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Home My WebLink AboutMiscellaneous - 11 BEAR HILL ROAD 4/30/2018 (2) 11 BEAR HILL ROAD 21 O1o64.o-0oz 1-0000.o AMERICAN CLAIMS SERVICE MULTI-LINE ADJUSTERS Letter 143 September 20, 2016 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Attention: Building Inspector Board of Health and/or Board of Selectman Insured: Vincent Location: 11 Bear Hill Road North Andover, MA 01845 Policy: 1183412 Loss Date: 4/20/16 Loss Type: Patio settlement ACS File: 160283 Dear Sir/Madam, Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under, Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy, loss date and file. On this date, September 20, 2016, 1 caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless a response is received within the next ten days we will not be obligated to pay any portion of this claim to you. Respectfully submitted, Tim McLaughlin Claims Representative 7 KIMBALL LANE BUILDING C LYNNFIELD, MA 01940 PHONE 781-245-9516 FAX 781-245-1077 claims.acs(a)-verizon.net Date........ ... . ."... ........ &OR TOWN OF NORTH ANDOVER o ' PERMIT FOR WIRING `4`4ACHU`�� i This certifies that ..,.... 7 ..................... ...... � has permission to perform .. . �. -................................................... wiring in rr the building off.......... ,/�..`.:QA?.....4............................................................................. at .......�..1....... ✓ ' F ................... ..................,Yojth Andover,Mass. Fee.. ..............:........Lic.No. ................. ... .............. 9 6 ELECTRICAL INSPECTOR Check#. l �G f ✓ `I`2�jl x Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/o7] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASEPRINT ININK OR TYPEALL INTORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. -,?p I 75-3 510 Existing Service q_ Amps /la / 2 yo Volts Overhead❑ Undgrd 9- No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: f(jL w ��,� 5� r Completion of thefibllowlntable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-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- BatterU0.0 ergency ig ting grnd.No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: ......................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Municipal El other p g Local❑ Connection No.of Dryers Heating Appliances KW SecNo.of Systems:* ev lc s or Equivalent No.of Water KW No.of No.of 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: L5251-0 (When required by municipal policy.) Work to Start: /0 /j- Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE C V19RAGE: 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 coversg&is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURA_NCE ND ❑ OTHER ❑ (Specify) i I cert,acnder the pains and penal' s of perjury,that the information on this application is true anti complete. 1 FIRM NAME, f'ti./L LIC.NO.: F 3Y a8-0; Licensee: Signature LIC.NO.: it-3 7 V" (If applicable nter"exempt"in the license number line) L/, Bus.Tel.No.: f�/ SsL$ add �i7�`c o � k�h Address: G,2 ,, ys 3 Alt.Tel.No.: 'Per M.G.L c. 147,s.57-61,security work rdquires 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. I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the { c permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE PECTION: Pass[a Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass N Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass N Failed Re-Inspection Required($.)❑ Inspectors Comments: I Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com .t The Commonwealth of Massachusetts Department of Industrial Accidents - 1 r I Congress Street,Suite 100 Boston,MA 02114-2017 4 d�M Svc v www.mass.gov/dia Worker Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A ' licantInformation Name(Business/Oigainizaticn/ludividual): �6 Address:,P6 /9 Phone#: � �� CJS ~ 3Q��D-- City/State/Zip: `Lt,� � ,.,, Are you an em Ioyer?Check the appropriate box: Type of project(xequixed) em to ees full and/orpart-time).* 7. ❑NOW'ddnstrudtion I•Q I a employer with P y 2.• am a sole proprietor or partnership and have-employees Working for me in 8. 0 Remo deliug any capacity.[No workers'comp.insurance required.] 9. []Demolition 3.[]lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repays or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.Q'PlU Bing repairs or additions 5111 am a general contracto.and I have hired the sub-contractors listed on the attached sheet. 11 F]Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.E]Other 6.❑We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),aadWehaveno employees.[No workers'comp.insurance required] *Any applicantthat checks box#1.must also fill out the section below showingtheirworkers'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 I Contractors that check this this must attached indicating 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. X am an employer that is providing workers'compensation insurance for my employees. .Below is the policy and,job site information. Insurance Company Name: l, Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: • Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date. Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a may be forwarded to the Office of Investigations of the DTA for insurance day against the violator.A copy of this statement coverage verification. J-do hereby certify under the•pains andpenalties of perjury that the information provided above is true and correct Date: Signature: 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 Phone#• Contact Person- 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 enferpri'se,and including the legal representatives of a deceased employer,or the receiver'or trustee 6fan 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 o£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 b6 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 xequired." 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 Pleasb 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of.Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Iridustrial,Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatioii policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write•"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burin leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia x of �MM�N • BOR�p a'� r: cjRlclANSCENSEPOT w :f Ft's N S SHE SOLE P�SS RE0 URNE�MR� :'�� `ppA �• 26 A A OZ453 26ob . NOR7y 1 1 O�.1 IED '6�~0 3? �� 6 °c � 4 � ArED P9 ��ssgcwus��y Town of North Andover BUILDING DEPARTMENT CONTRACTOR AFTER HOURS REQUEST FORM CONTRACTORS NAME: ADDRESS• CITY/TOWN:_�/r[/q?a� STATE: AA'�- ZIP: BUS.PHONE: CELL: MA.LIC#: MASTERS: JOURNEYMANS: PERMIT# f 2 7�r- N-GRID SR# 9 REOUESTED DATE: lo-9 - f TIME: JOB LOCATION: OWNER: PHONE: t0 j �(j D WORKERS CELL: REASON FOR REQUESTED INSPECTION AND JOB DETAILS: r CONTRACTOR SIGNATURE n`—" NORTH ANDOVER SUPERVISOR SIGNATURE: )_ e' ndj'or Contractors requesting INSPECTIONAL SERVICES due to weafterhour operatio- such as service related planned updates or special situations,will qired to provide a fo hour minimum charge of$150.00 paid to the Town of North Andover at that time. Community Development Division,1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.608.9545 Fax 978.688.9542 Web www.towndnorthandover.com 2064 AP ELECTRIC 26A ANTICO WAY WALTHAM,MASSACHUSETTS 02453 5-7017-2110 DATE PAY TO THE �-�. ORDER®F 7` , �^u L DOLLARS LTJ a i AD Citizens Ban FOR M, II300 206 Lom •o: 2 1 10 ?0 1 ? 5i: L 3 20 6 5 2 1 Z? liis ..... ... ........—. e 40 C- vvt 1 ( `�4 - �,/C'yz- 0, IN Q eit_ do I I I � 5 i i � �r � s s s s � • i � � t• NORTlf 1 SLEU Ib A�O L II �Jl 7 p�Nwrto �SSAC14 Town of North Andover BUILDING DEPARTMENT CONTRACTOR AFTER HOURS REQUEST FORM CONTRACTORS NAME: 1 dam ADDRESS: Ak CITY/TOWN: �—Irlll%aA STATE: ZIP: BUS.PHONE: CELL: MA.LIC#: MASTERS: JOURNEYMANS: ZE 3 a PERMIT# 2 76(— N-GRID SR# ;� REQUESTED DATE: lo-9 - 15- TIME: JOB LOCATION: OWNER: PHONE: �� 2 WORKERS CELL: REASON FOR REQUESTED INSPECTION AND JOB DETAILS: 1-1 ht CONTRACTOR SIGNATURE': - . NORTH ANDOVER SUPERVISOR SIGNATURE: Contractors requesting INSPECTIONAL SERVICES due to wee nd or after hour operatio such as service related planned updates or special situations, will be required to provide a fo hour minimum charge of$150.00 paid to the Town of North Andover at that time. (ommunity Development Division,1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com 2064 AP ELECTRIC 26A ANTICO WAY WALTHAM,MASSACHUSETTS 02453 DATE 1 5-7017-2110 I - 5- J ✓ PAY TO ORDER OFE �• t T 17 7: C� $ �5 K DOLLARS XX Citizens Ban 11'00206411' -1: 2L1070L75l: 1320652L ? L11' /