The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 40 CIDERPRESS WAY 4/30/2018 (2) THEMIIIIG:®[-SCC{ 015®L-7aCIIGROUP® April 2, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1591923 Insured: MEETINGHOUSE COMMONS C/O CROWNINSHIELD MANAGEMENT Address: 34,36,38,40 CIDER PRESS WAY, NORTH ANDOVER, MA Policy No.: R0623917A Loss Date: 02/12/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Lorraine A. Peirce Sr. Property Claims Examiner 1-800-688-1825 x1139 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. ® Fax:(781)329-1818 THEMORIFO[l K ®[EEDN 16`�fli GROUP® March 24, 2015 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1591189 Insured: MEETINGHOUSE COMMONS C/O CROWNINSHIELD MANAGEMENT Address: 34,36,38,40 CIDER PRESS WAY, NORTH ANDOVER, MA Policy No.: R0623917A Loss Date: 03/02/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Linda E. Babineau Property Claim Examiner 1-800-688-1825 x1253 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. ® Fax:(781)329-1818 Date .g:-. � Fktincxdcgs • ��.n TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . .+��.►.YY{C� c,.. . . .' �'� Z G . L has permission to perform .��.�. .�'on�c�. . .S�jLu►.4�.� . . _�/OD ; wiring in the building of . . . . . . . . . . . . . . . . . . . . at . . . 4.r. 3(� .�.3 j'.i Y(�. . . x'1.1. orth Andover, ass. ��Z �� Fe��y��. . Lic. No. . . . . . . . . . . . . ELECTRICAL INS CTOR Cl ck# I, IuU / 'Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.- 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 (PLEA SE PRINT IN INK OR TYPE ALL INFORMATION) Date: 527 CMR 12.00 City or Town of. NORTH ANDOVER 7 I nspeet�r of Wires: By this application the undersigned gives notice of his or her inten 'on to perform the electrical work described below. Location(Street&Number) 3 W 3�, •(� G� C_SS W Gti� �� Owner or Tenant /��1 OL '.J< I IC__ Tele one No. Owner's Address t fit .` P t"' �0 N 0 J dC Fr Is this permit in conjunction with a building permit? Yes Purpose of Building _ lirNO El (Check Appropriate Box) ��'S��- y�``t L C,- Utility Authorization No.� Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 9.0r) Amps �ZO�Volts Overhead �/ ❑ Undgrd L� No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowing tablemay be waived by the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool A bovnd.e ElI °'o mergency Ig ting rnd. ❑ Batte 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 Initiatin No.of Ranges No.of Air Cond. Total Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Toms KW No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:x �No.of Water No.ofo. No.of Devices or E uivalent Heaters KW Si ns Ballasts Data Wiring: ` No.Hydromassage Bathtubs No.of Devices or E uivalent g No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Fn uivalent Estimated Value of Electrical Work: UJ Attach additional detail if desired, or as required by the Inspector of Wires. (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 cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE cover ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: A'I „ LIC.NO.: / Licensee: /AlU,y,y��L �,�� K1�-e.� Signature (Ifapplicab e r "exempt”in the license pimber line.) LIC.NO.: Z? Address: 5 t,�.t--`S►Ov't, 1'�flJ„t C �t 1� K'.V( 5_C �1.�( Bus.Tel.No.:M M —Z' 10`t' *Per M.G.L c. 147,s.57-61,securi work requires Department of Public Safety"S"License: Alt.Tel.No No., Z 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 ELECTRICAL PERMIT NO. -INSPECTION ELECTRICAL INSPECTOR-DOUG SMALL PORT: , I.ROUGH INSPECTION: Passed—I ] Failed—[ ] Re-inspection requirecl($50.00)-[ j Inspectors'comments: (Inspectors'Signature-no initials) s bate 2•FINAL IN PECTION; Passed— Failed—[ ,] Re-inspection required($50.00) Inspec rsmmen . (Inspectors'Signature o initials) . Date 3•UNDER. INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ Inspectors'comments ectors'Signature-no initials) Date 4.INSPECT —SERVICE: - DATE CALLED NATIONAL GRID: NAME: Passed—[ j Failed—[ ] Re-inspection required($50.00)-[ Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ j Failed—[ ] Re-inspection required($50.00) Inspectors' comments: -I ] (Inspectors'Signature-no initials) Date I)0 O TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF Tin AREA TO BE INSPECTED IS NOT ACCESSIBLE AND ARE-INSPECTION OF$50.00 IS TO BE CHARGED. ,• The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): C to.. t a, � (�� 'S I`ce:s Address:_3 City/State/Zip: Vf(-Q95 p x_)f.nom C) Phone #: g 7 -3 -n a Are you an employer?Check the appropriate box: TyVNexwwojonstruction *ect(required): 1. y�I am a employer with 6 _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 c 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. 9. ❑Building addition • [No workers'comp.insurance 5. ❑ We are a corporation and its required.] .officers have exercised their 10.❑Electrical repairs or additions .E] 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' 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 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:_ U ou Polidy#or Self-ins.Lic.#: Expiration Date: Job Uite Address: - l,F,-55 City/State/Zip: k)0 � L Attach a copy of the workers'compensation policy declaratio 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. Sinature: hereby cer 'y under the pains and penalties of perjury that the information provided above is true and correct. Date: '] Phone#: 2-2 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#: Information and Instructions a Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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