HomeMy WebLinkAboutMiscellaneous - 10 COTUIT STREET 4/30/2018® MAPFRE The Commerce Insurance Company1m
Citation Insurance Companyw
Commerce"
Gore Road, Webster, Massachusetts 01570
INSURANCE- 508.949.1500 www.commerceinsurance.com
March 19, 2015
BUILDING COMMISSIONER or Board of Health or
INSPECTOR OF BUILDINGS Board of Selectmen
TOWN/CITY HALL Town/City Hall
NORTH ANDOVER MA 01845
RE: Our Insured: LORRAINE KANELOS
Property Address: LORRAINE KANELOS, 10 COTUIT ST
Policy#: BDVTDY
Date of Loss: 02/12/2015
File#: JWVW60-HNPKT9
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, 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 my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
ANGELA LEMOINE Telephone: (508)949-1500 Ext: 11524
CLAIM REP SR, CASUALTY Toll Free: 1-800-221-1605, Ext: 11524
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
March 19, 2015
..... ..�x� .t., s1
CIC 254 (Rev. 4/95) MAIL I71
n'
Date ... -.4� 9..
'0 TOWN OF NORTH ANDOVER
0.
PERMIT FOR WIRING
-Z 7, 0 ,"— -, ! ��e 721a�, .......................
This certifies that ..................................................................
h as permission to perform ....... :5 6��Illne ...............................
wiring in the building of ......... A ......... PLI Z- -7, 0
..........................................................
at ..... h2 .... ?7(J. ..................................... North Andover, Mass.
Fee4 Lic. No. .......... 10�f "A
11 ...............
ELECTRICAL INSPECTOR
Check
8095
U11Commonwealth of Massachusetts official use only
Department of Fire Services Permit N°. Jr
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leave hiank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts ElectricaLInsp
(MEC), 27 C 12.00
(PLEASE PRINT BINK OR TYPE ALL INFORMATION). Date: p
City or Town of: NORTH ANDOVER
To the or of ices:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) Q Co -f v 1 f ST
Owner or Tenant JgN-P ON V 2
Telephone No. S7� 317 Y51
Owner's Address SlAme
Is this permit in conjunction with a building permit? Yes El No �-y
L_I (Check Appropriate Box)
Purpose of Building_ ��ltJ Utility Authorization No. -S- -
❑ No. of Meters 6 cre
Existing Service 60 Amps Zy / 2 Volts Overhead n -"-g Und rd t
New Service Amps / _Volts Overhead ❑ Und d
� ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
-( (_4f_ -V 100 ArW 1
Com letion o the ollowin table maybe waived b the Inspector o Wires.
No. of Recessed Luminaires ;No. of Ceil.-Susp. (Paddle) Fans NO•°fTotalTransformers KVA
No. of Luminaire Outlets . of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above In_
nd. ❑ nd. ❑
No. of Receptacle Outlets No. of Oil Burners
No. of Switches No. of Gas Burners
No. of Ranges INo. of Air Cond. Total
T_
No. of Waste Disposers
Heat -Pump INumber Tons I
_
_._.
Totals:
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances KW
No. of water KW
Heaters
No. of No. of
Signs Ballasts .
No. Hydromassage Bathtubs
OTHER:
ALARMS INo. of Zones
o. of Alerting Devices
o. of Se-CnntAined
0 "umcipal ElCnnneofinn Other
No. of Devices or
:a Wiring:
No. of Devices or
o. of Motors Total HP I uni
Telecommcafi
No. of Devices
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.,
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the aims and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: 1v yv.Ji LIC. NO.: l 2`11 �1 f i
�t22c� Signature ► LIC. NO.: 2Z 3 2S
(If applicable, enter "exempt " iv the license number line.)
Address: 57- may, 4,, 00-01f('Bus. TeL No.. cna 317 93/
YY� Alt. Tel. No.:�T�g�,42-WJ
*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 E] owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $
4)
The Commonwealth of Massachusetts
j� Department of Industrial Accidents
' ! Office of Investigations
600 W
ashcngton Street
Boston, MA 02111
{ ' www.mass gov/dia
Workers, Compensation insurance Affidavit: Builders/Contractors/Electriciafls�plambers
DDliCInt rn+fnrrnaiinn
Name (Business/O rganization/Individual);
Address: to co+yt � st
U 720 Fled ri
City/State/Zip:Phone #:. V 31 c
set'
Are you an employer? Check the appropriate box:
I. ❑ l am a employer with 4. ❑ I am a general contractor and I
eTTIPIoyew (full and/or part-time).*.
have hired the sub -contractors
2. 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,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3.0 I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself [No -workers, comp,
C..I.5Z § 1(4),'and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
+Any applicant that checks bort# 1 moat also flit out the section below showing their workers' com
Type -Of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. [J Demolition'
9. ❑ Building addition.
10.❑ Electrical repairs or additions
I I .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
Homeowners who submit this affidavit indicating they are doing all work aiid then him outside cr Pullvy ontractors must submit a new affidavit indicating such.
IConMwtors that check this box must attached an additional sheet showing the name of the sub-contmaom and their wort;e;s' mmp. policy int'onnatran.
I ant an employer that.is providing:workers' compensation insurance for nty. enplayeeL Below is. the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
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 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
w Investigations of the DIA for insurance coverage verification.
I do hereby cerfiryyjdVer thorpains a crottles of perjury that the information provided abov is true and correct
Si twe: Date: 1J-
Phone #:`1031- 7
Wicfal use only. Do not write in "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 #:
O.�
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 undl acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' cornpensation 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 affridavit. The affidavit should,
be returned to the city or town that the application for the permit or license is being requested, nofthe 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 t
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. When 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 bum leaves etc.) said person is NOT required to complete this affidavit
r�
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesfigsttions
600 Washington Street
Boston, MA 42111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.govldia
Location 4 L) 4 s�
No. )S8 Date
'40"Th
TOWN OF NORTH ANDOVER
0
Certificate Occupancy
$
of
wu
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$ q0
#
Check
15991
Building
Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Tlris Slit", fbr QI1tCAi
BUILDING PERMIT NUMBER: � ` � DATE ISSUED:
SIGNATURE: /tel -
Building Commissioner/In for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:Par
mber:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Distrid Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft AL., t !,
Front Yard Side Yard
51 Rear Yard
Required Provide Regaired Provided
Required Provided
., 4-
1.7 Water Supply M.G.L.C.40.. ,Sr}) 1.5. Flood Zone Information:
Public ❑ Private ❑ 'V Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT
2.1 Owner of Record T'S �v
%G • /0,wew
Name ( rint) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
416 G /S
Licensed Construction Supervisor:
O N
Address V `7� A 7 ,O �1) �� �]j�/ �l
��
�J
S' Lure Telephone
Not Applicable ❑
D /� g
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
00
rn
X
Z
0
0
Z
rn
90
0
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Q
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work checkA a licable
New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work:
S of le Ir F •& ILI* ON 10;�
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
I. Building
•O 0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X tbl
70
4 Mechanical(HVAC)
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
D9\, ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
(yMnatuo / ermit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
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BOARD OF BUILDING REGULATIONS
d ; License: CONSTRUCTION SUPERVISOR
Number: CS 011396
Birthdate: 03/08/1952
_ 3rt Expires: 03/08/2004 Tr. no: 17208
Restricted: 00
JOHN J ENGLISH
3 OBSERVATORY RD
METHUEN, MA 01844 Administrator
e
The Commonwealth of Massachusetts ` ur
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
fie// 11�f4-e/S;
City /'v/i/%a%� Phone #
0 I am a homeowner performing all work myself.
F;;T I am a sole proprietor and have no one working in any capacity
F1 I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City Phone #:
Insurance Co Policy #
Company name:
Address
City- Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment_as_well_as_civil penaltiesin theinrm ofa STOP W-ORK ORDER..and_a.fine af..($7DO.DO)-ajd y.againstme. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby certify
of ndi, rni fhnf ffw infnrmn}inn nrnvk1PH aMva k hila and ryvrFe/_
Official use only do not write in this area to be completed by city or town official'
� 7 / (Iol 4 �G'�,�
City or Town Permit/Licensing
0 Building Dept
❑Check if immediate response is required .0 Licensing Board
p Selectman's Office
Contact person: Phone #: Health Department
El Other
NORTH ANDOVER BUILDING DEPARTMENT
400 Osgood Street
Tel: 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE: D S
NAME:6-]�� .�1 c�N� P� z oy' 220 len
ADDRESS: 1® Co �y l -� S7
97ho 3/ 7, 9.3/7
ZONING DISTRICT:
TYPE OF BUSINESS: Fle-c4 -I cl f n)
BUILDING LAYOUT PROVIDED: YES NO
AVAILABLE PARKING SPACES:
ZONING BY LAW USAGE: YES 4LNO
BUILDING INSPECTOR SIGNATURE
Revised I S1.5.04FO o �' !- s tk ,
BUSaVESS FORM FOR TOWN CLERK