (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.• Address: 6Z3 M©,u Al 0A4 AJC 0 3 03 L Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ la 37 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed 1 on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an ) electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass IN Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL, INSPE TION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 0211420.17 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: d 3 MUti% V-er'iy(),u J2 al City/State/Zip: d A4 A e>r c % 1J.11, 06 3ftone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 2.I amain a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors. with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.; 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have noemploye . es. [No workers' comp, insurance required.] Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 0 Building addition l llectrical repairs or additions 12. E] Plumbing repairs or additions 13.E] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-coritr'aciors have employees,' they must provide their workeis' comp. policy number. Iain an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: l`� .C'-f—,ev /y / .v Policy # or Self -ins. Lie. Expiration Date: Job Site Address: /90 C 4 i C e P"/ -,U j rd City/State/Zip: N. AmOa m- it'sA . Attach a copy of the workers' compensat policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 WORK 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 X do here thewns and penalties ofperjuty 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 # /- /,/- s" 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 t 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 I Date.R�2-11A-Z7 ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .......... Y .... 1... '--41 ......................................................................... has permission to perform .... .................... . .......... . wt ................................................... plumbing in the buildings .......................................................... at ......l s.)....i.N-3-d-.R.. J, . . ...... 7 .... I ... �). North Andover, Mass. ..... Fee ....Lic. No . . M� .................................................. I ............. PLUMBING INSPECTOR Check# r., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C� CITY [.. - - - --: /l/. !7_`i1a°✓ .. ..... _. ......_. _...: MA DATE PERMIT# �QLLJ� JOBSITE ADDRESS Ae) ;COWNER'S NAME) OWNERADDRESS': 1 TEL! FAX!' TYPE TYPE OR OCCUPANCY TYPE COMMERCIAL -,.� EDUCATIONAL RESIDENTIAL PRINT CLEARLY -. NEW: ._' RENOVATION:; REPLACEMENT:` PLANS SUBMITTED: YES! N FIXTURES Z FLOOR--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB- '..._..._'...-----._..... CROSSCONNECTIONDEVICE _... _.__._. ...._._. DEDICATED SPECIAL WASTE SYSTEM _...._..�............: ....... ... ...._............_ _ _. _ . _ . i .... .. _...... DEDICATED GAS/OIL/SAND SYSTEM - --,.._....._.._. ,.._._...__ ._.._._..:,__...__..,'._......_._..';...._._...; ..._....... _-- _--... _.... _ _ __... _ .._ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM " DEDICATED WATER RECYCLE SYSTEM '_.__.._ ` DISHWASHER_....' ._........:- ...__.....__._.__ ..__....... ._ _.. _ DRINKING FOUNTAIN i ..-_.. _ .......... - - _ I ._. _.._. ._.._ _...i _ ... _..-._ ..........; FOODDISPOSER I .._-.._.....-..,,..._....--_: __..._ .._ ._......_........_..... - . _..._;....__ ..... _.. _..._ L.._... -. _.....__................. ..........: ! FLOOR/ AREA DRAIN -••-_.._. _._____. _...___ .__.__. INTERCEPTOR (INTERIOR) '--'-- -- _--- ._.._.—_ ..__..__ _...._...__ .......__....... _. ____ _._._-- _-- KITCHEN SINK LAVATORY I , ROOF DRAIN .. _._..:... SHOWER STALL SERVICE / MOP SINK _.._-.---___.----__.-•-, _-- TOILET ` URINAL ------- ---- --„-._..._ •----..._ -_ _ .._.. WASHING MACHINE CONNECTION -- - WATER HEATER ALL TYPES WATERPIPING -__ ......—i__......_—...---......_--- -- --......__;.._:...__.... --- -- OTHER l INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW INSURANCE POLICY LIABILITY OTHER TYPE OF INDEMNITY ; BOND 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 true 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 cc pliance with all Pe in nt vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 UMBER'S NAME, MICHAEL HOUSE (LICENSE # 7173 _ .... ....... _.._. _. _ .-...._.. SIGNATURE - 3- JP. CORPORATION;/#377C PART NERSHIP;MP: . COMPANY NAME ; MERRIMACK VALLEY CORPORATION 'ADDRESS: 15 AEGEAN DRIVE, UNIT #3 CITY: METHUEN ;STATE! MA ZIP 01844 TEL I-- - — 978.689-0224 FAX; 978-689.2206 CELL j 978-815-4523 EMAIL : LLITTLE@MVALLEYCORP COM U i r w F O 7._ z o U w a z Q z 0❑ Z 7_ � ~ w O U w O W z 3 CL v� z N a d w w Q C7 Q z a o CL I -- CL a CL a 'A w x w LLw F O 7_ 7_ O F U w . a. z x O r� U Date ........ 6.... I... .............. TOWN"OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ., . This certifies that...........................!.e......................:................................. has permission for gas pta,lation .:...-.... .....:............................. inthe buildings of .....'...!............................................................................... at ..:.I................. .+.:..: .... .......... O.. ..,North Andover, Mass. :. Fee..10 ........... Lic. No. .. � .... ..................... . ................................... GASINSPECTOR Check # C XT MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYll = - MA DATE 111,771 PERMIT # JOBSITE ADDRESS %�D ,C�iY✓�� �. �i/U �1 OWNER'S NAME WZ//"J- OWNER (� ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ Nox APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY ❑ BOND ❑ 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 true 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 comp 'gnce with all Pent pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Michael H. House LICENSE # 7173 GNA U E MP0( MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION%# 3377C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME MERRIMACK VALLEY CORP. ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP 01844 TEL 978-689-022"", 978-689-2206 978-815-4523 FAX CELL EMAIL XT w F O z z"N, 0 U W a z a z w zz�� . o ❑ z z O HEl � w � ~ w O O w u W z z a w .. IL W N > O w z d (� z �=+ Q O a a N U r F a IL � a N 111 S w F- LL N W F O z z 0 H U W C z d c� x 0 x Ee N The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations N 600 Washington Street Boston, Mass. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual) : i Ilgee 1 '4. /�/o„/ t/��11. Add 0 City/State/Zip: ,V1! -990e' L) All V Z Phone#: Are you an employer? Check the appropriate box: I . I am an employer with �'t- 4.0 I am a general contractor and I employees (full and/or part time).* have hired the sub -contractors 2.3 1 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. employees and have workers' [No workers' comp. insurance comp. insurance. $ required] 5.0 We are a corporation and its 3. i. I I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no employees. [no workers' comp. insurance required.] Type of project (required): 6. 7 New construction 7. 0 Remodeling 8. L Demolition 9. ❑ Building addition 10. 0 Electrical repairs or additions 11. 0 Plumbing repairs or additions 12. L! Roof rep 'rs r 13.�lCbther Rtp " I *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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' comp. Policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. "� Insurance Company Name:_ 111116 J 7—, dl,,d / 4 Its„ , may_ Policy # or Self -ins. Lic. #: Expiration Date: �- Job Site Address: /YO 6" 2! City/State/Zip: v _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date). Failure to secure coverage as required under Section 25a of MGL 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby ce un pp :2t of per ry that the information provided above is true and correct. Si nature7Z: � AG"`l7ate: /%Xf;z/,:7 Print Name: S 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): I.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 6. Other 5. Plumbing Inspector Contact person: Phone #: V COMMOMEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building D North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: TEL #: 97f % q- -IFV NAME OF COMPLAINTANT:rAli T ADDRESS: D exfc-`tce),e COMPLAINT TYPE: Electrical: Plumbing: Gas: Building: �-}GG;U�� �+�'� Property Owner: /-S Address: lfxl4el-41ee Ta gu;L lti�� Other: ,IV qzz---1.4 Signed: J Complaint Form - Revised 6.2007 9402 Date. . Z.• . TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING This certifies that ..!P'L'C !/�?ae..%4-�.�. ..E-t/�7�......... �: has permission to perform l� . . plumbing in the buildings of ... .S. v!'? �........... ... at. �90...�-�r�.h..r� • ........ , Nor -1h A ndover, Mass. y f PLUMBING IN ECTOR Fee 30!a? . Lic. No.. Check # C EO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r' CITY���,�, MA DATE PERMIT# JOBSITE ADDRESS /90 ��;�c, WNER'S NAME _�_/✓' _ 0 P OWNER ADDRESS �^-_— TEL9 X:.7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL [] EDUCATIONAL ( RESIDENTIAL PRINT CLEARLY NEW: LRENOVATION: [ REPLACEMENT: PLANS SUBMITTED: YES � N0 FIXTURES -1 FLOOR- BSM 1 2 1 3 4 5 6 7 1 8 9 10 11 •12 13 14 BATHTUB � 7_711F,_ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEMt` m ! i i DEDICATED GAS/OIL/SAND SYSTEM F-7; 1 DEDICATED GREASE SYSTEM DEDICATED— -- -- __ GRAY WATER SYSTEM T DEDICATED WATER RECYCLE SYSTEM DISHWASHER --�_ I_.__.. DRINKING FOUNTAIN FOOD DISPOSER--__.:__ _ _ _ FLOOR I AREA DRAIN �- INTERCEPTOR (INTERIOR) I_ KITCHEN SINK LAVATORY, ROOF DRAIN - — - - IF - SHOWER STALL SERVICE I MOP SINK i ---_� < , TOILET - ___ URINAL _._ _7 E77 _ .. WASHING MACHINE CONNECTION .. _ _... WATER HEA TER ALL TYPES-- � I WATER PIPING -- - - OTHER F FI I LLJ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO [j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY C] OTHER TYPE OF INDEMNITY R BOND F 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 0 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 true 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 compliance with all Pe i e t rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '1 PLUMBER'S NAME MICHAEL HOUSE --------::::=LICENSE # 7173 / SIGNA UR MP El JP CORPORATION` .#F3377-6 ­_ PARTNERSHIP ]#LLCEJ# COMPANY NAME I MERRIMACK VALLEY CORPORATION ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP 01844 TEL 978689-0224 -« - - - FAX ( 978-689-2206 1 CELL [978 815- @ __ _.....r L 4523 EMAIL , LLITTLE MVALLEYCORP.COM� 0 m W O Z O F� U W C6 z a Q z w 00 Z f Z o L W �D w O fx w O W Q 3 U a 0 0 a I-- w a U J a. a � Q � W = w � LL W E� O Z Z O F� U W a cn z v z W a a v a 0 x 0 m The Commonwealth ofMassachusetts • - Department oflndustriglAccidents Office gflnvestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avylicant Information Please Print Lep-ibl Name (Business/Organizationflndividual): "j419011— G' P. Address: /-6— City/State/Zip _1 cL.Jf f�% ©/�� Phone M qvo,! —6w Are you an employer? Check the appropriate box: 1$ I am a employer with 4• ❑ I am a general contractor and I Type of project (required): ' employees employees (full and/orpart-time) * have hired the sub -contractors 6. [J Now construction 2. El am a sole proprietor or partner- listed on the attached sheet. 7• E] Remodeling ship and. have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. El We are a corporation and its g, F1 Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing, repairs or additions . m selfo workerscomp. Y [N ' p c. 52, § (4 1 , and we have no 1) 12.❑ Roofrep ' s insurance required.] employees. [No workers' 13.� E Other Gf� comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees Below is thepolicy and job site information. , Insurance Company A�111 Policy # or Self -ins. Lic. #: �J 3 Expiration Date: Job Site Address :_ /�� lC P, �/� City/State/Zip,"" �i� Attach a copy of the workers' compensationpolicy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 DTA for insurance coverage verification. I do hereby of perjurry/f�l at the inforjrtation provided above is 1�pue andcorrect. ^,C Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permitocense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown CIerk 4. Electrical Inspector 5, PIumbing Inspector 6. Other - - - Contact Person: Phone r r N Information and Instruction's 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 ofhire,. express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states 2leither the commonwealth nor any ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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. Anew affidavit must be fined 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 orpermit to burn leaves etc) said person is NOTxequired 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: Tho Commonwealth ofMassaehusetts Dep.adment efZndustdal Moldonts Af�ice q�B��estig;�txons . 600 WashiWoa Sixeet Basten, MA, 02111. TO. # 617-727,4900 W406 or 1-877:AMSS.AM Revised 5 26-05 Fax # 617"727-7749 www,znass,gevaa. Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Mark Muscatello c/o MJJM Enterprises, Inc. Property Address: 190 Chickering Road, Bldg. 4, Unit 310D Policy Number: HP2443758 Date/Cause of Loss: 3/26/2014, Water Heater Leak File or Claim Number: 29394-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143; SECTION 6, to be applicable. If any notice under MASSACHUSETTS .GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the addresses indicated above by First Class Mail. ons named above at the ley and Date ANDERSON ADJUMENT CO., INC. 50 Nashua Ro d, Suite 303 PO Box 1098 Londonderry, NH 03053 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 _ SENSE® IVE Under Massachusetts General Laws, Chapter 139, S, ct>�EE � April 7, 2014. Building Inspector 120 Main Street North Andover, MA 01.845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Edwin Ahern Loss Location: 190 Chickering Road, Unit 1, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100730633 Date of Loss: March 26, 2014 File Number: 14-12049 Claim Number: 14108087 Type of Loss: Water Damage APR 14 2014 TOWN OF NORTH ANDOVER fl1EALTH DEPARTMENT 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 313" 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. 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 I PYr, :l :lFi' ,t.. i�• + ,i .;e, li .� ,+t . - Ott .`*I� r. rr , r .. .. ,. ,[ .., .(' I . �. ' • • "moi „ 1 Phone: 978-632-2660 JAMES A. TRUDEAU Adjustment Service Inc. Fax. 978-632-2662 P. O. Box 7 Gardner, MA 01440 claims(c�trudeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 313 April 7, 2014 Building Inspector 120 Main Street North Andover, MA 01845 JBoard of Health 0 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Edwin Ahern Loss Location: 190 Chickering Road, Unit 1, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHO0100730633 Date of Loss: March 26, 2014 File Number: 14-12049 Claim Number: 14108087 Type of Loss: Water Damage 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 1.39, Section 313" 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. 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 J. NEW ENGLAND CLAIMS SERVICE, INC. w Incorporated 1985 . Reply To Mansfield, MA 02048 P.O. Box 345 TEL. {508} 337-8058 FAX {508} 339-5835 � i•W'C� 1x'm y.... i�f ail Sa4y,� wrandall@newenglandclaims.com OWN "ALTH Reply Tc 131 Dodge Street, Suite 6 Beverly, MA 01915 TEL. {978} 927-3000 FAX {978} 927-3002 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall ; North Andover, MA 01845 RE: Insured:Helen-I4odges _. rr s"- Property Address: `190 Chickering Road; Unit 4 302D, North Andover, MA 01845 Cause of Loss/Date: Water Damage Loss of 8/15/2012 File or Claim No: BOS050403 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date o; loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. S ignaturate NEW ENGLAND CLAIMS SERVICE, INC. 0 Incorporated 1985 ❑ Reply To Reply To Mansfield, MA 02048 131 Dodge Street Suite 6 P.O. Box 345 ;'';: Beverly, MA 01915 TEL. {508} 337-8058 " TEL. {978} 927-3000 FAX {508} 339-5835 FAX {978} 927-3002 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, See 3B To: Building Commissioner or Inspector of Buildings City Hall North Andover, MA 01845 RE: Insured: Helen Hodges Property Address: 190 Chickering Road, Unit # 302D, North Andover, MA 01845 Cause of Loss/Date: Water Damage Loss of 8/15/2012 File or Claim No: BOS050403 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. S ignatu to I '.0"'WER GROUP COMPANIES F40J1160 i1 £d hij!)KO!I,: t- C_nP1p4),-Jy September 05, 2012 Building Inspector's Office 1600 Osgood Street North Andover MA 01845 Insured: Helen A. Hodges Property Address: 190 Chickering Rd Unit 3021), North Andover, MA, 01845- 4558 Underwriting Company: Massachusetts Homeland Insurance Company Policy Number: HBIP39000 Date of Loss: 8/15/2012 Claim Number: OAA962090 BG5Q Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1000 or cause Massachusetts General Laws Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B 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 caused copies of this notice to be sent to the persons named above at the address indicated above by first class mail. Signature: Melissa Tripp, Adjuster Tower Group Companies Claims Department PO Box 5155, Buffalo, NY, 14240 Phone: (781) 884-4391 Fax: (781) 394-2592 www.twrgrp.com