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HomeMy WebLinkAboutMiscellaneous - 181 FARNUM STREET 4/30/2018 (2)N North Andover Board of Assessors Public Access NORTH of tt�.o ,a'�YO F T SswcNus� Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 GEWL roperty Record Card Parcel ID :210/107.A-0049-0000.0 FY:2013 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO Click on Photo to FARNUM STREET Location: 181 FARNUM STREET Owner Name: LAVOIE, PAUL N SUSAN H LAVOIE Owner Address: 181 FARNUM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 1.93 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2380 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 430,700 408,300 Building Value: 228,300 203,900 Land Value: 202,400 204,400 Market Land Value: 202,400 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2258463&town=NandoverPubAcc 10/24/2013 ai co co a) ❑ co Ned' U ❑ C (. 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O a Liao ` cc ? cLL-0- } m1��U O N a m C7 LRen LN U �❑¢❑F- W}:(DL)CL N Z W nvN OHI- N inB LU W i m U - in i!i : iri LL U LL ��w� j7L f0 co (n P. O o �m'c6OC'1..2, OCD m Ur cY,'9 1 O (1) co -( 76 _ 7 .+U' X cA (N = F-mu.2WCOYWg mm¢ o C) m C7 LLL U E c rn F- Oai ai .. U = : =p�.�.0 c F-1~ a � FU- oit@Zo aa,Z,2aci Y cowTfLu2LOL 2LLLLU � Li m m Date. !! A ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............................. ........ has permission to perform f-_ .. ............ 07, wiring in the building of ....................... at I 7 --net^, ....................................................................................... rt Andover, Mass. �Ando,, Fekkf ..... Lic./3 5%�% . ...... E�C**-'M'CAL INSPECTOR* Check #13p-5&7 lI 13p- -q '1' 213 7 5a V-1 Y o-- / 2-11 (0�� k Commonwealth of Massachusetts Offi�cjial Use Only Department of Fire Services Permit No. 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 C), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 07 / City or Town of-. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)/ �/ /y Ge -- ") U r).1 S-/ tete Owner or Tenant U l rVve rS ay o i- Telephone No. Owner's Address LRO rn-x— Is this permit in conjunction witp a building per it? Yes 12 --No ❑ (Check Appropriate Box) Purpose of Building F1174 // i Utility Authorization No. Existing Service/o Amps !oZG Volts Overhead Er Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity _axq (lc'14 `Q MX/ 0, V12 - Location ! Location and Nature of .Proposed Electrical Work: r -7Z--j46� j Ofiv 2 0 o, -rt IAD' & re, Tb s Comnletion of the followine table may he waived by the Insnertnr of Wiro.s No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. o otal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets 1 7 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o f Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Num er ons ""' "" KW ' '' ""'' ""' o. of Self -Contained Totals: Detection/Alertine Devices No. of Dishwashers ` Space/Area Heating KW Local ❑ unicrpal ❑ Other Connection No. of Dryers Heating Appliances KW Security ystems: No. of Devices or Equivalent No. of Water KW o. of o. o Data Wiring: Heaters signs Ballasts No. of Devices or Equivalent No. Hydromassage .Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: ��{ �L Peri Dt%/ a� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o. E ctrical Work: �jQpp (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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE L�— BOND ❑ OTHER ❑ (Specify:) trip rht rt 0 p -S tJ rar)C I certify, under the pains and penalties ofperjury, that lite information on this application is true and complete FIRM NAME:_iyG n //'� _„Q LIC. NO.: /3 Y&/ Licensee: Signature _ LIC. NO.: (If applicable, enter ' empt” in the license?. n+ynber line, Bus. Tel. No.: „W 2aY 2% 1 Address: 15 x Rd 11'i/s.W1W Y/e/ /)74 Ott 0 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work 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. I am the (check one ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ CV— The Commonwealth ofMassachusetts Department of Industdal Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationftdividual): d City/State/Zip: kn)mc�QJ VW 41A 0 l �qy Phone #: 7"l —OZ SY—d 7 i 3 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6.. ❑ New construction _ employees (full and/or part-time) have hired the sub -contractors listed on the attached sheet. �• F1 Remodeling 2. m aa sole proprietor or partner- ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in. any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11. F1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12,❑ Roof repairs insurance re required.] q � employees. [No workers' 13.❑ Other comp, insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i'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 boxmust attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. 1--i Insurance Company N, Policy 9 or Self -ins. Lic. M. �e1c-c /�vs Expiration Date: 1-2 111 Job Site Address: 1,5 l '12tl.P, City/State/Zip:N6e7///macyM 01 rV S.— 'Attach Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. X do hereby cert! rider the pains 004enaltles o erjury that the information provided above risue and correct 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 9: 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 ofhire, 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 employes." MGL chapter 152, §25C(6) also states that "every state or local tie -easing 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 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 fot• 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 aworkers' 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 Min 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 (ifnecessary) 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 any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CQmMonwe'alth ofM-assac meds Depattlnent of TndusWal .Accidents Office ofluvestigatious 600 Washington, Street Boston} X1.02111 Tel. # 617-727-4900 ext 406 or 1-877-MA&S.AFE Revised 5-26-05 lay, # 617-727-7749 7749 vaww.Mass.gov/dia V -i 10373 Date ...,.�..� �` .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........j...A...........r!................................................................ has permission to perform .............ln�C. .^-'r' ° � plumbing in the buildings of... oi-............................................................. at.........'0,"", 4�`'V y`'` 5. :................ North Andover, Mass. Fee........Lic. No. 11"'' 0. M.�.................. PLUMBING INSPECTOR Check # 16114 6e 6b�-Ivl & 44� 4A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ` 1 MA DATEf I,�3� _ PERMIT #.��� JOBSITE ADDRESS 1 �L. .r rY� S6- OWNER'S NAME POWNER ADDRESS rQA.V, TEL _JFAX TYPE OR _ OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES NO© FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _ —AL—A .—_ I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _{ _i __. _I _ i _f 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN OF=11 INTERCEPTOR (INTERIOR) KITCHEN SINKLAVATORY �J __j ----. _ _____1 __.___l ___i _____I ROOF DRAIN SHOWER STALL SERVICE MOP SINK TOILET I _ l f 1 ! .__ .__ I= _I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES VVATER PIPING R TU - " ---•--.� —f FF ----J -! .---j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW S LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. T CHECK ONE ONLY: OWNER [l AGENT 11-11 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in om iancewiAi ertinentrovision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 6 h L---IILICENSE # l i ( S GNATURE MP Ell JP CORPORATION R# PARTNERSHIP E-31 #F=LLC COMPANY NAME 1 ADDRESS �' ,°v� I CITY tne'�ur _.... __.. _-...-_I STATE ® ZIP TEL FAX EMAIL AWA H z 0 H U W a w oFl z ❑ O W O w CL z = tom - O Q w a O > w 9 cn a cn p zo a W� U J CL IL B z w H LL H zz 0 0-4H U a a � ,a The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): \J C Address: � �C; �, S-�— City/State/Zip:. Phone Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction ployees (full and/or part-time).* have hired the sub -contractors ❑Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.g ❑ gg addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ EIectrical repairs or additions required.] officers have exercised their 3111 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#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy 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 requiredunder 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. X do hereby cer�y under the pNns and penalties ofperjury that the information provided above is true and correct. Phone #: (z I ;) T -' 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 - 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-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 carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 (ifnecessary) 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 ofInvestigatlons 6.00 Washington Street Boston} MA 02111 Tei, # 617-727-4900 ext 406 or. 1-877:MASS.AFE Revised 5-26-05 Fax # 617-727-7749 www.mas$,govfdia Date ............�. f -?c1...1. l ............ ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................... ................................... . . . .......................... has permission for gas installation .... ...d-!.M.e4A ............. in the buildings of .......... C. Ij... .. .. 0 ... ,. ... .......e . .......... ........................................................................ at ....... �.� Ir North Andover, Mass. ................ .. .. .. ... .... Fee . ....... L-ic.--No. J ....... .. .... . ......... GAS INSPECTOR Check # 0 0 0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYMA DATE'. l PERMIT # vU JOBSITE ADDRESS - ✓• c OWNER'S NAME GOWNER ADDRESS TEJFAx TYPE OR PRINT OCCUPANCY TYPE COMMERCIALEDUCATIONAL ® ® RESIDENTIAL CLEARLY NEW: RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES F1 NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR —I I FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS �_ L _ _..._ _._._ __. _— -- I _ .— I -- MAKEUP AIR UNIT I - OVENi- POOL HEATER (- -� - _ I ROOM / SPACE HEATER ROOF TOP UNIT_ _ ! TEST UNIT HEATER- UNVENTED ROOM HEATER ! WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ug"" OTHER TYPE INDEMNITY ©f BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [. AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Al PLUMBER-GASFITTER NAME ,�j DifLICENSE # SIGNATURE MP ED MGF 0 JP ZJGF 0 LPGI ©{ CORPO TION ©# = PARTNERSHIP ®#= LLC COMPANY NAME: _jr nn ADDRESS�- CITY _ —f STATE ZIPLWa TEL FAX CELL - _ - ! EMA - -- -- 1.- F O Z 0 H U W a w h z� O �rl W F - mW LLI h IL Z U w �* W � � a w W C W o a a a J E. a Vala a 6i X- w 1— LL i W H O z z 0 H U � W � LJ -.P COMMONWEALTH OF MASSACHUSETTS NEW ENGLAND CLAIMS SERVICE. INC. Incorporated 1985 Reply To _ n s� Reply To Mansfield, MA 02048 131 Dodge Street, Suite 6 P.O. Box 345 ^" moi Beverly, MA 01915 M lflAXN7 iN I,RA1Xf. TEL. {508} 337-8058 °j 4'tR5 TEL. {978} 927-3000 FAX {508} 339-5835 FAX {978} 927-3002 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall North Andover, MAO 1845 To: Board of Health or Board of Selectman City Hall North Andover;MA 01845 RE: Insured: Michele & Gregory Stein Property Address: 614 Forest Street, North Andover, MA 01845 Cause of Loss/Date: Water Damage/ 12/16/2013 File or Claim No: BOS 05i0i I 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 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 or file number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destruction to a building or other structure, amounting to 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 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 chanter 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. Very Truly Yours, Robert L. Smith, Jr. Adjuster Date ..� °7 `� • . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... ..v.�?^�..!�-�^"-........... 0' has permission for gas in tallation in the buildings�f ... 4�4.L � .Ej.-- ......................... at . .d? ....... North Andover, Mass. Fee .. Lic. NoA4PPP2, .. 1% ...................... ! GAS INSPECTOR � R`�. Check # a 9549 This certifies that Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING U'v . /� has permission to perform .. K% ��4.- /�^y. /91 /1Y a��PI<,. . plumbing in the buildings of . /a- . V* .v!.=:...... ............... . at .... 5�// i �- ........... , North Andover, Mass. Fee s_ .. Lic. No /�(D�0z . / . ......................... PLUMBING INSPECTOR Check V .i Q MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY o f MA DATE�4_ S. �j PERMIT # `T JOBSITE ADDRESS a d S OWNER'S NAME L_ v� I P OWNER ADDRESS '- ( TELy AX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: �'� PLANS SUBMITTED: YES Q NO ._. FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 BATHTUB CROSS CONNECTION DEVICEI,� DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEMI ___.. ( ` ._,._ ► _ _1 ._ _._, I I _-..._____ _—_ I ._____.. I _ 1 .____., .) ( _I I DEDICATED GREASE SYSTEM J _..._._...I f ( _1 ___..._.I f -...._..__ I ( f J= DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM f I ..____.J l ..-.__.J .�..___.f „J I _..-... _..j ___._f ..._._-.J _v_I _I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER_I _.__1 .---._.._J FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) f I _._._.J -------I --j! _w I ..___J ( __— f KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL I . _1 J -j SERVICE / MOP SINK TOILET URINAL___f .__._J WASHING MACHINE CONNECTION d f ._ _ i _.__. ( M I _ -__J . f ' f WATER HEATER ALL TYPES WATER PIPING OTHER ______( __.____-( __-J i __f __.._ _J _.__I ._.__i f ___.._.__i -_....__I I_.__ I f I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES RI<O 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHERTYPE OF INDEMNITY F1I BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provi ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME __ D LICENSE # QLD ,.. --SIGNATURE h/IPJPQ CORPORATION # PARTNERSHIP D#JLLC 1 COMPANY NAME L �,,,�d%y�� r ADDRESS CITY �� STATE J ZIP TEL FAX L i CELL �IEMAIL H 0 H U W Pi W 0 a N O ~ W p W O W °" ft z uj f- Cf) w W CO) aLLJ ® � w Co O zo aa, a � w a � U J IL �r aLLI N w H LL W H z z 0 H U a z z as a O a It V. The Commonwealth of Massachusetts Department of IndustrialAccidints q 9 UIP W 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): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. y p ty workers' comp. insurance. 9 E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3111 am a homeowner doing all work officers have exercised their 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 #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating 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 employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: T 1 �City/State/Zip: V �0 ?� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 gerli& uunn,..de&r the pains and penalties of perjury that the information provided abooJve is true and correct. 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 #: G> -n 1 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 j oint 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 ofpublic 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 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 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 ofzndustrial .Accidents Office of Investigations 600 Washington Street Boston., MA 02111 Tel, # 617-727_4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 wWWjnass.9ov1dia FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT — - - - - - - - - TEST UNIT HEATER _ -1 -jr UNVENTED ROOM HEATER WATER HEATER OTHER F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO [I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0' OTHER TYPE INDEMNITY [jj BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENTEII SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine LLwvision of the [Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUM BER-GASFITTE R NAME Z� LICENSE Fm P 25� SIGNA-rURE IMP [a-M"GF El JP 0 JGF LPG] D CORPORATION D#F llG PARTNERSHIP FDA= LLC [,-J-# COMPANY NAME: -,ADDRESS --------------- 7 CITYZ ZIP ...... STATE F ----- ]TEL FAX CELL :EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY N DLJ cc MA DATE PERMIT JOBSITE ADDRESS wA y - OWNER'S NAME G OWNER ADDRESS 26!,�OTE -'7 O 7FAX —'j TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL D RESIDENTIAL CLEARLY NEW: ED RENOVATION: El REPLACEMENT: G:k— PLANS SUBMITTED: YES 0 NO E] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE --A DIRECT VENT HEATER DRYER FIREPLACE - A= FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT — - - - - - - - - TEST UNIT HEATER _ -1 -jr UNVENTED ROOM HEATER WATER HEATER OTHER F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO [I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0' OTHER TYPE INDEMNITY [jj BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENTEII SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine LLwvision of the [Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUM BER-GASFITTE R NAME Z� LICENSE Fm P 25� SIGNA-rURE IMP [a-M"GF El JP 0 JGF LPG] D CORPORATION D#F llG PARTNERSHIP FDA= LLC [,-J-# COMPANY NAME: -,ADDRESS --------------- 7 CITYZ ZIP ...... STATE F ----- ]TEL FAX CELL :EMAIL IT*n W�W O O H U W a a� -o ❑ Z W � � ~ W O� a O U w ft z a W 5 a O LLJ > � w w w CO) a o a a a � U J H a CL a � ui x w U. H O z z 0 H U W a c�7 a 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AVIA 02111 >� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Q �J' Please Print Legibly Name (Business/Organization/Individual): LUeG� Address: City/State/Zip: c��G�� 1GL� bf% Phone #: ��I 7�s� Are yo employer? Check the appropriate box: 1. I am a employer with _::5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.Efflumbirig repairs or additions 12.❑ Roof repairs 13.❑ Other *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 indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Tam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: fob Site Address:! CG"r �li1Gs�! % ��1�'��y��City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a :tne 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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certif under the pains and penalties of perjury that the information provided above is, trite and correct. ;iunafiirP• (\`Ya� /%�i:%�/�_.�, Tlata• 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 #: 11 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 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 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 1-877-MASSAFE Revised 5-26-05 Fax ## 617-727-7749 www.mass.gov/dia