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HomeMy WebLinkAboutMiscellaneous - 122 EDGELAWN AVENUE 4/30/2018 122 EDGELAWN AVENUE U-4 210/467.5-0122-0001.0 ` - ® The Commerce Insurance Company'' MAPFRE Citation Insurance Company'm 11 Gore Road,Webster,Massachusetts 01570 INSURANCE 508.949.1500 1 www.mapfrei nsurance.com March 30, 2016 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall N ANDOVER MA 01845 RE: Our Insured: MARCIA CARTER Property Address: 122 EDGELAWN DR UNIT 4 Policyk BCDYXM Date of Loss: 03/27/2016 Filek MHRM75-JWWJP6 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. ELIZABETH BOTTIERI Telephone: (508)949-1500 Ext: 15284 Sr Claim Representative,Property Toll Free: 1-800-221-1605, Ext: 15284 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. March 30, 2016 CIC 254 (Rev.4/95) MAIL M39 Date/ V . . . . . ,ORT#1 4, TOWN OF NORTH ANDOVER 0 Ax. PERMIT FOR PLUMBING ,SSACMU us S This certifies that . . . /9 . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . A . . . . . . A . ... . . . . . . . at /2 (X-� . . . . . . . . .I North Andover, Mass. Fee. .2�! . . . Lic. No..``f�. . . . . . . . . PLUMBING IN6PECTOR Check # IA'l �- y r �u j 8273 I� r. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Dated D Building Location o� z]4Q ���✓ Owners Name �f l�e �4e�/permit# Z 7 Type of Occupancy Amount ��—�-- New Renovation 17 Replacement ©� Plans Submitted Yes No ❑ FIXTURES cc w x " ° � Cn a w c x F a r O� A a as lAWVE�T 3MFLOC 41H1LOCR M FLOOR 6M - _ 7M RJOCR sly fLOCR (Print or type) l / Check one: Certificate Installing Company Name� Corp. 11 Addressd 11Partner. Business Telephone IF7' R—Firm/Co. L- e, Name of Licensed Plumber: Insurance Coverage: Indicate the�f insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent I hereby certify that all of the details and information ubmitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work d installa'ons performe nder ermit Issued this lication will be in compliance with all pertinent provisions of the Mai�w setts tate Plu ng Cod nd Cha 42 o eneral Laws. By: igna o icense um Title Type of Plumbing ice ' City/Town is se nuer�— Master Pq Journeyman ❑ APPROVED(OMCE USE ONLY The Commonwealth of Afaysachwet& De rt►netrl � � o industrial Accide t .f nus Office of Investigations 600 Mashinabn Street Boston, M4 82111 ��v f r WKVW.&t=&gov1dla Workers' Compensation 1witrance Affidavits Builders/Contractors/Eiectricians/Plumbers A licant Infonzation Please Print bly Name(Businessiorgenim ion/Individual): Address: CitylState/Zip: Phone#: . FJAA�myou an employer?Check-the appropriate box: Iam a employer with 4. ❑ I am a general contractor and IF7. 0 1�t(regnrre�:employees(mfl and/or part-time}.* have bred the sub-ecatrc. I am.a.sole proprietor or partner- listed on the attached sheet S odeling ship and have no employees These sub-contractors have working for me.in any capacity, workers' comp.insurance. lition [No workers'comp.insurance 5. ❑ Weare a corporation and its ing addition required.] officers have exercised their 'I am a homeowner doing all workright of exemption per MGL oradditions m sell + ing repairs or additions Y [No•workers comp. C. t52, §1(4),and we have no insurance required.]t .empiayees. [No work=? 12•Q Roof repairs comp.*Any applicant tha insurance required.] I3.❑.Other t Fiomeownens who sabn*this affidavit ind1 Catihfill n th C 81E ClCiti all work section below B their warlceis'compensation poiicy informution. 4contraetors that check this box mast attaohrd an additional sheet showing Etre rtemc of the soli-con d then hbe omside, nuactats must submtt a ru w affidavit rndicaiiag such I ass tail a traetois and their workers cera s:�. Fo in�rnietior ptoyer tlr�s prong workers'compensation JMWr,=e or information. f nr wFloyeec Below it the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: 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 required under Section 25A of MGL c. 152 can lead to the imposition of crim fine up to 00and/or one-year imprisonment; inal penalties of a Of Lip to 525050..00 a day against the violator as well as civil penalties in the form of a STOP WORK ORDER and a fine a 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 certify under the parts and penalties aJPerjury that the in ormatfon rovided above is true f p and correct Si tore: Date: . Phone#: Ofj`teial use only. Do not write in this area,m be completed by city or town official f!� City or Town: Permiit/License# Issuing Authority(circle ooe): I. 6.Other of Health 2-Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all atop Ioyers 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 ormom of the'foregoing engaged in a joint enterprise,and includirig the legal representatives of a dec zned employer,or the receiver ortrustee•of an individual,partnership,association or other legal entity,employing employers. 'Fioweveathe owner-Of a dwelling house having not more than three apa -aneft and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair wont an 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 shad withhold the issuance or renewal of a license or permit to operate a business or iito construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required" Additionally, MGL chapter I52,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter irtto any contract for the performance of public wort-, 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 compt_--tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)mind 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 requiredlo cavy workers'cdirrpensation 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,pleawcall the Department at the number listed below. Self**ztured O+mpanim ahould ent-th--- Self-insurance.license number on the*appropriate,line. r City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Departmeent has provided a space at the bottom of the affidavit for you to fill out in fit event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit4icense number which%-ill be used as a reference number. In addition,an appEcam that must submit multiple permit1licerm applications in any given year,need only submit one affidavit indicatmgcurrent policy'information(if necessary)and under"Job Site Address"the appiieam 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 afiFidaA is on file for futures 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. e.dog license or permit to bum leaves etc.)said person is NOT required tacomplete this affidaviL The Office of Investiptions would Hike 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 Commonwe2dth of Massachusetts Department of dusftW Accidents Office of Imvesfigatlions 600 Wad ington Strut Boston, MA 02111 TeL 9 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax lu 617-727-7749 vv WMC_ss.govldia Date./4:? .7.4. .�r... .. Of „Oa oT u 11'° TOWN OF NORT"NDOVER - PERMIT FOR GAS4NSTALLATION j s o . V ,SSACHU5Et e j j This certifies that . . . . C. . . . T has permission for gas installation . . ,2 f/. . . /7. . . . . . . . . . . . . . . . in the buildings of . . . . .// .. . . . . . . . . at . . �`.yb�`'°.�`... . . . . . . . . .. North Andover, Mass. Fee. . .7Q. . . Lic. No:.VSS!`�. . . . . . . rY . . . . . AS INSPECTOR Check#-, d1blf 70U2 MASSACHUSETTS UNIFORM APPUCATON FOR PERMrr TO DO GAS FITTING (Type or print) Date (- NORTH ANDOVER,MASSACHUSETTS Building Locations aS4,/ .✓ Permit# Q U L Amount$ 30. 1- Owner's Name � New❑ Renovation ❑ Replacement Plans Submitted ❑ � w v� v� U z z a C7 F ZF z. F W W cO WU a W Q W Q C .. F �n d z 0 O O w o4 O x O x w 3 A Cal .a U a > q a0. F O SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR ` 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) `` Check one: Certificate Installing Company Names E /c� El Corp. Address ��k 0 5� ❑ Partner. .a p 4± business Telephone p ,oi1_ LQrm/Co. C- C Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes —No If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy 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: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have su or entered)in above application are true d accurate to the best of my knowledge and that all plumbing work and install ions perf ed under it Issued for this a li ation will be in compliance with all pertinent provisions of the Massachusett State as ode ha r 142 o e Gen aws. By: Signature of Lic sed P mber Or Gas Fitter Title Plumber r3?9y, City/Town Gas Fitter (cense um er ® Master APPROVED(OFFICE USE ONLY) [3 Journeyman ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. [] New,construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9 F-1 Building addition ` [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ 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.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *.A applicant,that checks box#1 also P.II 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.. lContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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 required under 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 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 Contact Person: Phone#: i 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 Iicensing 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 c workers' compensation insurance. If an LLC or LLP does have p q QTY Pe - 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 location 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 Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MAS.SAFE Fax # 617-72.7-7749 Revised 5-26-05 uww.mass.gov/dia Address Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Documernt/Action and notes action Document/ document/ Num• Action Department Board of Appeals - Board of Heap - h Planning Board — Conservatiion Commission — Building Department MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only(800) 392-6108, Fax (617) 557-5675 10/06/99 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.313 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: DEXTER SMITH EDGCL�9w� Property Address: 122 EDGELON STREET, NORTH ANDOVER, MA 01845 Policy Number: 0467199 Type Loss: Water Damage Date of Loss: 08/18/99 Claim Number: 175590 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 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division 3 i9g3 CMA00021