HomeMy WebLinkAboutMiscellaneous - 133 BONNY LANE 4/30/2018 133 BONNY LANE
210/062.0-0049-0000.0
I
PO Box 55098
Boston,MA 02205-5098
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:- - EILEEN P DONOVAr?
Property Address: 133 BONNY LANE,NORTH ANDOVER, MA
Policy Number: HMA 0371941
Claim Number: BOS00053559
Date of Loss: 3/4/2015
Company: Safety Indemnity 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.
Eric Keenan Claim Examiner 3/5/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3548
Fax: (617) 531-6676
Email: EricKeenan@Safetylnsurance.com
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: in accordance with theprovisions of M.G.L,c.143,§.3L,the
Permit application form to provide notice of installation of wiring shall be uniforin throughout the Commonwealth,and applications shall be filed'
on the prescribed form.After a permit application has been accepted by an Inspector of Wiresappointed 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 maybe.deemed by-thesnsp.ector_of_W.ires abandoned_anddirvalidif 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
1 purpose by establishing an automatic four-year extension to certairrpermits-and licenses concerning the use or development of real property.With
k limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effector existence'during the qualifying period beginning on August 15,2008.and extending'tbrough August 15,2012.
1 ule —Permit/Date Closed:
1 Note:Reapply for new per
11 Permit Extension Act—Permit/Date Closed:
-9.509
� Date ........... ................
N TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
qCHUS
This certifies that ...................J..j��4,e 41 441-
. . ..........................................................
has permission to perform .....
.C.Lz.1...4�.�b A
.. ..........
.................
wiring in the building of............... .......................................
at ....................... .. ,North Andover,Mass.
10 U'
LiFee...... ............ c.No....O..��.,4........... --'4
PLECTMRI&LriNSPBCjbR
e c k #
Conunanweafli of Maddacluedefid Official Use Only
cc�
c� Permit No.
20parfinant o/}ire saruiced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MT-9),527 FUR 12.00
(PLEASE PRINT WINK OR TYPEALL INFORAMTION) Date: '7/13PO
City or Town of-.AhZC&C1,)C1e-rC. To the Inspe for of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) i j &m .e
Owner or Tenant 0)6-n \-101M011A1, ITelephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building S( 1 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: Z 6 0 ..e . ,a`
Com letion of the folloWn table ma be ivaived b,the Ins ector of il'ires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Tota
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators ` KVA Zo
No.of Luminaires Swimming Pool Above ❑ In- o.of Emergency ►g -ing
nd. grud. F1 Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o.of Detection an
Initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers
HeatPump Number ons K -o.of e ontaine
Totals: Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ unicipal ❑ Other
p g Connection
No.of Dryers Heating Appliances KW
Security
Devices or Equivalent
No.of atero.of No.of Data Wiring:
Heaters, KW Si ns Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs No.of Motors Total HP
TelecommunicationsofDevicer Wiring
Y g No.of Devices or E uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of IYires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: '"- 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 ins ce including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such cover is,in force,and has exhibited proof of sa3pe to theermit issuing o ce.
CHECK ONE: INSURANCE BOND ❑ OTHER F] (Specify:) '��?�I/� 1213ito
I certify,under the pains acrd penalties of perjury,that lite information on tilts application is true and coniple
FIRM NAME: et- 2,1 C LIC.NO.: 1�/.�5
Licensee: ( "h i b A Signature LIC.NO.:
(If applicable,enter 'eYem "in the 1'c nse number line i /►/I Bus.Tel.No-4i l
Address: 1 :1�f 1 f I Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security workJequires 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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
l
Date.�a . . .. , .�. .
HORTN
pF �.io ,tip
3� TOWN OF NORT ANDOVER
• PERMIT FOR GAS INSTALLATION
�9 qo+, �•••Sty '�
SSACMUSE
This certifies that . . o . . . . .t.
has permission for gas installation J . .r.':�. . �� . . . . .
in the buildings of . . . . . . . . . . . . . . . . . . . . . . : . . . ;
at . . . ` . . . . . , North Andover, Mass.
Fee. �""�Lic. No.. ?- _. . . . . .
GAS INSPECTOR
Check
6280 �i8
Location
No. Date
t
%ORTN TOWN OF NORTH ANDOVER
O.tt�.o
f s
a
1 Certificate of Occupancy $
�ss►cwust`� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
i
23855 Building Inspector
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Oate4 � 2 006t2 Permit #--------------
Building Location_ & �� Owner's Name 14-
Type
-Type of Occupancy ,<:�iqA:
Newx Renovation p Replacement p Plans Submitted: Yesp Np
N
vz;
y ¢ O w X
o
ero a 0OD > r<W zf. N
'
.Ji 4
t-• h W WH C O > u. t- W -jW
< u<i > E w j Z. < cc < t O O W o O Y J 1=-
'x O V s u 3 c V -j v C y o a U- O
SUB—BSMT.
BASEMENT
IST FLOOR
2ND FLOOR
ARD FLOOR
i 4THFLOOR
STH•FLOOR
6TH FLOOR
7THFLOOR
STH FLOOR
Instatiing Company Name I n
Check one: Certificate
Address i _! `-1
,rt tJ Corporation C
I t00 D• Partnership
Business Telephone �OrGas
q
Name of Ucensed Plumtter Jost
h110 D Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes O No O
If you have checked Yes, please Indicate the type coverage by checking the appropriate box.
A liability insurancei`
POIicY 0 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 O,vner or owner's Agent 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 the Pe ued for this application '11 be in compliance with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 0l the Ge era(Laws.
L
of License:
Plumber a re of lJcensed ►umber or Gas atter
Jt��J Gasfitter
Master'I Lic nse Number 3 Ulo
D 10 I . U NL Journeyman
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
NO.
i
APPLICATION FOR PERMIT TO DO GASFtTTING
Final Test: ROUGH GAS HIGH &
Tag Meter. LOW TEST
Passed: NAME A TYPE OF BUILDING
Passed:
Date
Date
Failed: LOCATION OF BUILDING
Failed:
Date
Date
PLUMBER OR OASFITTER '
FINISHED TEST
Passed: '
LIG NO. Date
Failed:
Date
VENT CONNECTOR
PERMIT GRANTED
Passed: .
fDATE,.._.,.__,..,.2,QDat_ e T-
-- Failed:
f 1 Date
OAS tNSPECTOR <z'
. w
The Commonwealth of Massachusetts
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): d��� t'L b/c.
Address: 9 LylwN t=ide Lb �,lTdSe7
City/State/Zip: o/96OPhone#: 9 ZL�T31- 9E
Are you an employer? Check the-appropriate box: Type of project(required):
1.( ] I am a employer with 115 4. ❑ I am a general contractor and.I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet $ ?• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
6 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.El 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' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#I 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:Ujh1bt:LS�1&-n--aL
Policy#or Self-ins.Lic. #: " (_)o03 q t/— 4 Expiration Date: 01 to 6 /c>oo M
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 certiift under the painnsy and penalties of perjury that the information provided above is true and correct:
Signature: (_ C- Date:
Phone#: C7 Zk-5-8/-a9 X1
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#:
Information and Instructions -
lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
ursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
xpress or implied,oral or written."
m employer is defined as "an individual,partnership, association, corporation or other legal entity,or any two or more
f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
eceiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
,wner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
!welling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
)r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
,4GL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
•enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
kpplicant 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
;rater into any contract for the performance of public work until acceptable evidence of compliance with the insurance
•equirements of this chapter have been presented to the contracting authority."
applicants
'lease fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
iecessary, supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificate(s)of
nsurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
nembers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have Y
;mployees,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
)e returned to the city or town that the application for the permit or license is being requested, not the Department of
[ndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
ompensation policy,please call the Department at the number listed below. Self-insured companies should enter their
>elf-insurance license number on the appropriate lime.
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 asproof 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 life to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
Che 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. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
vised 5-26-05 www.mass.gov/dia
Date....... .`-.�. .' .
40RTH
°tt"'°,•�"° TOWN OF NORTH ANDOVER
• o
p PERMIT FOR WIRING
I?
,SSACHUSE�
This certifies that .................
}.. �
has permission to perform � v� � .
..::.: .......... ........................................... ......... ......
�3.
e.
wiring in the building of ........,
at.......... ! ............ North Andover,Mass.
_ Fee..I,. Lic.No 3.
` 1 ELECTRICAL R
INSPECTO
K 1 L
E` Check #
7522
(commonwealth olaijachusel/a Offal Use Only — ------
2cc� Permit No.
L parhnent oI jire Seruice9
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cod�EC ,X27 CMR 12.00
(PLEASE PRINT IN INK OR TYPEALL 1 O 7ATION) Date: rJ
r
City or Town of: ;Y'�% To the Inspecto of YT a es:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number)_
Owner or Tenant , Telephone No.
Owner's AddressIs this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No. —_
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No-of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ 1 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ` / L10
Com lesion of thefollovimig table may be waived by the Inspector oj'6Vires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal
' Trsformers KVA _
No. of Luminaire Outlets No. of Hot'rubs Generators / KVA
No.of Luminaires Swimming Pool Above E] In- ❑ o.of Emergency-L-i-gTiTffig
rnd. rnd. 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
• 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 Kir Security Systems:*
_ No.of Devices or Equivalent
No. of Water K� No. of No.of Data Wiring:
Heaters Si ns Ballasts No.of Devices or Equivalent _
No. hlydromassageBathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail rf desired, or as required by the Inspector oj,l'Vir-es.
Estimated Value of Electrical Work: `---- (When required by municipal policy.)
Work to Start: 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 cov age is in force,and has exhibited proof of same tot permit issuingq offi e.
CHECK ONE: INSURANCE BOND [I OTHER [I (Specify:)' ' � /2173/ 07
1 certify,underihepajL2s and penalties of erjury,that ie information on this application is true and c m lete.
Fl" NAME: �j C, L PP LIC.NO.:
3
Licensee: (� ,� U ,� Signature LIC.NO.:
(Ifopplicable, enter ..exen t"in th license number �g.)
ii 1 j Bus.Tel.No.:y�?� �J-Ri-
Address: ��^ , N ( 'e,at 4 � Np � � Alt.Tel.No.:
`Per M.G.L.c. 147, s. 57-61,security wor 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. 1 am the(check one)❑ owner owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
t