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HomeMy WebLinkAboutMiscellaneous - 370 FOSTER STREET 4/30/2018 (2)i wI 0 0 +l Cl) I bm J ,1' (SooQ1[YJJ �I m m o -i �—L\ Commonwealth of Massachusetts City/Town of � System Pumping Record y` Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �,,� U�--�I IGI RECENE AUG - 12007 TOWN OF NORTH ANDOVER HEALTH DEPARTN10,4T DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System L'on: �( ,� lUc Address City/Town ql— `n 2. System Owner: Name Address (if different from location) City/Town State V t/-<� P Code Statue `Code Telephone Number ( a B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 0 -1q -o' If yes, was it Leaned? ❑ Yes ❑ No 5. Condi 'on of�Sf AI 6. System P,pmppd BY: , a _ -j-, A _ Name Company ^_'d�il 7. Location ie?e cpntent e17s ed: _ v Vehicle License Number ;> `` Y—(02 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record p C T 2 o 2009 Form 4 µN TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. O er foirnsTrna��jbux he information must be, substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ovotlaer approving authority. A. Facility Information 1. System Lesatis ft 1 of house,Nht side of house, Left front of house, Right front of house, eft ar ouse t rear o ouse. Left rear of building. Right rear of building. Address Citylrown State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code X01& Telephone Number B. Pumping Record 7, 1. Date of PumpingDate 1� r)2. Quantity Pumped: tali �so c 3. Type of system: ❑ Cesspool(s) Ky Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S. Lowell Waste Water 52 Signature of Hauler F5821 Vehicle License Number Date t5fonn4.doc• 06/03 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts RECEIVE City/Town of OCT C 2012 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left / ' ide of hous , Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address 317 o City/Town 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of. system: ❑ ❑ Other (describe): State K o<--�A r\e-2 Zip Code State` ULF6 Telephone Number Date 2. Quantity Pumped: Gallons Cesspools)Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond'tion of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location ere contents were disposed: L S. Lowell Waste Water 4Tfo'A t5form4.doc• 06103 F5821 Vehicle License Number ':�? a 5--ca Date System Pumping Record • Page 1 of 1 O MAPFRE Commerce INSURANCE - May NSURANCE- May 15, 2015 The Commerce Insurance Comoany'm Citation Insurance Companyw 11 Gore Road, Webster, Massachusetts 01570 508.949.15001 www.commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 Board of Health or Board of Selectmen Town/City Hall RE: Our Insured: LUIS MARTINEZ / JANICE A MARTINEZ Property Address: LUIS AND JANICE MARTINEZ, 370 FOSTER ST Policyk KH2746 Date of Loss: 03/09/2015 Filek JYWT97-HRMRP8 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. DONNA KIMBALL CLAIM CONSULTANT Telephone: (508)949-1500 Ext: 11527 Toll Free: 1-800-221-1605, Ext: 11527 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. May 15, 2015 CIC 254 (Rev. 4/95) MAIL I74 This certifies that . (� �� tib. ! P�7 A has permission to perform .� ►`� ... ���"�.................... . wiring in the building of..................... . at ....,North Andover, Mass. Fee . Lie. No.JM" ...... ... . ELECTRICAL INSPECTOR { Check # ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, §. 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed' " on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shaII b.e issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. I43, § 3L. Permits shall be limited as to the time ofAngoing consfzuction.activity, and maybe deemed_bytheinspector-of_Wires abandoned_and.inyalidaf lie.—. or she has determined that the authorized worl� has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cat}.qP..A pergmit shall be terminated upon the written request of either the owner or the jnstal- jr'ng entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sectipns.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain -permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically dxtends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008.and extending -through August 15, 2012. "We 8 — Permit/Date Closed: —� /c Note: Reapply for new permit/ ❑ Permit Extension Act —Permit/Date Closed: 4 c ` n ee rr l,ommonweaitk of MaLae� tial use only Permit No. t aG3epar� o��ire �ervice t Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. I/M eave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CUR 12.00 (PAF E PIUNT IN AOR TYPE ALL. NFO AY70h) City or 'Town of. 1), A v e -e- To the Inspector of Wires: By this application the undersigned gives notice of I& or her intention for pm fom the electrica work descrilbed below. Location (Street & Number) . 3 p cJ � . S tz.e:j Owner or Tenant L u i �,/_�tv1g 2� Owner's Address ( .��►✓'b t'/ Telephone No. 9'1 %- - 6t 3 -16 E q 3 Is this permit in conjunction with it building permit? Yes ❑ No (Check Appropriate Boz) Purpose of Building D1��. n e __ Utility Authorization No. Existing Service Amps T Volts Overhead [:1 ndgrd-© Wm of Meters Mew Service Amps I Volts OverheadE] Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �N a� ��,��", �� _ t� ,� k �� c �..,� •� i.tins, nfthv fnllnwino inhle mnv he waived by the Investor ofWwes. No, of Recessed Luminaires -- - No. of Celt:-Susp. (Paddle) Fans o. o Totat Transformers IVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Ab d e 0 In- grnd.: No. o Emergency gaffe Units No. of Receptacle Outlets No. of Oil Bursters FIRE ALARMS No. of Zones o. of Detection an No. of Switches No. of Gas Burners Initiating Devices No. of Ranges YOM No. of Air Cond. Tons No. of Alerting Devices of Waste Disposers Heallo. Totaalls _.._nm _er �►ns e o Self -Contained D Detection/Alerting Devices No. of Dishwashers t ' Space/Area Heating IOW Municipal Other. Local Q Connection Q X10. of Dryers Heating.A Appliances p �' Security stems: Na of evices or Equivalent No. of Water, No, of NO. of Ballasts Data Wiring: Devices E uivalent Heaters S Nay of or No. Hydromassage Bathtubs No. of Motors Total HP muni ,C'us irins� No. of Devices or E uivalent OTHER: _ _�• _»s�•....,.1 ,1.,...;T r.4—;-4 nr ne ramfin d hV the h=eCtOr Of Wire& Estimated Value of Electrical Work: (When required by municipal policy') Work to Start:_ Inspections to be requested in accordance with MEC Rule 14, and upon completion, INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical worts may issue utdess the licensee pmvides-proo€ of liability insurance including "completed operation" coverage or its substantial equivalent. The e, and has exhibited proof to the permit issuing office. undersigned certifies that such coverage is in forc CHECK ONE: INSURANCE 9 BOND -0 OTHER .11 (specify:) n is true ural conwiett I cert0% under the pains rind penalties o, f perjury: that the information on dds appacade FIRRMNAiVIE: l F�' { 5"� FC -1.t' Cn �P r�Bi c e� l� LIC. NO.: 14 ]Licensee: ��Q� (ti:t•C�-�[ 1 Signature `�_� ��` � _ LIC. NO.: -31 16 6 6_ (If applicable enter "exempt" in the license n ber line.) ( Bus. Tel. No.;5ffi-!j -14101 Address: qty W. O .. Alt. Tel. No.�s� ? � I *Per M.G.L. c. 147, s. 57 -ti 1, security work requires of Public Safety "S" I.ieeiase 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 agent. owner/Agent Telephone-No- PEiIJHT FEE' $ S Sigoa-tut 4 The Commonwealth of Massachusetts P nt>=rt Department ofIndustrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass gov/iia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aiennt 1Fnrnr*nn1;^— Name (Business/Organization/Individual): Address: Are you an employer? Check the app, 1. I am a employer with employees (full and/or.part time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work tmyself. (No workers' comp. insurance required.] t 5 f� Phone #: ` riate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. itisumce.$ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. fNo workers' comp. insurance required ] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.EffElectrical 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 ' r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors m sttssubmita new, �davit indi�ng such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have mployees. If the sub -contractors have employees, they must provide their workers' comp, policy number. r ---- — _'. _` ""Fluter m" is providing workers' compensation insurance for my employee& Below is the o "forma iott. P Ury and job site nsurance Company Name: (' (4 A R /'I '01 — A _ 'olicy # or Self -ins. Lic. #: �(f C 22� r Expiration Dater 3b Site. Address: J j' �0� ttach copy of the workers' compensation policy declaration page (showing thState/Zipe policy numer and : �Q• eco A 0 %c4s iration date). allure to secure coverage as required under Section 25A of MGL c. 5 2 can lead to the impositionbof criminal penalties of a ne 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 ' up to $250.00 a day against the violator. Be advised that a copy of this statem vestigattions of the DIA for insurance coverage verification. ent may be forwarded to the Office of to 6 - that the provided above is true and correct 'LIWIclat use only. Do not write in this area, to be completed by city or town oj)zckz City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: