Loading...
HomeMy WebLinkAboutBuilding Permit #262-15 - 69 FERNVIEW AVENUE 9/16/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ell eRn n"-U) Are , 1- ,D, 00-19-4h A�dcogre a , A X184,5 print PROPERTY OWNER r-U-L i Q} 4A acne Z & M aRG�; e �Rc�►-,n e"Z Print MAP NO: �n,/PARCEL: 64? ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 'Repair, replacement ❑Assessory Bldg El Others: ❑ Demolition ❑ Other �_ yt ' �DFlood lain Cr:1©Wetlands! "� WatsYiedlDistrictT - ®kWater/Sewer - -- -----�-_�r.;����..� „��.«.`.�l�.�x•..��`�:...�-.�.:���- � DESCRIPTION OF WORK TO BE PERFORMED: Ip' ,I'J �'Y1'J +i I i,Y) K i+Gh e Y1 `1) 0z, �� �.'� 09, Qa 1-,r, i-n Q1 Identification Please Type or Print Clearly) OWNER: Name: l A G t e CA +2 Phone: Address:} NJCLy Y1 KCLA Yl IJQYI4C.R,&, MPr OA-CIZ3 CONTRACTOR Name: I� 160 Gomn 15-}Aa 1o�,eh Q�o�. Phone: 9%4b54-E(3-2q4 Address: 1 rJ �Qrl�il J-4 Q1! KA O I L16 0 Supervisor's Construction License: C5 - J043 5OExp. Date: 0qI C)11 201E " Home Improvement License: Exp. Date: -0 31 oZ-4 f cW i(o - ARCH Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �J l� _C�i FEE: $ Check No.: �,q'� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - St nafure`of'cont�acf ..... ... .: . . - Location 7 ��'Ny� Q No. Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ vnC) ` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FWell ERAGE DISPOSAL ❑ Ta�g/Massage/Body Art ❑ Swimming Pools ❑ ❑ 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments a !Valer& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located 384 Osgood Street Located at 124 Main Street no Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area based on Exterior rtor 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 i 1 ' NOTES and DATA-- For department use I i i ® Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ❑ 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording - tust be submitted with the building application Doc: Doc.Building permit Revised 2008mi i r 'i NORT1.r . w: :. . : 1c . : ver r 0 .. No.a &6 is * : t _ h ver, Mass, LAKI' — 15 -V� cocN,cNtW,CK RATES S U BOARD OF HEALTH Food/Kitchen PERMT LD Septic System THIS CERTIFIES THAT e .�. i . ...... . ...... .. .'�!.. BUILDING INSPECTOR has permission to erect g �. �,�, Foundation ......�.................. dings ...... .. ...... ..... ..... ....�............. Rough to be occupied as .......�i.l... .. ...... ... ......0.400L'o ......�.. ....... ... ...................... Chimney provided that the person accepting this permit shall in every respect conform to th erms of the application Final on file in this office, and to the provisions of the Codes and B - aws relating to the Inspe tion, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR 1 r Rough VIOLATION of the Zoning or Building Regulations Voids this ermit r Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC N ST S Rough Service ........... ..... ........ ..... .......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Location 91Z Dat% • - TOWN OF NORTH ANDOVER ,e,` . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ �. Other Permit Fee $ v TOTAL $ 1 Check# 11 2f Building inspector Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 155000.00 m $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 69 Fernview Avenue Unit 10 262-15 on 9/16/14 Kitchen Remodel r 1NORTH" ' . W f 0 No. - C, h ver, Mass, l/6 cocM�c»ew�cK �1' 91.0 ►�PP,�'C5 S U BOARD OF HEALTH PERMIT T _LD Food/Kitchen Septic System � •• BUILDING INSPECTOR THIS CERTIFIES THAT ....... ,r//.G. .. ... .1. .'......................................................................• •, Foundation ��77 C AF.......................... has permission to erect .......................... buildings on .�o...l.. .........n! ............. Rough to be occupied as ......... :1. ?.?lP.G� ,, �'.`e . ......................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough •••••••••••• Service ....... ... .. .................... Final .� .... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. STAIaTOUCH PROPERTY SERVICES, ONC. Proposal Number: 7080 Project Proposal Date: 09/11/14 Revised : 09/15/2014 Prepared By: Office Hours: Monday- Friday 8:00am -4:00pm StarTouch Property Services, Inc. Telephone: 978-548-6297 515 Lowell St., Suite 2 Fax: 978-548-4613 Peabody, MA 01960 HIC License: #171532 Exp.: 3/27/16 Elliot Hacker Work to be Performed At: Margie Gardner 69 Fernview Ave., # 10 69 Fernview Ave., # 10 North Andover, MA 01845 North Andover, MA 01845 I. WORK DESCRIPTION REMODELING • Cover appropriate ares for protection • Remove and dispose kitchen cabinets • Remove and dispose kitchen tile backsplash • Remove and dispose carpet from entire apt • Remove VCT from kitchen floor • Labor and disposal fees INTERIOR CARPENTRY AREA: BEDROOM NEXT TO BATHROOM • Cover appropriate ares for protection • Cut the area 3'x3' in front on the door • Replace the plywood t fi p p yw d o ix the noise • Front door to be restored around lock set • Labor and materials AREA: KITCHEN • Cover appropriate ares for protection • Install new Kitchen cabinets keeping same layout as possible after obtaining specifications of appliances purchased from Sozio Appliances • Cabinets to be from Home depot in stock Hampton Bay, Style Hampton , Color medium Oak www.startouchpropertyservices.com ■ info@startouchpropertyservices.com Page 1 of 5 S'fl""ARTouCH PROPERTY SERVICES, INC. • Install Cabinets Hardware-Liberty Tapered Bow, 96mm Model#P0270AH-SN-C • Coordinate delivery of new appliances ordered from Sozio Appliances and removal of old appliances by Sozio or other provider at no additional cost to owner • Labor and materials AREA: KITCHEN • Cover appropriate ares for protection • Install Granite Sta.Cecilia • Install stainless steel sink 8" depth • Labor and materials PLUMBING WORK • Cover appropriate ares for protection • Disconnect all kitchen plumbing • Buy and install a Faucet-Delta Pull Out kitchen Faucet w/soap dispenser Model #Linden4353-SSSD-DST • Install the appliances • Install new garbage disposal • Install ice water line • Install sink drain • Connect Dishwasher provided by unit owner • Labor and materials AREA: KITCHEN BACKSPLASH • Cover appropriate ares for protection • Install Ceramic tiles price not to exceed $12.50 per sq ft • Apply Grout • Apply 1 coat of sealer • Labor and materials AREA: KITCHEN FLOOR • Cover appropriate ares for protection • Install Hardy-backer over plywood • Install ceramic tile 12"x12" Briton BT0166HD1 P2 • Apply grout and sealer • Labor and materials as INTERIOR P i AINTING • Cover appropriate ares for protection • Patch where necessary • Hand sand patches • Apply one coat of stain Kilz on water damage areas www.startouchpropertyservices.com info@startouchpropertyservices.com Page 2 of 5 STARTOUCH PROPERTY SERVICES9 ONC. • Apply 1 coat of latex primer to walls, ceiling, doors and trims • Apply 1 coat of finish flat white paint to all ceilings • Apply 2 coats of White Dove CC6 semigloss to doors and trims • Apply 2 coats of White Dove OC6 Eggshell on walls • Labor and materials ELECTRIC WORK • Cover appropriate ares for protection • Supply and Connect new Garbage disposal • Replace Light fixtures where required provided by unit owner • Connect Dishwasher provided by unit owner • Install the appliances • Labor and materials FLOORING WORK 9 Install new pad for carpet e 3/8 in., 5 lb. Density Rebond Carpet Cushion Pad e Install Carpet Everest 11 Tidewater-THS#HDB52522104 * Labor and materials INTERIOR CLEANING * At the end of the job the unit will be cleaned - All windows will be cleaned from the inside and outside as much we can - Labor and materials 11. EXCEPTIONS Permit III. TERMS 9 Interior Painting: Price includes up to 3 colors; additional colors will be an additional cost to be determined by the size of the building. * Exterior projects are always weather permitting. - We allow one punch list at the completion of the project to accommodate necessary touch-ups. a Color/material selections are final; any changes made may result in additional charges. a Any necessary materials will be stored in an orderly fashion. All debris will be removed on a nightly basis. e StarTbuch Property Services, Inc. is not responsible for any cracks resulting from the expansion &contraction of wood. All StarTbuch Property Services, Inc. proposals include a one-year warranty on all labor performed. www.startouchpropertyservices.com info@startouchpropeqservices.com Page 3 of 5 i STARTOUCH PROPERTY SERVICES9 O TQC. . Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above this proposal. All agreements contingent upon strikes, accidents, or delays beyond our control. . This proposal may be withdrawn by StarTouch Property Services, Inc. if not accepted within 30 days. . Please make sure to remove all expensive household items located around where our crew will be working. Star Touch will not be responsible for any loss and our employees are not allowed to move any furniture, electronics and decor items. . Condominium supplied dumpsters may not be used for disposal of construction waste materials. . Work will be accomplished between the hours of 7 a.m. to 5 p.m. . Contractor will obtain from Town of North Andover, as the Owners' agent, the building, plumbing and electrical permits necessary to complete the scope of work under this agreement (cost not included in proposal and will be paid by Owner) . No smoking within the condominium unit or within the building . Waiver of lien for material or labor will be provided to Owner by Contractor and all sub-contractors at time of final payment to the Contractor. . Contractor and all subcontractors agree to carry necessary Workers' Compensation Insurance and Public Liability Insurance as required by the law and Contractor will provide copies of the insurance certificates naming the Owners as Certificate Holders. e Quality and workmanship standard for this contract are defined by the National Association of Home Builders, Residential Construction Performance Guidelines for Professional Builders and Remodelers. 2nd Edition. In the event of a dispute these standards will be used. e Work will be completed by October 6th, 2014. Commencement of work currently expected to be September 15, 2014. IV. BUDGET All materials are guaranteed to be as specified, and the above work is to be performed in accordance with the drawings and specifications submitted for the above work, and completed in a substantial workmanlike manner for the sum of: . . • REMODELING ; $ 1,120.00 ---------------- ---------•------------ ------------------ ..................................... -----------------•-•r------------ --------- .............. INTERIOR CARPENTRY-AREA: BEDROOM NEXT TO BATHROOM $ 350.00 --•----------------•--• ........................-.......................................................... ..................................4............•-•...................... INTERIOR CARPENTRY-AREA: KITCHEN $ 2,680.00 .......................................-..........---........................ ................................................................t....,------------------ .............. AREA: KITCHEN (INSTALL GRANITE STA. CECILIA) ; $ 1,850.00 PLUMBING WORK $ 878.00 -------•---------------------------------------------------•-----------------------------------•-------------------------------------------- AREA: KITCHEN BACKSPLASH : $ 685.00 AREA: KITCHEN FLOOR $ 1,530.00 ------•-------- -••-------------------- ----------------- --•------- -------- --------- ............. ------ ............. --------------------- ----•--- INTERIOR PAINTING $ 2,500.00 ELECTRIC WORK $ 550.00 •......................•---....-----.....------. -----••-------- .................... ---•-- ..................................... •• ................... FLOORING WORK $ 3,875.00 -------------- ----•----------------- ................... ......... --•-------• --------•---......-•------ INTERIOR CLEANING $ 250.00 ----------•--•--------------------------------------- ------ ..................... --------------- ------------•-- ------------'......... --------•-••----•---•--•--- www.startouchpropertyservices.com ■ info@startouchpropertyservices.com Page 4 of 5 STARTouCH PROPERTY SERVICES, RNC. DISCOUNT $ (1,268.00) Total $ 15,000.00 I. Payments to be made as follows: 50% deposit at proposal signing, 50% at project completion. II. We accept all major credit card companies, but there is a surcharge fee of 2.75% up to 3.5% to cover the cost. III. A 12.0% annual late fee will be charged for payments not received within 15 days of project completion. Respectfully Submitted Frank Gomes, Project Manager On behalf of StarTouch Property Services, Inc. Wom The above prices, specifications and conditions are satisfactory and are hereby accepted. StarTouch Property Services, Inc. is oriz o do the work as specified. Payments will be made as outlined above. Signature Dater ...Z�Z�............................................................................................................................................................. ................................ www.startouchpropertyservices.com . info@startouchpropertyservices.com Page 5 of 5 START-1 OP ID:JO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/2014Y) 09/11/2014 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 CONTACT Foster Sullivan Insurance NAME: John Dussault 163 Main St. ac°No E,):978-686-2266 FAX No):978-686-6410 North Andover,MA 01845 ADDRESS:SS:jdussault@fostersullivangroup.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:SAFETY INSURANCE CO 39454 INSURED Star Touch Property Services INSURER B:AMTRUST NORTH AMERICA 15954 Inc 515 Lowell St INSURER C: Peabody,MA 01960 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSRTYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BMA0020187 08102/2014 08/02/2015 PREMISES Ea occurrence) $ 500,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,000 Business Owners PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO JE LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000 Ea accident $ , ,000 A ANY AUTO 6224552 08102/2014 08/02/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 100,000 AUTOS X AUTOS BODILY INJURY(Per accident) $ $00,000 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS X I ER B ANY PROPRIETOR/PARTNER/EXECUTIVEWWC3066969 08/02/2014 08/02/2015 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? F-] N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Elliot Hacker ACCORDANCE WITH THE POLICY PROVISIONS. Margie Gardner 69 Fernview Ave.,#10 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS404350 LISA M WWS 40 HIGEILAND ST pEABODy MA 61960 Expiration 09/01/2015 Commissioner �ie�am,�zza�uuea�o��aaaac�earelta - - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 111532 Type: Office of Consumer Affairs and Business Regulation xpiration:,. 3/27/2016. Corporation 10 Park Plaza-Suite 5170 r_ Boston,MA 02116 STARTOUCH PROPERTY SERVICES,INC. FRANK GOMES t 515 LOWELL ST STE 3k' PEABODY,MA 01960 Undersecretary Not valid 701ut signature fir= The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 1 Boston,YM 02111 =' www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information f� Please Print Le ibl Name (Business/Organization/Individual): 4A? 100 Cil `1''t�oe tgilt�JICCA 1-11C. Address: 510 �@1Ne. I I �5f. Sui k, z City/State/Zip: ?Mypom MA OP GO Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.D? I am a employer with 40 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ;Z Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp. insurance.+ required.] 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. [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.7 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: YAAP, ) -� UQg, VN Policy#or Self-ins.Lic.#: \ Yy C N%q r0q Expiration Date: 1 R10 LJO Job Site Address: 04 -R Poo 1 e W kye 1 'M1 A-0 City/State/Zip:0. AY\dQNX—_K I MA 01$46 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer 'y under the ains and penalties of perjury that the information provided above is true and correct. Signatur W. Date: Phone#: - 4e- 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#: v MetLife Auto&Home® Homeowner Operations Field Claim Office Mail Processing Center P.O.Box 2201 Charlotte,NC 28241 (800)854-6011 June 4, 2014 RECEIVED North Andover Health Department JUN 0 9 2014 1600 Osgood St TOWN OF NORTH ANDOVER Suite 2064 HEALTH DEPARTMENT North Andover, MA 01845 Our Customer: Melinda Ryder Claim Number: JDE36528 8S Date of Loss: May 3, 2014 Dear Sir or Madam: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has —_ been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 69 Fernview Ave, N Andover, MA Sincerely, Andrew J. White - DR Metropolitan Property and Casualty Insurance Company Senior Claim Adjuster (800) 854-6011 Ext. 7050 Fax: 866 947-1856 Email: ajwhite@metlife.com MetLife Auto&Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates,Warwick,RI. MPL MA-REGDEPT Printed in U.S.A 0698 Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman, City Hall City Hall N ANDOVER, MA 01845 N ANDOVER, MA 01845 RE: Insured: SANDRA TERRAMAGRA Property Address: 69 FERNVIEW AVE#8,N ANDOVER, MA Policy Number: HMA 0116991 Claim Number: BOS00036380 Date of Loss: 2/18/2013 Company: Safety Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 3/6/2013 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com v MetLife Auto&Home® OCOU Oco2» cfco3» Oco4» «fco5» Mieftifeo MetLife Auto&Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates,Warwick,RI. MPL MA-REGDEPT Printed in U.S.A 0698