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HomeMy WebLinkAboutMiscellaneous - 39 MILLPOND 4/30/2018Safety Insurance �Wo PO Box 55098 Boston, MA 02205 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: MICHAEL D PISCATELLI Property Address: 39 MILLPOND, NORTH ANDOVER, MA Policy Number: HMA 0351922 Claim Number: BOS00066513 Date of Loss: 12/17/2015 Company: Safety Insurance Company 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, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. 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 number. Michael Nimon Claim Examiner 12/22/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3138 Fax: (617) 535-5869 Email: MichaelNimon@Safetylnsurance.com Date. ......... TOWN O'F NORTH ANDOVER 1.0barAAA r-1 PERMIT FOR GAS INSTALLATION This certifies t hat ... J.A'. /. '. -�. -:� .............................. has permission for, gas installation .............. in the buildings of . :-�f/ � -r-.14 A-4 �(t ........................ at ... e."Ix-. North Andover, Mass. Fee. . Lic. No. ... ..... ...... Git INS E*�TOR Check # 7321 i —4% MASSACHUSETTS UNEFORMAPPUCATONFORPERAWTODO GAS G (Type or print) Date Ci NORTH ANDOVER, MASSACHUSETTS nA Building Locations V % i/'I-/ els `)� Permit # Amount $ '-A Owner's Name New ❑ Renovation 0 Replacement � Plans Submitted (Print or type) Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company .❑ Corp. ElPartner. INSURANCE COVERAGE Check one: I have a current liability Ilisurance policy or ii's substantial equivalent. Yes 0 No U If you have checked yes, please indicate the type coverage by checking the appropriate box. 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 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent �—.r —•=.y L—L Q.1 VL Lug U�,La b CULL uuunuauon r nave suomrn:ea for entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Perini ssued for this application will be in compliance with all pertinent provisions of the Massach� State GIC e and Chap 142A the General Laws. City/Town (OFFICE USE ONLY) �1 g ature of l 0 Plumber rj Gas Fitter E] Master 0 Journeyman Or Gas . , •;5TH. FLOOR (Print or type) Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company .❑ Corp. ElPartner. INSURANCE COVERAGE Check one: I have a current liability Ilisurance policy or ii's substantial equivalent. Yes 0 No U If you have checked yes, please indicate the type coverage by checking the appropriate box. 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 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent �—.r —•=.y L—L Q.1 VL Lug U�,La b CULL uuunuauon r nave suomrn:ea for entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Perini ssued for this application will be in compliance with all pertinent provisions of the Massach� State GIC e and Chap 142A the General Laws. City/Town (OFFICE USE ONLY) �1 g ature of l 0 Plumber rj Gas Fitter E] Master 0 Journeyman Or Gas i. The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations UT ..600 Washington Street Boston, XA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6ibly r %�1 Name (Business/Organization/Individual): � •• • . ' • ' Address: City/State/Zip: Phone#:j Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other .. �ecuen o___....noe.^..^.t; =mer wer: ers' comp�sation po?icy information. t Homeowners who submit this affidavit indicating they are doing all work and then ]sire 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. Lie. #: Job Site Address: Expiration Date: 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. I do hereby c_ar11ft_Xnder the Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License above is true and correct Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Check the appropriate box: n ' 1. I am a employer with 44. ❑ I am a general contractor and I employees (fiill and/or part-time).* have hired the sub -contractors i2.. I 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 *orkers' comp, insurance required.] ": -ny applicant that checks bot #1 must ass,flI out the Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other .. �ecuen o___....noe.^..^.t; =mer wer: ers' comp�sation po?icy information. t Homeowners who submit this affidavit indicating they are doing all work and then ]sire 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. Lie. #: Job Site Address: Expiration Date: 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. I do hereby c_ar11ft_Xnder the Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License above is true and correct Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 co=npiiance with the insurance coverage required." Additionally, MGL chapter 152, §25CM 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 certificates) 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 peraaitor license is being requested, not the Department of Industrial Accidents. Should you have any questions regardinag 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 permittlicense 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 "ail 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: i The Commonwealth ofMassaehusc, Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 `Fel..# 617-72.7-4900.ext 4'06 or 1-877-MAS.SAFE Fax # 617-727-7749 Revised 5-26-05 umrw.mass._govfdia N2 1942 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ............................................ ies that ................ This certif has permission to perform—. --7e ... ....... .... ......................... ............ 1, wiring in the building of ........ ....................... ............................... at.' -31 ....... 7�2 ... ...... U--� ................. . North Andover, Mass. Fee-.� .............. Lic. ....... ............................................................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer _0 04c Gommonwlez!R4 of Mujaliar4ust Office Use only Department of Public Safety Permit No. BOARD OF FIRE PREVENTION REGULATIONS 52, MR 12:00 Occupancy B..Fee a*cked F 3/90 (kivL C lank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFOR"kTION) / Date -z-- City or Town of The undersigned• applies for a fwrmit to perform the Location (Street 6 Number) -Z. 47 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: ctricawo escribec+ low. / do Yes v To the Inspector of Wires) (Check Appropriate Box) Purpose of Building Utility Authorization No., _ Existing Service Amps / — Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / 1;_ Volts Overhead ❑ Undgrd ❑ No. of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ,,JOTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES QWO U 1 have submitted valid proof of same to this office. YES UNO U If you have checked YES lease indicate the type of coverage by checking thee appropriate box. INSURANCE BOND ❑ OTHER❑ (Please Specify) © 2 ' ''& (Expiration Date) Estimated Value of Electri �,c /al Work $ OJ �/ Work to Start �� (- q a Inspection Date Requested:' Rough �� ` O Final Signed under thnal lies of per' ry: FIRM NAME l L Llceinsee Address I' icmz G %✓ i LIC. NO. -Signature LIC. NO:`=S=�r�--�-�` Bus. Tel. No. AIL Tel. No. OWNER'S INSURANCE WAIVER: I am aware that thekicensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit(application waives this requirement. Owner Agent (Please check one) _ Telephone No. PERMIT FEES (Signature of Owner or A�gentl TOTAL No. of lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures Above In. Swimming Pool gmd. Rfnd. ❑ Generators KVA No. of Emergency Li ung No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Bt;,rners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices ---- No. of Sounding Devices. No. of Self Contained DetectionlSounding Devices Municipal L°alD Connection ❑Other No. of Disposals ea( otal I otal No. of Purn s Tons KW No. of Dishwashers / S ace/Ari�j( ieatin KW _ No. of Dryers -Heating) vices' KW No. of Water Heaters KW No. ot No. of Signs f Ballasts Low Voltage Wiring 4 No. Hydro Massage Tubs No. of Ysotors Total HP ,,JOTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES QWO U 1 have submitted valid proof of same to this office. YES UNO U If you have checked YES lease indicate the type of coverage by checking thee appropriate box. INSURANCE BOND ❑ OTHER❑ (Please Specify) © 2 ' ''& (Expiration Date) Estimated Value of Electri �,c /al Work $ OJ �/ Work to Start �� (- q a Inspection Date Requested:' Rough �� ` O Final Signed under thnal lies of per' ry: FIRM NAME l L Llceinsee Address I' icmz G %✓ i LIC. NO. -Signature LIC. NO:`=S=�r�--�-�` Bus. Tel. No. AIL Tel. No. OWNER'S INSURANCE WAIVER: I am aware that thekicensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit(application waives this requirement. Owner Agent (Please check one) _ Telephone No. PERMIT FEES (Signature of Owner or A�gentl 2907 - �7r Date . . ............ ,AORTH TOWN OF NORTH ANDOVER 2 0 PERMIT FOR GAS INSTALLATION SA U This certifies thg-;/ . ............. has permission for gas install at ion. in the buildings of ................. 6� ..................... ............. I North Andover, Mass. at Fee.�.'r".. Lic."NodUer�� . .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING or print) Date 7 `-) a 19 �O fH ANDOVER, MASSACHUSETT�S INV KL % Building Locations��F P Owner's Name New ❑ Renovation M Replacement ❑ Plans SubmittedLIU ❑ Permit # Amount $ (Print or type) j� r ,� Check one: Certificate Installing Company Name AIIILI r /�/ ❑ Corp. Address Cg ' `� �/ ❑ Partner. /' '�f ✓tom % 's !i1 _�� �� �i � i �a 7 Y ustness Nance of Licensed Plumber or Gas Fitter Al H d, e 1-� OALO -I Firm/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. ❑ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. `• Ch k ature of Owner or Owner's Agent ec one. Owner ❑ Agent x A ---te to the I hereby certify that all of the details and intormatlon 1 nave suornmeu cur cnceccui ill "Uu— -F1F ..---" .-.- ..-- ---- ---- best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas�Code and Chapter` 42 of the General Laws. ". By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber Q7—? J57`w ❑ Gas Fitter License Number ❑ Master r� Journeyman CIO n U F C Z Z Z C F car] C n H W a C C y C W y O U N z w F w U C %