HomeMy WebLinkAboutMiscellaneous - 36 RICHARDSON AVENUE 4/30/2018Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address
Policy Number:
Date/Cause of Loss
File or Claim Number:
Josephine DiMauro
36 Richardson Avenue
HP0346704
1/28/2015, Water/Ice Dams
31993-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
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.
Signitgy,6 and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Date. �?1 �Z.(.�L ........
O` ..ao ,sae OL
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .../Pn.. SG�i. .............
has permission for gas installation
in the buildings of . ...... V rp ............
at Norhe.. ndover, Mass.�
Lic. No. ?V' %. X`te
.............
GAS INSPECTOR
Check# -?,� .OV
.kr
FIXTI IRFC
- - - - - - - - -W (a - - -
W
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
°
City/Town:L�O�amaou r , MA. Date: 3 Z Permit#
Building Location: 3& RIAO&Cd _4C6 Owners Name: ftl&%AM
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
C6
New: ❑ Alteration: X Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No X
FIXTI IRFC
- - - - - - - - -W (a - - -
W
C6
Z F u)
C13
C)
=
m 2 0 (DLuOU
to
H
O
=
W
ZO z z
W to W �
O
m
W
O
W
F-
?
LuW
W❑
O
OCO
H 5
Q F—
W
rn U z
F -W
0
F -W
to
O
Q
Llj
W
W Lu
U W z O --1 1—
co
H
O z
0° W
J
O
C7
z
LL
O
l4
co
x
F>
W
W
J.-
W W
1��� O IX w
O(/TA?i�C V o❑ LL0 C9 x
w-
x
-i o
a�
m
H>>>
O
SUB BSMT. [
w
BASEMENT
1 FLOOR,
NDFLOOR
2
3 KuFLOOR
4 FLOOR
5 FLOOR
6 IH FLOOR
7 FLOOR
81H FLOOR
.�
Installing Company Name: SAV AGt
PIGa
�
J ITa
Check One Only Certificate #
Address:_X 391 City/Town:&kj Q
State:
10,14
El Corporation
El Partnership
Business Tel: g -A-'604 - 15z0
Fax:
Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes X 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 ❑ 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
Signature of Owner or Owner's t1 ent Owner El Agent El
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
--- w. V lily nuameaye dna uIdL do piumomg worK ana mstanations perrormea under the permit issued for this application will be in
compliapce with alnPertinent provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
` Type of License:
By ❑ Plumber qmml�u K.
Tit
e � Jy ❑ Gas Fitter Signature of Licensed PliThriber/Ga9fritter
XMaster
Cityrrown ❑Journeyman
APPROVED (OFFICE USE ONLY) El LP Installer License Number: 1
• �L
The Commonwealth of Massachuseft
Department oflnduarfid Accidents
Q07ee of Investigations
..600 Washington &reef
Boston, MA 02111
>ti'wMumass.gov/dia
Workers' Compensation hmamnee Affidavit: guilders/Contra
Dctors/ElecfriGians/pin�crs
pZ cant �ormsLi inn
Name (Business/0rgaaiz.fi0. ndMdnal):
City/State/Zip:�_ q��M �j },1 a3o�9 Phone#:_ q'?8• g09 -11 SO
Ar
e yon an employer? Check tale appropriate box:
i. ❑ i am a employer with 4. ❑ 1 am a general contractor and I i
employees (fel and/or part time) *-
2. I am a sole proprietor or
have hired the sulk
listed
partner_
ship and have no employees
on the auacired sheet t
These sub contractors have
worldng for me in any capacity.
[No workers' P, msurance
workers' comp, insurance.
5. ❑ We are a corporation and its
3. []rem.]
am a homeowner doing
officers have exercised their
.1 all work
myself [No workers' comp.
right of exemption per MGL
C. 152, §1(4), and we have no
insurance required.] t
employees. [No workers,
cOmP ice
fiat aMlicagt dist checl's baa #1 must also SII out the section below sho�g wnzicers' ]
S
Trgpe of project (required):
6. ❑ New construction
7. (] Remodeling
8. _[] Demolition
9. ❑ Bwldiag addition
10.❑ Blecttrical repairs or additions
.11.❑ Plumbing repairs or additions
12.0 Roof repairs
omeowaecs who snimzrt dns affidavit indi 9i aze p=r -y mi CM
#Camiractors drat check this box must cafiag e1' � all wozk sad then hire ontside oaahact0n mast submit a naw affidavit indicating such.
attached an additional sheet ah � and duii wozke:s
showing he zsame of - comp, policy hfin,,fion.
I am we employer that isproviding workers' compensation wSzOmee for my ensployen Below is the
information. Pommy and job site
hmra= Company Name.-
Policy
ame:Policy # or Self -ins. Lie. P
Expiration Dane:
Job Site Address;
Attach a copy of the workers' com ChY/Zip:
pensation policy deciaradon page (showing the policy number and esPiration date).
Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/orone-year ivatprisonment, as well as civil penalties in the irnm of a STOP WORK ORDBR and a fine
u e stigations m $250.00of athe dayDTA agafoinrst firinsue violator Be advised that a copy of this statement may be forwarded to the Office of
Inverance coverage verification.
TJ f
rw irereoy ceri#y under the pains � pedes o
//�j .fP�7u►y that the ueformation provrded above is true and correct
�•��w use onry. un not write in this areato be completed by city or sown o fjzciaL
City or Tows:
PermitUcense #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. CitylTown Clerk 4.
6. Other Electrical inspector S. PIumbi� IaspectDr
Contact Person:
Phone #:
Date .
2...........
... .............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. ./....`.'.w.C—........- ,",............
has permission to perform.....4�.A—Ik1..... .............
wiring in the building ofP{. /'Nfq 2 o
................................................................................
3 t Coat ....................R�
.....................�........... orth Andover, Mass.
0
o Z
Fee..,5~ . ^ 7n Lic. No... .............. .. ......... ............. .
E CTRICAL INSPECTOR
Check #
10679
R � �
Commonwealth of Massachusetts OfficialUse0nly
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPEALL INFORMATION) Date: 2- 2.7 12
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑
Purpose of Building V�p rnL„
Telephone No.
No Q (Check Appropriate Box)
Utility Authorization 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 Proposed Electrical Work:
K -
Com letion o the fnllowina table m be waived b the I s t W'—
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
Swimming Pool Above ❑ In- E]
rnd. ernd.
No. of -Emergency Lighting
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
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
I Tons
"""
I KW
I" "•"'••••'•'
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El other
Connection
No. of Dryers
No. of Water KW
Heaters
Heating Appliances KW
No. of No. of
—Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
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 if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 4-6ca0 (When required by municipal policy.)
Work to Start: Z- L.H _ j L, Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE RJ BOND ❑ OTHER ❑ (Specify:)
I certify, under the a1ns and penalties ofperjvey,. at the inforrpatior. on this application is true and commplete.
FIRM NAME: �Ip�nc. O , L,4 I 1Z LIC. NO.: {gfScl25
Licensee: �� � et zzt �o Signature LIC.NO.: 41,512-5
(If applicable, enter `e�n pt" in��P license number line.) Bus. Tel. No.• •&-,'S, Q 52 - -4S(' ✓L
Address: `�7 1,�cr t, � I L `�cc�- 3.4001, AJ (.( 030'7 i Alt. Tel. No.: 33 - 'I Ir-I}S
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
• ELE(CTICAL PEPJMT NO. INSPECUON+ PORT:
ELECTMC,AL INSPECTOR -• , '
3i'i)NDD+R GROUND INSPRMON:
passed—[ j wiled— [ I Re-iuspection required ($90.00) - [ ]
Tnsapectors' comments:
(Inspectors' Signature -• no initials) Date
S. INSPECTION -• OTIMR:•
Passed — f wiled ( _ ' Re -inspection xequixed ($50.00) - [ J
Inspectors' colo aments:
l;spectoxs'ignatuxe no initials} Date
D O OR TAGS .ARE TO BE FILLED OUT A" LEFT OX SITE IF THE AnA. TO BE INSPECTED IS NOT
.ACCESSIBLE AND A. RE USPECTION OF $50.00 IS TO DE CHARGED.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
IN 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): 1- t (z ` ri��,� slu-If
_11c,
Address:
j1 c-
Address:
City/State/Zip: P one #:
an employer? Check the appropriate box:
AWI
1. am a employer with 3
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
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. ❑ I 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. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ B lding addition
10. Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
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
p Y Name:.
Policy # or Self -ins. Lic. #:!��
L Z� St7�� �(0 3 a 2 c`� 4
ExpirationDate:
-Job Site Address:
fi ��t �— n om—
City/State/Zip: J"
4 L:t e_, P14—
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 ce tr under pains and penalties of perjury that the information provided above is true and correct.
Si ature: -Pa �\ �-�-- Date: 2--2-3- 1 Z
Phone #: (.,-3 o rf S 2 — 4s- (o(,
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
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 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 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 # 61.7-727-7749
www.mass.gov/dia
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. 114�`�C......�j ...... .'--c
Z4'Ir . ............
has permission to perform ....
.0.7pric ..............
wiring in the building of ............. .........................................
at ...... /z' -J .... 1.10 .... orth Andover, Mass.
. ... .. ...... ... .. ......
�c�o�
Fee—:5-- -�7� Lic. No. .......... .. ...
E gcrRIC��AL INSPECTOR
Check #
10679
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR9 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:G � DATE ISSUED:
I ��
SIGNATURE:
Building Commissioner/Ingwor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
O®a
3
Map Number Parcel Number
�q
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R 'red Provided
1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
f36
Name (Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
icensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
25.
Licens^umber
Address
'72Y. li s—?V'rw
Expiration Date
igna Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
`C) Z
Company Name _'-(-t
Registration Number
Address
/ <� •�'�� �3yJ
Expiration Date
Si natu Tee hone
O
Z
rn
90
O
r
v
M
r
z
a
0
SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) ►
Workers Compensation Insurance affidavit mu be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildiwdcrmit.
Signed affidavit Attached Yes ....... No ....... ❑
SECTION 5 Description of Proposed Work checkapplicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other Specify
f
Brief Description of Proposed Work:
Zo F a LIE ?, 1: -4�; +(
ire i? cj �
SECTION 6 - F.STTMATF.D CONCTRITCTICIN MR.TC
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OF7E+TCIAL USE ONLY ,
1. Building
p
b C) O O• 0,0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SEUIIUIN 7a OWINER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
—Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, gv My N 7 ZDA'-%;- 44 O vSs as OwnAuthon ez d Agen of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Rt=rlol 1-9 r'lyll K c VfJ E
Print Nam
Signature of er/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST 1ST2 ND 3 KD
SPAN
DU\4ENSIONS OF SILLS
DLMENSIONS OF POSTS
DiMENSIONS OF GIRDERS
1-TEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
6
�1
0
9
O
F=4
E
3 �
r W W
Z o
kij cy W
J= F
9 �Q° �
o Q
�Ni
a
cz
a O
i G � a a
o o `° W o G
U w w
�o
m c
o
�c�
Q
S
W
ac
y
jFv0�
w
r
94
O
c `
O N
F
W
3 �
r W W
Z o
kij cy W
J= F
9 �Q° �
o Q
�Ni
a
cz
a O
i G � a a
o o `° W o G
U w w
�o
m c
o
�c�
Q
S
W
ac
y
o �
c `
O N
1
++ C
W
O
v V
:ccm
A
s o
:off
y
o
w
Ea
o
w
CD C
o
cn
_ ts
+.
0 a.
ca
�'•
E �
: 0 m
ts rn
CD C
a «.
m m
E
a
� y
H
O
=
V)
cm
Go
•
y
• y O
O
•�•' y
A
m
E"o
aLJI
E
m
y '
C
C
a
C2
_
:mom
0.2
m
N O
A
W
C
'
d
CMZ
C
m
m r 3CL
N
o
•w
ev
•E
c.t 6
Z
v *" ama y
o
CD
Q CD
cl .100 s
O.
O O O
ca y•�
g
O
�a
L-
awm�
R
r
co
O
c
L
0
Z p„
O y
D �
coI Qm
C
c
C.*
0
CD
•y O •O
mCD co
co
m
d ~�
CD
e_ov o a
a. Q
c �
c
� ev
r -L cm
ca
C Z CD
0 CL
U CO)
C
•C C
_c
d
y
is
uj
0
Y/
uj
W
W
X
LUW
C4
1
W
A
o
w
a
w
o
w
cn
o
cn
co
O
c
L
0
Z p„
O y
D �
coI Qm
C
c
C.*
0
CD
•y O •O
mCD co
co
m
d ~�
CD
e_ov o a
a. Q
c �
c
� ev
r -L cm
ca
C Z CD
0 CL
U CO)
C
•C C
_c
d
y
is
uj
0
Y/
uj
W
W
X
LUW
C4
REG. #101862 K00FnvG - SwiHc - InsULAr101V
' / Date
From: S 'f /�/'kF_*') tJ
! r r �n'1 %q ,Z �3 j 6 / ► C Ifeg a o J, o YI
(Name) (Address)
To: urnN/ L SA1Rt81M A AMl SINS 299FM9 CO., Qt., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01642
I (we) hereby authorize the Contractor to furnish all materials and labor necessary to Install, construct and place the
Improvements described below In -on building located at No.
\-f
'2 4-3 f 0 x/
Street,
City Al AI1JDVft State ��1091_f
In accordance with the following specifications:
;"?j f ; AI.I _FA L
!� 2 C a r7i en Ctl ; r� i
•
L +t ✓ �"L r~
"i /,ISM r'� �
>` N J
( t 1,4 lL r1f i f i i ►-! �" i2 c �=
C N i N rr-(, _f
Gc.J-,#I —(EA
P 'L ✓ +�
`{. i 1 'tJ If V-^
i . ?y�
LTJ !4 i j G- 1
All of the above work to be done in a good and workman -like manner.
All men and equipment insured. Premises to be left clean upon completion of work.
For the total sum of � f X /-' 0 y f /-I t-( ) dollars.
Entire Sum to be paid immediately upon completion In accordance with plan as shown below.
0
0
0
0
0
0
0
a
STPAUL
TRAVELERS
INSURER: THE TRAVELERS INDEMNITY COMPANY
1.
INSURED:
RAYMOND DAMPHOUSE & SONS
ROOFING CO INC
75 BUTTERNUT LANE
ME THUE N MA 01 844
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6KUB-663X466-A-05 )
RENEWAL OF (6KUB-663X466-A-04)
NCCI CO CODE: 11347
PRODUCER:
INTERNET INSURANCE AGCY
522 CHICKERING RD
NORTH ANDOVER MA 01845
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 08-22-05 to 08-22-06 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GA
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 08-26-05 BK
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: INTERNET INSURANCE AGCY
753XF
ST ASSIGN: MA
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of fswestigatioss
600 Washington Street, 7`h Floor; Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
U I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
tmmplo er roviding workers' compensation for my employees working on this job.
address: 13 fi I^t HJT' L.�
city: %y)1� 74 v / /�I ✓✓1 R phone#� �r�%�, (,,;j 1'/��5
insuranee—Co.% 2 /� �/'t 6 �/(S Aolicv #
I am a sole proprietoeneral contracto or homeowner (circle one) and have hired the contractors listed below who have
the following orkers `TlVpensa ton po ices:
an 'nam - q�l:� i�/�.M^ t �iS �� J 1L•E,t cr i�kl` �G or1 Cr Ce, --tAc—
address•
c2mpanvnamer,
addressr
city:
n&one #�-
insuran eeco policy# -
Attaeitfa��itl'a�a�,shg��+�e
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to
51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day
against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage
verification. (73Nreby certify under ins and penalties of perjury that the information provided above is true and correct.
_ C
itgnatttre 3 �z _Q Date
Print namey�9 c' �: 5 7 A /'� �/` %G/G)'/dr J rL Phone #q%� U 6 '�—� d
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
❑Licensing Board
❑ check if immediate response is required
❑Selectmen's Office
[]Health Department
(revised 9/95 PJA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
'' � `ms`s'*.. � :�za: •, F '`n` . .p .s '' k„ , . S. . 4 -,amt Fr w�r
:. , .yam ,. �� �. �.�,..e»�= .:...:H;r:w .=ter, w�.:ex�:. ., � ,7 ..�.��` :,, �, '" �•=•
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
•ff c e of Investilati®tis
600 Washington Street, 7t' Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
N '
t �
This certifies that .. .. .. ..........: :. �. ..... .
r
his permission for gas installation.... .'................... .
in the buildings of ... .....�.... ! ..'..:�. ' . ?:.. ............. .
at ........... `. �...:.................. . North Andover, Mass.
Fee......... Lic. No.......7...
WHITE: Applicant CANARY: Building Dept.
. . . . . . . . . . . . . . . . . . . .
GASINSPECTOR
PINK: Treasurer GOLD: File
t
Date ......................
0
MORTN
TOWN OF NORTH ANDOVER
wOf 4..ao ,s1'YO
��
A?
h �
PERMIT FOR GAS INSTALLATION
r
N '
t �
This certifies that .. .. .. ..........: :. �. ..... .
r
his permission for gas installation.... .'................... .
in the buildings of ... .....�.... ! ..'..:�. ' . ?:.. ............. .
at ........... `. �...:.................. . North Andover, Mass.
Fee......... Lic. No.......7...
WHITE: Applicant CANARY: Building Dept.
. . . . . . . . . . . . . . . . . . . .
GASINSPECTOR
PINK: Treasurer GOLD: File
4 C/
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING t
(Print or Type)
NORTH ANDOVER Mass. Date
lhuilding Location 3 (0 01 ch Q/ --ds o n A V Q Permit # 13 6 !�
.� /UQ �/� CL' OYP�'i +1.1 CL Owners Name TO I M A u20#lys�3
• New '7 Renovation Replacement V! Plans Submitted D
FI T )R=c
lJ
(Print or Type) Check one: Certificate
Installing Company Name ` 6tft Rock P(1-1 Cor? � Corp. t/
Address - - Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter Rob et -4 B/QnCIleTT'�
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Q Other type of indemnity Q Bond Ej
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 17 Agent F7
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 perfomted under' Permit issued for this application will -be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By
Title
City/Town:
APPROVED OFFICE USE ONLY)
TYPE LICENSE: La_a4�-- 6
Plumber
Gasfitter Signature of Licensed
Master PlunlbS or Gasfa.tter
Journeyman �f
License Number
�n������n����������■1111
W4"6 2
(Print or Type) Check one: Certificate
Installing Company Name ` 6tft Rock P(1-1 Cor? � Corp. t/
Address - - Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter Rob et -4 B/QnCIleTT'�
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Q Other type of indemnity Q Bond Ej
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 17 Agent F7
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 perfomted under' Permit issued for this application will -be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By
Title
City/Town:
APPROVED OFFICE USE ONLY)
TYPE LICENSE: La_a4�-- 6
Plumber
Gasfitter Signature of Licensed
Master PlunlbS or Gasfa.tter
Journeyman �f
License Number
J
Z
O
W
N
W
U
LL
LL
O
M
O
LL
3
0
J
W
m
z
O
W
a
N
_Z
N
N
W
¢
C)
O
¢
CL
z
O
F
U
W
IL
N
z
1
a
z
LL
W
W
LL
0
z
cc
W
1—
F -
LL
N
a
c�
¢
0
¢
W
m
J
a
C
Z
J
O
W
H
z
a
¢
0
r
W
a
♦,
s
Location �
No. Date
N
L't!
�,. TOWN OF NORTH ANDOVER
A
1 Tt1 L
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
Building Inspector
Div. Public Works
Location
..No.
.r
Date t
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
} s^ Building/Frame Permit Fee $ 77
MU t<� Foundation Permit Fee $
s4Cs
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
U r
Building Inspector
Div. Public Works
tl
a
„
I
Z
O
J
5
m
Ln
1
0
a
°
ad
W
W
sz-
W
h W 6
i
0
U
z
z
a
A.I
1
0
a
°
ad
W
W
sz-
W
h W 6
i
rA
M
w
O
a
P.
vi
O
°
w
rs:
v
U
x
Oj
a
o
w
w
w°
aG
C �
w
c7
cY.
w
rA
°
cn
c
cn
zCL
a
H
COD
W
1=
ac
W
CO3
1--
tR
i
m
C
O
.N
E
m
CL
N
A
mt
O
cm's
Q
C2 y O
c � o
a
CL o
N my0„~
yr
dt A C
•-
o�CcDa
Ocm
�� C
O ; O 'O
O Z
4 -CZ S m
5
O
zoo
rI
O
O
F`V.1
O
E
O i
� O
� w
Z
CD
O.
O y
G C
CO Q!
C
CO)CD
N) {y O
'r= CO CO
�I.
CD O �
0
O O a
CL. o�cC
Co
O cc
C .5.0
CL 0 CD
c Z m
0 CL
V CO)
C
O
C_
■ C
C.
H
D
N A
O m
O
N
CA
�
m
C_
C �
.'
m
i
A =
•= C
N W
a
H
COD
W
1=
ac
W
CO3
1--
tR
i
m
C
O
.N
E
m
CL
N
A
mt
O
cm's
Q
C2 y O
c � o
a
CL o
N my0„~
yr
dt A C
•-
o�CcDa
Ocm
�� C
O ; O 'O
O Z
4 -CZ S m
5
O
zoo
rI
O
O
F`V.1
O
E
O i
� O
� w
Z
CD
O.
O y
G C
CO Q!
C
CO)CD
N) {y O
'r= CO CO
�I.
CD O �
0
O O a
CL. o�cC
Co
O cc
C .5.0
CL 0 CD
c Z m
0 CL
V CO)
C
O
C_
■ C
C.
H
D
81979
DEPARTMENT OF PUBLIC �AFE17
ry
Si
CONSTRUCTION SUPERVISOk 1ICFN.:,
y Number: E}:Fires: F Mas..." ...'/
CS 059001 08/03/!998 (:? !_+.;
.e
Restricted To: 00 tc psstss a current edition of the
i,s a•_':4setcs State Building Code
JOSEPH T RAZA is case for r <<ocation of this
PO BOX 23/999 MAIN ST
W BOXFORD, MA 01985
n
1