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HomeMy WebLinkAboutMiscellaneous - 24 SALTONSTALL ROAD 4/30/2018\� � o � I � N cn, � � 0 0 o Z . N� D Or r I o o o n v �_�_ February 25, 2015 Town of North Andover Building Commissioner 1600 Osgood Street North Andover, MA 01845 DINELEY CLAIMS SERVICES FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GENERAL LAWS, CH. 139, SEC. 3B INSURANCE COMPANY: Vermont Mutual COMPANY INSURED: Pamela L Poirier PROPERTY ADDRESS: 24 Saltonstall Rd, N Andover, MA POLICY NUMBER: H017093712 DATE OF LOSS: 2/25/15 CAUSE OF LOSS: fire CLAIM NUMBER: HC207849 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 j Date... .................................. p►ORTh TOWN OF NORTH ANDOVER o PERMIT FOR WIRING CMUs�t This cer-tifies that . �'e.!` I{`.--. ....................... has .permission to perform ... f...f''' ................................................................... wiringm the:huilding of............................................................................................................... at .......>/ 1tD a......J;!%�...:......................>Ne hAndover,Mass. Fee"". Lic. No... ,!..............(/././s:................?1"�`"~--- ELECTRICALNSPECTOR / .4 Check # _ F-"772 Gy� ., i ` N Commonwealth of Massachusetts Official Use Only Permit No. Department ®f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: Z® if -s/ l City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intent' to perform the electrical work described below. 1:1 Location (Street & Number)_,2( Owner or Tenant Telephone No. { Owner's Address 1 Is this permit in conjunction with a building permit? Yes ' ' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: y . Comtiletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: 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- ❑No--.OTEmergency rnd. grnd. Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches ) ' GU No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: N*­**­­­­..Ier ­ To ����� KW .�����������........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Systems:* SecN o evi es or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: O G Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �OU ' (When required by municipal policy.) Work to Start: A:5Inspec ions 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: INSURA=NCE k BOND ❑ OTHER ❑ (Specify:) I"certify, under the dins and pe hies ofperju% tha then information on this application is true and complete. FIRM NAME:. &t4A S�� to N �— LIC. NO.: Licensee: &Ail/ Signature LIC. NO.: (If applicable, "e t" in i ,e at ) Bus. Tel. No.: — l Address: \ � � Gy�� Alt. Tel. No.: a` 1 PS" *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 FPERMITFEE- $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§ Rule S: 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 shallbelimited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL, ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ]FINAL., INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ea Date: DEB WEINHOLD ... TOWN OF ME RIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents X Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Compensation insurance Affidavit: Builders/Conti'actors/Electricians/plumbers. TO BE FILED WITH THE PERMCTT'ING AUTHORITY. Name (Busines�>o s/Oigauizaiionllndividual): Address: 9,44 1 City/State/Zip: (\) 9 (� 4 1 Phone #: Are you an employer? Check the appropriate box: 1. I am a employer with �. employees (full and/or part-time). 2 I am a sole proprietor or partnership and have no employees working for me in an ca acity [No workers' comp. insurance required.] Y P 3.[]lam a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have lured the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its. officers have exercised their right of exemption per MGL c. 152 81(4) and we have no employees: [No workers' comp. insurance required.] Type of project (required): 7. Fj NoVd6nstr66iion 8. WemodeliM 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions i2T _ 'plumbing repairs or additions 13% 0 Roof repairs 14. n Other *Any applicant that checks box #].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 state whether of not fhose,entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is, providing -workers compensation insurance for my employees. Below is the policand job site y information. Insurance NX�_s Company Name- Expiration Date:. Policy # or Self -ins. LIG. #: t �,Ol �6y` A� City/State/Zip� g � Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a firie 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 ay be forwarded to the Office of Investigdtions of the DIA for insurance day against the violator. A copy of this statement m coverage verification. coverage z dpenalties of perjury that the information provided above is true and correct Hereby cerci un Si aiure: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License H. issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing inspector 6. Other Phone #: Contact Person: r 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 enferprise, and including the legal representatives of a deceased employer, or the receiver'd r 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 applicaiitmho_has not produced -acceptable evidence of compliance with the insurance coverage requhred." 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 IndustrialAccidents. 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 thai 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 requited to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia |Cut) .: � k ^ . \ y / � Q 2-«Q 3 © / 3 ° « \LL . gLL- z z s q e. »& D z : y o ^2LJ �e ®00 - ��:� ..Date) c) 7%.ate......... 11394 of ".�p7"'tio TOWN OF NORTH ANDOVER 9 PERMIT FOR PLUMBING CHUS�t ;} Thi's,certifies that ........ ............. .....�.IZ,. c-0w., . has permission to perform ..............W.i........1................................................... plumbing in t e b ilding of .. �...? . c� _. at.:;...:::........................................�'......... North Andover, Mass. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [p NO D1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0i 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 AGENT 0 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 provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S (LICENSE # SIGNATURE IVIPis JP Q CORPORATION n# PARTNERSHIP # _ ( LLC COMPANY NAMES j �L�?� �.�// ,.�_ ADDRESS r �, CITY -- - - STATE ( ZIP TEL FAX CELL C _ _ j EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' POWNER TYPE OR PRINT CLEARLY CITY �_�ae�'z _ l MA DATEQ=S`-_( PERMIT# JOBSITE ADDRESS! Drvl j OWNER'S NAME /j U C_CPIl ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL& NEW: M RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® NOM FIXTURES -1 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM =1 L DEDICATED GRAY WATER SYSTEM ,._.,__-_.. JE .-J===—==== DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _I ..___.__._€ -_--- ..______ I _._._€ _€ ___.-__ f _.____ E .____) __._ ( .__...} ___.._..t _._.__... i _� _ ...__ _'• FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ! J � J �!------1 __.___f ____€ _.___1 ._.__J ____I _.___..1 ._€ _ € _______i ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [p NO D1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0i 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 AGENT 0 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 provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S (LICENSE # SIGNATURE IVIPis JP Q CORPORATION n# PARTNERSHIP # _ ( LLC COMPANY NAMES j �L�?� �.�// ,.�_ ADDRESS r �, CITY -- - - STATE ( ZIP TEL FAX CELL C _ _ j EMAIL ON 3J N ❑ LU CL ui LU r� Q rid .-_0 The Commonwealth of Massachusetts Department of IfidustrialAccidents M - A r 1 Congress Street, Suite 100 F Boston, MA o2114-2017 f �< www mass.gov/dia ODM SY•�9 Wokers' Compensation Insurance Affidavit: Builders/Cont�raetors/Electricians/Plwmbers. r TO BE FILED WITH THE pEg�TTIPIG AUTHORITY• Please Print Lessibly_ Anca-- ---VAivacia„a Name (Business/Organization/lndividual): Address: �'c Ci /State/Zi "^ ' %� , 01A 0l�K Y Phone #: 9� tY p: Y�� Type of project (required): Are you an employer? Check the appropriate box: em to fiill and/or part-time,).* 7. [1 No 'oonstructlon 1.[] I am a employer with P Y ees ( 2 M I am a sole proprietor or partnership and have no employees Working forme in $. Itemodeliiig an ca acity [No workers' comp. insurance required.] 9• El Demolition Y P 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10E] Building addition 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Elecixical repairs or additions ensure that all contractors either have workers' compensation insurance or are sole . 18 ` 12. 'Elumbing repairs or additions proprietors with no,employees. 5. L]I am a general contracto land I have hired the sub -contractors listed on the attached sheet. 13•. ] Roof repairs These sub -contractors have employees and have workers' comp. insurance.: 14. Oilier 6.FJ We are a corporation and its. officers have exercised their right of exemption per MGL c. 152 91(4) and 'we have rio empldyees. [No workers' comp. insurance required.] *Any applicant that check's box 4l must also fill out the section below showing their workers' compensation policy information: Horneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. r,.. tContractors that check this box mustattached an additional sheet showing the name of the sub -contractors and state wheiher or not (hose, entities, have employees, If that subcontractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. elow is the policy and job site B information. Insurance Company N Policy # or Self -ins. Lie. Expiration Date:- Q q s�+ o SV 2b4 k A City/State/Zip: Job Site Address: mpensation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' co a criminal violation punishable by a fine up to $1,500.00 Failure to secure coverage as required under MGL c. 152, §25A is enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p ay be forwarded to the Office of Investigations of the DTA for insurance day against the violator. A copy of this statement m coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct i, // Phone #: Official use only. Do not write in this area, to he 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 r e 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'6r- 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•whd 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 - Pleasb 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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia —1 1��/�- Date.................................................. TOWN, OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .&.\ C�P—e—C �—o ........................ ....... ...... . ............. ........ has pen-nission for gas inAallation . ................................................ in the buildings e iz- ........................................................................................... at ... 2.q ....... ... ................................................................................. North Andover, Mass. G4 Fee ._;� .. ...4............... Lic. No.. .... ........... Check # q I ?-a GASINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .E MA DATE �� '7 '!S'- PERMIT # CITY � � c+v�,�e 2 �� JOBSITE ADDRESS ti (Sl��� iy 1V.5 4 OWNER'S NAME -G J OWNER ADDRESS I TEL___ FAX ( :� TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL& PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: RE PLANS SUBMITTED: YES F- --Jj NOR APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER COOK STOVE C- �=1 R _ . _..- ... f I DIRECT VENT HEATER ----_- DRYER I_ -- FIREPLACE FRYOLATOR — L —j FURNACE GENERATORS .T... -I -_-- f - �---�- GRILLE _ -- - - - =----_ - _ .._ INFRARED HEATER LABORATORY COCKS_ MAKEUP AIR UNIT _ .. l .. OVEN POOL HEATER __ _ I ROOM / SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER `_ UNVENTED ROOM HEATER —Jl=== iT - -- -- 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 APNO 13 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Vp OTHER TYPE INDEMNITY Ej 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 Q 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 compli -ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ���26}-� LICENSE IS GNATURE MPMN MGF jII JP 0 JGF 0 LPGI E] CORPORATION 0# L �( PARTNERSHIP ®#� � LLC [J#= COMPANY NAME: 5Y% w �j ADDRESS _, CITY f'1?_ _ -� STATE ZIPTEL 1 - FAX (� 1 CELL ! EMAIL_-- con H O z z H U W P -i A � W z O w W }rl OE a U w qt z W L F- COD Q w CO CL O w w w Cf) a a sLn a a U J . F, a CL s w H LL H O z z 0 H U W W C�7 The Commonwealth of Massachusetts . Department of IndustrialAccidents I Congress Sheet, Suite 100 - Boston, MA. 02114-2017 �r www mass.gov/dia • a�Af SV. yt Workers' Compensation Insurance Affidavit: Builder/Contractors/Eleciricians/�lumbers. AUTHORITY. TO BE FILED WITH THE PERMMTT'NG APPncanLiuxvx,ua��vu ization/Individual): Name (Business/Org 'an , Address: v City/State/Zip: %•q O I -W Y Phone #: Type oftproject (required): A.re you an employer? Check the appropriate box: to full and/or part-time)'* 7. [1New'constru'otion 1.Q I am a employer with em P yees ( 21M I am a sole proprietor or partnership and have no employees working for mein 8. [] RemodeliAg any capacity. [No workers' comp. insurance required] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself [No workers' comp. insurance required] t 10E] Building addition 4.❑ I am a homeowner and will be, hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers' compensation insurance or are sole j sa- t. proprietors with no employees. J2T Plumbing repairs or additions 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13•.1 Rb6f rel airs These sub -contractors have employees and have workers' comp. insurance.t 14.Q Other 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no empldydes: [No workers' comp. insurance required] *Any applicant that check's box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submitithis ,affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this liox must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #:. Expiration Date: !�L/ fila j(, �� G Ci /State/Zi Job Site Address: t9-7 � ,q L p Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde�liepains andpenalties ofperjury that the information provided above is true and correct. Phone #: % b *l 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 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Phone Contact M Information and Instructions F 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 o£hb're, 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 receiv&'& 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 xequi'red." Additionally, MGL chapter 152, §25C(l) 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 certificates) 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 IndustrialsAccidents. 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 permitAicense number which will be used as a reference number. In addition, an applicant thai 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 beprovided 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 NOTrequired to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 219200.00 m $ - $ 254.40 Plumbing Fee $ 31.80 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 31.80 Total fees collected $ 418.00 24 Saltonstall Road 302-16 on 9/9/15 Kitchen Remodel May 16, 2014 THERlOBiIF0L0(r131ED11RiRflGR0UPm v FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 313 Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1474460 Insured: PAMELA L POIRIER ROBERT J POIRIER Address: 24 SALTONSTALL ROAD, NORTH ANDOVER, MA Policy No.: F0104545 Loss Date: 05/01/2014 Loss Type: Building or Other Structure Damage A 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, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, "a'aa '61 - Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 Date. 149. ► o , ti° 3? �` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �9SgACNus This certifies that . t z ............ has permission for gas installation ... 45 .................. in the buildings of .....P.Q. t 111. P.In........................... at North Andover, Mass. Fee. ),I" . Lic. No.. )XVI. ... &SINSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO ASFITTING (Print or Type) lUr��` , Mass. Date G Z/ P mit # t� J Building Location 2 y_ 1 /+ L /(—Owner's Name Type of Occupancy_ 0 New ❑ Renovation ❑ Replacement 0--_ Plans Submitted: Yes❑ No ❑ Installing Company Name CALL14-14-A--, Check one: Certificate # Address. 91 81&i76AZ El --Corporation —A&: 00 U&L, ❑ Partnership Business Telephone Ci'F C/��� 1 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ,r� Ls effLC d( / INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes B-- - No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A Ilablitty Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) In above 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 sli pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Zenral taws. Type of License: <( Title _ Plumber Sigfnb ure of/ricensed Plumber or Gas Fitter It asterr lJcense Number Cily/Town Journeyman u�r�rx7vr� o c . o ME NEMNEMIMEM M No MEMO No No' �mmm MOMEEMNE MININEEMUM mom *91 ENEEMERIENNEEM ME 0 Elm mom MENEM Installing Company Name CALL14-14-A--, Check one: Certificate # Address. 91 81&i76AZ El --Corporation —A&: 00 U&L, ❑ Partnership Business Telephone Ci'F C/��� 1 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ,r� Ls effLC d( / INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes B-- - No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A Ilablitty Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted (or entered) In above 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 sli pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Zenral taws. Type of License: <( Title _ Plumber Sigfnb ure of/ricensed Plumber or Gas Fitter It asterr lJcense Number Cily/Town Journeyman u�r�rx7vr� o c . o r_ v V m i> c o -1 � r � o m A m m X' a' m O 0 0 A w O X N N A O v ` m N I O a r_ v i> c x � o m m a' O a O A N y m r m C r m m m N A m -1 C) 2 m N m in r- 0 0 '71 0 m O m m 0 to C W m O X r 4