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HomeMy WebLinkAboutMiscellaneous - 365 APPLETON STREET 4/30/2018N March 11, 2015 THERlOBtIFOO.00f�DED0-0�aRAGROUPm U 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.: P1589921 Insured: LEONARD BLUM BLUM, DAWNA Address: 365 APPLETON STREET, NORTH ANDOVER, MA Policy No.: D0678227 Loss Date: 02/09/2015 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, Marie J. Landers Property Claim Examiner 1-800-688-1825 x1136 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. DORCHESTER MUTUAL INSURANCE CO. FITCHBURG MUTUAL INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 Telephone: (800) 688-1825 p Fax: (781) 329-1818 ,i 0134 Y s *0 0 Date .',.�.-/`f... // ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......:.. d �f3"%.. �....... .............. has permission to perform .,,G�i wiring in the building of ��lr!<' �j�l!/h at ...... 9. ...... r.�......�....43.0.4.............. , North Andover, Mass. Fee....... Lic. No../4.-/,3.......................................................4� ELECTRICAL INSPECTOR Check # /�. Common -wealth ®f Alassachusetts Official Use Only ®e�7a t'i ens OAF Fire Services Permit No BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (ME527 CMR 12.00 ®�� (PLEASE PMT DV NK OR TYPE ALL INFORMATION) Date. G _ /0 —/ Cgty or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her intention to perforin the To the ele electrical workpeqtor lescribed below. Location (Street & Number) 3 6� 0p%� f s f Owner or Tenant Owner's Address Telephone No. ///OZyK ­1� Is this permit in conjunction with a building permit? yes Purpose of Building EJNO ❑ (Check Appropriate Box) Utility Authorization No. /// a Z y 1p 3 Existing Service Z90 Amps 1 Z.d / Z %;Volts Overhead ❑ Undgrdg No. of Meters New Service Amps _Volts Overhead ❑ Und rd Number of Feeders and.Ampacity g ❑ No, of Meters Location and Nature of Proposed Electrical Work: 0-2 Com lesion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus No. of � p. (Paddle) Fans Transformers Total No. of Luminaire Outlets No. of Hot Tubs KVA Generators KVA. No. of Luminaires Swimming Pool Above E In_ 0.0 mergency 'Ellg - d rid• Batte Units g No. of Receptacle Outlets No. of Oil Burners FIBS AA,A�aM No. of ?.,ones No. of Switches No. of Gas Burners No. of Detection and No. of Ranges Initiating Devices No. of Air Cond. Total No. of Waste Disposers Heat PumpNumber Tons ns No. of Alerting Devices --. .. �........._.. No. of Self. -Contained No. of DishwashersDetection/Alertin Devices Space/Area Heating KWLocal ❑ Municipal No. of Dryers Connection El Other r S' Heating Appliances KW Security Systems: No. of Water No. of No. of Devices or E uivalent Heaters KW No. of Data Whin Si s Ballasts . g' No. of Devices or E uivaIent No. Hydromassage Bathtubs No, of Motors Total Hp Telecommunications Wiring; OTHER: No, of Devices or E uivaIent .. u Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires: Work to Start:6-13-11 (When required by municipal policy.) N 7Inspections 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 I certify,X BOND ❑ OTHER ❑ (Specify:) under the' and penalties o FIRM NAME fP�%ury, that the information on this application is true and complete. �g v �lCiC�Q,,,� Licensee: 6 Pj � (' ,r 4 [J Si LIC. NO. (Ifapplicable, enter ewe pt in the license n mber line.) Signature LIC. NO.: Address: / 3 dS €#� 3 9- 3 S ! Afe_-f'4 ue l y/� ©/ Sr►f y Bus. Tel. No. - *Per 26 732y *Per OWNER'S c I47, s 57 61, security work requires Department of public Safety "S" License: Alt. 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/Agent Y Signature ❑ owner's agent Telephone No. PERMIT�� ELECTRICAL PERMIT NO. INSPECTION" REPORT: ELECTR][CAL INSPECTOR - DOUGMALL <• I. ROUGHINSPECTION: Passed — [ ] Failed — [ j Re -inspection required[ ($50.00) - [ I Inspectors' comments: '7 ILITRT .A T xis �u. i UA Ar' 4.1 A.L" . aLLCU — Inspectors' comments: -no �Ata��ICI,LL,L J- �J�LL'dLure - no 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ j Inspectors' comments: (Inspectors" Signature - no i Date Date Date DOOR BAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TM AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Ij a Codi n ePQr�e oh�e4 �Il Ar! (� f� ca�t ers, �® _ 6'�fee ooflh�h QsQ a�� for�� ls o�® �4s��v� �i4j`Q�'cs lyses Addr°S�°°ssiplg�l $ a �as��,�� oslo�, th oh�Qojrs debts �������y���sgo�Q1I1ee� . 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Elec�zcal aspect Phone # or S, Pleb �g�pector Location sc 4)o7 No. Date Mo�TM TOWN OF NORTH ANDOVER a ; ; Certificate of Occupancy $ CH <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #w 2412 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: r IMPORTANT: Applicant must complete all items on this page LOCATION 3 IMIO)e -/-,o n -f t Print PROPERTY OWNER eUh ' D Acv {i1 if al�GyJ Unit # o / �o Print - MAP NO: 0S , OPARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 49 100 year-old structure yes 61 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ AI eration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition�y„ ❑ Other 7 ry f } -an.4� w DESCRIPTION OF WORK TO RF PFRF0RMFn- D el), / (Identifica ion lease Type or Print Clearly) OWNER: Name: 11 aral Address: 3 k101191, _rblu CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No 6d;>/ -,F<? 7 / FEE SCHEDULE., BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ % ©, DOD FEE: $ 110 � Check No.: 2� Receipt No.: NOTE: Persons contracting it registered contractors do not have access to the guaranty fund - - � u.. rF 1 4� .0 Signature of Agent/Owrier.: _ Signature of contra°etor.. :: Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perri Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses r Copy O t` ontra+ -t ❑ P-looii°u'i-ossectiorliEleva-tion Plan Of P= Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector yes No ®ANGER ZONE LITERATURE: yes �o MGL Chapter 166 Section 21A —F and G min.$1oo-$1000 fine Doc:.Building Permit Revised 2011 June/mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ FTannin g/Massage/Body Art ❑ Sv✓irriming Pools El Well ❑ Private (septic tank, etc. ❑ Tobacco Sales ❑ I Food Packaging/Sales ❑ Peirnanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM - DATE REJECTED PLANNING & DEVELOPMENT ❑ COMME DATE APPROVED El ��,s6io�'�G"%,r4l �E�E�3 e���:, `Jil:Ul: i,i iJdl vll.iidG�L11V COMMENTS HEALTH Reviewed on Signature k. COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Name (Business/Organization/Individual): Cf 1?62 Address: 6,r (�" /" ���� City/State/Zip: N (1 �'L ��//�y' Phone #: 166P/ — d 0 ? Are you an employer? Check the appropriate box: .1 -El I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. EJ 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. 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 Job Site Address: 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. X do hereby certify 4deM*pains andpenaldes ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # X �- Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone • O 5 0 as c O L C H c O V V p� ccC m C O � N � �a m c _ts ts o o. r.+ N CoCDs CD s cm C L N Nrww.:>3 m •O R � N W N E CD a� • y m m opo¢ C C Z :mor i C0., y Z C LO O Q a W .y 'd= C Oc O m •N u •b- Q CD C ED Nj a m ':10 °0 = to mN = F� t. r a 4- m m ca N CD N C cm O R m aC IM c m 0 cm C �C N m s O Z 0 CD 5 U— Q � U U) �0 CO FA U 0 0 �.1 co L C Z co C. 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RC2 mCM c o C N CD 6 VJ � 'fl _ Co cc-o NCD O -� y m C:D o,c= CD C3 y O I '— Z • c o 0 n Q ca -,D C W C ;:5 -==c "" Z �i o.• •H AD A C -N LU C31 cm C3 .p c COD n O '- O Go m_ �p CO N •p F- = C31 dt m Z Cl) mi 0 E � U H Mp c 0 O U c oc C/) c m P-4 0 c c N m t Ill R� U 0 IzvP4 O GD O CD L 0 o v CD C. O H � C CD p) i p 'O CD AgCD co m m CD CD Q O CD c0ca a o a CL Q Cc C.3 -5.0 EL CD CDz C.7 y c C c CL 0 F µoRTH TOWN OF NORTH ANDOVER a=�t<r"so `6 °4V°0 OFFICE OF BUILDING DEPARTMENT L 1600 Osgood Street Building 20, Suite 2=36 "�ssso�li t5 ��5 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:_ _ ��- JOB LOCATION: Number Street Address 150MEOWNER ` (!0 jj1+rc.1 If Qp Name Home Phone PRESENT MAILING ADDRESS SG�{yl Uty Town Srnf-� . . p * Map/Lot i /(f (?70A Work Phone Zip Code Ad/S C) _czo 7 ae-7 The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual -for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who gwns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two fancily structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations.11 The undersigned "homeowner" certifies that minimum inspection procedures and requires requirements. / HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption the Town of North Andover Building Department e will comply with said procedures and BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535