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HomeMy WebLinkAboutMiscellaneous - 240 MARBLERIDGE ROAD 4/30/2018 (4)m AMERICAN CLAIMS SERVICE MULTI -LINE ADJUSTERS BUILDING INSPECTOR/COMMISSIONER, BOARD OF HEALTH AND/OR BOARD OF SELECTMAN Building Inspector Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Insured: Morgan Address: 240 Marble Ridge Road North Andover Policy: PHO 0100 71 35 97 Loss Date: April 13, 2015 Loss Type: Addition and deck ACS File: 31996 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Tim McLaughlin Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 04/14/15 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 / FAX (781) 245-1077 E-MAIL — claims.acs@verizon.net Date...... ..... . ........................ VER .ATION Check# 1� (0 11 9441 ... P.�to ...................... er, Mass. ...................... GASINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I N. Andover MA DATE7/31/2014 PE IT # Lf G-1— JOBSITE ADDRESSI 240 Marble Ridge Rd OWNER'S NAME GOWNER ADDRESS Same TEL,�— i-1FAX1� TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: Q REPLACEMENT: ® PLANS SUBMITTED: YES❑ No El APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE I DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST i UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meters x and Associated Robg{ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 c mpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME I Joseph Marino LICENSE # 8736 SIGNATURE MP ❑ MGF ❑ JP ® JGF LPGI ❑ CORPORATION Q# 3285C PART RSHIP❑#LLC ❑#� COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 TEL 1 (508) 832-3295 FAX 508-926-4347 j CELL 508-832-4614 EMAILJMarino@RHWhite.com x\0 \\ ROUGIi GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY I FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES U)LU w <Z .0' LL (JOR. ..Lu -.0 2,< 1-4 << w oz CM3 U) LU IXU) LL[< LU L ®DATE (MMIDDNYYY( �- CERTIFICATE OF LIABILITY INSURANCE page 1 of z r 08/29/2013 THIS' OERTBFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CEIRTFFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conferrights to the oertificate holder in lieu of such endorsement(s). willira o£ Massaahusotts, Inc. c/o 26 Century Blvd. P. 0. Box 305191 Nashville, TN 37230-5191 R. E. White Construction Company, Inc. 41 Camra], 6treet P. 0. Box 257 Auburn, MA 01501 INSURERA:The ebartea Oak rico Sneuranco Company 25615-001 INSURER S:Tra1101*gi property Casualty Coiggany of Am 25674-003 INSURER C: National Union Piro Inauranca Company o£ 19445-001 INSURER 0; Travelers Indemnity Company 25658-001 �.�wlvn IYYIYI�Cr[� THIS IS TO CERTIFY THAT THE 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`. I IMIT^ti QW)W1111 hAAV UA%I= oocr.l M-1 ., .,— INSR TYPEOFINSURANCE OO SUB - - - -- POLICY NUMBER nu�uu vcu o POLICYEPF 9/7./,2013 r 1-/AfIJ I,LNI1Vlb. POLICY EXP LIMITS EACHOCGURRENCE $ 2,000,000 r� TO RENTF,p ��� 183(Eeoceuron�c 1 R 300. QQQ . A GENERAL X LIABILITY COMMP,RCIAL GENERAL LIABII.ITY CLAIMS^MADE OCCUR VTC2000 977209948-13 9/1/2014 MED EXP (Any one argon $ -LQ'-0 0 0 PERSONAL&ADV INJURY S 2AD0, QOO ]3 VTJCAE 977R955A,-13 9/1/2013 9/1/2014 GENERAL AGGREGATE $ 4-000 000 GEN'LAGGREGATE AUTOMOBILE LIMITAPPUES PER; POLICY PR4 LOC LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS HIREDAUTOS X NON -OWNED AUTOS Cont Dad X Cv11 Dad PRODUCTS-COMP/OPACsG $ X000 000 OMBJ(� E%SRGLFLIMIT . 3CCIdenl S 2,000,000 BODILY INJURY(Perperaon) $ X BODILY INJURY(Peraccidont) $ eraERTY TAMAGE ccida ^� X S EACHOccURRENCS $ 5,000,000 C D D UMBRELLA LIAB1 OCCUR EXCESS LIAe CLAIMS -MADE N(A BF6766Z40 VTC2K B 82057185-13 VTC2KUH A203A71A-13 /1/2013 9/1/2073 9/7,/013 9/1/2014 9/1 2814 / 9/1/3014 AGGREGATE $ $, 000, 000 DED $ RETENTIONS 10,000 WORKERS COMPENSATION ANDEMPLOYER8'LIABILITY y/N ArrvPROPRIE7oRrPARTNFRIFXECU7IVEl I NE OFFICERMIEMBEREXCLUDED7 u ((Irst ldto Ibbgm) U(yEtS Kale i ION uF UNI:RATIONS below }( 0 - TARYlJ, E.L.EACHACCIDENT F 1, 000 OQQ E.L. DISEASE-EAEMPLOYFE S 1,000,000 FJ., D18EASE-POLICY LIMIT S 1, 000, 000 )ESCRIPTION OFODFRAiI[)RIG f i nn^TIONSf VE Evidence of Inmurance WICLES (Attach Acord 107, Addlfonel Remarks Schodvin, II more ep sen Ifs naqulred) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE C*11:4197604 TPI:1694012 Cert. -20287680 ©1988-2010ACORD CORPORATION, All rights reserved. CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Date � . /-�/- a "), ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ........................... .................................. ... .. ..... ......... has permission to perform wiring in the building of ... ............. ............................. 22' W ..... ...... North Amdover, Mass. ..... .......... at r.7--.. ...... ... �- 9� e7 Fee �� ............ Lic. Noe��-A$h4 ................ ...... ELECTRICAL INSPELM Check #,2 4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.�j'a Occupancy and Fee Checked r� [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: ---/0//4J0 f City or Town of: NORTH ANDO'V'ER To the Inspector of Wires: By this application the undersigned gives notice. of his or her intention to perform .the electrical work described below. Location (Street & Number) '4Lt 0 MR rbl e f eyal.e roa 6 Owner or Tenant R o Telephone No. Owner's Address SfJIM Is this permit in conjunction with a building permit? YesNo �j ❑ (Check Appropriate Boz) Purpose of Building f 1, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity --- , Location and Nature of Proposed Electrical Work: cm -e -,r - QpF,', No. of Meters No. of Meters rt/17or�,� + Wh=•.u�.�--&tunar aerau u aesirea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (en required by municipal policy.) � Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE .COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage ism force, and haa exhibited proof of same to a permit issum, office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER. (Specify:) I certify, under the pains and penalties of perjury, that the informationthis applicaharis true and complete. FIRM NAME: n �G LIC. NO.: 035S Licensee: AT 1`P i'1 J- M r A i Signature LIC. NO.: ' 0 �$ (If applicable, enter "exempt " in the license number line.) nn Address: 0 /s / Bus. Tel. No.: % S 1 1 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lec. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ qk.& jPt t-4-4e- `f) "C t ,- www.rrxass,gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/ElectricianOpium hers Applicant Information Please Print Lem_bly Name (Business/Organization/Individual): Iin I Address: P, 0 . City/State/Zip: L rL4 ✓,�./ 00TF_ S Phone #: 721 3a/ 9g43 Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts I . i Department of Industrial Accidents `: ►� Office of Investigations ' ' �•''' 600 K'ashinagton Street \\r- Boston, MA 02111 workers' comp. insurance. [No workers' comp. insurance t ,- www.rrxass,gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/ElectricianOpium hers Applicant Information Please Print Lem_bly Name (Business/Organization/Individual): Iin I Address: P, 0 . City/State/Zip: L rL4 ✓,�./ 00TF_ S Phone #: 721 3a/ 9g43 Are you an employer? Check the appropriate box: l . ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/orpart-time).* have hired the sub -contractors 2Aemployees i am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised. their right of exemption MGL myself [No workers' comp. per c. 152, § 1. (4), and we have no insurance required.] t employees. [No workers' er comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I O'J�?`Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs I.3.❑ Other -- - n ,,,"L also uu oui the section below showing their workers' compensation policy information. t i iomeowners who submit.this affidavit indicating Utey arc dutiig Eli work a ict Ehen hire cuside contractors musi submii.a new arndavit indicating such. +Conuaotors that check this boa must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an emploVer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ` %% Insurance Company Name:_ ( � r ! 4 1,016 A0 Policy # or Self -ins. Lic. #: 3V Expiration Date: C 7 0 0 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 ofth�for insurance coverage verification. I do hereby c i under a pai penalties o pry that the information provided above is true an correct Siartature: � J� �v� Phone #: 3 Official use only. Do not write in this area, to be completed by city or town offcciaL City or Town: Permit/l ii Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector $. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or.trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' 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 lam, or if you are required to obtain a workers' compensation policy, please call the Department at the nnmber.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 permitliicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/iicense 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. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-72:7-7749 Revised 5-26-05, www,inass.gov/dia