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HomeMy WebLinkAboutMiscellaneous - 42 SUMMER STREET 4/30/2018 42 SUMMER STREET 210/065.0-0064-0000.0 I \ 1 Safety Insurance 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 NO ANDOVER, MA 01845 NO ANDOVER, MA 01845 RE: Insured: DARLENE M ELLIS and THOMAS ELLIS Property Address: 40-42 SUMMIT ST,NO ANDOVER, MA Policy Number: HMA 0097485 Claim Number: BOS00039280 Date of Loss: 9/10/2013 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 313 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. Connor Donovan Claim Examiner 9/12/2013 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 ! Phone: (617) 951-0600 EXT 5362 Fax: (617) 603-4926 Email: Connorponovan@SafetyInsurance.com March 16, 2015 Inspector Of Buildings Town Of North Andover 1600 Osgood Street North Andover MA 1845 Claim Number: 033556099 Policy Number: 52569400004 Company Name: Arbella Mutual Insurance Company Date of Loss: 3/3/2015 Insured: Katherine Tylus Property Location: 42 Summer St North Andover, MA01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed$1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Stephen Laucella Crawford&Company 204 Second Ave Waltham,MA 02451 CC: Ci /Town Fire Dept, Ci /Town Health De �' P City/Town pt i 96-51 41_ Date.................................. NORTH TOWN OF NORTH ANDOVER 4L PERMIT FOR WIRING COW Thi s certifies that ......... ...... .... ....... ....... ................ has permission to perform ........ ................................. wiring in the building of......... ................................................... at.... ....... .......................North Andover,Mass Fee.. Lic.N6��?.33.6.X.......... .. .......i... .. .........�< .. ...... 'r K/R� 'i�A46R"1;2� N�S�PECTOR Check # 1L.vmrnuiren =affa,ea Uff nDaa����,aeaa��ad� _ Permit No. l " Department of Fire Services Occupancy and Fee Checked a 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(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) ]Date: V.40-� & Z0/O 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 ,4 TLS ' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes li�---•- No ❑ (Check Appropriate Box) Purpose of Building /l Utility Authorization No. Existing Service UO Amps /Zo Zt o Volts Overhead 0j"""Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Natufe of Proposed Electrical Work:' ;Z;tm, e,y/& 4Ed/01/F aGCf��s • Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus addle Fans No.of Total P ) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lig mg No.of Luminaires Swimming Pool rnd. rnd. Batter Units No.of Receptacle Outlets o.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 'No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges - - o.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons „KW No.of Self-Contained "otals: I Detection/Alerting Devices Municipal El No. of Dishwashers Space/Area Heating KW Local❑ Connection Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of WaterNo.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: -Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and con:ptete. S' /2/ F IC.NO.: �I 20 33 6FIRM NAME: Licensee: ///OSignature ? LIC.NO.:jF-7 y/V-5 (Ifapplicabenter "exem tt"in the license number li e. / Bus.Tel.No.: Address: /_$$%3 5 —7,-6 A✓PP_W-t AGr- PW 1.V-0- 7_,�444 Alt.Tel.No.: "375-376, *Per M.G.L c. 147 s.57-61,security work requires Department of Public Safety"S"License: Lie.No. does not have the liability OWNER'S INSURANCE WAIVER: I am aware that the LicenseetY insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts 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 Leizibly Name(Business/Organization/Individual): Address: City/State/Zip: 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition j working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 Name: �- Policy#or Self-ins.Lic.#: Expiration Date: 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: N° 1 6 7 6 Date...s . .. '... f �aORTM, O • aj°.,�`` AL TOWN OF NORTH ANDOVER g 0 p PERMIT FOR WIRING : c L6 SS US This certifies that ..... ,.t............ ./c -� e- 0 has permission to perform .....,..,_........'............................................................. R wiring in the building of......`"/. ............. ................................................. at....7... ...........:.... ,Nortthh;Andoover,Mass. Fee,?6.-.� ...... Lic.Nom,., .21..... �....�,a,pc...,...... '`ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Office Use Only 011e Tommunwraltll of ftt000elluoum Permit No. Iii ti'.• �' I Dcpartment of PubUr #afetn Occupancy& Fee Checked's� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR1 x:00 (PLEASE PRINT IN INK OR,, TYPE ALL INFORMATION) Date __S City or Town of /V - �111'/� To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) `7 1���- Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes I--.] No F (Check Appropriate Box) Purpose of Building Utility Authorization No. h Existing Service Amps —J Volts Overhead �l Undgrnd No. of Meters New Service Amps / Volts Overhead I_J Undgrnd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above.--, In- grnd. I- grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total /" No. of Detection and No. of Ranges No. of Air Cond. / tons � yJ Initiating Devices r, Heat Total Total j No. of Disposals No.of Pumps Tons KW No. of Sounding Devices No. of Self Contained i No. of Dishwashers Space/Area Heating KW Detection/Soundinq Devices No. of Dryers Hed� Heating Devices KW — Local Municipal Other Connecn ! I No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Com\pplleted Operations Coveraqe or its substantial equivalent. YES NO �c. have submitted valid proof of same to the Office. YES NO - If you have checked YES, please indicate the type of cov.rage by checking the appropriate box. r O Q INSURANCE BOND -: OTHER = (Please Speciiy) li J (Exp ration Datei Estimated Value of Electrical Work $ ��� AA // Work to Start Inspection Date Requested: Rough _ Final /vd U/ _ Signed under the P� alties f perjury: /�Q FIRM NAME JAS l A/U/vvl LIC. NO. Licensee G Signature _ _ LIC. NO. �A , U Bus. Tel. No. —,2(o a S'9�, % — Address _ �/d� �� T/V��L�0�u>`� �i Alt. Tel. No. _,,6a 3—6,:" e,?V 7L OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not h�ie�h®itr�UFance coverage or its substantial equivalent as re- quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent 11 (Please check one)