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HomeMy WebLinkAboutMiscellaneous - 11 WAVERLY ROAD 4/30/2018 (2)N) r MH P1tHL I rl VERMONT MUTUAL INSURANCE GROUP@ -va,lr89 STATE STREET - PO BOX 369 MONTPELIER, VERMONT 05601-0369 fj�l Claims 800-435-0397 shicc. 182) Property/Liability Claims Fax 802-229-7647 Auto Claims Fax 802-229-8941 E-Mail claimskvermontmutual.com March 31, 2015 NOTICE OF PAYMENT OF PROCEEDS UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 175, SECTION 97A. NOTICE OF CASUALTY LOSS UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 Town of North Andover Tax Collector/Building Department 36 Bartlet Street Andover MA 01810 RE: Insured: Vidal Prim iterio-Suriel Claim No.: HC209262 Policy No.: H012291849 Date of Loss: 01 -Mar -2015 Property Location: 11-13 Waverly Road, North Andover, MA 01845 Type of Loss: Ice/Snow To Whom It May Concern: A claim has been made involving loss or damage to real property of the above -captioned property loss location which may either exceed $5,000.00 or cause Massachusetts General Laws, Chapter 175, Section 97A, to be applicable. We have requested per the statutory requirements that the claimant provide us with any certificate of municipal liens from the collector of taxes of the city or town wherein the insured property is located. If any notice under Massachusetts General Laws, Chapter 175, Section 97A is appropriate, please direct it to the Claims Department and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Additionally, the damage to the real property in question may exceed $1,000.00 and this letter constitutes notice pursuant to Massachusetts General Laws, Chapter 139, Section 3B. Thank you for your cooperation. VERMONT MUTUAL INSURANCE COMPANY -NORTHERN SECURITY INSURANCE COMPANY, INC. GRANITE MUTUAL INSURANCE COMPANY Date ..... �— --% I"°... . HORTN 0 TOWN OF NORTH ANDOVER D PERMIT FOR GAS INSTALLATION This certifies that ... ... :�.. ? �... �. has permission for gas installation..��.........-:�........... in the buildings of .......... � 7 at . /-........... . ! 12 , North Andover, Mass, // G 7J ' Fee: U'..... Lic. o........ . z -.y."........... .G INSPECTOR Check # 7110 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date / Q NORTH AN// / ANDOVER. MASSACHUSETTS Building Locations —// [n/ A U Q/ Owner's Name New ❑ Renovation ❑ Replacement ❑ Permit # Amount $ LAI Pua:� Plans Submitted ❑ (Print or type) Name j I Address.. / /'t �'� t ��• l/1! �1 h /Lit, tj 1\ Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Chec one: I have a current liability Insurance licy or it's substantial equivalent. Yes ❑ Nor_] If you have checked }_es, please ' cate the type coverage by checking the appropriate box. Lial ility insurance policy Other type of indemnity ❑ Bond ❑ Ownerisllnsurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the M General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State_Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed ❑ Plumber ..�� ® Fitter Lic MMaster ❑ Journeyman Or Gas x w GOn U a w x w H z a F w c� w F z r x w > w U x x z w w .. H P z z w o z 9 p H w x o x 3 a .Qa o a > SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 87H. FLOOR (Print or type) Name j I Address.. / /'t �'� t ��• l/1! �1 h /Lit, tj 1\ Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Chec one: I have a current liability Insurance licy or it's substantial equivalent. Yes ❑ Nor_] If you have checked }_es, please ' cate the type coverage by checking the appropriate box. Lial ility insurance policy Other type of indemnity ❑ Bond ❑ Ownerisllnsurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the M General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State_Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed ❑ Plumber ..�� ® Fitter Lic MMaster ❑ Journeyman Or Gas The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): / r Address: City/State/Zip: -4 U T ,f N Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors 2.employees lam 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.] 3. ❑ I am a.homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required] t employees. [No workers' .. —t: ---- comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other t- 211: L`�C [n:' SCCilO'.1 compens mon Policy:.^.fG.^: s4�on. Homeowners who submit this affidavit indi ating they are doing all work and then ]lire 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. lam an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance 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). fiFailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 cerfAder the pains G 6v G M7rj that the information provided above is ue an correct M7nafP. 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: amu, 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, §25CM 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 cerdficate(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. 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 tower that the application for the perruit 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 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 bum 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 Ma&sachusetts Department of industrial Accidents Office of Investibations 600 Washmgton Street Boston, AZA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 w�wJ.mass..gov/dia Location - ?P No.. -s� t Date �i 1 TORT" TOWN OF NORTH ANDOVER 3? •' a °L p Certificate of Occupancy $ * Building/Frame Permit Fee $ 6P- SSC U — .- Eta Foundation Permit Fee $ ... s�Nus ro Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ g TOTAL $ Iii' �0 7520 Building Inspector Div. 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O CD =N 'R a ' � 0 CL 0 rA CD O N /� O CCD CL 2 1 :� 1 3 Cood N .�� � CS cc 1 a L CD HCD . CD R r., C-3 .. O OCOD 1 CD W �3 -CD o C2 ,..r . �CD ED a3 ..:► N : CD o CD m m o o :O 0= 1 o 0 V =' o c� 0 6 C/) d° cn ?? o C) n ?� 7y c X y .'? C) 0 �i n ` x o r 0 CD o ( O x Ic 0 c 3020 Date ..1'g/� 17e - - oRTM TOWN OF NORTH ANDOVER pf 44�io ,61h0 p PERMIT FOR GAS INSTALLATION This certifies that .. C. l j10� ( Ski P ... C. S'. R. �c�•U. t�� iq �. Q.... S40 -j has permission for gas installation . ...�+ in the buildings of . �` t: G ? R ............... 0 �:'�.I.Y . ss. at .... ..... ............... , North Andover, Ma Fel;0!k . Lic. No.. 9, �.47j.. .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO U GASFITTING (Print or Type) . -- ��Mass. Date _�© 19 P mit # _ r,_— {tib- �___ ,= Building LocationX��� \ied2 Owner's NameX �� �IL &t2-� <r, - X iU /�►�}d6y�iZ ►M 1� Type of Occupancyx9eot-eL G New 0 Renovation E Replacement X 6f4Cl FIXTURES Plans Submitted: Yes No installing Company Name12140 fly,,, I. rr✓u Check one: Certificate Address GL C- 1-,4-iztL � S -/J = Corporation -f4t,^✓zsNCc- 0ayq( = Partnership Business Telephone 8 G" 3z T? Firm/Co. \ame of Licensed Plumber or Gas Fitter ,or -45& INSURANCE COVERAGE: i -iave a current liability ins ante policy or its substantial equivalent ,which meets the requirements of ,\,IGL Ch. 142. Yes _ No if .ou have checked yes, please indicate the type coverage by checking the appropriate box. y liability insurance policy - Other type of indemnity C Bond - 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 walves this requirement. Ch PA1 one: Owner V Agent [j - nature nature of Owner or Owner's Agent .erebv certify that all or the details and information I have submitted for entered) in the above application are true and accurate to the best of my knowledge and that aft p1uri21ting work 7,.o installations performed under the permit issued for this application will be n compliance with all pertinent provisions of the Massachusetts State Ga, Code and Chapter 142 of the Cewral Laws. Type of License: 3s - Plumber .� _ ale ��taster Gafi r 19nature of Licensed Plumber or Gas Fitter _ Journevman '-363 :c%Town License .Number t, APPROVED (OFFICE USE ONLY) t i ,) I VI Y W U1 Z OC W 64 O u m Z i rn V rn 661 Q r Z D 0 H W111 Q n Q °C Z O s O < W 7. Z 66JQ u W y Z W O Q (A .O cg W Q W N U) P: Q Z~ W C, U );,. > W W u_ OC Z O Z Q W t++ > Q W is Z F. QCdQ ;0./1 m O O W O 5 2 0 Cr S W 3 0 V S W u oe > G a r 0 SUB-BSMT. I I BASEMENT I ! 1st FLOOR i 2nd FLOOR I I 3rd FLOOR 4th FLOOR I I 5th FLOOR I 6th FLOOR I I I I I ! I 7th FLOOR 8th FLOOR installing Company Name12140 fly,,, I. rr✓u Check one: Certificate Address GL C- 1-,4-iztL � S -/J = Corporation -f4t,^✓zsNCc- 0ayq( = Partnership Business Telephone 8 G" 3z T? Firm/Co. \ame of Licensed Plumber or Gas Fitter ,or -45& INSURANCE COVERAGE: i -iave a current liability ins ante policy or its substantial equivalent ,which meets the requirements of ,\,IGL Ch. 142. Yes _ No if .ou have checked yes, please indicate the type coverage by checking the appropriate box. y liability insurance policy - Other type of indemnity C Bond - 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 walves this requirement. Ch PA1 one: Owner V Agent [j - nature nature of Owner or Owner's Agent .erebv certify that all or the details and information I have submitted for entered) in the above application are true and accurate to the best of my knowledge and that aft p1uri21ting work 7,.o installations performed under the permit issued for this application will be n compliance with all pertinent provisions of the Massachusetts State Ga, Code and Chapter 142 of the Cewral Laws. Type of License: 3s - Plumber .� _ ale ��taster Gafi r 19nature of Licensed Plumber or Gas Fitter _ Journevman '-363 :c%Town License .Number t, APPROVED (OFFICE USE ONLY) Location // WAuLORi Y P0Ad a cC No. p Date 0 r NpRT1y TOWN OF NORTH ANDOVER A " Certificate Occupancy $ of �cNA uBuilding/Frame /Frame Permit Fee ssE 9 $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ % Check # G �� 17889 Building Inspector �t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: Q DATE ISSUED: �O- U SIGNATURE: 6u� Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: � Vr� 1.2 Assessors Map and Parcel Number: '10 Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide RegWred Provided Re red Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infomntion: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT "1.1'101 10 'i .t(iCt: 2.1 Owner of Record LVAVI/V/ Name (Print Address for Service.: 0 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 1 Si ature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Co truction Supervisor, 6C ,,,, v ( Licensed Construction Su {( � 'License Fq��afl Address Signature Telephone Not Applicable ❑ Number I( Expiration Date 3.2 Registered Home Improvement Con ctor V14 6jr,,`aO�/� Company Name / ":2 2 / Not Applicable ❑ Registration Number ////05 Expiration Date Address � /� s � 7 Signature _ Telephone t: 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 checkatt a Ikabte New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ I Addition ❑ Accessory Bldg. ❑ I Demolition ❑ Brief Description of Proposed Work: RCL�'qce' V d&1 -0 r5 UV I Other ❑ Specify C Q C's or! a %mei 1(prr4 s SECTION 6 - F.STIMATFn CONSTRT7r nN rncTc 4ee 11 wI'VtdWs (Iva V Pv-� Item Estimated Cost (Dollar) to be Completed bV permit applicant OF>FTC><Ar. USE ONLY 1. Building 1 � I I Q 406 (a) Building Permit Fee Multiplier NO. OF STORIES 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) / �- 1 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number �1L'v 11V1� is v��l�c.a�e�u ailViliLJA 11V1\ 1V DE 1, V1q.iLr+1LL Wt1C;P1 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 1, - ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are tn:e and accurate, to the best of my knowledge and belief �&r# I Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEIVIENT OR SLAB SIZE OF FLOOR T11VIBERS 1' 2' SPAN DMIENSIONS OF SILLS DMNSIONS OF POSTS DIMENSIONS OF GIItDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH VINEY 1S BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE t u P2 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) Signatua of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ACQRD,, CERTIFICATE OF LIABILITY INSURANCE °A120112004 PRODUCER 978-975-4344 THIS CERTIFICATE IS -ISSUED AS A MATTER OF INFORMATION INTERNET INSURANCE AGENCY, INC 522 CHICKERING ROAD ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER, MA 01845 POLICY NUMBER POLICY EFFECTIVE INSURERS AFFORDING COVERAGE NAIC # INSURED D.G. CONTRACTING, INC. DAVID 428 PLEASANT STREET NORTH ANDOVER, MA 01845 INSURERA: NORFOLK & DEDHAM INSURER B: NORFOLK& DEDHAM INSURER C: ARBELLA PROTECTION & NORFOLK & D I NsuRERO: AIG INSURANCE INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD'L C POLICY NUMBER POLICY EFFECTIVE POLICYEXPIRATION LIMITS REPRESENTATN AUTHORIZED RE SEN T E GENERAL LIABILITY EACHOCCURRENCE $ 1,000,000 A X COMMERCIALGENERAL LIABILITY R0401723A 07/01/2004 07/01/2005 .AMA'- 1011FNIED PREMISES Eaoccurence $ 100,000 CLAIMS MADE I OCCUR MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMIT APPLIES PER: PRODUCTS)COMP/OPAGG $ INCLUDED POLICY PRO, jECTLOC B AUTOMOBILE LIABILITY COMBINED LIMIT $ 1,000,000 ANY AUTO 90151692 06/12/2004 06/12/2005 (aaccideSINGLE BODILY INJURY ALL OWNED AUTOS X SCHEDULEDAUTOS (Per person) $ BODILY INJURY $ HIRED AUTOS NON>OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GA RAGE LIABILITY AUTO ONLY, EA ACCIDENT $ OTHERTHAN EAACC $ ANY AUTO AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 C X OCCUR F—I CLAIMS MADE 4600020399 12/10/2003 12/10/2004 AGGREGATE $ 1,000,000 C 0001370 12/10/2004 6/10/2005 $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU> OTH> TORY LIMITS ER D EMPLOYERS'LIABILITY WC333-27-74 03/31/2004 03/31/2005 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E. L. EACH ACCIDENT $ E.L. DISEASE , EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE) POLICY LIMIT $ 500,000 OTHER y DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001/08) V "A=RD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 10 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATN AUTHORIZED RE SEN T E ACORD 25 (2001/08) V "A=RD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of /nvesdgedons Boston, Mass. 02111 Workers' Compensation Insurance Affidavit U td U10021VI-0 Please Print city &YI �,b-CIVLI Phone # % i 5 ? _Z q� I am a homeowner perforating all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone PoNcv # Failure to secure coverage n required under section 25A or MGL 152 can lead to the Imposition of ahninol penalties ar,a tine up to i1,5oo.00 andlor one yeas' ImpfMOIN, eat_as.rmeD_se_cbA.pendties.lnbohmdASTOP WDW.ORDERand.s.flne d-(;10D.0o)�d+4� apai�-rale I understand that a copy of this statement may be forwerded to the Office of Investigations of the DIA for coveraps verification. I db hereby certfy undlar Me pains slabs or perjury that the intiormadon provided above is true and consd. Signature Date L,2� /fir/ / Print U ld & J 11-0- Official use only do not write In this area to be completed by city or town offidar # 9 7,-F- XIs' 7 �(S-- City or Town P inn ❑ []Check of immediate response Is requarod Building Dept ❑ Licensing Board ❑ Selectman's Office Confect person: phone # ❑ Health Department ❑ Other y RI v, y CO) CO) 10 0 CD az y � c CL. = H a40 CD o p Q,� o c� =r co CD o CD C O nC S C I 4cmfg =r_ s � cego =- CL C2 t�ao m C.) Z _ =� o.7 °.� m N 17 „F a o Sr -,G o m 0 y N O_ O ' �O o:� fC m n q� tTl I CKcn g am C dO it n y O p� N zCOL I- � � C/)o 40 c 0 �s �� mcc N C CosamQ �Jyr Co.) ErE: n oo� lit a. cl 04 s Cl Imi 0 9 0 "NA, � z, 0 CJ �' A a Z ro M � x 0 *was CL 0 c Date.. ?..z... ... I ... 611 ....... I 40RTN 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAGMUSEt t12 This certifies that .............. . ........... ............................................. has permission to perform I ................................. ........................................... ,o- wiring in the building of ............. ....... ............................. at ... /i?r ..... ............ ........................ ...... . North Andover, Mass. A .. ................................. Fee ..................... Lic. No .............. ?.� .................. ELECrRICA;ANsPXMR Check # loz!> 5667 UOrnawnweaillt of %fla9jaclrt4jelf-5 OiliciJI Usei;ly s/J cc�� Pernut No. ._Ueparlmertl of Jire Service3 �� Occupancy and Fee Checked BOARD OF FIRE PRISVEINTIUN REGU .ATIONS (Rev 11/991 I APPLICATION FOR PERMIT T :SII work to he hcrlormcd m .xcord:mcc %. nth tht (PLEASE PRIiVT ltV INK OR YTP .-1LL IN O ?A1,17 City or "Down of: (� o By this application the undersigned Lives notice of h s or)he Location (Street & Numbed)- 11`` (,, 4 v L Owner or Tenant D )`A I - l X05 1 Owner's Address ITU tJJ Uj/71y/ Is this pernnit in conjunction with a building permit' ;1'ur-mse of Buildim, E::isting Service Amps / \`tilts. Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: PL)Sc.Ic L1614T51j'm (leave blank) PERFORM ELECTRICAL WORK \I�s;scl;usclls Electrical C.rdc (,SIE( 1, i2- l iM '_ C)O /Vj Date: i �i/'\ To the Inspeclor of Fl7r-es. intention to perform the electrical o:ork described below. �nzdr Telephone No. 9W T�OJ-32V 6307:71 Yes ❑ No JA (Check Appropriate Bos) Utility Aulhoriz_•ntion No. Overhead ❑ 1tn and ❑ No. of Meters Overhead ❑ Undgrd EJ) No. of Meters i /1-1 -P(-)QG jG ME qjl 7pl9A #`'z'f- '�4 jv7— c c 2 S I Comnle.ion ofthe folluudne ruble mar be united be the insoertor of Wires. No. of Recessed Fixtures No. of Ceil -Susp. (Paddle) FansNo. of Total 'transformers KVA No. of Lighting Outlets No. of Ilot Tubs Generators KVA No. of Lighting Fixtures Above in- Sntiinuuing Pool 1. ❑ grnd. ❑. IN o. o FEE1er9ency Lialitina Battery Units No. of Receptacle Outlets ;' s. of Oil Burners FIRE ALARIIIS No. of Zones s No. of Stitches No. of Gas Burners No.. Detection and Initiating Devices No. of Ranges "rota] No. of Air Cond. Tons Nu. of Alerting Devices Heat Pum Number Tons K\V No. of Self -Contained No. of Waste llis P users Totals: I Detection/Alerting, Devices No. of Dishwashers Space/Area Heating KAV Local❑ lVlunncipal ❑ Other Connection No. of Dryers Heating Appliances K11: Security Systems: No. of Devices or Equivalent No. of Nater KN No. of !N' 0. ^1 Dain Wiring: Heaters Signs Ballasts N o. of Devices or Equivalent No. Hvdromassaoe Bathtubs b No. of Moors Total hiP Telecommunications Wiring: No. of Devices or E uivalent OTHER: ;7110C/7 uaarrfunur uefun y unircu, pr- u3 regimen o!' me tr ,Sr;L— Ur uj r,;r rs INSURANCE CM ER -AGE: Unless •..'-rVr_d py ;�,� �� .I:e i10 pe.m,t fVi if pCr101n'...'lt. .t ..,�_(, 1.., J... .. . the licensee piovid':s proof of liability insurance includiu>_ "completed operatioin - co�era,e or its substantial cq-a.a t:t undersigned certifies that such cover,e is in force, and has exhibited proof of same to the per mit issuin office. s. CHECK ONE: INSURANCE BOND 0 OTHER (Specify: Cx /G Go. Estimated Value of Electric 11,Vork: ,Q 5700,01)(When required by municipal policy.) lEzptau Date) Work to Start: f� 7 Inspections to be requested in accordance with NIEC Rule 10, and upon completion. I c•ertif)•, rurrlcl. Elie pain. and pe�ttnliies of perjru-)•, that the information ori this applicalion is trite and complete. IrIIL\I INA ilIE: LIC.NO.: 0k3 Licensee: HO Jr Sigrnatu e TA LIC. IN0.: 0063 E (If applicable, enter ..e,, 111pl- in the license mrnrn�� X900 G) 10 �,! 13 us. Tel. No.: G0 Address: � oo p � � 0� f/r J " 1 �____�-_Z fUt. Tel. � o.: OWNER'S INSliI2:�NCE WAIVER: Ian aware that the Licensee oes not lime the I abrlil); insurance co.e1. eF norma v Lanni .". b. Liv- B, :Itv >i,natu;c 5elc,:, ! he, b; 'a,n•.c this requ;mnuiit. 1 ant, the ((!:(- '. �i ) 0 Onncr,':1,csnt r_rr 1, U, PLEASE FiLL OUT BACK SIDE Z Q U W J W 4t W LL r a Check Date: Jan/05/2005 Vendor Number: 0000000135 Check No. 1007943 Invoice Number Invoice Date Voucher ID Gross Amount Discount Taken Late Charge Paid Amount electrical permit Jan/04/2005 '0001N86 250.00 0.00 0.00 250.00 Check Number Date Total Gross Amount Total Discounts Total Late Charges Total Paid Amount 1007943 Jan/05/2005 250.00 0.00 0.00 250.00 r / , J'✓ l � v `� c tt