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HomeMy WebLinkAboutMiscellaneous - 200 BRIDLE PATH 4/30/2018 (2)Date............................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......► n cJlrv�Prs . 0tz 5 .................... has permission for gas installation .P...�,,:.....t�N Win thebuildings of ................. -V ..................... at ....2.0)......r '. r ...................... ......�-......... ,North Andover, Mass. Fee�4).�....... Lic. No...10.V .. .... !M ................................................... GAS INSPECTOR Check # �C\ �% 972. l V �a loe<�� d, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [� MA DAT/ PERMIT # 1 -7,2-7,2E JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TE_ C JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: d RENOVATION: [j REPLACEMENT: 13 PLANS SUBMITTED: YES 0 NO Q APPLIANCES 1 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 FURNACE GENERATOR v (1• r re. ___. __ I _.._ J I __ .____ __ - i __ GRILLE.- INFRARED HEATER LABORATORY COCKS- MAKEUPAIRUNIT OVEN _ POOL HEATERS (- 1 ROOM I SPACE HEATER Rt -OF TOP UNIT- TST UNIT HEATER UNVENTED ROOM HEATER WATER HEATED - "VA O"ER ......._...._... - -- - - - - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ++' LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ® BOND F 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 r --1I AGENT �[ 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 corn iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I J o_mAS o t W r5r LICENSE # D SIGNATURE ' MP ® MGF El JP ® JGF Q LPGI Er CORPORATION ©# PARTNERSHIP®#LLC D#� COMPANY NAME: !q _ ADDRESS �r r wyic w� _ _ CITY�wren �.Q _ �� STATE mh ZIP l N3 JTEL �7 FAX I CELL _ 'EMAIL V �a loe<�� d, W a Iii w LL The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations quo 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl, Name (Business/Organization/Individual): Address:���� City/StatPhone #: Are y an employer? Che* th appropriate bog: 4. ❑ Type of project (required): 1. I am a employer with r I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* have hired the sub -contractors 7. ❑ Remodeling 2111 am a sole or listed on the attached sheet. proprietor 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.] officers have exercised their 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 Of 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 anew 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: Policy # or Self -ins. Lic. #: Expiration 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 ofthe DIA for insurance coverage verification. I do hereby cc�e t under the pay�{s and penalties of perjury that the information provided above is true and correct Si afore: / ,1JI�L Date: Y—� f/f 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 Phone t.. 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 (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 Coa onwealthofMassae MsPtts Department of Industrial Accident. - Office ofTnvestigatious 600 Wasbi gton Stzeot Boston} NM.A, 021 b 1 Tel. # 61.7-727-4900 ext 406 or 1-877-MASS.AFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdxa Phone: 978-632-2660 JAMES A. TRUDEAU Fay 978-632-2662 Adjustment Service Inc. P. O. Bog 7 Gardner, MA 01440 claimsAtrudeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B December 31, 2013 Building Inspector 120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Marie Dow Loss Location: 200 Bridle Path, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100781042 Date of Loss: December 25, 2013 File Number: 13-11850 Claim Number: 13102363 Type of Loss: Sewer Back -Up 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 writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Joshua M. Trudeau Claims Adjuster Town of North Andover NORTif Office of the Conservation Department or ° ° `'• Community Development and Services Division � u":rte,,.• ti •^'",* 27 Charles Street """°''� SS�CHU`�ES North Andover, Massachusetts 01845 Alison McKay Telephone (978) 688-9530 Conservation Associate Fax (978) 688-9542 December 31, 2002 Resident 30 Timber Lane/2,2S, aaq, aCic &,41& North Andover, MA 01845 RE: Violation of the Massachusetts Wetland Protection Act (M.G.L. C.131 S.40) and The North Andover Wetlands Protection Bylaw (C. 178 of the Code of North Andover). Dear Resident: This department has recently observed yard waste materials (logs, slash, & leaves) in a wetland drainage area at the comer of Bridle Path and Timber Lane. This material is prohibited from being placed within a wetland and its 25 -foot no -disturbance zone per state and local wetland protection regulations. Your neighbors at 225, 224, and 200 Bridle Path have also received notification, as it is not clear who is responsible for the dumping activities. This department has the jurisdiction to require such materials to be removed from these protected resource areas and their associated 25' no -disturbance zones as it is considered an "alteration" to the resource area. An "alteration" includes, but is not limited to, the placement of fill (including yard waste materials), excavation, or regrading (Section II. (b) of the North Andover Wetland Regulations). Wetlands and their buffer zones are not an appropriate location to deposit yard waste or any other material. In accordance with the provisions of MGL c.40 s.21D and Section 178.10 of the North Andover Wetlands Protection Bylaw any alteration of a wetland resource area or the buffer zone is punishable by a fine of up to $300 per day. The North Andover Conservation Commission has determined that the responsible party shall remove the material to a location outside of the 25 - foot no -disturbance zone. A fine will not be levied at this time. Current snow cover conditions may affect removal attempts at this time. Removal of debris materials shall occur as soon as possible, when the snow cover has melted. The material shall be removed by February 1, 2003. An inspection shall be made after this time to ensure compliance of this removal. If the material can not be removed by this time due to continuing snow cover events, please inform this office so that we may grant an extension. Thank you for your anticipated cooperation. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Sincerely, Alison E. McKay Conservation Asso fate Cc: Julie Parrino, Conservation Administrator NACC members File