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HomeMy WebLinkAboutMiscellaneous - 124 SAW MILL ROAD 4/30/2018 124 SAW MILL ROAD 210/104.6-0063-0000.0 Cunningham Lindsey U.S.,Inc. P.O.Box 703689 Cunnlnjj,.,,,, lla m tv Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 795 T3 P1 95000058985 Building Commissioner or Inspector of Buildings 120 MAIN STREET { No.Andover,MA 01845 Form of Notice of Casualty Loss to Building FZW Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 783980 Policy Number: 783980 27 Company Name: MERRIMACK MUTUAL FIRE INS In 0) Cause of Loss: ICE DAM LO Date of Loss: 2/12/2015 Insured: Kemal & Betul Arlin Property Location: 124 Sawmill Road Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date..�.....�.z--..... 3i;.'�``°-�•�.."�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACNUS This certifies that ..............�,J. /3 ................�Trc ...................... has permission to perform ........ ..T„/2 ....5.4u................... wiring in the building of.....A.l?)Al?),v ° Y 7 3 at......2:. ... .!.G.4.....................AECTRICAL North Andove}•,Mass. O G • Fee -5..�" .. Lic.No. .1.33/1............. c! .. ............. I Cf j� INSPECTO Check # "� 0850 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: in accordance-with theprovisions of M.G.L.c.143,§,3L•,the 4 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an inspector of Wires appointed pursuant to M.GI c. 166,§32,an electrical permit shall be issued to the person,fum 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,§37,Permits shall_be limited as to the time of ongoing construction activity,and maylme,deemed_by_the7nsp.ector_of_Wires abandoned.and.invalidafhe—. 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 certaiwpermits•and licenses conceming 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 15,200 d extending through August 15,2012. ule 8—Permit/Date Closed: i **Note:Reapply for new per ❑Permit Extension Act—Permit/Date Closed: t € vnutiatuuaa[<Ic D� a3�aelettJa ofFcial Use/Only ��•• PerrnitNo._ ApartnWl tt.DI SVrU1Ca3 BOARD OF FIRE PREVEN-PION REGUlAII NS Occupancy and Fee Checked Q [Rev.1/Q7] Qmve-blank-) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORH AU work to be perrhaned in accordance widi die Massachusetts Electrical Code Cj, 7 CMR 1?00 (PLEASE FRN1YBVY OR TIDE r IN )IM'I TIOM Date: - Z City or Tome ok N Yl C�v✓� To the Insp ctot•of wires: By this npplication the undersigned gives notice ofhi rherintend to PeLform the electrical work described below. Locatign (Street&Number) Owner or Tennnt Telcpbone NO Owner's Address Is this permit in eonjunetion tilt a bua ing permi Yes ❑ NoK (ChedEApproprintel3ox) Purpose-of Building l ki1 utilityAuthorizntion No. Existing Service Amps / Volts Overbead❑ Undgrd❑ No,of Meters New Service. Amps / Volts Ova rhend❑ Undgrd❑ No,of Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Wor1c JWyI � C tz A»vA i n� Com letion Dfthe foilmdi table amp be ipaiited by the LS actor of l'l' No. of Recessed Luminaires No,of Ceil.-Susp.(Paddle)Finns No.of Total Trnnsfortncrs 1CVA No. of Luminnire Outlets No,of Hat Tubs Gmerntors It~VA No.of Luminaires Swimming Pool Above ❑ In- . ❑ o.o mergency i,tg eng rad. rad. Bette Units No. of Receptncle Outlets No.of Oil]Burners FEE, ALARMS NO. of zones No. or Switches No.of Gas Burners o.of flctcction and i Initinting Devices No. ofRnnges No.of Air Cnnd. 'L':'ota No.ofAlertingDevices No. of'Waste IDisposers lientPump Number Tans It o,ofSett- ontainerl Totals: YDetection/A.tertin 7 Devices No.ofDisliwnshers SpacdArca Renting JCVY Local❑ Municictioa pal El Other Counc No.of Dryers Heating Appliances qy Security 5ystems: No.oi'ti nicr No.oflDeveces or E uivnlcnt Renters laNo. Signs Ballasts DataNo.ofDevicesor I; uivnlent No.Hydromassage Bathtubs No.of Motors Total IIP Telecnimmnnicntions wiring: No.of ticvices or 1C uivn7ent OTHER: ER: d tfach addithuml detail rfdeslreai or Ds required hp t/le Inspector of wj Estimated Value of Electrical Worlc: (When required by municipal policy.) Work to Start: inspections to be requested in accordance with MEC Rule 10,and upon completion_ =1NSU42ANCC_COYIsIno:permit=fo"r-tlie=pe�fdrmcisibe nf`electFtcnl Wotk-may-issue itril the Iicensee provides proof oflinbllity insurance including"completed operation"coverage or its 9bstantiat'equivalent_ Thi undersigned certifies thatsuch c verage is inform:,and has exhibited proof s e to epe it' snip of$ece_ CHECK ONE: INSURANCE BOND ❑ OTIiER ❑ (specify: __ ___. ___ _. _._----___.._._..._t_____.__...�__ ___� . ' ,�.-____. F eestij �y Illt[fEf'-tLLQt1�tSt QI(t• pE!�tiFj��fllQf'r c Iti DF latf011 tY'tIrLS[t �IC1rt1011 [tZr 1TI C`tl I'ERM NAltr][R: �I t/ �Q P i i PP D1rr�fel L,IC.KC).. Licensee: (J SignatureLIC.NQ�.:t+,� (If applicable,enter mpt"hla timnse u r er line Rus.TeI.Na.. 'rid` Address: 5 vt 14 Alt.Tel.No:.: *Per M.O.L.a. 147,s.-51-6I,security wDrIcrequirefi Department ofl6ublic Safety S"License: Lic.No. ONVNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normalI3 i required by law By my signature below,I hereby waive this requirement I am the(check one)❑awner El owner's age ' Owner/Agent Signature Telephone No. PERIIII'I`.l-ER. S 2- P77 'die Connizoniveadth of fassaclaaisetts De parftent of Industr alAccidepzts Office of I7rPestaga,&,,T = I Congress Sri eet,Sr,�te_100 ' Boston,l-A 02114-JoI7, )p OR" ms govfdii -Workers' Compensation TLiasu'ance Aff3da7M: Bui@dei-s/Contractorslhflec�gc��_nslP�»,��xs �`>rnat�o . .. . . Pfleais+e Print LeMly . Name (Businesslorganization/Ind!Odual): Address: City/Statef zip: Phone#: i Are yore a� employer?Check the appropriate bor: Type of project(required)- I-❑ I am a employer with `i• ❑ I am•a general contractor and I have hired the sab-contractors 6. []New construction P (full andlor part time). ' t 2.❑-I am a sole proprietor or partner- listed on attached sheet 7. ❑Remodeling j ship and have no employees These sub-contractors have S. ❑Demolition working forme iu any capacity. employees and have workers, [No W.Orkers Comp.insurance camp.iF►�ce.$ 9- E]Buildmg addition reed_] 5_ ❑•W e area corporation and its 10-El Elecbical repairs or additions 3.❑ I am a homeowner doing all wofficers have exercised their ork 11_❑Plumbing repairs or additions myself- [No workers' comp. right of exemption per MGL 1� Roo£r ams insurance required]t c- 152, §1(4),and we have no eF employees.[ljo workers' 13-❑Other camp,insuran e reEn T #Any npplicnnt6at ebccks box al mustnlso fill out the section below showing tbeirwor][ers'compensation policy iufammation. Eomeovraers who submitthis affidavit indicating they are doing all work andtheo him outside contractors mist submit a-new affidavit indicating such =Contractors that cheelc this bmrmust attached on additional sheet showing the name of the sub-contractors and sintewbether or not those entities have :mployeos. If the sub-contractors have employees,they must provide their workers'comp.policy number. anz all Cap,loye7-heat is providiezg workers'cotnpeersatioli insUrance for•Illy employees. Below is thi policy wid job site Fq for ination- fi=ance CompanyName: Policy#or Self-i-ds.Lic.#: PxpirationDate: Job Site Address: City/State/Zip: Attach a copy othe worlrers' cotlapetnsataam gPolicy declaration page(slaowiag tine policy number grad expiration date). Fan7.tu-e to secure. coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of cririlival penalties of a Bae 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 far insamnee coverage verification_ -l'do Hereby ceertz}ry ulzderthe eaftis and enahtes pfPedlnY that the hyanwdioti proWded above is bize and correct Phone 1#• Offzeial use only. Do-noi sprite in this area,to be con pleted by cit},oryowl l gfficiat City or-Tow n: - :`` Permitf]License# Issnivg A"thority(circle one): 1.Board bf Health 2.Badding IDepartdaent 3. CiWr'Ov n Clerk 4.Electrical Inspector 5.Plumbing Iuspee-tor 6. 0&6r Contact Person: Phbae#:- 9255 Date. . Ah „pRTM' TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SS emus This certifies that . . .Cnll . . ./.` ,/rJ,,S' , , , , , , , , , , , , , , , , , , w has permission to perform . .�.Qp��GP�,�yy. . . s , , , , , , plumbing in the buildings of . . q,,ClJ?. . . / ! / , , , , , , , , , , , , , , at. 1 Z . . . , . . ., North Andover, Mass. Fee k<47'p.Lic. No..ZK,f1& PLUMBING INSPECTOR Check # � � .� r � t MASSACHUSETTS UNIFORM"pLICATION FOR PERMIT TO DO PLUMBING (Type or pant) NORTH ANDOVER,MASSACHUSETTS Building Location �� Date '—/ �,6 a Permit#— — OwnerS L� Amount—^ New Renovation 13 Replacement �� Plans Submitted Yes No FIXTURES SIBME IS>r ROOR 7p7R��l M 3M FLOCK 41H IIDQR M 61HELOOR 71H EN10CMR (Print or type) Installing Company Name (00-L Check one: Certificate Corp. Address t V n Partner. Business Tel �Firm/Co. Name of Licensed Plunmber: Q Insurance Coverage: Indicate the type of coverage by checking the Liability insurance policy Other of indemnity appropriate box: type demnity Bond ❑ Insurance Waiver: I,the undersigned,have been made three insurance aware that the licensee of this application does not have any one of the above Signature Owner ❑ 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.p t Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta bin Code era Laws. By: rgnawre rcense er Title Type of Plumbing License Cityaown ;:;�6 3/r APPROVED(OFFICE USE ONLY License Master E3 Journeyman The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPHcant Information Please Print Le ibl Name (Business/Organization/Individual): p¢ Address: City/State/Zip: &I u ph �4& 41,f(' Phone#: '1� a 6-r 5120 Are you an employer?Check the appropriate boa: 1•Elto er I am a em with 4. I am a Type of project(required): employer ❑ general contractor and I r��employees(full and/or part-time). have hired the sub-contractors 6. New construction 2•!_T 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 me in any capacity. workers' comp.insurance. [No workers comp. insurance 5. 9• ❑Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑El trical 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 required.] t 12.[]Roof repairs insurance re ] employees.ployees. [No workers' comp.insurance required.] 13.0 Other `Piny apphe :that checks box rl must also fill oLi the section below S­,;"g+,he.•., information.icy t Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors must sumit 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 is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: /o�"� �Gt/,✓flit 1G / n�/ G Uelt City/State/Zip:_,/. h ✓l/L /j'fA 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 ainpand penal ' of perjury that the information provided above is true and correct Si ature: Date.: Phone#: S 2 c2 51 z/-� [[6.Other al use only. Do not write in this area, to be completed by city or town official r Town: Permit/License# g Authority(circle one): rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ct Person: Phone#: L ;r 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 apartinents 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-contractors)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 totem that the application for the permaitor license is being requested,that 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 andprinted legibly. The Department has provided a space at the bottom of the affidavit forou to fill out in the event Y the Office of Investigations has to contact you regarding th Please be sure to fill ' Y g g e applicant. m 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 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 anquestions, please do not hesitate to give us a call. y The Department's partment s address telephone and fax ep number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiigations 600 Washington Street Boston,MA 02111 Tel. #617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass.govfdia s • r - 1 1 �r =COMMONWEALTH OF MASSACHUSETTS LICENSED AS A JOURNEYMAN PLUMBS ISSUES THIS LICENSE TO I CRAIG B ADAM jco 6 WHITE AVE �_. I . METHUEN MA 01844-6234 I 26318 05/01/12 759257 1 W.