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HomeMy WebLinkAboutMiscellaneous - 32 HARKAWAY ROAD 4/30/2018 32 HARKAWAY ROAD 210/095.0-0053-0032.0 t I LaMarche Associates 5 North Road, P.O. Box 250 RECEIVEDy . ._�. �_ Chelmsford, MA 01824 10d PiP,r " ^"~ + 978-256-8586 Fax: 978-256-8590 2014 SEP 1 I AM 11 September 9, 2014 ' -ry Building Commissioner/Inspectori;o ullctir�g�="i 1: NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, 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, cause of loss and LA file number. Insured: 32-34 HARKAWAY CONDO TRUST Loss Location: 34 HARKAWAY ROAD NORTH ANDOVER, MA 01845 Policy Number: BOP007019601 Date of Loss: 9/6/2014 Cause of Loss: Wind LA File Number: MA-2-25069 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. Cara Murphy Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 LaMarche Associates 5 North Road, P.O. Box 250 RECEIVED � Chelmsford, MA 01824 T OLIN Cit`"1 978-256-8586 Fax: 978-256-8590 WN SEP 1 I AM 11: September 9, 2014 a� Or Building Commissioner/Inspector;otu:ijactirl' `.I T } NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, 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, cause of loss and LA file number. Insured: 32-34 HARKAWAY CONDO TRUST Loss Location: 34 HARKAWAY ROAD NORTH ANDOVER, MA 01845 Policy Number: BOP007019601 Date of Loss: 9/6/2014 Cause of Loss: Wind LA File Number: MA-2-25069 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. Cara Murphy Adjuster LaMarche Associates,Inc.-600-349-1525 Page 1 of 1 LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 978-256-8586 Fax: 978-256-8590 September 9, 2014 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, 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, cause of loss and LA file number. Insured: 32-34 HARKAWAY CONDO TRUST Loss Location: 34 HARKAWAY ROAD NORTH ANDOVER, MA 01845 Policy Number: BOP007019601 Date of Loss: 9/6/2014 Cause of Loss: Wind LA File Number: MA-2-25069 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. Cara Murphy Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 Date.. ..'. ...f.�...3...... ponrN TOWN OF NORTH ANDOVER PERMIT FOR WIRING s4cMuse This certifies that ....................fA.... 'JE ,.....G✓r/ G/.S�.. ........n4 e, has permission to perform ...... �....0 wiring in the building of..�..( � �`/j 1'T i� ........................................................... .................... .........A.................... orth Andover,Ma v� Fee.)/.C)..::=.....Lic.No. .. .............. .!..7.................... .... . _ ........ ...... r E E CAL INSPECTOR' Check# �� 4, l,ommonwea&o f MjacLeffi Official Use Only c� Permit No. J�Z/ 2, a1JePartment 013ire Servica9 BOARD OF FIRE PREVENTION REGULATIONS 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(NEC), 7 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFXV4A— TION) Date: 31H It 3 City or Town of. f To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the Rjectrical work described below. Location(Street&Number) 32,—3 �IAJ2k/9 W Owner or Tenant MrL` 7071 Telephone No.V g—AP—770- Owner's Address Is this permit in conjunction with a building permit? I'es No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. J.�� ;Z 7 Existing Service 10 O Amps / U Volts Overhead Undgrd❑ No.of Meters p2. New Service aw Amps 00 /a QVolts Overhead JK Undgrd ❑ No.of Meters _ Number of Feeders and Ampacity b Location and Nature of Proposed Electrical Work: ar' �^D AW aA-x, dt V � l/u 1 Completion of the followin 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 SwimmingPool Above ❑ In- El o ting Emergency Lig b arnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained ........ ....................................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent Ballasts Heaters KW No.of No.as Data Wiring: Signs No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: r No.of Devices or Equivalent OTHER: .,� Attach additional detail if desired,or as required by the Inspector of YVires. Estimated Value of Electrical Work: (When 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 cove be is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Ef BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,thatggiaa nform tion)0n this applicatign!�� ue and complete. FIRM NAME: p ^ & LIC.NO.: q Licensee: J d� L, {� "m Q U e'. Sre LIC.NO.: (Ifapplicable, enter "exem tin he lirense umbel line.) Bus.Tel.No.: Address: /u Z 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 one) ❑ owner ❑ owner's anent. 1 Owner/Agent Signature Telephone No. PERMIT FEE: $�� ..� d ,� , 1 ne (,commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i' 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/Organizadon/Individual): t� E •� C Address: IDA_ City/State/Zip: rA2A -CQ Phone#: A e you an employer?Check the appropriate box: Type of project(required): 1 I am a employet with 4. ❑ I am a general contractor and I g 6. E]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 I 0.[V Electrical repairs or additions 3.❑ I 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' 13.[1 Other comp.insurance required.] . *Any tVplicant 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: (} Policy#or Self-ins.Lic.I#:_ W-� a-0 Ott 0 S 3 Expiration Date: Job Site Address: (n(� City/State/Zip: ti Attach 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. I do hereby certify under the pains nd penalties of perjury that the information provided above is true and correct Si nature: Phone#: 04- a — 10 5 FIBoardof ly. Do not write in this area,to be completed by city or town official Permit/License# ity(circle one): alth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1 \Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,-4 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 tor 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-contractors)name(s),addresses)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 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia s ' :COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS " AS A-REG JOURNEYMAN:ELECTRICiA { ISSUES THE ABOVE LICENSE TO JOSE .L MARQUEZ PO :.BOX 1 f LAWRENCE MA 01842,:-OO.Q1 i6 927 :39744 E 07/31/13 . 1 .. Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �v I This certifies that . . . . . . . has permission for gasC.pp. llation . . PS . . . . . . . . . . . . . . . . . . . in the buildings of. . . Z,... . . . . . . . . . . . . . . . . . . . . . . . . . . . at . .32-- .1�2�(_,�. t.. . . . . . . . . . .North Andover, Mass. . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# j 8596 I F F U .s MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:—NO— ANdO MA. Date: Permit# Building Location: WAV - Owners Name: QcL GType of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES W co vi W F- CO) v = z W 0 W w v CO IN- o = co w z l'- a Ix z "' } W z to O F- W W W g m 00 Q a W O O W X W F V W W W Z W N O w FW- p = Z WWu J F 1Q= LU O z J 0 u- = W W W U O t=i C9 2 = O a. H> >> O SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 TH FLOOR 5 FLOOR 6 TH FLOOR, 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: Q � 2 Corporation Address: Yt . 60 City/Town: 4�. State: ❑ Partnership Business Tel v- T/S— /O.J Fax: %7� - pfd g--d� �� A � p�Q Firm/Company Name of Licensed Plumber/Gas Fitter: Jc7S .( , � L �� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy � Other type of indemnity E] 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 Signature of Owner or Owner's Agent Owner El Agent E] By checking this box❑;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. By Type of License: [}-Plumber Title p-Gas Fitter ig t Licen er/Gas Fitte ['Master , City/Town El—JouratP Installer License Number: APPROVED OFFICE USE ONLY �P Installer 01 N qk n 4 S 'pot The Commonwealth of Massachusetts I--.... Department of Industrial Accidents .J','F—= Office of Investigations 600 Washington Street "{ . Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contractors/]Electricians/Plurnbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): M� QUb 7, UM t Yi1�ilU/tiICAI L � Address:_ City/State/Zip: D 18gt Phone#: FAre you an employer? Check the appropriate box: 1.[ I am a employer with�_ 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. El construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [N6w6rkers'. comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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 $Contractors that check t g such. his box must attached an additional sheet showing the name of the he 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. information.an employer that is providing inffoworkers'compensation insurance for my employees. Below is the policy and job site e,. Insurance Company Name: 1 C A b/ vk- Policy#or Self-ins.Lic.#: Vy (r, a C) D_0 C)0 S3 Expiration Date: oZ / Job Site Address: 2 Z 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. ,1 do hereby certify u er the pains and ties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: )tn, 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 COMMONWEALTH OF MAS' SACHUSETT ' PLU[j E3ERS AND GASFITTERS • �JCEN,,,:D AS A MASTER PLUMF3ER `. ISSUES THE ABOVE LICENSE TO: M.! RQUEZ PO lix `1co LAWRi OC:E MA 01842.-0001' ` . � I 15/01/14147775 i - COMMONWEALTH OF MASSACHUSETTS I SHEET -rA a I AS A MASTER-UNRESTP.ICTED ` ISSUES THE ABOVE LICENSE TO: JOSE:.--L< MARQUEZ m ; �; R0 BOX i LAWRENCE MA 01842-00.01 � . 12498 04/28/1.3 7.921• >. } i i i COMMONWEALTH OF MASSACHUSETTS : • - OF ELECTRICIANS AS A,R.EG JOURNEYMAN EL'ECTRICIAM ISSUES.THE ABOVE LICENSE TO, JOSE ,.L MARQUEZ PO BQX" 1 LAWRENCE MA 0184.2 0001 - - :39744 E 07/31/13 `814;927 kl;am .. I . i I i i 1 01.11808 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . .,Tas e— Al. . . . . . . . . has permission to perform lf"b .""7. . . . . . Lplumbing in the buildings of. . . . . at . . . �` '. ,�,o , . , . . . . . . North Andover, Mass. Fee .�q':59. . . Lie. No. PLUMBING INSPECTOR Check 4 ICi _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY R - - i� _I MA DATE _ PERMIT# C JOBSITE ADDRESS ! L. /1�`TK.�RC1J OWNER'S NAME (,(Q - a POWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL O RESIDENTIAL PRINT /� �1,. CLEARLY NEW: 01 RENOVATION: REPLACEMENT: 01 PLANS SUBMITTED: YES© NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 _ 7_- 8_ 9. 1.__.._0 11 ...._._.12._- ._-13__IiI(I(4E 1...4 BATHTUB CROSS CONNECTION DEVICE ------ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM ...... DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN -----_t FOOD DISPOSER r' FLOOR IAREA DRAIN t _. 1 .__.-__I _.__-_-_ ____._1 ( .__._..._I ____.__� _..---__.i ...... _.___.� ..............._t _......_� ( --..___{ INTERCEPTOR INTERIOR KITCHEN SINK ---__- LAVATORY ( J .._! 1 -_--_--._-! .__---! -___-_J _-_._._-1 _.___.__ _.____f ..-_...1 ROOF DRAIN ( -J __I _-____I __. l _--_J _-`{ _._.___! ._.--J _l _ SHOWER STALL f _.. I ( ___( .__.___I —__f _.n._._1 _t ..___J _.__1 __..-.. .__J __.( SERVICE/MOP SINK ._._.._� ____I _l ! T ILET I I __.._._.J ._ _f J —_ .J 1 .__-_.J T ( ___] _ _ 1 URINAL _4 .....___-_I f I ..___-t _....__.1 L.7.21 ._--.__-_i -_.._--.t _____._I .._._..__J _-__._....t ........___-J +ASHING MACHINE CONNECTION 4 ATERHEATERALLTYPES I I ! t -- ( _..._�! ._-1 .^. .I L.-_ii ......i=J WATER PIPING ( - iJ _._.._.t _I d ---_-__I _. ! 4 _ ( ._.-._.._i I OTHER _._.___ -_i ..___....__I II — �I INSURANCE COVERAGE: �( I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESkT NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY D) 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 E-11 AGENT j 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 compl'ance wi II Pertinent provision of t { Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L v I LICENSE# ' MP a_ JP CORPORATION Vj1# ;PARTNERSHIP 0# _3 LLC/O 0 /q8 COMPANY NAME el ri;T DDRESS CITY[ �/��t _ ;STATE /Gtg ; ZIP Q/ �/� TEL FAX g-�1/B�G CELL ----, EMAIL ` 1 y , 5 \a�7 �r, V �— t c.� etc ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Q Z A a I r 1" The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Ut www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ✓m aroy e Z Pto m r L w Address: if),, o . ox City/State/Zip-XX_4 W fz"C.p, i1/1 q d 1 y/ Phone#. Are you an employer?Check the appropriate box: Type of project(required): 1.LTJ I am a employer with I 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.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 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.]f employees.[No workers' 11dother comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. A Homeowners who submit this affidavit indicating they Aire 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. G(�f Cc / Insurance Company Name:. `/ a 4- Policy#or Self-ins.Lic.#: r/(J C, J-0 0-0 0 d 30 83 Expiration Date: r}// Job Site Address: 32—: t, ll-V &ad City/State/Zip: /Ur?. 2�/d4 � zU Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby cert under the pains and penalties of perjury that the information provided above iistruu and correct, Simature: Date: Phone#: 70 1 —l 0 Official use only. Do not write in thi 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 ofhire,- 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-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 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 CommonweaXth 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 Revised 5-26-05 Fax#617-727-7749 www.mass,gov/dia COMMONWEALTH OF MASSACHU.SETT • 03 ; PLUf r DE• '� • � RS AND GA5FI7T�R5 -ICD AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO JUS L M! RQUEZ ,: } P O V-)X I C.� AlA 01842.-0(101; i 115,1 15/01/14 , 14777 5 COMMONWEALTH OF MASSACHUSETTS° j SHEET METAL WORKERS-' AS A MASTER-UNRESTRICTED:. ` ISSUES THE ABOVE LICENSE TO'..; i` JOSE.:. L..% HARQUEZ in PO BOX°..1 LAW RENLE 14A 01842 0`001 r 12498 . 04/2$/7.3 ]..9213..:;::'`:.: • all • '� �• .................. OF NORTH, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that............H.......A...�.r........� z -414oal ...............................I..... has permission to perforinee U,-%Nq-k V-Tr -A wiringin the buil ing of ............................................................................ ..u.-'1..............:.............. ... North Andover,Mass. -ZIP- Fee!5��................... Lic.NoAj]...... 04........ .. ....... ECTRICAL SPECTOR Check# 1 WILL ntslwLza o:iDa.m.-9:JU a.m. for same day inspection Commonwealth of Massachusetts Official Use only ° Department of Fire Services Permit No.—r �� BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked 1Rev. l 1199] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC)�/7(, 1 .00 (PLEASE PRINT W INK OR TYPE ALL IN O TION) Date: / City or Town of: n, 0 To the Inspector of Wires: By this applioation the undersigned gives notice of his or her intention to erform the electrical work described below. Location(Street&Number) Owner or Tenant e Telephone No. 76 Owner's Address S/9 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Au horization 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 Pro osed Electrical Work: v W � Pt - Com letion o the ollowin table m be waived b the Ins ector o Wires. No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No. of Hot Tubs Generators KVA No.of Lighting Fixtures swimming Pool EDAbove n- A01 .o mergency ig Ing ❑ rnd. d. Batte Units No. of Receptacle Outlets t{ No.of Oil Burners FIRE.ALARMS No. of Zones No. of Switcheso.o etection and 1 No.of Gas Burners Initiatin Devices No. of Ranges No.of Air Cond. TonsTota] No.of Alerting Devices SS No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained a Totals: Detection/AlertinLy Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems: o. of ater No.of Devices or E trivalent Heaters KW o Si ns Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent Z OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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: INSURANCE J BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical.Work: (Expiration Date) {When required by municipal policy.) ofi 1 Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. YJ I certify, under thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: r, G Cdgkc ' LIC..NO.: - t� Licensee: b! ignature - I (If applicable, enter "ex pt"in the license numb line.) 10. Address: 01 5 1. a' , ra Bus.Tel.No.- ' OWNER'S NSURANC WAIVER: I am aware that the Licensee does not have the .ia t ityAlt.Tel. o.,-- coverage normal] S� required by law. By my signature below,I hereby waive this requirement. I am the check one y Owner/Agent ( El El agent. Signature Telephone No. PERMIT FEE: $ - .� C�Ounal A powers & Corm --__ y Offered By Councillor g-gi ,� �46�HeL1� �. Cate: AucTust 28 , 2006 ° 7-t kn Ordinance ReauirinQ The Installation of An Outside Electrical Disconnection Device and The Installation of Common Area Electric . Meters. --------------- Be .Be It Ordained By the City Council of the City of Revere _ Section 1. Title 15, Chapter 15,04 of the Revised Ordinances of the City of Revere is hereby amended by adding a new section as follows: Section 1S.04.1Electrical Disconnection Device , All persons applying for an electrical permit for all new construction, where substantial renovation is involved,-or any alterations to an existing electrical service, or any change in the use or occupancy of the r structure, shall.be required by the Wire Inspector, to install an outside electrical disconnection device to shut down electrical power to the structure in the case of an emergency. Section 2. Title Z5, Chapter 15.04 of the Devised Ordinances of the City of Revere is .hereby amended by adding a new section.as follows: . . . _ . ..,5 eetion�:s;Q4r�?�:�•Eleetr-icMuer All . .. .�. persons applying for an electrical permit for a new two family dwelling or for a multi-use dwelling, where common areas exist, and for all construction where substantial renovations are involvedf where ri common areas exist, shall be required to install an electrical meter for the-proposed use as well as. a separate electrical meter for the common areas, 6N Ine t,'ommonweaim 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/Organiza6on/Individual): l.V l q z_ u� , LJ Address: 9, a . City/State/Zip: ,t,(1 .e Ci j 4Phone #: O " T <<J /C)5 r)Are you an employer?Check the appropriate box: Type of project(required): �I am a employef•with / 4. ElI am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors6. ❑New construction.F_1 I am a sole proprietor or partner- listed on the attached sheet 1 7• [J Remodeling ship and have no employeesThese sub-contractors have 8. E]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 10,9 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.6 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' comp.insurance required.] . 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeownm 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 andjo b site information. Insurance Company Name: Policy#or Self-ins.Lic.#:_ W(�, Expiration Date: �-�-- + Job Site Address: lrr� City/State/Zip:Ao ' AVIA) J ep, Al l Cl l�It 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 civilenalties in the form om1 of a STOP WORK ORDER and a fine of up to$250.00 a da against y g t the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains d penalties ofperjury that the information provided above is true an correct. Si nature: Date: l l 3 Phone#: Official use only. Do not write in this area,to be completed by city or town Effilcia City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electmbing 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 tor 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-contractors)name(s),addresses) 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 ipdicating current A 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,IIIA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia Date...... . ../. .. . ...... .. NORTH o� TOWN OF NORTH ANDOVER ' PERMIT FOR GASINSTALLATION . a h SACNUSEtt 7 This certifies that . . .do I-e'4 — . pee?f.4. . . . . . . . . . . . . . . . . . has permission for gas installation 7R4 7�-. . . . . . . . . . . . . . . . . . � in the buildings of . . .�r'.0.n. . . � . .PAZ. . . . . . . . . . . . . . . . . . at . . .. . . . . . . . . . . . . .. North Andover Mass. 071 Fee. .�la S� Lic. No.:- /. ��� ,Lr � . . . . . . .GAS INSPECTOR Check# /1�D 7915 J V MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: u , MA. Date: _ permit# a� Building Location: Owners Name; Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration:[❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES tY co u� W W 0) W Q U)LU U x O W 0 W N m x f- W V W F- O x W w O z Z p W IY W 0 f- p y W W W m 0 Q a w o O Q r W F v w U) W 0 ~ w a p Q w � = x Z U WLL Z O J 1... F O Z J (� LLXWI— x Z W it O Q IY w W to W O z 0 0 F- > z I-- :C2 � > 090ujzzUj 1-- SUB BSMT. BASEMENT j—FLOOR iffo FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 -FLOOR Installing Company Name: (�„ Check One Only Certificate# �p ��/ El Corporation Address:_ ,t• r?j ilWTown: l'" State: �( `��C / ��C`�/X:— z�� Partnership Business Tel: [L J (.� Name of Licensed Plumber/Gas Fitter: C El Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 19 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 Signature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box❑;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. By Type of License: �Plumber Title Gas Fitter Signature of License lumber/Gas Fitter ❑Master Cityfrown [Journeyman License Number: APPROVED OFFICE USE-M,Y ❑LP Installer The Commonwealth ofMassachusetts Department oflntlustria[Accldents Office of Investigations' 600 Washington Street Boston,MA. 02111 www.mass gov/claa Am licant Information Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers bl Name(Business/organization/Individual): CoII Please Print Le i L tu Address:-LA9CCDO(D City/State/Zip:" y t/ //4- d RV lPone#: C - `7 0 ��� [EII an employer?Check the appropriate box: a employer with 4. ❑ I am a general contractor and ITypeof project(required): loyees(full and/or part-tune).* have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached sheget.t 7. ❑Remodeling and have no employees These sub-contractors haveing for me in any capacity. workers'comp.insurance. $' ❑Demolition workers'comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition red.] ,officers have exercised their 10•❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions lf.[No workers'comp. c. 152, §1(4),and we haveno ance required.]t employees.[No workers' 1211 Roofrepairs comp,insurance required.] 13.M Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required Wider Section 25A ofMGL e. 152 can lead to the imposition of criminaldate). fine up to$1,500.00 and/or one-year imprisonment as well penalties of a as civ' Of up to$250.00 a da against civil penalties in the form of a STOP WORK t the ' � ORD Y g violator. Be ER and a advised that a copy of this statement m fine Investigations of the DIA for insurance coverage verification. may be forwarded to the Office of I do hereby cer i y under the pa' s and penalties ofperjury that the information provided above is true andcorrect. ` Signature: e ?hone#: 7 Date: FOfj7c!ause only. Do nod Write in this area,to be completed by city or town official own: Permit/License# uthority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: Information and Instructions ctlons 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-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 Iicense 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 referencd 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(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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related for 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 Office of Investigations would like to thank you iu 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: Tlxe olonv,�eal` r oa MassachLiSetts Department of Industrial Accidents O e,e(I1UVeSUgat[ons _ 600 Washington Street Boston;M. 02111 TeI.#617-727-4900 ext 406 ox X-877-MASSA FE Revised 5-26-05 Fax# 617-727-7749 WWW- ass.jZ-ovMa 1 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424 111312011 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 NORTH ANDOVER HEALTH DEPT. = - NORTH ANDOVER TOWN HALL EIV NORTH ANDOVER MA 01845 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Re: Insured: JUAN LOPEZ Property Address: 32 HARKAWAY RD UNIT 32,NORTH ANDOVER,MA 01845 Policy Number: 1043119 Type Loss: Fire(including Fire caused by Lightning Date of Loss: 1110112011 Claim Number: 296940 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139,Section 313 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 or file number. MPIUA Claims Division CMA00021