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HomeMy WebLinkAboutMiscellaneous - 102 LACY STREET 4/30/2018N 0 0 Q J O O O O O Liberty Mutual., INSURANCE November 11, 2014 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Re: Property Address: 102 Lacy St, North Andover, Ma 01845 Policy Number: H3521835101640 Underwriting Company: LM Insurance Corporation Claim Number: 030873291-0001 Date of Loss: 10/28/2014 Attn: Town/City Official Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §199, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A & B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111, § 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 1 V t.tLEO "61•NO o Town of North Andover BUILDING DEPARTMENT Division of Professional Licensure Office of Inspection 239 Causeway St., Suite 500 Boston Ma 02114 Attn: Mr. Richard Paris Mr. Paris, March 4, 2008 Please be advised the electrical inspections for Mr. David Peters, Licensed # 13525A, located of 102 Lacy St. North Andover, may has been finalized and approved on March 3, 2008 under Permit # 7817 and #7978. Please call me if you have any further questions. Regard, Peter Murphy, Electrical Inspector North Andover Electrical Inspector Community Development Division, 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com 1 16 DIVISION OF PROFESSIONAL LICENSURE OFFICE OF INVESTIGATIONS Application for Complaint 617-727-7406 www. mass.gov/dpl Date Received (stamp): Entered into the Database (Date): / / Docket #:, Acknowledgement letter sent (Date): / / Signature: Please complete this form as fully as possible. (PLEASE Do NOT wRrrE ABOVE LINE.) Please type or print legibly in ink. SUBMITTED BY: �7 Name: MU%�/�� t/ Pe7r 2 477" Last Name First Name M.I. 7, 31) ; a •9D6R,-1 Address: /4�0 Cusp' D s; 7a' e"Pg ,3 Number Street Daytime Phone 41aeny 11y"4– Bl - e -Is City State Zip Code Evening Phone Best way to reach you: ❑ Evening Ph ne Daytime Phone ❑ E-mail: 1-91n4,1 ?Pi1;&0 LICENSEE SEEKING CrPLAZNT AGAINST (use separate form for e h licensed individual/business): Name: r%Z Last Name First Name M.I. Address: TZ -F 5,'9$ / Number Street 79' 6,V0 ?ct1q Daytime Phone y g(Sl Gyle '�c—�,t1c 5f3v2�tyW t) 1,T'79 1 3 :5— 1.57-4 City State Zip Code License Number/Type Class %2F`1r_1e�L T L C'o f7siil xJ�t", Business Name S111-� 97 0 6 g0 F?r� Business Address Daytime Phone City State Zip Code Business License # / Type Class Please check the trade or profession that this application for complaint pertains to Accountant Funeral Director Aesthetician Gas Fitter Architect Hair Salon Athletic Trainer Hair Stylist Audiologist/Speech Language Health Officer Pathologist Hearing Aid/Instrument Barber Home Inspector Barber Shop Chiropractor Land Surveyor Dietitian/Nutritionist Landscape Architect Dispensing Optician Manicure Salon Drinking Water Manicurist Ed. Psychologist Marriage & Family Therapist _eO" Electrician Mental Health Counselor Electrologist Occupational Therapist Engineer Occupational Therapist Fire or Burglar Alarm Assistant Optometrist Physical Therapist Physical Therapist Assistant Plumber Podiatrist Psychologist Radio/TV Tech. Real Estate Agent/ Broker/Salesperson Real Estate Appraiser Rehab. Counselor Sanitarian Social Worker Veterinarian Page 1 of 2 Description of the incident(s): Briefly describe the incident(s) that led to your application for complaint and note the times and dates that events occurred. List the names of all individuals involved. Please attach additional pages if needed. 46r 7Tn / Jify 0 -7 r /�'��/t �=,e�l� /x'12 LDA4 eO PPr4 o ::j�T�*AWm,r-�_ . ke 77,6 nn, LXL?a L �r4�h/ .©rte, i tJa%"u� 5572t�L�— �5� t AAF ,v, r4,-L `:54Wl 7-4 a ee r,17,Ac7 /►9 �2 P� l�-azs �a 2. R.� PAj � Da Dpi �i1>� �� �%�n° r ��hZ�vr��S � ilIv /ZC--S po'vg (Please use a separate sheet if necessary. Do not write in the margins.) Additional information or materials attached XYes ❑ No To speed up the application for complaint process, submit legible copies (not the originals) of all relative documents supporting your application (e.g. contracts, medical records, cancelled checks, etc.). You will receive an acknowledgement letter notifying you if a complaint is issued based on your application. If a complaint is not issued, you will receive information on additional resources that may be available to you. AUTHORIZATION FOR RELEASE OF RECORDS AND FORM REFERRAL My signature to this form, or a photocopy thereof, authorizes the Division of Professional Licensure to: (1) receive copies of all medical, dental and mental health records relating to my application for complaint, and (2) to refer my application for complaint to other appropriate law enforcement authorities to investigate and/or prosecute. Please note that all applications for complaints are examined to determine their factual basis. The act of filing an application for complaint does not assure or imply that disciplinary action will be taken against the licensee. I attest that the information provided is true, correct and complete to the best of my knowledge. Signature 11Date Mail this form to: Division of Professional Licensure, Office of Investigations 239 Causeway St., Suite 500 Boston, MA 02114 Page 2 of 2 Peters Electric Contracting, Inc. 928 East Street Tewitbury, MA 01876 978-640-8919 078-640-89h,Fax BILL TO 102 Lacy st. No, Andover ma Invoice DATE INVOICE # 1/20/2007 1220 P.O. NO. TERMS PROJECT QUANTITY DESCRIPTION RATE AMOUNT Service change 100 amp to 200 amp Hot tub 50 amp circuit w/GFCI.c/b Addition/Deck lighting.. 2,000.00 800.00 2,000.00 2,000.00 800:00 2,000.00 'hank you for your business. Total $4,800.00 ' Department of Fire Services Permit No. Occupancy and Fee Checked r` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: `l e,70 ^ D -7, City 7- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned giv s otice of is or her intent' o o perform the electrical work described below. Location (Street & Number) tJ G, Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps New Service Amps Number of Feeders and Ampacity Location and Nature of Proposed E Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. / Volts Overhead ❑ Undgrd ❑ No. of Meters / Volts Overhead ❑ Undgrd ❑ No. of Meters ComnlFtinn nftho follnwina tnhlo mn„ ho, e.t h„ 4— ,.rw;. No. of Recessed Luminaires No..of Ceil.-Susp. (Paddle) Fans No. o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑n- ❑ rnd. arnd. o. o mergency Lighting Battery Units No. of :Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. Of etection an Initiatin Devices No. of Ranges No. of Air Cond. o Tonsns No. of AlertingDevices No. of Waste Disposers eat Pump Totals: 11 umber JTons Ko. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal[I Other Connection No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equivalent No. of Water Heaters KW No..Of No. o 'Signs Ballasts ITelecommuni Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP cat�ons firing: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 1 certify, under the pains an !ties o perjufy, that the 'nformation on. this ap ica, n ' true and complete., FIRM NAME: // LIC. NO.:�,7 Licensee: Signature LIC. NO.: (If applicable, e er "exempt" it thliV11 7;7 Address: mbe`��u' Bus. Tel. No.. . Alt. Tel. No. *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety 'S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ave the liability insurance cov rag normally required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,. MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le ibl ante (Business/Organization/Individual): .ddress: ity/ tate/Zip: �° Phone #:� L e ou an employer? Check the appropriate box: 1 am a employer with 1' 4. ❑ I am a general contractor and I employees (f and or part-time).* have hired the sub -contractors ] I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ] I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8.E]Demolition 9. ❑ ilding addition 10. Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. z an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site rmation. /) A .rance Company Name: cy # or Self. -ins. Lic. #:_ Site Address: la tch a copy .of the workers' Expiration Date: City/State/Zip: policy declaration page (showing the policy number and expiration date). .are to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. advised that a copy of this statement may be forwarded to the Office of stigations of the DIA for insurance c e age verification. hereby certify under the of perjury that the information provided above is true and correct. fflcial use only. Do not write in this area, to be completed by city or town officiaL :ity or Town: Permit/License # ;suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other Iontact Person: Phone #: 7 Date.................................. HORT!{ TOWN OF NORTH ANDOVER MAW p PERMIT FOR WIRING i • SSACMUS� This certifies that ....v�t7Llr/d�rr .......................................................................... has permission to perform .. '�' L�� . 9 1*77/lib aal wiring in the building of..............7"................!�. at ......... �!.O. �� .. Ll�� ..... .T ............................., North Andover, Mass. d !� Fee . f©........... Lic. No../... ..... .� �/ % .. ELECTRICALINSPECTOR Check # 3159 rI:WA Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. —751-7 Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Cl -- 2- 0 D 7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned giv9s.Doce ofbis or her intentio perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Existing Service New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed E Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig ing Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners oetect6on an No. InitiatingDevices No. of Ranges No. of Air Cond. TotalNo. Tonnsso. Alin Devices oAlerting No. of Waste Disposers eat Pump Number Tons .. ...... . No. oSelf-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ un'cipal ❑ Other Connection No. of Dryers Heating Appliances g pp KW Security Systems:* No. of Devices or Equivalent No. of Water KW o. o No. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEILA i BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an !ties o peri , that the 'nformation on. t/tis ap ica n ' true and complete., FIRM NAME: / LIC. NO.: � Licensee: 11010111 ' Signature LIC. NO.: (If applicable, e er "exempt" it th�li Imbe�� Bus. Tel. No.: Address: 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 ave the liability insurance cov rag normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. yb,/ C) iv The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual):DK�ta� l -r °' Address: A, City/State/Zip:°Phone #: Are ou an employer? Check the applropriate '& box: 1. I am a employer with 4. ❑ I am a general contractor and I employees ffullandor part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ B ilding addition 10. Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # l 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. /J A 4 Insurance Company Policy # or Self -ins. Lic. #: Job Site A Attach a copy of the workers' Expiration Date: City/State/Zip: 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. 1 advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance c e age verification. I do hereby certify under the 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date / . ... y- . ! . '�; ... ..=�. ........... ... .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies th .......... &—� a ................ ............................................................... has permission to perform ........ ...... ................. wiring in the building of ........ ...................................................... at ......... .................... . North Andover, Mass. Feb 3 ... . ....... Lic. No../—.' ............ ............ Check # 'JAG U 7973 R IV Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of hi or her intention to perform the electrical work described below. Location (Street & Number) /61,z 7-4 W 11f Owner or Tenant / fD Telephone No. Owner's Address r , Is this permit in conjunction with a building per ' ? Yes a No ❑ (Check Appropriate riate Box) Purpose of Building Utili ,Authorization No. Existing Service /u Amps �Volts Overhead Undgrd ❑ No. of Meters l New Service '200 Amps -�W4( Volts Overhead Q/ Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: COm letion of th 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 pains d enalties of, perjury, that the information on this a cation is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, a erm t " in the license num line. Bus. Tel. No.: Cis `9 Address: C Alt. Tel. No.: *Per M.G.L c. 147, . 57- 1, security work requires epartme of Public Safety 'T'License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the L censee 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. ..1-- -ifi ruu1e may oe watvea oy the fns ector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ N-0.—Of mergency Lighting rnd. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FFRF. ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers He Heat Pump Number Tons IKW No. of Self -Contained Totals: I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of No. of f Devices or Equivalent Heaters KW Signs Ballasts DatNo. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains d enalties of, perjury, that the information on this a cation is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, a erm t " in the license num line. Bus. Tel. No.: Cis `9 Address: C Alt. Tel. No.: *Per M.G.L c. 147, . 57- 1, security work requires epartme of Public Safety 'T'License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the L censee 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. 331-iz g %�Elyt�v� u2 _ vSE �� A&I/otiMt n is r"j oh 3-x-06 P>0,7 M 4_ z d� k- ! �r 44 M. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 el www.n ass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationlindividual): Address:--q2� � zw—) City/.State/Zip: Phone #:. �,� h ��j ��1 CT Are you an employer? Check thi appropriate box: L ❑ I am a employer with 4. ❑ 1 am a general contractor and I Type of project (required): employees (full and/or pari -time).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am asole proprietor or partner- listed on the attached sheet. # 7• ❑ Remodeling ship and have no employees These su&contractors have 8. Q Demolition working for mein any capaci �'� [No workers' comp. insurance workers' comp. insurance. .5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10 -0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 1.52, § 1(4), and we have no 12.7 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.l 'Any applicant that checks bo)t# I 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. lContraetors that check this box mustatteched an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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. Lie. #: Expiration Date: Job Site Address: City/StatelZip:, 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature: Date: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: to 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Lim ited, 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, 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 dine. City or Town Officials i 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 starriped 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 licensei or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and. fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.74900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.mass.gov/dia �i M in 6 z L h tv c �o � o O L yr C O �CO�i V r d'O dC �tC O O m N = y �o m :cam O v � cp y - E Q i y 0 Ma m3 rt+ cm� :_ o ca • y O O :Em � CID o • y O m C: _ = OCR 90 i' C o aC=* Q c= ' ....i ;mom m `O Of d C H O y O C 'C ~ .0.. y O y0„ 4i W O � r -0 .� C +� F.. ,N a=rc Z ". o .y O y a s = eyv �oy'� C �aMm F, 0 CO) h ■7E L O c Q ev a CO2 O O o. CO2 C O C3 :N L O V CD C. 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The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove A. New _Used (1 Qe�^Y B. Type/radiant Circulating �C C. Manufacturer "Me-x'f-1 &'�1 _Lab. No. Name/Model No. Cellar size Dimensions/ Height -1-ength Width Chimney A. New __Existing n-,r�c.►S B. Size (flue area) -J2// C. Other appliances attached to flue (Number and flue sizp) D. Prefab (Manufacturer—name and type) --- / 4 --- E. Masonry/Lined Flue liner R type b manufacturer) Unlined F. Height (refer to diagrams) a xe p' f ct- i -C m � "t . cap OVER, IC' Z' MIN. 3' MIKIo CHIMNEY HEIGHT Hearth (non-combustible)L A. Materials f, V LG B. Sub -floor construction C_' a& C. Minimum dimensions (refer to diagram) 1-. a'+ C Clearances and Wall Protection (see stove installation clearances chart) A. Type of wall protection provided \0 d' i C- B. Clearances. (refer to diagrams) FIREPLACE CORNER l6" HEARTH WALL/CENTER 13 -- T �Q CHIMNEY HEIGHT Hearth (non-combustible)L A. Materials f, V LG B. Sub -floor construction C_' a& C. Minimum dimensions (refer to diagram) 1-. a'+ C Clearances and Wall Protection (see stove installation clearances chart) A. Type of wall protection provided \0 d' i C- B. Clearances. (refer to diagrams) FIREPLACE CORNER l6" HEARTH WALL/CENTER 13 Location No Date "ORT" TOWN OF NORTH ANDOVER 0L Ami In Certificate of Occupancy $ > : ; Building/Frame Permit Fee $ �,sJ1CNU5Et Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ *N connection Fee $ T6T,4L �, $ .h/ r 1U91 Building Inspector %jai,`'�wLv Div. Public Works ryORT/ KAREN H.P. NELSON Town of 120 Main Street, 01845 Director -6483 BUILIANG 'ws .::.::�,,� NORTH ANDOVER (508) 682 s�cNuse CONSERVATION DIVISION OF PLANNING PLANNING & COMMUNITY DEVELOPMENT May 9, 1991 Thomas & Ann McMonagle 102 Lacy Street North Andover, MA Dear Mr. & Mrs. McMonagle: It appears, by the visible aspects of your wood stove available at the time of my inspection, that the installation complies with the requirements of the Massachusetts State Building Code. Yours truly, L%. y D. Robert Nicetta, Building Inspector c/K. Nelson, Dir.