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HomeMy WebLinkAboutMiscellaneous - 32 CIDERPRESS WAY 4/30/2018 (2) �J --- I ro N THELII0211:11 -M ©CIIIII IL IGROUPo July 25, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B 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.: P1598125 Insured: MEETINGHOUSE COMMONS Address: 24, 26, 28, 30 & 32 CIDERPRESS, NORTH ANDOVER, MA Policy No.: R0623917A Loss Date: 07/24/2015 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, William Lamb Claims - Property manager 1-800-688-1825 x1137 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. i2c@ Fax:(781)329-1818 THEM021,,-,®(-QCT ®l�IIIIAI�II GROUP@ April 3, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B 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 11600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1592090 Insured: MEETINGHOUSE COMMONS C/O CROWNINSHIELD MANAGEMENT Address: 24, 26, 28, 30 & 32 CIDERPRESS, NORTH ANDOVER, MA Policy No.: R0623917A Loss Date: 03/07/2015 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, Lorraine A. Peirce Sr. Property Claims Examiner 1-800-688-1825 x1139 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. jv@ Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax:(781)329-1818 a Official Use Only Commonwealth of Massachusetts i l.�- [ '--"pnt of Fire Services Permit No. Occupancy and Fee Checked `^! 11-ATIONS [Rev. 1/071 (leave blank • a�TRICAL WORK b}'t7'LAO .7 CMR 12.00 Date TOWN O f Wires: pER F NORTH A vork described below. This MST FO N�OVER �hon6eN�o certifie s that. . . W�R�NG 'elepb'7 has permis -ze sion to per Wiring in fOrnl neck Appropriate Box) at the building of � �n No. �'3�o I �S 1T_ Fce �� ,,�/ y�Q No.of Meters fit• f 3 �" Lic N5, , . ✓3 No.of Meters °• ��.�•tr ''�! , North • • . Andover Check# D � Ando er, Mass. P5 EL CTR/CAI INSPi-��i ') &—ro ible may be waived by the Ins ector of Wires. Jo.of Total No. rr•� Transformers KVA No.of Luminaire Out a Generators KVA No.of Emergency ig ting No.of Luminaires Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS �m6fZones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: I Detection/Alerting Devices ElMunicipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection Heating Appliances KW Security Systems:" No.of Dryers No.of Devices or Equivalent No.of WaterNo.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or E uivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5,v oo (When required by municipal policy.) Work to Start: '(o z I t L— 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 cove is is. force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Lf BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. _ FIRM NAME: , h c A-C t< c�L7`'�< LIC.NO.: ) t Licensee: 1/u ((_ M>tL�t c��.41 ') Signature �LIC.NO/.: Z� (If applicable,rter "exempt"in the license number line. Bus.Tel.No.. -Iz$ Address: I ' 6 L W "'� A n t Ir ISS Alt.Tel.No.: o� *Per M.G.L c. 147,s.57-61,security work requires Department o License:Public Safety"S" e. 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. $ Signature Telephone No. e r J ! .- ' �JJJLftil.r.LJ.Lf.•�(��•7���i JI.L�/�Y�.'l�F•"ff.'��dL l�l•'�r .�j fj .'.•.1��jiL.r,}�1,�� J.®��i � r 720sset�.-,�_�� �'afleQ-�[ � �e-xnspeetzoxt3ret�uzxe�'(��'d.OQ)�[ � or �ns�ectoxs'�opxmexts: ir. �. (znspeefoxeigignatuxe-xQoMIals) .^ Pate 'asse +aile --[ ate ins ectioxt eo�uixe ( O.0 0)•-[ T �n�ecta�-s'comm,extts: (i iisp adaxs'giguature-)Io iuitials) Pate s,rJNDAR GROM 3NMO9CION. 'asset•-jiailet�--� e�istseetio�xec�uixet�($sd.4Q)H[ iaspectozs'coxnmextts: ' chigectoxs'sign ature-•1-10 initials) late ' �p'�ClTTOJ,i1•—i9EJ�,'�LJ CE: � . sse�-- �`aiie�--[ � �e�xnspectioxtxequixe�(�50.OU)�[ � ' ,,�iectbxs9 eoxam.epfs: . {Zuspectoxs',�ign2.tuxe••7io itials) date . OMR: Ta [ Wild, [ �_ '?fie�nspecttoxt�er�pixe[�($�0.0D)• [ � - eCtOx�'CAI2l�e11tS: � . Ohs gectoxs'signatuxe••3ao zurtials) date ' h� Y 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): Lr_CC.fN,.4,,C C_ Address: 4 , b-3 K d a b City/State/Zip: Lt,/,4�� v{vr-c_ _ ,v�,¢ ('hone#: Are y an employer?Check the appropriate box: Type of project(required): 1. I am a employer with L., 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.[�] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling 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 required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they 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: Lac AJ O J t,-Lk— Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Z 3 ���"1-Pou City/State/Zip: �(�)Q. `F' Attach a copy of the workers' compensation policy declaration pag (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 �ceit�under the pains and penalties of perjury that the information provided above is true and correct. Si natul v Date: op Phone#: 97 3t. 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#: 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 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 the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Devised 5-26-05 Fax# 617-727-7749