HomeMy WebLinkAboutMiscellaneous - 102 MILLPOND 4/30/2018I
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800 Ma Oniv (800) 392-6108, FAX (800) 851-8424
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: MARIE ANN MOORE
Property Address: 102 MILLPOND, NORTH ANDOVER, MA 01845
Policy Number: 1205083
Type Loss:
Freezing
Date of Loss:
01/25/2013
Claim Number:
309585
FLd 0, 5 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Claim has been made involving loss, damage or destruction of the above captioned propert, which may either
exceed $1000.00 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.
MPIUA Claims Division
CMA00021
1/30/2013
Date... 4-7�7
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... � ...................................
has permission to perform ....... hbb , E .............
wiring in the building of... M.I;nQ.6&-4 .. .......................................
,at ..... -,C,A7viD ....... , North Andover, Mass.
FeeI ic. No..Jjk: 4 ............. .. . ...... ..
.,.,:.5.r ............
LECTRICALIN
Check # �Z63-9 912266>(oCo SPECTO
10827 M vv� OIZ�-
I
50..60
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. l 09 :�'-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:
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention top rfQrm the electrical work described below.
Location (Street & Number) tO^(a-- M c�Jo�l\,. a dfr17 ` le9sF\nT
Owner or Tenant S--" < I ,Mc,g V 4c h e J Telephone No. 972' -a CM 1,
Owner's Address "k i & 1
Is this permit in conjunction with a building permit? Yes ❑ No
(Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion of the following table may be waived by the In ector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
s Total
of
Trsformers KVA
Tran
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires �.
Swimming Pool Above ❑ In- Elo.
rnd. rnd.
o Units Emergency Lighting
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches 3
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Dis osers
P
Heat Pump
Totals:
Number
Tons
KW
.......................
No. of Self -Contained Sw0L'
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Y
Heating Appliances KW
Security Systems:"
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or EQ uivalent
OTHER:
Attach additional detail if desired, or as required by the inspector oj Hires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: S — L� - �-)— Inspe ions 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 M BOND [IOTHER [_1(Specify:) - h e.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: tt LIC. NO.:
Licensee: ��-e �.,� /� J"q\SSignature LIC. NO.: 1143- Q
(If applicable, enter "exemp " in the license numberline.) us. Tel. No.:
Address: ` &`r C,4u -. Idc.�'��— � �t MA Qalss 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 PERMIT FEE: $
Signature Telephone No.
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Cjhsp ectoxs' Signature •- pAt als) Pate r
asset.--[+ailec--[e 5nspectionxequixe ($O.t10) [ )
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Pate
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The Commonwealth of Massachusetts -
Department offndustrurlAccidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: LU � 54 Le � � tk (A (t r)--- .
City/State/Zip: AA 4' MA '*1 SS Phone #: -7ii (-
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ T am a employer with
4. ❑ T am a general contractor and I
6. ❑ New construction
employees (full and/orpart-time) *
2.I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. x
7• E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working forme in any capacity.
workers' comp. insurance.
g• (] Building addition
El
[No workers' comp. insurance
5. ❑ We are a corporation and its
Electrical repairs or additions
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbingrepairs or additions
myself. [No workers' comp.
c.152, §1(4), and wehaveno
12.❑Roofrepairs
insurance required.] i
employees. [No workers'
13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information.
Homeowners who submit this affidavit indicating they fire doing all workand then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information.
X am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
JInsurance Company Name%
Policy # or Self -ins. Lic. #: 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 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 maybe forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
X do hereby certo under the pains and penalties ofperjury Aat the information provided above is true and correct.
Signature: Date:
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. CitylTown CIerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other - - -
Contact Person: Phone
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 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 `Neither the commonwealth nor any of its 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. Ran 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 whichwill 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 (ciiy 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 filled out each
year. More 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 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 Cot��,a.onwealthofMassadhosotts
Dapadmant ofMustdal Accidezits
4f'£ice gInvestigatiQ..
600 Wubi gto>a. Stxeet
Boston, MA. 021 Z X
TOL # 617-727-4900 ext 406 or 1-877:MA.SS.A.I B
Revised 5-26-05 Fax 0 617^727-7749
100 w
Location ��/1211
No. Date
Check # / b d
25382
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee(NG �6
TOTAL
Building Inspector
:f
014t Cnumuwnw alih of ffluriadpnem
Etpa tultnt of Public 9-afttq
BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00
oflloe use Only
Permit No. 3 C) K :.
Occupancy d Fee Checked
3190 peace thank) 1
't
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CM 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date odd
%* or Town ofNORTHANDOVER
To the Inspector of Wlrea:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street d
Owner or Tenant
Owner's Address Coln -e__
Is this permit. in conjunction with a building permit: Yes _ No ( (Check Appropriate Box)
Purpose of Building
Existing Service Amps volts
New Service Amps _J `Jolts
Utility Authorization No.
Overhead `i Undgrnd El No. of Meters
Overnead Undgrno C No. of Meters
Number of Feeders ano Ampacity 1
Location and Nature of Proposed Electrical Work
No. of Lignting OutletsI No. of `got -:-s I No. of Transformers Total
KVA
No. of Lighting Fixtures i Swimming Pcoi Abcve.— in. r—
grro. _ grno. I Generators KVA
No. of Emergency Lighting
No. of Receotacte Outlets No. of Oil turners Battery Units
No. of Switch Outlets I No. or Gas :timers FIRE ALARMS No. of Zones
No. of Ranges I No. Cf Air C„r.c. 'otat No. of Osiecuon and
:cns Initiating Devices
Heat o:al .-oral
NO. OI DIsoOlal! I No.ol
?umcs :ons P<ty No. of Sounding Devices
No. of Sort Contained
No. of Oishwasners SoaceiArea Heattro K`'/ OetectionrSounotng Devices
t
No. of Dryer! I Heating Devices KW L•ocai —' Municicao Other
Connection
No. or - No jt Low voltage
No. of Water Heaters KW I Signs °a las;s Wiring
NO. Hydro Massage Tubs I I No. of MoicrS TOlat HP
OTHER:
INSURANCE COVERAGE. Pursuant ;o one reouirements _-t Massac-t.sers general Laws
I have a current Liability Insurance Policy inctuotng Ccmo:etec Ccerations Coverage or its substantial equivalent. YES = NO = 1
have submitted valid proof of same to the OttiCe. YES = 40 = If you have CheCKed YES. please indicate the pe of Coverage by
checking the apJproortate box. r
INSURANCE 1L BOND = OTH ),_ (Please SceC:1r1 C��OfC S�z't2 i n S
Estimated value of E!ectncai Work S'0 U2 •�� (Exouation Oatet
Work to Start Insoecnon Date Racl:es;ec: Rougn Final
Signed under the Penal les of perjury:
FIRM NAME G P S UC. NO.
Uconese f -1G eOZS S g^a: re UC. NO
Gh �� 3��GCi L�
.
Address a" 1 ( AP)i
OWNER'S INSURANC
quiroo by Massacnuse
(Please cnock onel-
�/ Sulk. T:l. No. ' 6' 7 —0e ys
I am aware tnat the t_:censee toes not nave one insurance coverage or its substantial equivalent as re.
Laws. ano that my signature on :n;s --ermtt application waives this requirement. Owner Agent
Teteonone No PERMIT FEE S / tU
(Signature of Owner Or Agentl
4W
N,2 1308
Date./ ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...L.,..... ....................... ..................
has permission to perform .......
wiring in the building of ... / ......
.... ............ ..'L . . ............... —
t4l.� ................. . North Andover, Mass.
at ...... A2 . ....... ).,)
Fee.: "�Lic. No.. 1q
. . ........................................................... r
...
ELECTRICAL INSPECTOR
r—
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG
(Print or Type)
N0. ANDOVER , MA —.Mass. Date 14 —4V :.ig %Y. Permit
a Building Location 1211aq MILLPOND Owner's Name
NO . ANDOVER , MAType of Occupancy RES
G
New ® Renovation ❑ Replacement ❑ _ Plans Submitted: Yes❑ ' No ❑
Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate r
Address 91 B . ,MONT STREET ❑ Corporation
NO . ANDOVER , MA . 01845 ❑ Partnership
Business Telephone 508-689-9233 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142-
Yes
42Yes R7 No ❑ '
If you have checked Les, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy Z] Other type of 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) In ove appticatlon are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit sued for this appllcatl will b�In7pflance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the neral law
"y
Y Type o(Ucense:
Plumber gnatur o c nse um a or Gas Fitter
Title Gasfilter
Master Ucense Number M-3440
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SUB—aSMT.
BASEMENT
I ST FLOOR
1
J
21,10 FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
GTH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate r
Address 91 B . ,MONT STREET ❑ Corporation
NO . ANDOVER , MA . 01845 ❑ Partnership
Business Telephone 508-689-9233 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142-
Yes
42Yes R7 No ❑ '
If you have checked Les, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy Z] Other type of 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) In ove appticatlon are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit sued for this appllcatl will b�In7pflance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the neral law
"y
Y Type o(Ucense:
Plumber gnatur o c nse um a or Gas Fitter
Title Gasfilter
Master Ucense Number M-3440
City/'Town
O .
' .. .�`+:��+ „+,-.,,,.'}�{•. '"- `.`--'�C-"`-rsi.-1�.•'Y�ic�';r.�"+r'�+-.r'{s...4.r�"''"� '"`,.es,,:",..k,.:"'..
Date. .'......
�.2022
A
f NORTH ,' TOWN OF NORTH ANDOVER Q
0 � `p PERMIT FOR GAS INSTALLATION-
P"
�9SSHCHU`�ES 9 -'
This certifies that . jf el L
has permission for gas installation ... S..L j`.'
in the buildings of ..% fl 1 D ..... . .
at ..: /7 q. .............. North Andober, Mass.
Fee. 7.. Lic. No..
AS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File