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HomeMy WebLinkAboutMiscellaneous - 115 MOODY STREET 4/30/2018 115 MOODY STREET 210/080.0-0006-0000.0 \` J/ i i Providing Insurance and Financial Services StateFarw Home Office, Bloomington, IL +� February26, 2015 North Andover Building Department State Farm Claims 1600 Osgood St PO Box 106110 North Andover MA 01845-1048 Atlanta GA 30348-6110 CERTIFIED MAIL: RETURN RECEIPT REQUESTED RE: Claim Number. 21-5V98-859 Our Insured: Scott Thompson Date of Loss: February21, 2015 Loss Location: 115 Moody St, MA 01845.1713 Tax Block: **TAX BLOCK`* Tax Lot: **TAX LOT** To Whom It May Concern: State Farm Fire & Casualty Insurance Companywrites to provide notice as required by Massachusetts law in connection with the matter referenced above. State Farm®received notice of loss or damage in excess of$1,000 at 15 Moody St North Andover MA 01845-1713 We hereby notify your office pursuant to General Laws c. 134, §313 that State Farm intends to make a payment of$1,000 or more in connection with the above referenced insurance claim. Further, the applicable amendatory Policy Endorsement informs the insured of the Massachusetts requirement by stating the following: "We are required by Massachusetts law that we must notify the local inspector of buildings or Board of Health at least 10 days before we make a payment of$1,000 or more for loss to a building or structure. We must also give notice if there is damage which makes a building a health or safety hazard or dangerous or unsafe for occupancy regardless of the amount of our payment. If, prior to payment, we receive official notice of a pending or existing lien against your premises, we must delay payment until the matter is settled. If we are required to pay all or part of the amount of the lien, we will not be obligated to pay that amount to you." If you have questions or need assistance, please call us at(800) 803-9089 Ext. 6103587995. 21-5V98-859 Page 2 February26, 2015 Sincerely, Dave Kilgore Claim Representative (800)803-9089 Ext. 6103587995 State Farm Fire and Casualty Company cc: Holding Code Pso Southbo 21-6006 I �� Date A ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. .. . .......... ........... ... ... .................................................. has permission to perform ......................................................................................................... wiring in the builging, ...... ... .. .............. . .;,0 15 M664 at ..............................................I.........................................................No�Anddo r, ass. -�Z) li /,vt Fee...e��...............Lic.No.2....1.0.....0.... ....................... . ....... ... ..I............... g�� i;�JECMR Check# —ML. 17 -r 5 Date......... ................................. TOWN OF NORTH ANDOVER Pg F.MIT FOR WIRING gs�cHu This certifies that .................. ..... Z............................... has permission to perform ... .....................................................................z wiring in the building of.............. ..........'5 C),-,/ .......... ..................................................................... ................ at ........./1 .........Mo.6.dy...... ......................^orth Andover,Mass. ...... ... ............. .......... ELECTRICAL.... Fee... . .............Lic.No?x/Llo.. ...ml...4-............ . ............................. Check# 7 77- 13 611-7113 'k,4-vv-% -4° I--4 �jx-e-& a, V)n-uL- �.� L � i t� I LH 251413P j � = Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),5 7 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: P1, F7�3 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) /1 s Aod!, 5�', Owner or Tenant 4,f,//ts 74o „,-,� Telephone No. Owner's Address Sa'"tc Is this permit in conjunction wi h a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Ifol c h f L Utility Authorization No. - Existing Service / 616 Amps �20/ 20, Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity / Location and Nature of Proposed Electrical Work: Zh� fCfo � C,�r�nvc n, ./ .,��,,) Completion of thefollowing 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 J No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches 2 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "" ' ' ' "" -***" " 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 No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: >! , No.of Devices or E uivalent OTHER Vt4 r., /Lf Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of�Ele trical Work: <�o (When required by municipal policy.) Work to Start: eft,f_'j 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 cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify) I certify,icnder the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: ' �P!° Signature LIC.NO.: -Z Yo-If (If applicable,enter"e e pt" the license nt mber line.) Bus.Tel.No.: Address: _ 7d 7`f j.-fc��. Imo, Wd�,i,�,, �/I/f I� Alt.Tel.No.: 5 p- *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 Signature Telephone No. PERMIT FEE.$ ,1 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be fled 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 EN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ ,. Inspectors Comments: 1 Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INION:_ 6 Pass ' Failed Re-Inspection Required($.) ❑ Inspectors Comments: + Inspectors Signature: v cf �� .� / Date: FINAL INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: C Date: DEB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 4 � The Commonwealth oflMlassachusetts Department oflndustrird Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nance(Business/Organization/Individual): r "'U''�� Address: -70 1414e o s' 11 *// City/State/Zip: WV11 r 11 04M 04_C41 Phone#: 7V- 3 3- j:­d—e8' Are you an employer?Check the appropriate box: - Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction Xployees (full and/orpart-time).' have hired the sub-contractors7•2m a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition - [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.D Electrical repairs or additions 3.❑ I am a homeowner,doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 1s providing workers'compensation insurance for my employees. Below is thepolicy and job site information. W-&-t�S40-I07f TInsurance Company Name:. —1' 7(l,G-l('e- Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy tleclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certlo under thepains and penalties ofperjury that the information provided above is true and correct. Simature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town of ca 1 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:-2 Phone#: A, a r � , Information and Instruction's 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 employeils 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 ofits 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. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confnmation 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 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. Anew 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 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 Coxx�mojaweattf o assacl?vsPfts Deparimeut of Industdal.Accidents Office ofInyestigations 60 Washixtgtw Stxeet Boston?MA.02111 TO,#617-727-4900 axt 406-or 1-877,MASSAFF, Revised 5-26-05 Fax#617-727-7749 'fRMxF Urn Aoo fallSFfiio s i COM�IIta[+IWEALTH_Or�_-ASSACHUSETTS ' rLECTi�ICIANS RWISTERED.MAST.ER ELECTRICIAN. ISSUES THE ABOVE LICENSE TO - MARC D ,'ALMEIDA �O .HENDERSON RDi t WQGUR.N MA 01$0.1-591.9_ • 's7 I' J , j F 4� ac, A k e d �a CC C� 1 #3 i' Bank ACCT# 8245912840 DATE: 07/12/2013 America's Most Convenient Bank® 800-747-7000 TD BANK NA P O BOX 1377 LEWISTON,ME 04243-1377 TOWN OF NORTH ANDOVER DEPOSITORY ACCOUNT 120 MAIN ST NORTH ANDOVER MA 01845 THE FOLLOWING ITEM(S)THAT WERE DEPOSITED INTO ACCT#8245912840 HAVE BEEN RETURNED UNPAID. WE HAVE DEBITED YOUR ACCOUNT AS INDICATED BELOW. THE ASSOCIATED FEES WILL BE REFLECTED ON YOUR MONTHLY ANALYSIS STATEMENT. IF YOU HAVE ANY QUESTIONS OR CONCERNS,PLEASE CONTACT US AT THE NUMBER LISTED ABOVE. CHECK# DEPOSIT DATE CHECK AMOUNT REFERENCE# RETURN REASON 1090 07/10/2013 55.00 726876051 NON SUFFICIENT FUNDS TOTAL ITEM(S) 1 Pee,, TOTAL AMOUNT $55.00 115 N04 Se� (49�2-t)�I I C 14 � �� k- Soo 1 Cr 00000 33 �4 dao Ioollaod4t 99 *211274450* 07/12/2013 m NSF 000000741690531 a This is a LEGAL COPY of your —0` check.You can use it the same way you would use the original IL' 10 9i check. .A fU ALMEIDA ELECTRIC Df•oe RETURN REASON (A) -0 MARC D.AL.MEIDA NOT SUFFICIENT FUNDS D. N C3 --1r w WKMA GUc, Cash Letter 1 of 1 [� .t � � �(/ CJ. Bundle 1 of 1 C]C3, „ b�:tinlr'ra••— �7/l/7/ ��'q'.�'�— Item 1 of 1 C3 rD /4 C3 Ba i904, y m C3 PD01040�' g01130179A>I: 06 0024744160 u'00 L090u' 41:0 L 130 L 7981:0600 29 7444u' 11'000000 5 SOO." 061000146 07/11/2013. 000004557541660 a) 011301798 07/11/2013 000000018070767 t 061000146 07/12/2013 000004566251029 *211274450* 07/12/2013 000000741690531 061000146 07/01/2013 000004355195980 011301798 07/02/2013 0000000181207A5 061000146 07/03/2013 000004403777233 *211274450* 07/03/2013 000aD0733859191 r Q N O O .,PAY ME OQ�D�EF IIF FORDO-03 NLY 'n1M Av�OVEq l!)G EFUNT ANOO N O N y M O d Op M M O O) CN 43 co >03 201 07/10/2 13 0000q3 876051 *>21 ,274 07/10/21013 03/120/1 2 8/20131 000 6466 * 211274 6/28/2013 00000 P266466 zg�z r Vv 1 Cao o i i a 4 -�r� ✓� s 10003 Date �� �� . . . ' TOWN OF NORTH ANDOVER K PERMIT FOR PLUMBING This certifies thatw . .� � . . ! . '-o. . . . . . . has permission to perform . . �. . � 1. . . .1. �.�'�. . . . . . . . . . . plumbing in the buildings of . . 1 . -A-y-C,---.j. . . . . . . . . . . . . . . . . . at . . . .i 1 C5 . M.0 ba 1.�j. �.•. . . . . . . . . ,North Andover, Mass. Fee il.i. . . Lie. No. All . . .N.'I' . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR G � Check# 0�Q p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY -j:l Vr-\Nn o�c—Q Ti MA DATEb Id 1� PERMIT# JOBSITEADDRESS Llls�M S� OWNER'S NAME POWNER ADDRESS , TEL[:�__ ,— FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL 01 RESIDENTIAL PRINT CLEARLY NEW: Fil RENOVATION:[ET" REPLACEMENT:Q PLANS SUBMITTED: YES N00 FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _.. ( _.._.._._1 DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM .---.--.._f DISHWASHER DRINKING FOUNTAIN __...i _.._..... I I fI { I FOOD DISPOSER __A- ___I= f FLOOR/AREA DRAIN INTERCEPTOR INTERIOR -- KITCHEN SINK LAVATORY { I ...L_J _-.__-...J ____-_....E Rl)OF DRAIN SNOWERSTALL -- S AV_MOP SINK TIUILET UP NAL 1 ....__I .__..__.I .___._..._J � _.__.' ( ( I # f ....__J .__....I -- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING OTHER __._._.f .-.-__...! . -._I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES - NO 0 Q� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _I BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. 9[ CHECK ONE ONLY: OWNER D, AGENT J0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Peltiwaa r)rovision of the -- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME W.�����n►1��rr� ' I LICENSE# I � SIGNAT MpEr JP j CORPORATION R. 1# PARTNERSHIP #=LLC COMPANY NAME JV.���ctti�ls�r, �„Q1y ; ADDRESS Q, Z1c _ _ CITY _"'1.�a�n� _.__..__..... ..^�STATE :t`1 ZIP D f 8��c `Elbe, TEL --._ . FAX CELL��EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a ti � j p . a ` ` The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name(Business/Organization/Individual):��� \��L Address: M 5_ \r 2 Al City/State/Zip: n` VT Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑Ne construction �mployees(full and/or part-time).* have Hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.# 7• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ace 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. 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). Failure to secure coverage as requiredunder 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 cert u�n er the pains a d penalties of perjury that tlZe information provided above is true and correct. Signature: f%'// Date: Phone#: 1 — S�_7 Uct'� 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#: ,, A 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-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. 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 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 Massachusetts Department of Industrial.Accidents Office of Investigatitons 600 Washington Street Boston,MA 02111 Tel.#617-727_4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax##617-727-7749 wwwamass.gov/dia ' COMMONWEALTH OF MASSACHUSETTS PLUI ASERS AND GASFITTERS LICEN�AD AS A_MASTER PLUMBER f !I ISSUES THE ABOVE LICENSE TO¢ 1 I WILLIAM T HAR INGTON .I 08 MAPLE 'IDGE RD METHUEN MA 01844-4166 13779 05/t !./14 156635 '°i Date. /0 5. . . TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING ,sSACMus c� This certifies that . . . . . . . . . . . • • • • • • • • • . . . • . . has permission to perform . . .!�� . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of ./ „ . .f�.� at . . . > . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. 3G. . .Lic. No./.s: .(/ x. . . . . . . . . . ,.-.. . . . . . . . PCLUMBING INSPECTOR Check # 7 7 Z 8207 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) "w ,Mass. Date 9/6 20�Permit# r _ _ .t Building Location I�5 hepb� S� Owner's Name Owner Tel# Type of Occupancy Re(S' n New ❑ Renovation ❑ Replacement Plan Submitted: Yes ❑ No ❑ FIXTURES z >W 0 Z x W w F z O z Oa u� = EH U UZO �uQ 0 x 3 a a � H 0 � � SUB-JjSMT BASEMENT 1 * lsr FLOOR 21D FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH F1,00R +1 1 1 Installing Company Name �,l � ,g1 C �`,� �, Check one: Certificate Address '// Aze-Wc t- SZ corporation AN b!'^" %f=1)- .1� ❑ Partnership Business Telephone# ti f�/c�j ❑ Firm/Co. Name of Licensed Plumber c_1 f-- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IT No ❑ If you have checked M,please indicate the type coverage by checking the appropriate box. A liability insurance policy dF Other type of indemnity ❑ 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 waives this requirement. Check one: Owner ❑ Agent 13Signature of Owner or Owner's Agent I 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 th t issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of th' al s. By Signa' a tensed 1 Title Type of License:Master 1�— Journeyman ❑ City/Town / APPROVED(OFFICE USE ONLY) License Number 59 Date...../...0 .d.� f NCRTM TOWN OF NORTH ANDOVER PERMIT FOR WIRING M c� _ `tip+• �,sS/ICMUSE� This certifies that J ' !�4"�� G�'G`�` �!/� ...,.. ....... .......... .... .... .... ..... has permission to perform ........ ..V` ���...�.........J.�..�. ...... �`.�� f wiring in the building of............... f ��� S� at................................... .. .. ,North An ass. ............ ..�� Fee //5..................... Lic.No.............. ......... ...... . ....... � T............. ELECTRICAL I SPECTOR Check # . l,ommonweaA of Mad:3achwelb Oflicia Use O ly As./ cc�� c�77 a.L.Jeparinrenf o1,}ire �erviced Perntit N Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CNIR 12.00 (PLEASE PRINT IN INK OR TYPE.-ILL iNPDRAL I TION) Date: City or "Town of: A/pl--r7q � 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 R Number) /fj /lrM14> .5 ►eE r- Owner or Tenant K`'i T/' A:�7OZZC4- Telephone No. 9IE3--6S 3-7 x-68 Owner's Address Is this permit in conjunction with a building permit.' Yes No ❑ (Check Appropriate Box) Purpose of Building; �U,.�/fr n/ n/ Utility Authorization No.--Loop op �(/sem Existing Service �� Amps �AN`olts Overhead Undgrd ❑ No. of Meters New Service 1.1V Amps Ili /t;-V#aN'olts Overhead Undgrd ❑ No. of iVIeters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Q h G' ��'f� B T C I OU •f�r ivy F h eu, lc-O'-F Corn pletion of the foil ounr�table may be waived by the lns ector o/'(Vires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No. of Lighting Outlets No.of blot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ 1n- ❑ o.o ►neits ►g ►tng rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones of Detection and No.of Switches No.of Gas Burners No. Initiating Devices No.of Ranges No.of Air Cond. Total Tons No. of Alerting Devices Tons a No.of Waste Disposers Heat Pum P . umber 'Tons KW No.of Self-Contained N Totals: Detection/Alerting Devices No. of Dishiv asl►ers Space/Area Heating KW Local 0 co n nnectioecho n El other Co Heating Appliances Security Systems: No. of Dryers PP K��r No.of Devices or Equivalent No. of Nater KWNo.of o.of Daia Wiring: Heaters Sighs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of\lotors Total IIP 1'elecommunientions Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the o«-ner,no permit for the performance of electrical work may issue unless 3r 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 01, BOND ❑ OTHER ❑ (Specify:) � M a y (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with iv1EC Rule 10, and upon completion. I c•er•tif j•, under the paitrs acrd penalties of petjmy,that the information on this application is true and complete. F1101 NAME: LIC.NO.: Licensee: I/j Q`` (n' t" /gLF i"7 Aa Signature "X Q 76 C.N0.:�- 1-1f/e: (If applicable, en r "e cnnpt-in the license rrrunber h Y Bus.Tel.No.: Address: �-M t"�4 Q /� Y i Alt.Tel.No.: OWNER'S INSURA CE WAIVER: 1 am aware that the Licensee does not/rare the liability insurance coverage normally required by law. By my signature below,l hereby waive this requiremcul. I am the(check ouc) ❑ol.\mer ❑ ov.- -'s went. Owner/Agent ^ Signature 1'cicphone No. Pr•nturT r7E : s /A d PLEASE FILL OUT BACK SIDE � f Location ���. y No. 13 �1 f Date v NORTH TOWN OF NORTH ANDOVER 0 • • OR + s • s ; , Certificate of Occupancy $ Building/Frame Permit Fee $CHUS /d Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �� 8 i5853 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 1 � SIGNATURE: .� Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 115 y no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: . Zoning Distrid Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R 'red Provided v 1.7 Water Supply M.G.L.CAO. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public Q/ Private ❑ Zone Outside Flood Zone LR"/ Municipal Q� On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record FL Name(Print) /� Address for Service (tet- " q18-1083--7588 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone M SECTION 3-CONSTRUCTION SERVICES 7� 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number mn Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number r Address r Z Expiration Date /1 Signature Telephone Y/ 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 check applicable) New Construction ❑ Existing Building Repair(s) ❑- Plterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: FNiS� /err,c �2EXi , �n/cL�DirG or' TS i-{- SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant , 1. Building (a) Building Permit Fee � SoO Multiplier 2 Electrical (b) Estimated Total Cost of > 5 Do Construction 3 Plumbing 4, 600 Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 /0,500 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, KE-, K�Z-�L 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, Ke.7-4 K ZE` as Owner/Authorized Agent of subject property • Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name 7W. '?1q/Zoo z Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T11VIBERS 1 ST2ND 3RD SPAN DM ENSIONS OF SILLS DINIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE z 5KY 6 t � FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT WEt1-a W6-27-EL PHONE Vla-683-75S9 LOCATION: Assessor's Map Number 100 PARCEL SUBDIVISION LOT(S) STREET 1�002>V :Sr ST. NUMBER J/S ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED * DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm c vTS l'7 � i9 11,799 7 �t l Z STY W FSO N /00 y I HEREBY CERTIFY r10 rM rlrLr IarSURoR AND PLOT PLAN ro rHE BANK mr THE DWELLING IS LOCATED ON IN THE LOT AS SHOWN AND rMT IT DOES CONFORM FM THE 70-W OF Mo, RNGbVNrZ ZONING RROMAFIONS fRat DING SErBACKS FROM S RSM & Lor Lmss.- 1-10127-H ,gN,po��- 109 • I FURTHER RPIFY THAT THIS DUELLING IS NOT LOCATED IN r FB RAL FLOOD HAZARD AREA AS DRAWN FOR SHO DN ON Fa ITY PANEL ZSoO qQ 3 C �Nlx*' DI9TEr, -Z-93) KE/Thi L/NOX' /l C/2�EL ir d 1/ STEP `L.S. THIS PLAN' YE. ORr1Claw-'PuRPOSES - NOT FOR BOUNDARY BOUNDARY INFORMATION MI1RRIIMACK 1sNGINENJUAVO SERVICES TAKEN FROM EXI riC RECORDS. BB PARE[ STREET rI isyz0 ANDOVER, MASSACHUSETTS 01810 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) Signature of Vermit Applicant 9�DJZoo Z Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector • Town of North Andover Building Department .. 27 Charles Street . A North Andover, MA. 0.1845 _ D. Robert Nicetta 's>=,; tip Building Commissioner (978) 688-9545 978 688-9542 Fax HOMEOWNER UCENSE EXEMPTION Please print DATE JOB LOCATION !/S /vlPJDy� e��-t- Number Street Address M;aF/lot ..HOMEOWNER Name Home Phone Work Phone 'RESENT MAILING ADDRESS 5``t Ti M 56C- LIQ /V(E'Th,ai.'`� M� or �4 r City Town State Zp Code The current exemption for"homeowners"was extended to include owner-occupied filings of two units or less and to allow such homeowners to engage an individuWfor hire who does. not possess a license, provided that the owner acts as supervisor (State Budding Code Section 1 08.3.5.1) .DEFINITION OF HOMEWOWNER: Person(s)who owns a paricel of land on which he/she resides or intends to reside on which there is, or is intended to be, a one or two family dwelling,allached or d�ched structures _ Gesso y to such use and(or farm structures. A person who consb lits snore O)an'one borne in a two-year period shall not be'considered a homeowner The undersigned"homeowner'assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner'certifies that hPWshe understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that hetshe wi11 ' comply with said procedures and requirements. HOMEOWNER'S SIGNATURE �LC. APPROVAL OF BUILDING OFFICIAL NvR , h.. LED 0 of _.,....... over No. - _ �a - o0 COCH C.0 dover, Mass., a A0RATE0 OPP H �`,`�y BOARD OF HEALTH ERMIT T D Food/Kitchen Septic System �/ BUILDING INSPECTOR THIS CERTIFIES THAT.......I7 0'1%.A �........................ .... ...... .. .............................................. ......................... .............. Foundation 3 S A U4+t.1 buildings on ......... Y • has permission to erect.....................y...... ............... Rough to be occupied as.... AI�.f ..... .. rf .. .. .... .....A. /`.............................................. Chimney provided that the person accepting this permit shall in everyrespect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Law relating to he Inspection, Alteration and Construction of Buildings in the Town of North Andover. 8 O/to //0 •� Q PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR Rough ........... ................................................. ....... ........................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. R i x: Of ,OAT.,, ~O 'r9 •..ree.'`SSS }3' SS CMUS, j CERTIFICATE OF USE & OCCUPANCY s TOWN OF NORTH ANDOVER Building Permit Number /c3 Date S5 0700 3 HIS CERTIFIES THAT ;. THE BUILDING LOCATED ON /�� �a 4 C�y S MAY BE OCCUPIED AS G IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING s; CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Building Inspector J. i 0R 74 LED � Town of dover No'. J3 o' A41 C�C 110 dover, Mass., �y DRATED Y S+ H G BOARD OF HEALTH PERMIT T Food/Kitchen Septic System Cj BUILDING INSPECTOR THIS CERTIFIES THAT.......�7...r,� P,/`., ..' ....... ....................................... ... .......... Foundation 3 Sll 4C% acsY buildings on . has permission to erect.....................y....... g d..... ....................... .................... Rough=... ........ to be occupied as.... ....e�......A A& Chimney ............................................................... ..................................... . ............ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final )W16,,,.�_ c3-18—03 this office, and to the provisions of the Codes and By-Law relating to he Inspection, Alteration and Construction of Y�v Buildings in the Town of North Andover. so/4 �® •� ii� 1Z PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. zrp!�K ,1=C"*- PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STAR-TS ELE TRICAL INSPECTOR t Rough �� .................................................. ............................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR / Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.