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HomeMy WebLinkAboutMiscellaneous - 145 BOSTON STREET 4/30/2018 / 145 BOSTON STREET l 2101107.B-0045-0000.0 / V i I { I i i I� f I i I it pi 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 N. ANDOVER, MA 01845 N. ANDOVER, MA 01845 - RE: Insured: PETER RADULSKI'andNICOLE RAIDULSKI Property Address: 145 BOSTON ST.,N. ANDOVER, MA Policy Number: HMA 0320267 Claim Number: BOS00044002 Date of Loss: 7/3/2014 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 Cha ter 139, Section on 313 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. Anne Dunphy Claim Examiner 7/8/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: 617 951-0600 EXT 3061 Fax: 617 531-6644 Email: AnneDunphy@Safetylnsurance.com 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 forth 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.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 ofongoing construction activity,and may be-deemed by the7nspector_of_Wires abandoned-and-invalid-iflie—_. ._ 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 K�—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. Permit/Date Closed: ,��/ 1, ***NO e:Reapply for new permit ermit Extension Act—Permit/Date Closed: • • Date.-2..-.Z.3. .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACHU -e- This certifies that ... ...... ...........A.:1................a .......... .............. has permission to perform_ .............. ............ ................... wiring in the building of..... ....................................... at//�.................. . ................... .......... North Andover,Mass. &V ........ Lic Fee ... No.. ... 4 .ELEcmicA**L*'INSPEft0R Check 8596 t 1 � •� � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CoZ(mC),527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 9 City or Town of. NORTH ANDOVER To the Inspector of Wire ,-� By this application the undersigned gives notice of his or her intention to perform the electrical work dei os:ri edb below. Location(Street&Number) es Owner or Tenant i/Telephone No. Owner's Address Is this permit in conjunction with a building permit? ' p yes � 0�0� Check A Purpose of Building /1 �� � ( ppropriate Box) S��Y'����L �IIWRY g Authorization No. Existing Service Ams P / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Un[1 rd g ❑ No.of Meters Number of Feeders and Ampacity 2= / _ ��/s—� Location and Nature of Proposed Electrical Work. /v/J lQ�maIF�e t! o"� Completion of the followin table may be waived by the Ins ector o{Wires. " No.of Recessed Luminaires No.of Ceil;Susp.(Paddle)Fans 0. 01 Total Transformers KVp, No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above1:1In- o. o mergency ig g d• rnd. Batte Units -— No.of Receptacle Outlets No,of Oil Burners ,,, FIRE ru AaidlS ido.of Zones 1 No.of Switches No.of Gas Burners No,of Detection and � No.of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other ► No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.ofo. No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: l No.Hydromassage Bathtubs No.of Motors Total HP TelNo.of Devices or E uivalent ecommunications Wiring: No.of Devices or E uivalent OTHER:fjn- St I Ac /_e-.5Estimated Value of Electrical Work: �p=lQ"�Q dam— Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to StartO% Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless f 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 2 BOND ❑ OTHER ❑ (Specify:) I certify, under the ns and penalties of per'ury, tha the information on this application is true and t� FIRM NAME: � � ��G �G p LIC.NO.: 1,j4- Licensee:1y, d ignaturer- (If applicable, enter"exempt"in the license n r line.) �I.IC.NO.: Address: I Bus.Tel.No.: j�—y 7 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt TelLic.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 E] own agent. Owner/Agent Signature Telephone No. PERMIT FEE. S " ~ - j7A b The Commonwealth of Massachusetts ki l Department of Industrial Accidents Office of Investigations it ,i U 600 Washington Street ��;'�" Boston, MA 02111 www_nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plnmbers Applicant Information Please Print LmObly Name(Business/Dipnizadon/Individual): Address:y,SoZ City/State/Zig i� i 0���Z Phone #: l`�� �7% -e� ,17J- Are you an employer?Check.the appropriate box: L❑ I am a employer with�_ 4, ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am.a.sole proprietor or partner_ listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These subcontractors have 8. ❑Demoittion working for mein any capacity, workers' comp.insurance. q ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) 10.❑Electrical red-] officers have exercised their repairs or additions 3.❑ I ant a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No-workers'comp. c. 1.52, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs q ] .employees. [No workers' comp. insurance required..) 13 ❑Other *Any applicant that checks boz'#l 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. r xConhactors that check this box must attached an additional sheat showing the name of the sub-contractors and their workers'comp•policj rw rsation. I am an employer that is.providing: information workers'compensation insurance for m1'employees. Below is 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 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 andpena/ties ofperjury that the information provided above is true and correct Signature: Date: Phone#: O fficialonly. Do not write in this area,to be completed by city or town offrciaL n Permit/License# ority(circle one):ealth 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspectorson: Phone#: 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 locai 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 I52,§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 cant'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 numberlisted below. Self-insured companies should enter their Self-insurance license number on the appropriate tine. City or Town Officials i 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 Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date.�✓1 V� . ".��T 4, TOWN OF,NOTH ANDOVER ' PERMIT FOR PLUMBING a * r s SS US - --��'"- � y This certifies that . . .1./9!� . . .17. . . . . .7. . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . PRS.4.1 �.`' �` ` : . plumbing in the buildings of . . .1.+. . . . . . . . .. !. . . . . . . . . . . . . . . . . . . at . . . . . . ... . . .. . . . .- . . . . . , North Andover, Mass. Fee.7(x. .7 .Lic. No. . . . . . . . ....2 . . , .. . . . . . .. PLUMBING INSREC;TOR Check # t �� 7991 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO (Type or print) DO PLUMBING NORTH ANDOVER,MASSACHUSETTS / YS Building Location /11121'1�.: 13nSnnOwners J „ Date -p r Name��,�r, y Permit# e� T e of Occu anc Amount New Renovation Replacement ' Plans Submitted yes No ❑ Fa7URES U U 2ZMQ I•IOCR 3RU ELOCR 5IH IIOCR GIH IIOCR StH�g I I ' (Print or type) -�� Installing Company Name ---/ /I f'�- �� Check one: Certificate '�r71 �otP �.. - . Address _/�1 c S6 /LILle 0 Partr2er. usiness ele bon _ F1Finn/Co. Name of Licensed Plumber. /o Insurance Coverage: IndicattY7 f-msurance coverage by checlung the appropriate box: Liability insurance policy Other type of indemru ty � Bond Insurance Waiver. I, the undersigned,have been made aware that the Iic three insurance ense°of this application does not have any one of the above ,Signature Owner ED Agent ❑ I hereby certify that all of the details and information I have submitted(or entered) above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be t compliance with all pertinent provisions of the Massachusetts State p bin-Codein By ha ter 142 of the General Laws. �i a of l.,rcensea um er - Title Type of Plumbing License City/Town APPROVED(oFmcE usE oNL.y �-cense Mmoer Master ❑ 3ourneyman Date. P. `'.C/ t 40 R'"1�o TOWN OF NORTH ANDOVER 3: °AL a ° : PERMIT FOR PLUMBING �.ISACHUS� This certifies that C,!!` . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . t . . .�. . . . . . . . plumbing in the buildings of . . .�.�.L.s'. . ... . . . . . . . . . . . . . . . at. 5� . . . . . . . . . . . , North Andover, Mass. Fee. . .11.) . . .Lic. No.9.�3. . .. . . . . . . . . PLUMBING INSPECTOR Check # 6. I 6025 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS c,r [� i Date l Ik 1 -7 �.ric`/_ Building Location f 13d S Gv� `��-Yc cn Owners Name Cmt,r pyar/y ` S 'C-� Permit# J V Amount Type of Occupancy r.,s,��Jl New Renovation Replacement ri Plans Submitted Yes No ❑ FIXTURES [• J ccW to W i vo w U C C3 u SLRFS\IE RiSEVEvr y M FLOOR 210 FLOOR F10M 4M FIDCR 51H FLOOR 6M FLOOR 7M FLOCR SIH KJXR (Print or type) p Check one: Certificate Installing Company Name _ , 4-1, S ❑ Corp. Address ►v U ' �` 2oq Partner. Business Telep one Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M 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 ignature 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 plumbingwork and in llabons pe rm b' Ced under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac etts t Chapter 142 of the General Laws. :f By: igna re o ens um er y e f lumbing License Title City/Town tcens um r Master Journeyman ❑ APPROVED(OFFICE USE ONLY fes,.