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Home My WebLink AboutMiscellaneous - 28 CEDAR LANE 4/30/201800 0 m I I 1 9 r M Commerce INSURANCE - December 19, 2014 The Commerce Insurance Companyw Citation Insurance Companyw I I Gore Road, Webster, Massachusetts 01570 508.949.15001 www.commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 Board of Health or Board of Selectmen Town/City Hall RE: Our Insured: JOHN RAPOSO JR / JACQUELINE RAPOSO Property Address: 28 CEDAR LN Policyk BCYHHM Date of Loss: 07/03/2014 Filek JTNW51-HKCVY8 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, 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 my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. REBECCA MCGOVERN THERRIEN Telephone: (508)949-1500 Ext: 15189 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15189 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. December 19, 2014 CIC 254 (Rev. 4/95) MAIL M33 US This certifies that Date. TOWN OF NORTH NNDOVER PERMIT FOR PLUMBING ............ has permis�ion to perform ................. plumbing in the buildings of .................... at ............ North Andover, Mass. Fee,.,.z5- ...... Lic. No. .... ....... Check # 4N.� =NSPECTOR MASSACHUSETrS UNIFORM "pLICATION FOP, PERMrr TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 2�,- ce&,AR- 6 A,,' Owner New 0, Renovation Replacement I fli V41-1AiFFY-qrN Date Permit Amount Plans Submitted Yes rl NO [3 (Print or type) Check one: Certificate Installing Company Name Corp. Address _ Ad &� - 7 71'1 Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by chmking the appropriate box: Liability ins� policy M Other t3W of indemnity Bond Insurance L the undersigned, have been made aware that the licensee of this applicaton does not have any one of the above three insurance Signature I Owner Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and * tZan t, is P med under Permit Issued for this application will be in g CW4��E�,T ms coulpliance,�Nitb all pertinent provisions of the Massachus S urnbin 142 of �the (General Laws. By: Sip7mulre or I %,,� f0A14Uz"—" bing Lic=e Title Tyr =j City/Town ;z 17,9 ff �, — I APPROVM (OFFICE USE ONLY MEMO Number Master Journeyman v C, The Commonwealth of Massachusetts Department of rndustrial Accidents Office of rnvestigations ..600 Washington Street Boston, AL4 o2111 UV www.massgov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please P, Name (Business/Organization/Individual):—.- Z/ -3 -C 4 -SO Address: P_ City/State/Zip:_ Jq - & 0 �9ZO Phone #: Are you an employer? Check the appropriate box: 1. El I am a employer with — 4. 1 am a general contractor and I employees (full and/or part-time).* 2. E5(+am have hired the SUb-contractors a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' Comp. insurance. [No workers' comp. insurance 5. 0 We are a corporation and its required.] 3. 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-) 7fl Z13-,�,7V Type of project (required): 6. E] New construction 7. Remodeling 8. Demolition 9. Building addition 10 -El Electrical repairs or additions .11.0 Plumbing repairs or additions 12T� Roof repairs 131� Other -11 UUL Lau Ve! —0 0"�' '" "t- th--- w0rr=� compm—sation poliev information. 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 insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: fAttach a copy of the workers' compensation policy declarati City/State/Zip: on page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M'GL 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 certift under the . ns andpe s ofperjury that the information provided above is true and correct. Cl 1 77, ZI—i 7-0 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone to, 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 To,%m 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 Washuigton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 wwv,.mass..gov/dia 3469 Date. . ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . '. . . . r,-. �'. .'� has permission for gas installation ...... r/- ......... in the buildings of ... ............................ at ........... North Andover, Mass. Fee. Lic. No. .......... GASINSPECT61� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer <E. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 0__ (Print or TYPO po/rV Mass. Date tl Permit 0 Building Locati d (f _r / /j on 114jiA-e —owner's Name 0/,?' Type of Occupancy New C] Renovation. 0 Replacement (3 Plans Submitted: Yeso NoV Installing Company Name z Check one: Certificate Address �/V, Corporation )j A4 4 " 0 Partnership Business Telephone/ 7d'p C3 Firm/Co. Name of Ucensed Plumber or Gas Fdter INSURANCE COVERAGE: I have a curre$ liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability insurance pollcyI5 Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement Check one: OwnerO Agent C3 Signature of Owner or Owner's Agent I hereby certify that all of the details and information I 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 ap I' ti 'IPbe in pliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General L Aw BY of Ucense: Plumber Signaturd-of Licehsed Flu�nber or Ga4/Fitter Title Gasfifter Master Ucense Number City/Town Journeyman APPPaRffTo-TF1ZE USE ONLY)