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HomeMy WebLinkAboutMiscellaneous - 171 HILLSIDE ROAD 4/30/2018 (2) 171 HILLSIDE ROAD r 210/025___0-0046-0000•0 Liberty Mutual, Liberty Mutual Insurance New England Region Central Property Unit INSURANCE 75 sylvan street Danvers,MA 01923 Tel:(800)566-0323 November 13,2015 Town of North Andover Attn:Building Inspector 120 Main Street North Andover,MA 01845 Re: Property Address:171 Hillside Rd,North Andover,Ma 01845 Policy Number: H3521220040840 Underwriting Company: LM Insurance Corporation Claim Number:032666491-0001 Date of Loss:12/10/2014 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss,.damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A &B, or Mass. General Laws, Ch. 143, � 9, or Mass. General Laws,Ch. 111,§ 127B. This letter should not be construed as a waiver or estoppel of any of the terms,conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address,policy number,claim number,and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: _ 1 Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 1 t'F \ S i, A< I Pr PROPERTY OWNER �QI S-f- Y- * Unit# Print MAP NO:o-JJ PARCEL: ZONING DISTRICT: Historic District yes _aa- Machine Shop Village yes aa" 100 year-old structure yes ,has-- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building YOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial impair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other l]'Septic ❑Well b Floodplain D Wetlands El Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �,j �-e S r-, .---i �1 -� 4o(3 F' (Identification Please Type or Print Clearly) OWNER: Name:_ ice rJ 4- Phone: Address: CONTRACTOR Name: 7 � w Phone: q -7 Address: 5 . �O(J\,e A-G,_) IF &) Supervisor's Construction License: S_ILI`I /$ Exp. Date: $ i Home Improvement License: I--,)©7)Ot 6 Exp. Date: I 1°I )i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ A; C( S O O FEE: $ Check No.: 2111 Z, Receipt No.: T' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _. ...; Snature_of Agent/Own _ Signature of contfacto Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract a Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature w COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location No. Date TOWN OF NORTH ANDOVER O L F' 9 ;•a ; : Certificate of Occupancy $ ' suMus<� Building/Frame Permit Fee $ Foundation Permit Fee $ c Other Permit Fee $ TOTAL $ Check #24657 3a Building Inspector _074- . Oft4ceofConsumer Affairs&BusineessRe nHOMEIMPROVEMENT CONT guiation�.,Uv Registratiori'N TRACTOR Expiration=°�4 120296 tc_-.`--1:111.9,(2011 Type; e Indual , Tr# 290924 TESTA BUILDING'& JAMES TESTA ,' REMOQELItG 5 APPLETON ST' i� N.ANDOVER, REET� -5' Undersecretary Nlassachtasctts- Depai-tlllCnt of Pu#clic Slrfct,� Board of BuRti41�g Rc'Julation..iin�1 5titn�txl'd� � ConstructiOn Supervisor License License: CS 54718 JAMES M TESTA 5APPLETO,N ST N ANDOVER, MA 0'1845 . Expiration: 6/8%2012 C'ununi�siuncr -ti, Tr#.:r29825 NORTH 0 of over 0 No. - ti o. , dower, Mass..- 47A__ 4 i i 1 COCHICHEWICK -11-1c RATED PPa�.�S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..............Q.. ........�........ ........... ...... .......... .............................................. Foundation has permission to erect........................................ buildings on ...... . ......1... .....� !CI.... ...................... Rough Chimney to be occupied as.........."accepi !�i�...... .... ..............l�V... �..:. y provided that the persois permit shat in every respect Co rm to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final ' 10 PERMIT EXPIRES IN 6 M THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S Rough .............................................. ......................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocaipy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry Wall To BeDone FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. TESTA Building and Remodeling 5 APPLETON STREET NORTH ANDOVER , MA 01845 HIC. 120296 exp. 11/19/11 CS 54718 exp. 618/12 (978) 682 2023 PHONE/ FAX Proposal October 4 , 2011 Proposal Submitted To: Robert Kent HOME PHONE: (978) 171 Hillside Road North Andover MA, 01845 Job: New roof Complete removal of all demolition and construction materials generated by Testa Building and Remodeling and its subcontractors. Construction: Strip and re shingle roof. Install water and ice shield 3 feet up the roof and tar paper the rest of the way. Install new 30 year architectural shingles charcoal gray in color. A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications,for the sum of: $9500 Nine thousand Five hundred dollars ONE THIRD TO START SECOND THIRD WHEN HALF DONE FINAL THIRD WHEN FINISHED Authorized signature � I reserve the right to cancel this contr4ifotcepted in_30_days Signature `- Signature DO NOT SIGN IF THERE ARE ANY BLANK SPACES The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MM 02.111 'Y www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): 7e 5-� J3, cor j Address: Ar3 e I-- 5)- City/State/Zip T1® �rJ�cu-U Phone#: 9-7,%— Are 7,%Are you an employer?Check the appropriate box: 1•❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): Vnployees(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 sheget. t 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. . ❑Demolition [No workers comp. 5. 9• ❑Building addition ' p ❑ 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 insurance required.]t employees. 12•❑Roof repairs [No workers comp.insurance required.) 13•(P-Other i2 o or 6L.�11 c *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 in such. Contractors 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 information. employees Below is the policy andjob 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. J aY ado hereby certify and r the pains andpena[ties ofP er'u tliaf the information provided above is true and correct. .i nature: Date: none#: -7 %— 6 S 9, Official use only. Do not write in dais area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electric 6. Other al Inspector 5.Plumbing Inspector Contact Person: 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-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 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 referencd number. In addition,an applicant that must submit multiple permit/licease 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 tor 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 Co1-n.`rowWc—a1t1-j o,i 14assacl�t?setfs Depazbnent of Industrial Accidents Oi1ce of InVestigafions 600 Washington Street Boston}MA,02111 Tel. 4 617-727-4900 ext 4406 or 1-877-M-A.SSAIiE RPVicPA Fax#617^727-7749