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HomeMy WebLinkAboutMiscellaneous - 265 HAY MEADOW ROAD 4/30/2018a r 6-1 _/z Date................. 7..% ........... TOWN OF NORTH ANDOVER This certifies that ...... if ....... PERMIT FOR WIRING has permission to perform .......... wiring in the building of .............. 5 .......................................... North Andover, Mass. at ........ . ..... ...... 'loru, P0 Fee..:$7�� Lic. No. ........... (9 L��Cm�(CAL INSPECrPR Check # C�op Z,,-I�F12- 1b t r Commonwealth of Massachusetts Fin Department of Fire Services la =­'pu ru BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [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 C R 12.00 (PLEASE PRINT IN INK OR 7-YPEALL INFORM TION) Date: 7 City or Town of. NORTH ANDOVER To the Inspect& ofVires: By this application the undersigned gives notice of hi or her *intention y perform the electrical work described below. Location (Street & Number) k &,ov,-/o 4J Owner or Tenant Telephone No. Owner's Address d -,0- I uildi permi Yes No (Check Appropriate Box) Is this permit in conjunction with 0 Purpose of Building 01 Utility Authorization No. f. u.,ez,( Existing Service Amps 'Volts Overhead Undgrd No. of Meters New Service Amps Volts Overhead Undgrd F1 No. of Meters Number of Feeders and Ampacity 4 Location and Nature of Proposed Electrical Work: tA—/ Lt 44'" Completion ofthefollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires /0 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 Ei In- grnd. grnd. E3 IVo--. —oT Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo. 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: INPMP.�T]Xn� KW ........... .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Mun'cc�Pl El Other Conne ion No. of Dryers Heating Appliances KW Security Svstems:* 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 ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with WC Rule 10, and upon completion. INSURANCE COVER ' AGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides propf 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. CBECK ONE: INSURANCE F1 BOND M OTHEREI (Specify:) I certify, under the pains an ena tesqfperj ry,that 1C, information on this application is true and complete. FIRM NAME: # le t-. / . - := '? ---, - � /-) 4d LIC. NO.: Licensee: A 14' V Signature LIC. NO.: (If applicable, enter "exempt" in. the license number line.) �f Bus. Tel. No.: �'Z&Fffd Zel;70 Address: 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 on0E1 owner El owner's agent. Owner/Agent Signature Telephone No._ FPERMIT FEE.- $ I-Rouo.� ..Py"c ON, --l-4 tZ of*lals) Pate k2. YMAL WgROCtIOW, pi; Ereecatox-[�E�Cil gignature -)ao wilals) Pate UNDOM GROW _WSPACTIO.N. Pas -sea—[ I rns'pectors, Comments: cinqv ecfors�' FignafRxe -)10 inims) pate —0 NAT-TONM� G 31:133; assocl—f I Re -Inspection required MOM) -I I ;Sell—F I pectoye - COVIMeAts: fta�turo - io �Ultlals) Pate aOR TAGS AM'XO33Y, MTXD P'UTAO XEFT ON131TEN TMAPXA TO 13NINSPECTUD 19 -NOT up The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address:- Ile City/State/Zip: 110t 61 rX51' Phone #:— 9 7n Are you an employer? Check the appropriate box: I - 0 1 am a employer with - 4. 1 am a general contractor and I (full and/or part-time).* have hired the sub -contractors hemployees 2. 1 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.] officers have exercised their 3. 1 am a homeowner doing all work 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. 0 New construction 7. Ka"kemodeling 8. E] Demolition 9. E] Building addition 10. El Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy andjob site fa in/ormation. I� surance Company Name: Policy 4 or Self -ins. Lic. #: Job Site 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. f do h ereby certtfy rderfie p*s 4thilpenalties ofperjury that th e information provided above is true and correct Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitALicense ,/J_ 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 #: 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 (LLQ 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 perinit/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. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX M70-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM Facsimile (214) 488-6766 "*******"�*'*'*******AUTO**3-DIGIT 018 753 T3 P1 95000058943 Building Conimissioner or Inspector of Buildings r W.J. 120 MAIN STREET mov EZ.'---: N ANDOVER, MA 0 1845 Mmm Claim Number: Policy Number: M Company Name: Cause of Loss: co LO C) Date of Loss: Insured: C, Property Location: 97A Cunning�am va indsey Form of Notice of Casualty Loss -to Building Under MASS. GEN. LAWS Ch. 139,, Sec 3B 2668675 266867502 BAY STATE INSURANCE COMPANY ICE DAM 2/15/2015 ANTHONY AND RENEE SERRANO 265 HAY MEADOW RD Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three' applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. 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. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 HENRY KARL RADEMACHER ............... ...... ............. * ....... -*-*-*-- ....... Methuen, MA 01844 978-681-8376 MA. Lic. # 20313-A # 27821 -E 978-681-8376 978-852-2970 cett June 14, 2013 Peter Murphy Town of Tiorth Andover Electrical Inspector I would like to cancel my permit for the kitchen remodel at Serrano Residence 265 Hay Meadow Road. In June 2012 1 was contracted by Dan Batat at Focal Point Renovations to perform the electrical work for this remodel. Prior to my involvement, the contractor had purchased the recessed cans and started to cut holes for them. My work was to install these fixtures and complete the -remodel witing for $1 M.00. After the rough inspection, I was paid $1200 �this includes the deposit I received). In November the contractor told me the homeowner wanted under cabinet lighting and would deal with me directly for this. I was paid $657 for this. At this time the original countertOD devices were still in place because the homeowners were still deciding on the back splash, I would replace the devices, install the island =tet and install the istand pendant lighting after the tile was installed. Since this tftne, I've not spoken with the contractor on this but ' I've received several text messages that the tile was on order, wrong tile came in, etc. I was busy s it wasn't or, jrny mind o IL L I U. On June 11, 2013, Tony Serrano called me and told me Focal Point was out of the picture and his tile installer need to know which outlet should be the GFCI. I told him that an unlicensed person shouldn't be doing this. I told him I'd be glad to connect with Focal Point, settle our terms and finish the project. He told me it's all done except for the GFCI. Again I told him that a licensed person should do this and if we can't find Focal Point, I would finish the project for less than the $,650 balance that was owed. At this point he threatene4d to take me tocourt if I wouldn't finish for free. I told him I understand his situation and asked him to consider mine. We could not come to an agreement so that's why I'm canceling this permit. Sincerely, Karl Rademacher P.S. VU be on vacation until June 28 th but, I'll have limited cell and email if you'd like to contact , Tlie. Page I