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Home My WebLink AboutMiscellaneous - 21 CLEVELAND STREET 4/30/2018N_ O O N CO Q O O N v O O O O O Liberty Mutual® INSURANCE November 13, 2015 Town of North Andover, Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 21-23 Cleveland St Unit 23, North Andover, Ma 01845 Policy Number: H6521844770640 Underwriting Company: LM Insurance Corporation Claim Number: 032379665-0001 Date of Loss: 2/25/2015 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, § 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, § 3A & B, or Mass. General Laws, Ch. 143, 5 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 July 28, 2015 DINELEY CLAIMS SERVICES Town of North Andover Building Commissioner 1600 Osgood Street North Andover, MA 01845 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GENERAL LAWS, CH. 139, SEC. 3B INSURANCE COMPANY: Vermont Mutual COMPANY INSURED: 21-23 Cleveland St Condominiums c/o Mike Sacco PROPERTY ADDRESS: 21-23 Cleveland St, North Andover, MA POLICY NUMBER: BP21032497 DATE OF LOSS: 2/15/15 CAUSE OF LOSS: ice dam CLAIM NUMBER: BOP52809 PROVIDING SERVICES IN NEW ENGLAND NEW YORK NEW JERSEY PENNSYLVANIA DELAWARE MARYLAND OHIO VIRGINIA AND FLORIDA 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, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the undersigned and include a reference to the above -captioned insured, location, policy number, date of loss, and claim number. If no reply is received from your office within ten days, we will assume that you have no lien of any type against this property, and we will proceed to pay this claim in full. Insurance Claims Services Tel 877-302-0203 • Fax 877-245-4987 PO Box 479 • Waitsfield, VT 05673-0479 www.DineleyClaimsServices.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 form 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 of.ongoing construction activity, and maybe.deemed_by.the_Inspector_of Wires abandoned_and_invalid-ifhe—.. _ 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 of2010 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 ` 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 effector existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. ule—PermME)ate Closed: '�-1� x Note: Reapply for new permit fO Permit Extension Act — Permit/Date Closed: Date /..O . ... T .. ..��. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that `t has permission to perform .... ........7 .........1.....`..4.. ..................................... wiring in the building of .... t A/�-� ... .11l .. ............................ at .Q ...... 1. v�-� %� Gi AW.......... , North Andover, Mass. ..... ............................ 1- Fee<::Q � ......... Lic. No. /. ... ......................................... ELECTRICAL INSPECTOR Check # 2 7-- I= k U Common -wealth of Massachusetts Official Use Only j Department ®f Fore Services Permit No. L � (( moo .Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Occupancy (leavebimk UST APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININKOR TYPE ALL INFORNf_ATIOI9 Date: /0— 7-// 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) f //e%_�_ 1/, e/ S7, Owner or Tenant j} Re tj 13 nl G(' Telephone No. 603S— Owner's Address s' vN e Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building (,�� 1 I wVc (� UVITQ 21 f 3 Utility Authorization No. Eyast ng Service lav Amps /Zd 1'2 q p Volts Overhead [0_1*�' Undgrd ❑ No. of Meters ;2— 9 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: j11J51,/1 Su/6, recnl Cnmvletion of the following table may be waived by the Inspector of Wires. No. of Recessed LumiYnaires V No. of Cel: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ 'In- ❑IN nd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners F1T?tE ALARMS Nc. of Zones No. of Switches No. of Gas Burners No..of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices . No. of Waste Disposers p Heat Pump Totals: Number `. Tons NW ............... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heatin ]KW l? g Local Municipal E] other ❑ Connection No. of Dryers r3 Heating Appliances KW Security Systems:* No. of Devices or Eq uivalent No. of Water KW . Heaters No. of No. of Signs Ballasts . Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Equivalent OTHER: Q c rtS id e_ 5v ,i+-4jv C, FC t Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /O —Z6-// 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Azwv /11 6, LIC. NO.: Licensee: i Signature _ LIC. NO.: (Ifapplicable, ent r "`exempt" in the licen a number. line. C- Bus. Tel. No* • - *3 ?s`7ya�P" Address: �XPk ys C'1,ze fe'bY Alt. Tel. No 30� 5.7? 7aZ *Per M.G.L c.147, s. 57-61, security work requires Department of Public Safety !-S." License: Lie. 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. nl nPr/AcrPn4 7_77_7-77 .. The Commonwealth of Marsaehusetts ! Department of Industrial Accidents M � Office of Investigations. � ilii i 600 Washington Street �s� Boston, MA 0211I www.tlzussgov/dia Nn:Iicant infnr•..►�t:.... . Workers' CompensationInsiaranee Affidavit: Builders/Contracforsxlectricians/Plumbers Name (Business/Organization/Individual): Address: • City/State/Zip:. Phone #:. Are you an employer? Cheek.the appropriate box: ' 1.I] l�am•a em to er with P Y 4 (] t am a general contractor and I Type of project (required): emgloyees (fall and/orpart-time).* 2. ❑ I am.a.sole proprietor. have hired the sub -contractors listed b' ❑ Newcolistrnction or partner- : ship and. have no employees on the attached sheet I These su&contractors have % ❑ Remodeling 8. ❑ Demolitiotr working for me in any capacity, [No workers' comp. insurance p workers' comp. insurance. 5. ❑ We are a corporation and its 9• El Building addition required.] 3. ❑ I ain officers have exercised their 10.❑.Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions myself. [No workers' comp. insurance•re aired. t -required.] .c, 152, § 1(4); and we have no employees, [No workers' l2.[] Roof repairs comp. insurance required 13 ❑Other *Any applicant that checks boy'# I must also fill out the section below showing their workers' bompensation policy information. t 1 Tomeowners who submit this affidavit indicating they am doing all work a,1d then hire outside contractors must submit a new n�davit indicating - $Conkaetors that aherJc thisbox must such. rttaehed an edditior_3I sh>�t shoving the r ame efilre sub contractor and their Vmrka ' cer p, polic/ inCa, �. adon I adsa a empleyer the ispParaidi�rg:moo„+tern' lrrforpnation. ' CONAReaseadog acasmrancefar F.�y er�rplOyees: Below is tlse policy seed j®b site Insurance Company Policy # or Self -ins. Lie, Expiration Date: Job Site Address: ' Ciiy/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 Iead to the imposition of criminal penalties of a- fine up to -$1,300.00 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. Ido hereby certify under the pains and penalties of perjury that the information pPovWd above is true acrd correct. Signature: - Phone #: 1Official use only. Do not w- Pine :A2 T r is area, to be ran, by cky or tr wn official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town-Clerk 4. Electrical Inspector 6.Other 5. Plumbing Inspector Contact Person: Phone #: Date ......�:..� ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that G G� L has permission to perform !�1 t c` //�LLc✓/L c 171 Zig wiring in the building of AGi / ................................................... . ........................ �"� ...................... ....�,North Andover, Mass. '. o � • Fee. 200. ..... Lic. No...!..&/24. � ............1...� ... .. 7- ..... .�...... ELECTRICAL INSPECTOR Check # �� 9267 `f (-.ommonwea& o f Mamachadetb s 2epartment 013ire sewicee BOARD OF FIRE PREVENTION REGULATIONS 1 Official Use Only J Permit No. / Occupancy and Fee Checked z [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2 - L /0 City or Town of. jV, A fib 6 "p— 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)- r� C ��, /V) 'sLV j- Owner or Tenant A Bt L (zc= A L-ry lbTelephone No. Owner's Address al -al C.�e%dt �811J !) 5'T Is this permit in conjunction with a building permit? Yes ®No ❑ (Check Appropriate Box) Purpose of Building oi?t i)<) .� M . Utility Authorization No. �� p b Existing Service o10(_) Amps iZe, /Z40 Volts Overhead ® Undgrd ❑ No. of Meters New Service QOO Amps 1 243 / Z L/(U Volts Overhead ® Undgrd ❑ No. of Meters 2— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6L I IR_ C, 6�z/Y10E ?7 CQ 9,e_ W et7-1 AJ 0 -LD -�SEPUlCe_ Completion ofthe following table may be waived by the Inspector of'Wires. No. of Recessed Luminaires No. of Ceit. Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above E] In- E:] rnd. grnd. No. ot Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons ...................... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Z - S- J U 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 K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: MA MAA O to e-Z,6CTkt C—,,--- LIC. NO.: Licensee: M J C d iqEL M4MI- l0 (4igna LIC. NO.: (If applicable,a ter "exempt" in the license number line Bus. Tel. No.: 1% Z3_ Address: Z AU S3 /l). /v eryJ 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 PERMIT FEE:�z'! Signature Telephone No. ,D S 12 - /k 7 1"'a7QL G9 6 I y i� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: S s'r City/State/Zip:__ 4 yn' ; tr-&) mA Phone #: 7c� �2-3 % Are you an employer? Check the appropriate box: 11-11 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2U�l am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance 5. ❑ required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. We are a corporation and its 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. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing 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. I 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. 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. #: Job Site Address: Expiration Date: 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 ce!:YQ undlrthis and poalties of perjury that the information provided above 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 #: Locatione(�'�/��-G�l/� No. Date 6-2,-10 NORTH TOWN OF NORTH ANDOVER 3't i • O 0 9 Certificate of Occupancy $ 10a _I • �� s,,�;s <�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r 2 3 L Building Inspector CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 424 Date: 6/2/2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 21 Cleveland street MAY BE OCCUPIED AS 2 Family IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Abel Realty Trust North Andover MA 01845 Building Inspector (0) m m m m m X m m C= S7 CO2 Cl) 10 - 0 CD ;i = a ca. CD O '0 CL CL 5 CO) q >CO -0 CD CD CL cr =r CD Er CD 0 CD ca w 23. c CD cop) CD CL C2 CO) CD CO2 10 CD CD a O CD a I Fl, CA CCD ca 0 C/) CA 0 - r_ To - 0 CL C l< cm, CD 0 Z CD CD )lt C=2 =-o CL= c C2 x1l N ^ . 4, O p- 41 z 0 0 0 "b4 cn Eg I 0 CD p 0 IV \ bl — 0 -A 0 - r_ To - 0 CL l< cn Eg I 0 CD p r- It �j (D IV \ bl — .80- VRI rL- i 0 - r_ To - 0 CL N Date -0- /- / G . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �! �. . .......°.... ................. . has permission to perform .. Pr & 0 `. !` ."................. . plumbing in the buildings of . . ST /I,- " t at ... 9 ?�' . ? . �...0 `' ` `( ... ,,,North Andover, Mass. Fee./?.,,!7 . I . Lic. No.& ?.0%./.. .......4----,..� �.� . � ...... . / PLUMBING INSPiCTOR Check # 84Y4 R MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Lo01r C Owner New ❑ Renovation 0 Replacement ❑ F'IXTITRFC Date 6 — / D Permit #&C/ Amount IL 2 i Plans Submitted Yes ❑ No (Print or type) �� / �/ Check one: CertificateInsfialling Company amN e / ( L. o G d ❑Corp Ad ss P b a Partner. ❑ Business Telephone7 — 3 U Firn /Co. Name of Licensed Plumber: Insurance Coveraee: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond E Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and ' ormation I have best of my knowledge and that all plumbing d instal compliance with all pertinent provisions of the Massachuset By: �. �. Title Type of City/Town/6-70, icense Nun APPROVED (OFFICE USE ONLY 11 Led (or License Agent Master Journeyman ,'true and accurate to the application will be in General Laws. ,f The Commonwealth of Massachusetts Department of industrial Accidents Office of investigations Uf 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.- ox:❑ 0I am a employer with 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 subcontractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] 3. [:11 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t 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 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other —1-- ecuon oe_oe: saowmb +hei wo i e s' comp» cation troIicy information. t Homeowners who submit this afndavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractor; 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. #: Job Site Address: Expiration Date: 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 and penalties of perjury that the information provided above is true and correct Si ature: Date: Phone #: 11 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector 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 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 thecity 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 www.mass..govldia Location No. o Date 3 -.?g- U 2 HORTN O't�o TOWN OF NORTH ANDOVER ,•,4•C Y 3 Certificate Occupancy $ + ; , of s�cMus `� Building/Frame Permit Fee $ _Z Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # '� J 4 u l Building Inspector TONM OF NQ AN , O ;VER BUILDING DE A RTMENT s WILDING PERMIT NUMBER j' � DAM ISSUED '�7 3, '� ,IGNA LAW: Building Commissioner for of Buildings Date ECTION 1- SITE INFORMATION 1..1, Property Address: 1.2 Assessors Map and Parcel Number. O <fD,2`t 602 Map Number Parcel Number 1.4 Property Dimensions 1.3 Zoning Information; nm District , ,,, Use S BUILDING SETBACKS tit a Tat Ar e�` Fronta S ' _ Front Yard Side 0":Rear Yard Provide Prdvided _ . _._ Provided . carter, supply M Cz1.c.40. 34) ls. Flood lone S I's Sewerve 1* -d systeiW ILc d Private 0 zoo Outside Flood Zoe 10' "`Municipal ❑ 1� ,/ On Sae Disposat S�§tpm ,CTION 2 PrIkOPER'TY OWNERSIEI /AUTHBItIZED AG !1T l Owner of Record < m me (Print) // / Address,for Service: .S LC- ✓V \p 1 Wl 1A V? nature _ ,... Owner of Record: y ame Print Address for Service: 0 z tature Tel hone m -T10N 3 - CONSTRUCTION SERVICES �p Licensed Construction Supervisor. Not Applicable ❑ Tom, n nsed Construction Supervisor: 040 1( 2 License Number ress V "n C.� atureTelephone Expiration -.Date . r tegistered Home Improvement Contractor Not Applicable ❑ pany Name Z Z I U /05— �(� u -e L (4` f S -t Registration Number M r ess r lure Telephone Expiration Date 1 SECTION 6 ESTIMATED CONSTRUCTION COSTS " Item Estimated Cost (Dollar) to be Co feted by permit applicant ; I. 'Building a . (.) B utlduig Permit Fee .. 2 Electrical (b) Eshmated Total Cost.uf . . Construction _ 3C/C� d 3 PlumbingBuilding Permit fee (a) x (b) 4 Mechanical QffAC-- 5 .Fite Protection . Y 6 Total 1+2+3+4+5 Check Nuurber > - SEC 014'7n -OWNER AUTHORIZATION TO BE COMPLEM WHEN' OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAW I' as Owner/Authorized. Agent of subject property Herebyauthorize to. act on My behalf, in all matters relative to work authorized by this�building permit application- Signature pplication.Si ture of Owner Date' SECTION 7b OWNEWAUTHORIZED AGENT DECLARATION I' as Owner/Authorized Agent o�subject Property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief /. Print Name 0 !i Date SIZE ' BASEMENT OR SLAB SIZE OF FLOOR TI?dBERS l -2NLJ IKV DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHM4NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE CERTIF KATE OF L IAB I L ITY INSURANCE DATE 04-23-01 (MM/DD/YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS °FI HAM INSURANCE SERVICES INC UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER 122 BRIDGE STREET THE COVERAGE AFFORDED BY THE POLICIES BELOW. PELHAMNH 03076- I N S U R E R S AFFORD I NG COVE RAGE INSURER A: Liberty Mutual INSURED INSURER B: The Maryland Thomas Doyle DBA INSURER C: Thompsons Construction & Roofi R West St. INSURER D: Salem NH 03079 INSURER E: COVERAGES HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA:D CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATF GENERAL LIABILITY B [x] COMMERCIAL GENERAL LIABILITY SCP 34865353 04.17-01 04.15-02 FIRE DAMAGE (Any one fire) $1 300,000 j [ ] CLAIMS MADE [x] OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 [ ]POLICY [ ]PROJECT [ ]LOC PRODUCTS - COMP/OP AGG $2,000,000 AUTOMOBILE LIABILITY [ ] ANY AUTO COMBaccident) $INGLE LIMIT [ ] ALL OWNED AUTOS (EacBODILY INJURY [ ] SCHEDULED AUTOS (Per person) [ ] HIRED AUTOS BODILY INJURY $ NON OWNED AUTOS (Per accident) G [ ] PROPF� Tv DAMAGE (Per c GARAGE LIABILITY AUTO C',.. i A:(:i)I:NI ] ANY AUTO $ [ ] OTHER ' A'; EA ACC $ AUIC 0'+_ AGG $ EXCESS LIABILITY EACH OCCURRENCE $ [ I OCCUR [ ] CLAIMS MADE AGGREGATE $ [ ] DEDUCTIBLE $ [ ] RETENTION $ $ $ WORKER'S COMPENSATION AND [X] WC STATUTORY ] OTHER A -[ A EMPLOYER'S LIABILITY WC2.31S-314995-019 0421-01 04-21-02 E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Roofing Job at 6 MIDDLESEX ST. NO. CHELMSFORD, MA CERTIFICATE HOLDER [ ]ADDITIONAL INSURED: INSURED LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FRANK DEAMICIS THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR 6 MIDDLESEX ST. TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUTBLIGTON OR LIABILITY OFANYILKINDTOUPONSOTHEHAINSURER.SLL ITS OAGENTSIOR NO. CHELMSFORD, MA 01863 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE (7/97) 6 ltl 'L I Page 1 of 2 D. Robert Nlicelta, Building,Commissioner TOWN OF NORTH ANDOVER Office of the .Buil ing Department Community development and Senices 27 Charles Street. North Andover,V11assachusetts 01845 DEBRIS DISPOSAL FORM Telep anc (9?8) 688-9545 1=AX (978) 688-9542 In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at / in NaVL� (Site location) ��- 0Z Signature of permit applicant Date Michael McGuire, Local Building Inspector James Decola, Electrical Inspector James Diozzi, Gas/Plumbing Inspector Page of c Vropozat Free Estimates {{ 105 Haverhill Street Fully Insured -(�ethuen, MA 01844 THOMPSON'S ROO G (978) 691-1355 Shingles — Slate — Rubber Roof Single Ply — Copper Work PROPOSAL SUBMITTED TO - PHONE DATE Walter Mazrenko 3-6-02 STREET JOB NAME - 35 _ reet ljr. CITY, STATE AND ZIP CODE JOB LOCATION Methuen MA 01844 21-23 Cleveland Street No. Andover MA ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. Strip off all roof shingles on front side of building .Renail all loose boards and if any need replacement it will cost $3.00 . a ft. 1x8 Cover holes with metal going up the sides where the birds are getting in Install 8inch aluminum drip edge Apply ice and water shield 3 ft. up all along edges Apply 151b. felt paper on rest of roof area Reshingle with a 25 year 3 tab shingle Cut in 2 roof vents Remove all work related debris 25 year warranty on.material 10 year guarantee on labor construction lic. #060112 improvement #128612 60 'Ae prop0ge hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Two thousand eight hu ------ dollars($ 2,800.00 Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner Autrwn according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and Signature above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully Note: This proposal may be rnvarari h„ W—L—an't (:mmnantafinn Intttmnra .uifi.'1__ K..... if nnf — —f—A ... ;.6;— 01creptance of Vropozat — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. 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