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HomeMy WebLinkAboutMiscellaneous - 120 MARTIN AVENUE 4/30/2018 ------------ 120 MARTIN AVENUE 210/045.F-0026-0000.0 l ® The Commerce Insurance Companysm MAPFRE Citation Insurance Companyw NSU RAN CE® 11 Gore Road,Webster,Massachusetts 01570 508.949.1500 1 www.mapfreinsurance.com October 26, 2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MAO1845 RE: Our.Insured: TAREQ RAHMAN/SHAZIA RAHMAN Property Address: 120 MARTIN AVE Policy#: BCKZVT Date of Loss: 09/25/2015 File#: KVNT32-JMHYH9 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. KEITH FITZGIBBONS Telephone: (508)949-1500 Ext: 15712 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15712 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. October 26, 2015 CIC 254 (Rev.4/95) MAIL V10 Date. �/4��f .. .... H°QTN 3r °` TOWN OF NORTH ANDOVER 10 0 a - PERMIT FOR GAS INSTALLATION _ h CHUSEt�( r - T"his certifies that . . . .!�' ..!!.�!!'r ' . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . e .?`r'!. . . . . . . . in the buildings of ./ . . 'S!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .Z4 . �`. . .�. . . . . . . . . . . ., orth A over, ass. Fee. . Lic. No..�- a3 r �. . . .lh. . . . . . . GAS INSPECTOR Check# // 8159 1 AUWNU$gws uNiFORM i+PUCATIoN•FoF1 PERmrr To Do GAS IVnNG ow or Type) �lP`� �_iJ f/ l��,p,lass. Oats —_.... Peni+lt ®trald�nii LOcztlOn� �!'l I,� l Owrmr'a Cho* TYpa a OccdMtKY /tPY- i Novi ❑ geovation Q Replacomord Cl Plane Submitted: Y480 NO Q m M yMj Mj n�( as a: _ '►lU a w u = O c w < i y44 o c r 1; M of p W � t = « s O t � ~ bi v ,AWe 1.9 39 W s a+ r d X # e u u a > o O s z O sui�aswt. iAlre MENT aet FLOOR FT, tN0 FLOOR Sim FLoOR eta FLOOR SIR fL00n M FLOOR ttfl'FLOOR . OT0 Ft0Oi Inihaslit►a:contpeny fYarrhe ° Check one. CutNioeEe Addrbaa c� � GAF e� � 13 Corp: llon ,.�. ❑ Partnefshlp ^, Name of Lk~Pklrltber Of Oas MO.'f INl�e�NtMe�O�RF� ' . 1 tin e s a utia iia 5neuntie6 poky of Ni iobsUroial'eQutvalenl rvihich mets thb rdqukanieni .-6f-MGL Ch:02. Yse Nth O it you have chocked,&s,pease Wcate the typt eOt MOt by cheftMg the epproptlete bit. A WRY hisurWo PWIcY 4 o ter%"of WemnIty❑ Hond ❑ OWNER*h INSUitANCE WOMAN`I air ai mfro that the liuneeo does ra bW the Inmento eovemoe reWrbd:by Cthepter 142 Of the Mass. (mend tkNe, ark t O my ftMure on this 1lOMR s00atlon wahres lWw requirement. 1\ check one: _.._._..._........-.e Owner[3 ASeM t3 I haaby to*that all of 1M do Ws and in nrajkm h hwo tWWrIad(u m;end)In$bow iia►an tnro and VMRAG b Un WA-91 MY !' t�»%4p end iiia ata p',umWq`: *and indiffikO M under tiN it i'A wfii in ot"o anoo with ell . pMstont powdw dr NI!t l=4t-a$tla State Qat end Chapter M 0l!M s �A`e� gy of Lke w. thanker SighWWol Uokood R~or QwRtW CRr/rown J�urney!n$n TOTAL BTU LOAD ON THE SYSTEM( air-- Date... e TOWN OF NORTH ANDOVER 10 .2 PERMIT FOR WIRING '7S CHUS This certifies that ........... 1(,........................ has permission to perform ........ -V......... ree........... wiring in the building of............. .ryv................................... ......... orth Andover,Mass. . Fee...... Lic.No...�?13,4�............... . . ... ..... .. . . ....... ............... LE [CAL IN PE R ... Check 'q f 10835 { Commonwealth of Massachusetts Official Use Only e Permit No. i c e 3 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ---- — t\\J� q�q Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [J— (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / 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: Completion of the ollowing table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.ol Emergency Lighting rnd. grnd. Battery Units 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 Heatin KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices 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 Wo r o, hen required by municipal policy.) Work to Start:t�S_\�,- y Wspens 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 Covera a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and complete. 3 FIRM NAME-M S b l-L .Pc_`T(1-i fig— gf,LV,C f LIC.NO.: Licensee: A,,< " O�—Signature `/" LIC.NO.: (If applicable,enlLqr Ilexemjg"in t e license number line) Bus.Tel.No.: -` W —VW6 Address: �� � 4�— °> (���1'��y radJ �� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. f 7 • ,�j�„(JPJ�Ij,�•J•i.l OAL V..1:/.L�-l�iL.�l. ®� r k _ .G_J1-�.L71�.�..0�0.�.�,�•f.�3.�lS�.ILGYi.f•V'�"s .:-_ . . ... . _ ;1m8pBdOrs"Comme,nts : eoxs' ignafuxe x�ofials) _ plate . + x 8`l.'"S ON; �aSSet�( +ailecl� r - atensectio�xeruixe0($ 0.00)- [ �Sts,�lect ¢' ommex�fs: . - ps�ectoxs'0igxta ze•-)Io' 'fials) Pate ' Passed; (60.00)- I'n.spctoxs'comments: (lnspectoxs�,�ignafuze-�o tiniiiaTs) Pate assert--C ) 'ailetl--je-nspectionxequizet {$50.0Q)•-[ ) Is�ectoxs'eoxamep�fs: (J(-Qspecto)rs'sign.ature••no Wiials) Pate ,seaenspectiottxe0uixed($50.00)-•[ peetoxs'corirxae7�ts: _ • baectoxs'signature xroinitials) Date ' 3Off.TAG9.ASE TO 09 FMEED QVI A Ib DEFT ONSITE IF TM.APXA TO BE WSPECTU D 19 NOT --- j The Commonwealth of Massachusetts Ln Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): L Lf—S– L (�,L., (��� Cs,� Address: 1�c) City/State/Zip:.to�ON,5 S,C 4 Mq Phone A,r�eyou,an employer?Check the appropriate box: Type of project(required): 1.Lf I am a employer with�_ 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• 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.E1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *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 are doing all work and then hire outside contractors must submit a new 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. C Policy#or Self-ins.Lie.#:U �j �r, ` Expiration Date: Q0 Job Site Address: `��-� ,A�1 City/State/Zip: t Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). M 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. Ido hereby certto under the pains and penalties of perjury that the information provided above is true and correct. - Simnature: _ Date: Phone#: Official use only. Do not write in this area,to he 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#: r 4 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 j 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple p'erm'it/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 Comm.onwealth of Ma ssa.,chusetts Department of Industrial.Accidents Office of Investigations 600 Washington Stme-t Boston.,MA 02111 Tel.#617-727-4900 oxt 406 or 1.-877,7MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwanass.gov/dia. Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: MARY F PHILLIPS i Property Address: 148 MAIN STREET #K-323,NORTH ANDOVER,MA Policy Number: HMA 0313360 Claim Number: BOS00031064 Date of Loss: 7/28/2012 Company: Safety Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 7/31/2012 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com