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Home My WebLink AboutMiscellaneous - 41 PHILLIPS COURT 4/30/2018 41 PHILLIPS COURT I �� 210/095.0-0037-0000.0 i I i MAPFRE The Commerce Insurance Company'"" Citation Insurance Companyw 11 Gore Road,Webster,Massachusetts 01570 Commerce r N S U R A W C e- 508.949.15001 www.commerceinsurance.com February 13,2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: OFELIA HABENICHT Property Address: 41 PHILLPS COURT UNIT A Policy#: BDYXSX Date of Loss: 02/09/2015 File#: JWWC48-HNPRV5 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. i i LISA LEAHY Telephone: (508)949-1500 Ext: 15846 Sr Claim Representative,Property Toll Free: 1-800-221-1605, Ext:15846 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. February 13, 2015 INTERIOR WATER DAMAGE DUE TO ICE DAMS CIC 254 (Rev.4/95) MAIL 788 ........ Date....... ................ ......... nr TOWN OF NORTH ANDOVER t PERMIT FOR WIRINGle ! $$gCHU - This certifies that .. .!.(.�. .15 ... G 5� 0!�P& has permission to perform ... �.�.... .! ........ .......... wiring in the.building of...... .t`s:�. ..�4.........:.....:..............:....:................ at .... 1...... h..`. :!. 5. .. ...................................,North Andover, ss. Fee. Lic.No. �1. ? '...t`t". ' .......... ............ .:.. ll..., -# ELECTRICAL INSPECTORU Check# 12 fficia Use Only Commonwealth) of Massachusetts O� �j Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(N j,5 7 CMR 12.00 (PLEASE PRINT ININK Old TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To theInspec or of f Wires: By this application the undersigned ive tice of his or he intention to perform the electrical work described below. r Location(Street&Number) 1 l�g CCX) Owner or Tenant A-n"S &pn ell+ Telephone No. Owner's Address Is this permit in conjuncji n i a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / y Volts Overhead ❑ Undgrd❑ No.of Meters Ilk New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters. Number of Feeders and Ampacity Loc ion and Natu AProposed Electrical Work: pry {Stf 6d/ Z Sw cs Completion of the following table may be waived by the Inspector of Wires. 1�o.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- ❑ o.o Emergency Lighting g rnd, grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices Heat Pump Number Tons KW_ No.of Self-Contained No.of'Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other QF p g Connection No.of Dryers Heating Appliances KW Security Systems:*vice y No.of Devices or Equivalent Nef ff Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.,-Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent ` OTHER.. Atiach additional detail if desired,or as required by the Inspector of Rres. Estimated Value o E//le trical Work: �� (When required by municipal policy.) Work to Start: 14 /b /� 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 Jk undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �k BOND ❑ OTHER ❑ (Spe ' :) I certify,under the ins anMpeXc, fry,that the infor a i n on is application is true and complete. FIRM NAME: . .9 LIC.NO.: Licensee: ej4eA r!,AA Signatur LIC.NO.: (If applicable,en ger "�gxe t"in the lic Se timber line..)_ Bus.Tel.No !T79 Address: ��' rl4fCfs /�1�- Qr�Z( Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: 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 PERMIT FEE.$ Signature Telephone No. re ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the .tit 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 shall be 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.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work 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 cause.A permit shall be terminated upon the written request of either the owner or the installing 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 Sections 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 fiirthers 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 extends,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. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass[a - Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: a ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors mments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection'Required($.)❑ Inspectors Com a ts: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC.MA. .......dweinhold(cDtownofinerrimac.com a The Commonwealth ofMassachusetts - 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): Address: City/State/Zip: �,(Jjel4cA 01Y7,( Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction art-time ( ) employees full and/or .* have hired the sub-contractors p listed on the attached sheet.� 7• E]Remodeling 2. I am a sole proprietor or partner- � ship and'have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work g p rr��--,, right of exemption per MGL 11.❑Plumbing repairs or additions L� myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' 131i Other comp.insurance required.] *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 Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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.#: Expiration Date: Job Sitio 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 requiredunder 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 hereb c t and tie pains and penalties of perjury that the information provided boy is true and correct. Si ature Date. Phone#: T7 9 -d3 S 76 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#: b Information and Instruction's 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¢LC)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. nmation 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 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(ifnecessary)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 CommoaweajthofMassachusetts Department of industrial Accidents Office of Investigations 600 Wasliinpn Street Boston.,MA 02111 TO,#617-727-4900 ext 406 or 1-877:MASSAFF, Revised 5-26-05 Fax#617-727-7749 www.mass,govfdia